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Ilhan F, Boulogne S, Morgado A, Dauleac C, André-Obadia N, Jung J. The Impact of Neurophysiological Monitoring during Intradural Spinal Tumor Surgery. Cancers (Basel) 2024; 16:2192. [PMID: 38927899 PMCID: PMC11201881 DOI: 10.3390/cancers16122192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/15/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Surgery for spinal cord tumors poses a significant challenge due to the inherent risk of neurological deterioration. Despite being performed at numerous centers, there is an ongoing debate regarding the efficacy of pre- and intraoperative neurophysiological investigations in detecting and preventing neurological lesions. This study begins by providing a comprehensive review of the neurophysiological techniques commonly employed in this context. Subsequently, we present findings from a cohort of 67 patients who underwent surgery for intradural tumors. These patients underwent preoperative and intraoperative multimodal somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs), with clinical evaluation conducted three months postoperatively. The study aimed to evaluate the neurophysiological, clinical, and radiological factors associated with neurological outcomes. In univariate analysis, preoperative and intraoperative potential alterations, tumor size, and ependymoma-type histology were linked to the risk of worsening neurological condition. In multivariate analysis, only preoperative and intraoperative neurophysiological abnormalities remained significantly associated with such neurological deterioration. Interestingly, transient alterations in intraoperative MEPs and SSEPs did not pose a risk of neurological deterioration. The machine learning model we utilized demonstrated the possibility of predicting clinical outcome, achieving 84% accuracy.
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Affiliation(s)
- Furkan Ilhan
- Neurophysiology & Epilepsy Unit, Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, 59 Boulevard Pinel, 69677 Bron, France; (F.I.); (S.B.); (N.A.-O.)
| | - Sébastien Boulogne
- Neurophysiology & Epilepsy Unit, Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, 59 Boulevard Pinel, 69677 Bron, France; (F.I.); (S.B.); (N.A.-O.)
- Tiger TEAM, INSERM U1028, UMR5292, Lyon Neuroscience Research Center, CNRS, University Claude Bernard Lyon 1, 69675 Lyon, France
| | - Alexis Morgado
- Neurosurgical Department, Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, 59 Boulevard Pinel, 69677 Bron, France; (A.M.); (C.D.)
| | - Corentin Dauleac
- Neurosurgical Department, Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, 59 Boulevard Pinel, 69677 Bron, France; (A.M.); (C.D.)
| | - Nathalie André-Obadia
- Neurophysiology & Epilepsy Unit, Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, 59 Boulevard Pinel, 69677 Bron, France; (F.I.); (S.B.); (N.A.-O.)
- NeuroPain Lab, INSERM U1028, UMR5292, Lyon Neuroscience Research Center, CNRS, University Claude Bernard Lyon 1, 69675 Lyon, France
| | - Julien Jung
- Neurophysiology & Epilepsy Unit, Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, 59 Boulevard Pinel, 69677 Bron, France; (F.I.); (S.B.); (N.A.-O.)
- EDUWELL Team, INSERM U1028, UMR5292, Lyon Neuroscience Research Center, CNRS, University Claude Bernard Lyon 1, 69675 Lyon, France
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Mishra MK, Pandey N, Sharma HB, Prasad RS, Sahu A, Pradhan RS, Yadav V. Diagnostic Accuracy of Somatosensory Evoked Potential and Transcranial Motor Evoked Potential in Detection of Neurological Injury in Intradural Extramedullary Spinal Cord Tumor Surgeries: A Short-Term Follow-Up Prospective Interventional Study Experience from Tertiary Care Center of India. Asian J Neurosurg 2024; 19:210-220. [PMID: 38974440 PMCID: PMC11226304 DOI: 10.1055/s-0044-1787052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Objective Intraoperative neuromonitoring (IONM) is an acknowledged tool for real-time neuraxis assessment during surgery. Somatosensory evoked potential (SSEP) and transcranial motor evoked potential (MEP) are commonest deployed modalities of IONM. Role of SSEP and MEP in intradural extramedullary spinal cord tumor (IDEMSCT) surgery is not well established. The aim of this study was to evaluate sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and transcranial MEP, in detection of intraoperative neurological injury in IDEMSCT patients as well as their postoperative limb-specific neurological improvement assessment at fixed intervals till 30 days. Materials and Methods Symptomatic patients with IDEMSCTs were selected according to the inclusion criteria of study protocol. On modified McCormick (mMC) scale, their sensory-motor deficit was assessed both preoperatively and postoperatively. Surgery was done under SSEP and MEP (transcranial) monitoring using appropriate anesthetic agents. Gross total/subtotal resection of tumor was achieved as per IONM warning alarms. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP were calculated considering postoperative neurological changes as "reference standard." Patients were followed up at postoperative day (POD) 0, 1, 7, and 30 for convalescence. Statistical Analysis With appropriate tests of significance, statistical analysis was carried out. Receiver-operating characteristic curve was used to find cutoff point of mMC for SSEP being recordable in patients with higher neurological deficit along with calculation of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP for prediction of intraoperative neurological injury. Results Study included 32 patients. Baseline mean mMC value was 2.59. Under neuromonitoring, gross total resection of IDEMSCT was achieved in 87.5% patients. SSEP was recordable in subset of patients with mMC value less than or equal to 2 with diagnostic accuracy of 100%. MEP was recordable in all patients and it had 96.88% diagnostic accuracy. Statistically significant neurological improvement was noted at POD-7 and POD-30 follow-up. Conclusion SSEP and MEP individually carry high diagnostic accuracy in detection of intraoperative neurological injuries in patients undergoing IDEMSCT surgery. MEP continues to monitor the neuraxis, even in those subsets of patients where SSEP fails to record.
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Affiliation(s)
- Manish Kumar Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Nityanand Pandey
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Hanjabam Barun Sharma
- Department of Physiology, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Ravi Shankar Prasad
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Anurag Sahu
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Ravi Shekhar Pradhan
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Vikrant Yadav
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
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Reddy RP, Singh-Varma A, Chang R, Vedire A, Anetakis KM, Balzer JR, Crammond DJ, Shandal V, Lee JY, Shaw JD, Thirumala PD. Transcranial Motor Evoked Potentials as a Predictive Modality for Postoperative Deficit in Cervical Spine Decompression Surgery - A Systematic Review and Meta-Analysis. Global Spine J 2024; 14:1609-1628. [PMID: 38047537 DOI: 10.1177/21925682231219224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVE The purpose of this study was to evaluate whether transcranial motor evoked potential (TcMEP) alarms can predict postoperative neurologic complications in patients undergoing cervical spine decompression surgery. METHODS A meta-analysis of the literature was performed using PubMed, Web of Science, and Embase to retrieve published reports on intraoperative TcMEP monitoring for patients undergoing cervical spine decompression surgery. The sensitivity, specificity, and diagnostic odds ratio (DOR), of overall, reversible, and irreversible TcMEP changes for predicting postoperative neurological deficit were calculated. A subgroup analysis was performed to compare anterior vs posterior approaches. RESULTS Nineteen studies consisting of 4608 patients were analyzed. The overall incidence of postoperative neurological deficits was 2.58% (119/4608). Overall TcMEP changes had a sensitivity of 56%, specificity of 94%, and DOR of 19.26 for predicting deficit. Reversible and irreversible changes had sensitivities of 16% and 49%, specificities of 95% and 98%, and DORs of 3.54 and 71.74, respectively. In anterior procedures, TcMEP changes had a DOR of 17.57, sensitivity of 49%, and specificity of 94%. In posterior procedures, TcMEP changes had a DOR of 21.01, sensitivity of 55%, and specificity of 94%. CONCLUSION TcMEP monitoring has high specificity but low sensitivity for predicting postoperative neurological deficit in cervical spine decompression surgery. Patients with new postoperative neurological deficits were 19 times more likely to have experienced intraoperative TcMEP changes than those without new deficits, with irreversible TcMEP changes indicating a much higher risk of deficit than reversible TcMEP changes.
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Affiliation(s)
- Rajiv P Reddy
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anya Singh-Varma
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Chang
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Abhinav Vedire
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Varun Shandal
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joon Y Lee
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Hejrati N, Srikandarajah N, Alvi MA, Quddusi A, Tetreault LA, Guest JD, Marco RAW, Kirshblum S, Martin AR, Strantzas S, Arnold PM, Basu S, Evaniew N, Kwon BK, Skelly AC, Fehlings MG. The Management of Intraoperative Spinal Cord Injury - A Scoping Review. Global Spine J 2024; 14:150S-165S. [PMID: 38526924 DOI: 10.1177/21925682231196505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Scoping Review. OBJECTIVE To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.
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Affiliation(s)
- Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, St.Gallen, Switzerland
| | - Nisaharan Srikandarajah
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - James D Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Allan R Martin
- Department of Neurological Surgery, University of California Davis, Davis, CA, USA
| | - Samuel Strantzas
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | | | - Michael G Fehlings
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Harada N, Sakaeyama Y, Fuchinoue Y, Abe M, Terazono S, Matsuura C, Kubota S, Mikai M, Sugo N, Sugiyama K, Kondo K, Nemoto M. Differentiation between Anterior and Posterior Roots Using Compound Muscle Action Potential in Intradural Extramedullary Spinal Tumor Surgery. Neurol Med Chir (Tokyo) 2024; 64:36-42. [PMID: 38030261 PMCID: PMC10835576 DOI: 10.2176/jns-nmc.2023-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
This study aims to determine the cutoff values for the compound muscle action potential (CMAP) stimulus in anatomically identified anterior (motor nerve) and posterior roots (sensory nerve) during cervical intradural extramedullary tumor surgery. The connection between CMAP data from nerve roots and postoperative neurological symptoms in thoracolumbar tumors was compared with data from cervical lesions. The participants of the study included 22 patients with intradural extramedullary spinal tumors (116 nerve roots). The lowest stimulation intensity to the nerve root at which muscle contraction occurs was defined as the minimal activation intensity (MAI) in the CMAP. In cervical tumors, the MAI was measured after differentiating between the anterior and posterior roots based on the anatomical placement of the dentate ligament and nerve roots. The MAIs for 20 anterior roots in eight cervical tumors were between 0.1 and 0.3 mA, whereas those for 19 posterior roots were between 0.4 and 2.0 mA. The cutoff was <0.4 mA for both the anterior and posterior roots, and sensitivity and specificity were both 100%. In thoracolumbar tumors, the nerve root was severed in 12 of 14 cases. All MAIs were determined to be at the dorsal roots as their scores were higher than the cutoff and did not indicate motor deficits. The MAIs of the anatomically identified anterior and posterior root CMAPs were found to have a cutoff value of <0.4 mA in the cervical lesions. Similar MAI cutoffs were also applicable to thoracolumbar lesions. Thus, CMAP may be useful in detecting anterior and posterior roots in spinal tumor surgery.
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Affiliation(s)
- Naoyuki Harada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Yuki Sakaeyama
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Yutaka Fuchinoue
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Mitsuyoshi Abe
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Sayaka Terazono
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Chie Matsuura
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Shuhei Kubota
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Masataka Mikai
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Nobuo Sugo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Kunio Sugiyama
- Department of Clinical Functional Physiology, Toho University Medical Center Omori Hospital
| | - Kosuke Kondo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Masaaki Nemoto
- Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University
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Aprato A, Branca Vergano L, Casiraghi A, Liuzza F, Mezzadri U, Balagna A, Prandoni L, Rohayem M, Sacchi L, Smakaj A, Arduini M, Are A, Battiato C, Berlusconi M, Bove F, Cattaneo S, Cavanna M, Chiodini F, Commessatti M, Addevico F, Erasmo R, Ferreli A, Galante C, Giorgi PD, Lamponi F, Moghnie A, Oransky M, Panella A, Pascarella R, Santolini F, Schiro GR, Stella M, Zoccola K, Massé A. Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures. J Orthop Traumatol 2023; 24:46. [PMID: 37665518 PMCID: PMC10477162 DOI: 10.1186/s10195-023-00726-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment. MATERIALS AND METHODS The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment. RESULTS Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated. CONCLUSIONS This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients. LEVEL OF EVIDENCE IV. TRIAL REGISTRATION not applicable (consensus paper).
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Affiliation(s)
- Alessandro Aprato
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy.
| | | | | | | | - Umberto Mezzadri
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | - Alberto Balagna
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
| | | | | | | | | | | | | | | | | | - Federico Bove
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | | | | | | | | | | | - Rocco Erasmo
- Ospedale Civile Santo Spirito di Pescara, Pescara, Italy
| | | | | | | | | | | | - Michel Oransky
- Università degli studi di Roma, ASST degli spedali Civili di Brescia, Brescia, Italy
| | | | | | | | | | | | | | - Alessandro Massé
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
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Angelliaume A, Alhada TL, Parent HF, Royer J, Harper L. Intraoperative neurophysiological monitoring in scoliosis surgery: literature review of the last 10 years. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3072-3076. [PMID: 37434021 DOI: 10.1007/s00586-023-07837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Patients with spinal deformities undergoing corrective surgery are at risk for iatrogenic spinal cord injury (SCI) and subsequent neurological deficit. Intraoperative neurophysiological monitoring (IONM) allows early detection of SCI which enables early intervention resulting in a better prognosis. The primary aim of this literature review was to search if there are threshold values of TcMEP and SSEP in the literature that are widely accepted as alert during IONM. The secondary aim was to update knowledge concerning IONM during scoliosis surgery. METHOD PubMed/MEDLINE and Cochrane library electronic databases were used to search publication from 2012 to 2022. The following keywords were used: evoked potential, scoliosis, surgery, intraoperative monitoring and neurophysiological. We included all studies dealing with SSEP and TcMEP monitoring during scoliosis surgery. Two authors reviewed all titles and abstracts to identify studies that met the inclusion criteria. RESULTS We included 43 papers. Rates of IONM alert and neurological deficit varied from 0.56 to 64% and from 0.15 to 8.3%, respectively. Threshold values varied from a loss of 50 to 90% for TcMEP amplitude, whereas it seems that a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted for SSEP. Causes of IONM changes most frequently reported were surgical maneuver. CONCLUSION Concerning SSEP, a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted as an alert. For TcMEP, it seems that the use of highest threshold values can avoid unnecessary surgical procedure for the patient without increasing risk of neurological deficit.
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Affiliation(s)
| | - Toul-la Alhada
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | | | - Julia Royer
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Luke Harper
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
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Pan Q, Yu H, He X, Weng Y, Zhang R, Wang H, Li Y. Lumbar Sympathetic Trunk Injury: An Underestimated Complication of Oblique Lateral Interbody Fusion. Orthop Surg 2023; 15:1053-1059. [PMID: 36855251 PMCID: PMC10102305 DOI: 10.1111/os.13692] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/21/2023] [Accepted: 02/01/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE Lumbar sympathetic trunk (LST) injury is one of the major complications after oblique lumbar interbody fusion (OLIF). LST injury often manifests as unequal skin temperature in lower limbs after operation, and there may be a large number of missed diagnoses due to the lack of attention and different diagnostic methods. The study aimed to investigate the incidence and clinical characteristics of LST injury after OLIF. METHODS The data of patients with lumbar degenerative diseases who underwent OLIF in our hospital from April 2016 to October 2017 were retrospectively analyzed. Finally, a total of 54 patients were included. There were 10 males and 44 females, aged 58.4 ± 10.9 years. The skin temperature of lower limbs was measured before and a day after surgery. The patients were followed up at 1 week, 6 weeks, 6 months, and 2 years after the surgery. Likert five-point scale was used to evaluate the discomfort caused by LST injury. Injury severity score was introduced to grade injury degree according to the recovery time of postoperative symptoms. The chi-square test was used to analyze the association of incidence of lumbar sympathetic trunk (LST) injury with contributing factors, such as gender and number of surgical segments. RESULTS The unequal temperature was not found before surgery in all the patients. Postoperatively, 16 cases (29.6%) had difference of skin temperature more than 0.5 °C and were diagnosed with LST injury. Eight patients (14.8%) had self-perception of skin temperature differences, and 12 patients (22.2%) had other symptoms, such as muscle pain, numbness, and weakness, which were not statistically different between patients with and without lumbar sympathetic trunk injury (p > 0.05). In the 16 patients with LST injury, the difference of skin temperature between the two legs was 0.6 ± 0.1 °C on the first day, and the temperature difference lasted for 1.5-~12 months. According to Likert five-point scale, two cases (12.5%) were poor, and 14 cases (87.5%) were moderate immediately after surgery. Fifteen cases improved to some extent 6 weeks to 12 months after surgery. CONCLUSION Postoperative LST injury is mainly manifested by different temperature of lower limbs. The incidence was higher in patients with multi-segment OLIF than in those with single-segment OLIF, and the subjective experience of most patients with LST injury was moderate discomfort.
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Affiliation(s)
- Qunlong Pan
- Department of Orthopaedic, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Haiming Yu
- Department of Orthopaedic, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiaoyu He
- Department of Orthopaedic, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yiyong Weng
- Department of Orthopaedic, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Rongmou Zhang
- Department of Orthopaedic, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hanshi Wang
- Department of Orthopaedic, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yizhong Li
- Department of Orthopaedic, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Külzer M, Weigand MA, Pepke W, Larmann J. [Anesthesia in spinal surgery]. DIE ANAESTHESIOLOGIE 2023; 72:143-154. [PMID: 36695838 DOI: 10.1007/s00101-023-01255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/26/2023]
Abstract
Over the past 20 years improvements in surgical techniques and perioperative patient care have led to a considerable increase in surgical procedures of the spine worldwide. Therefore, the spectrum was extended from minimally invasive procedures up to complex operations over several segments of the spinal column with high loss of blood and complex perioperative management. This article presents the principal pillars of preoperative, intraoperative and postoperative management relating to spinal surgery. Furthermore, procedure-specific features, such as airway management in cervical spine instability or implementation of intraoperative neuromonitoring are dealt with in detail.
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Affiliation(s)
- Mareike Külzer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Wojciech Pepke
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Jan Larmann
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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Di Domenico M, Viola D, Izzo A, D'Ercole M, Signorelli F, Montano N, Visocchi M. Methods and Principles of the Intraoperative Neurophysiologic Monitoring in Neurosurgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:45-49. [PMID: 38153448 DOI: 10.1007/978-3-031-36084-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Intraoperative neurophysiologic monitoring (IONM) is an innovation introduced in neurosurgery in the past decades. It aims to support and guide the neurosurgeon to obtain the best surgical result possible, preventing the occurrence of neurological deficits. The somatosensory evoked potentials (SSEP) assess the integrity of the sensory pathways monitoring the dorsal column-medial lemniscus pathway during spine and cerebral surgery. Motor evoked potentials (MEPs) provide information on the integrity of the motor pathway monitoring the efferent motor pathways from the motor cortex to the muscle through corticospinal (or corticobulbar) tracts. Free-running EMG is the standard technique to monitor peripheral nerves, roots, or cranial motor nerves during surgery. Intraoperative EMG signals are activated during cranial motor nerves damaging or after an irritative stimulus. The duration, morphology, and persistence of EMG reflects the severity of neural injury. Nerve mapping consists of recording muscle activations given by direct nerve stimulation. This technique makes use of a stimulation probe available to the neurosurgeon which allows administering current directly to the nervous tissue (nerves, roots, etc.). Intraoperative neurophysiological monitoring (IONM) represents the standard of care during many procedures, including spinal, intracranial, and vascular surgeries, where there is a risk of neurological damage. Close communication and collaboration between the surgical team, neurophysiologist, and anesthesiologist is mandatory to obtain high-quality neuromonitoring, thus preventing neurologic injuries and gaining the best surgical "safe" results.
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Affiliation(s)
- Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Diana Viola
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Signorelli
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
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Multimodal Neuroelectrophysiological Monitoring Combined with Robot-Assisted Placement of a Transiliac–Transsacral Screw for the Treatment of Transforaminal Sacral Fractures. BIOMED RESEARCH INTERNATIONAL 2022; 2022:3383665. [PMID: 35915799 PMCID: PMC9338859 DOI: 10.1155/2022/3383665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/30/2022] [Indexed: 11/22/2022]
Abstract
Objective This study aimed to evaluate the safety and efficacy of the fixation of transforaminal sacral fractures using TiRobot-assisted transiliac-transsacral (TITS) screws under multimodal neuroelectrophysiological monitoring (MNM). Methods From January 2019 to May 2021, 22 patients (17 male and 5 female patients) with transforaminal sacral fractures who were treated with closed reduction and placement of TiRobot-assisted TITS screws under MNM were retrospectively evaluated. The average age of the patients was 43.32 ± 11.40 years (range: 19–63). The patients received MNM, including somatosensory-evoked potentials (SEPs), motor-evoked potentials (MEPs), and electromyographic monitoring (EMG), prior to surgery, during closed reduction and the placement of the guidewire and TITS screw, and at the end of surgery. The operation was adjusted according to the MNM results. Results Overall, 22 TITS screws were inserted in 22 patients, including 5 TITS screws in the S1 body and 17 TITS screws in the S2 body. The average time needed for screw placement was 27.95 ± 6.84 mins, and the average frequency of X-ray fluoroscopy exposures was 31.00 ± 5.56 for each patient. Anterior ring fixation was performed in 4 patients using an external fixator, in 5 patients using cannulated screws, and in 13 patients using reconstruction plates. The mean follow-up time was 14.46 ± 2.46 months (12–20 months). Tornetta and Matta radiographic outcomes were excellent in 10 patients, good in 9 patients, fair in 2 patients, and poor in 1 patient. The proportion of excellent and good ratings was 86.36%. At the final follow-up, the average Majeed score was 82.18 ± 14.52, with clinical outcomes that were excellent in 9 patients, good in 9 patients, fair in 1 patient, and poor in 3 patients. The proportion of excellent and good ratings was 82.82%. Preoperatively, the amplitude of the SEP on the injured side was lower than that on the contralateral side before reduction in 9 patients (>50%). In this study, no screw was mistakenly inserted into the sacral canal, and no surgical site infection occurred. Conclusion MNM combined with TiRobot assistance can safely implant TITS screws and can effectively identify the neurological function of patients under anesthesia and reduce iatrogenic nerve injury.
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Singleton M, Ghisi D, Memtsoudis S. Perioperative management in complex spine surgery: a narrative review. Minerva Anestesiol 2022; 88:396-406. [PMID: 35315618 DOI: 10.23736/s0375-9393.22.15933-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The last two decades have seen a significant increase in the number of spine surgical procedures performed worldwide. This type of surgery includes a wide variety of procedures, from mini-invasive discectomies to multi-level spinal arthrodesis and osteotomies. Moreover, different surgical approaches are described at different spine levels: the anesthesiologist should be aware of the potential benefits and risks for the patients and be prepared for their management. In this narrative review we seek to describe basic concepts of perioperative spine care and address evolving areas in which care is changing. We will discuss preoperative concerns, intraoperative management including airway management, choice of maintenance, intraoperative neuromonitoring and anesthetic effect, blood management and the dynamic topic of anesthetic and analgesic techniques. Finally, we will briefly address the issue of perioperative complications as they relate specifically to spine surgery.
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Affiliation(s)
- Michael Singleton
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Daniela Ghisi
- Anesthesia, Intensive Care and Pain Therapy, Istituto Ortopedico Rizzoli, Bologna, Italy -
| | - Stavros Memtsoudis
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA.,Department of Public Health, Division of Epidemiology, Weill Cornell Medical College, New York, NY, USA
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