1
|
Zhang H, Carreon LY, Dimar JR. The Role of Anterior Spine Surgery in Deformity Correction. Neurosurg Clin N Am 2023; 34:545-554. [PMID: 37718101 DOI: 10.1016/j.nec.2023.06.005] [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: 09/19/2023]
Abstract
There are a range of anterior-based approaches to address flexible adult spinal deformity from the thoracic spine to the sacrum, with each approach offering access to a range of vertebral levels. It includes the transperitoneal (L5-S1), paramedian anterior retroperitoneal (L3-S1), oblique retroperitoneal (L1-2 to L5-S1), the thoracolumbar transdiaphragmatic approach (T9-10 to L4-5), and thoracotomy approach (T4-T12). The lumbar and lumbosacral spine is especially favorable for anterior-based approaches given the relative mobility of the peritoneal organs and position of the vasculature.
Collapse
Affiliation(s)
- Hanci Zhang
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA.
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St., 1st Floor ACB, Louisville, KY 40202, USA
| |
Collapse
|
2
|
Anterior spine surgery for the treatment of complex spine pathology: a state-of-the-art review. Spine Deform 2022; 10:973-989. [PMID: 35595968 DOI: 10.1007/s43390-022-00514-8] [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] [Received: 01/04/2022] [Accepted: 04/10/2022] [Indexed: 10/18/2022]
Abstract
The use of anterior spinal surgery for the treatment of spinal pathology has experienced a dramatic increase over the past decade. Long relegated to treat complicated anterior pathologies it has returned to mainstream spine surgery techniques for all types of conditions, providing a significant boost to the spine surgeons' armamentarium to address a wide variety of types of spinal diseases more effectively. Anterior surgery is useful whenever there is significant spinal pathology that requires direct visualization of the anterior vertebral column to best restore spinal alignment, structural integrity and neurologic function. These pathologies include spinal deformities, tumors, burst fractures, infections, vertebral avascular necrosis, pseudoarthrosis and other miscellaneous indications. Currently available approaches to the spine include transabdominal, paramedian retroperitoneal, lateral oblique retroperitoneal, thoracotomy, and thoracolumbar extensile. Most of the lumbar approaches are now done through a muscle splitting, minimalistic approach that has decreased their morbidity or more recently via tubular approaches, such as lateral lumbar interbody fusions or other ante-psoas approaches. New retractors, instrumentation, hyperlordotic implants, approved biologics and even image guidance for disc preparation and precise implant placement are all recent advances that will hopefully improve surgical outcomes in patients following anterior spinal surgery. Most importantly, these approaches require added expertise and training with a dedicated team consisting of an anteriorly trained spine surgeon working simultaneously with a dedicated vascular surgeon to ensure maximum safety and superior patient outcomes. This state of the review is dedicated to familiarizing practicing spine surgeons with the most commonly used anterior spinal approaches along with cutting-edge instrumentation and fusion techniques to improve their options for the treatment of difficult spinal pathologies.
Collapse
|
3
|
Iyer RR, Vitale MG, Fano AN, Matsumoto H, Sucato DJ, Samdani AF, Smith JS, Gupta MC, Kelly MP, Kim HJ, Sciubba DM, Cho SK, Polly DW, Boachie-Adjei O, Angevine PD, Lewis SJ, Lenke LG. Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery. Spine Deform 2022; 10:733-744. [PMID: 35199320 DOI: 10.1007/s43390-022-00482-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/22/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits. METHODS Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%. RESULTS Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines. CONCLUSION A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients. LEVEL OF EVIDENCE Level V.
Collapse
Affiliation(s)
- Rajiv R Iyer
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Michael G Vitale
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA.,Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Adam N Fano
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Hiroko Matsumoto
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA. .,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.
| | - Daniel J Sucato
- Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Long Island Jewish Medical Center, North Shore University Hospital of Northwell Health, New York, NY, USA
| | - Samuel K Cho
- Department of Orthopedic Surgery, Mount Sinai Medical Center, New York, NY, USA
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Peter D Angevine
- The Daniel and Jane Och Spine Hospital at New York-Presbyterian/Allen, New York, NY, USA.,Division of Spinal Surgery, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Lawrence G Lenke
- The Daniel and Jane Och Spine Hospital at New York-Presbyterian/Allen, New York, NY, USA.,Division of Spinal Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
4
|
Shlobin NA, Raz E, Shapiro M, Clark JR, Hoffman SC, Shaibani A, Hurley MC, Ansari SA, Jahromi BS, Dahdaleh NS, Potts MB. Spinal neurovascular complications with anterior thoracolumbar spine surgery: a systematic review and review of thoracolumbar vascular anatomy. Neurosurg Focus 2020; 49:E9. [PMID: 32871559 DOI: 10.3171/2020.6.focus20373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal cord infarction due to interruption of the spinal vascular supply during anterior thoracolumbar surgery is a rare but devastating complication. Here, the authors sought to summarize the data on this complication in terms of its incidence, risk factors, and operative considerations. They also sought to summarize the relevant spinal vascular anatomy. METHODS They performed a systematic literature review of the PubMed, Scopus, and Embase databases to identify reports of spinal cord vascular injury related to anterior thoracolumbar spine procedures as well as operative adjuncts and considerations related to management of the segmental artery ligation during such anterior procedures. Titles and abstracts were screened, and studies meeting inclusion criteria were reviewed in full. RESULTS Of 1200 articles identified on the initial screening, 16 met the inclusion criteria and consisted of 2 prospective cohort studies, 10 retrospective cohort studies, and 4 case reports. Four studies reported on the incidence of spinal cord ischemia with anterior thoracolumbar surgery, which ranged from 0% to 0.75%. Eight studies presented patient-level data for 13 cases of spinal cord ischemia after anterior thoracolumbar spine surgery. Proposed risk factors for vasculogenic spinal injury with anterior thoracolumbar surgery included hyperkyphosis, prior spinal deformity surgery, combined anterior-posterior procedures, left-sided approaches, operating on the concavity side of a scoliotic curve, and intra- or postoperative hypotension. In addition, eight studies analyzed operative considerations to reduce spinal cord ischemic complications in anterior thoracolumbar surgery, including intraoperative neuromonitoring and preoperative spinal angiography. CONCLUSIONS While spinal cord infarction related to anterior thoracolumbar surgery is rare, it warrants proper consideration in the pre-, intra-, and postoperative periods. The spine surgeon must be aware of the relevant risk factors as well as the pre- and intraoperative adjuncts that can minimize these risks. Most importantly, an understanding of the relevant spinal vascular anatomy is critical to minimizing the risks associated with anterior thoracolumbar spine surgery.
Collapse
Affiliation(s)
| | - Eytan Raz
- 3Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Maksim Shapiro
- 3Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | | | | | - Ali Shaibani
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | - Michael C Hurley
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | - Sameer A Ansari
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | - Babak S Jahromi
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| | | | - Matthew B Potts
- Departments of1Neurological Surgery and.,2Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; and
| |
Collapse
|
5
|
Anterior Vertebral Body Growth-Modulation Tethering in Idiopathic Scoliosis: Surgical Technique. J Am Acad Orthop Surg 2020; 28:693-699. [PMID: 32618681 DOI: 10.5435/jaaos-d-19-00849] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The management of idiopathic scoliosis in the skeletally immature patient can be challenging. Posterior spinal fusion and instrumentation is indicated for severe scoliosis deformities. However, the skeletally immature patient undergoing posterior fusion and instrumentation is at risk for developing crankshaft deformities. Moreover, bracing treatment remains an option for patients who are skeletally immature, and although it was found to be effective, it does not completely preclude deformity progression. Recently, fusionless treatment options, such as anterior vertebral body growth modulation, have been developed to treat these patients while avoiding the complications of posterior rigid fusion. Good results have been shown in recent literature with proper indications and planning in the skeletally immature patient.
Collapse
|
6
|
Tan T, Rutges J, Marion T, Fisher C, Tee J. The Safety Profile of Intentional or Iatrogenic Sacrifice of the Artery of Adamkiewciz and Its Vicinity's Spinal Segmental Arteries: A Systematic Review. Global Spine J 2020; 10:464-475. [PMID: 32435568 PMCID: PMC7222674 DOI: 10.1177/2192568219845652] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES There is paucity of consensus on whether (1) the artery of Adamkiewicz (AoA) and (2) the number of contiguous segmental spinal arteries (SSAs) that can be safely ligated without causing spinal cord ischemia. The objective of this review is to determine the risk of motor neurological deficits from iatrogenic sacrifice of the (1) AoA and (2) its vicinity's SSAs. METHODS Systematic review of the spine and vascular surgery was carried out in accordance to PRISMA guidelines. Outcomes in terms of risk of postoperative motor neurological deficit with occlusion of the AoA, bilateral contiguous SSAs, or unilateral contiguous SSAs were analyzed. RESULTS Ten articles, all retrospective case series, were included. Three studies (total N = 50) demonstrated a postoperative neurological deficit risk of 4.0% when the AoA is occluded. When 1 to 6 pairs of SSAs (without knowledge of AoA location) were ligated, the postoperative neurological deficit risk was 0.6%, as compared with 5.4% when more than 6 bilateral pairs of SSAs were ligated (relative risk [RR] = 0.105, 95% CI 0.013-0.841, P = .0337). For unilateral ligation of SSAs of two to nine levels, the risk of postoperative neurological deficit does not exceed 1.3%. CONCLUSION The current best evidence indicates that (1) occlusion of the AoA and (2) occlusion of up to 6 pairs of SSAs is associated with a low risk of postoperative neurological deficit. This limited number of low quality studies restrict the ability to draw definitive conclusions. Ligation of AoA and SSAs should only be undertaken when absolutely required to mitigate the small but devastating risk of paralysis.
Collapse
Affiliation(s)
- Terence Tan
- The Alfred Hospital, Melbourne, Victoria, Australia,National Trauma Research Institute Melbourne, Victoria, Australia
| | | | - Travis Marion
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Charles Fisher
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jin Tee
- The Alfred Hospital, Melbourne, Victoria, Australia,National Trauma Research Institute Melbourne, Victoria, Australia,Jin Tee, Department of Neurosurgery, Level 1, Old Baker Building, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
| |
Collapse
|
7
|
Preoperative CT Angiography Informs Instrumentation in Anterior Spine Surgery for Idiopathic Scoliosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00123. [PMID: 32377614 PMCID: PMC7188266 DOI: 10.5435/jaaosglobal-d-19-00123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022]
Abstract
The objective of this study is to evaluate whether the artery of Adamkiewicz localization with preoperative CT angiography influences anterior spinal instrumentation. Methods Children with idiopathic scoliosis who underwent anterior instrumentation and with a preoperative CT angiography were evaluated retrospectively. Data included curve type, artery of Adamkiewicz level/laterality, surgical approach laterality, number of instrumented levels and segmental vessels ligated, intraoperative neuromonitoring changes, and postoperative neural complications. Results Thirty-nine girls and eight boys (mean age 12 years [6.7 to 16.8 years]) were analyzed. Instrumented curves indicate 28 thoracic, 14 thoracolumbar, and seven double major. The artery of Adamkiewicz: T6 (left-1), T8 (left-1), T9 (left-4/right-2), T10 (left-11/right-4), T11 (left-4/right-4), T12 (left-1/right-2), L1 (left-2/right-1), and L2 (left-3/right-2). Four had bilateral dominant segmentals, whereas in nine patients, none was identified. T10 (32%) and left side (57%) were most frequent. On average, 7.1 (4 to 11) segmentals were ligated per case (total 355). Dominant vessels were ipsilateral to/within instrumentation levels in 30%. Discussion In children with idiopathic scoliosis who underwent anterior instrumentation, the artery of Adamkiewicz was identified on the left in >50% and at T10 in 32%. In one-third of the patients, the artery was within intended surgical levels and resulted in instrumentation modification.
Collapse
|
8
|
Safaee MM, Pekmezci M, Deviren V, Ames CP, Clark AJ. Thoracolumbar Vertebral Column Resection With Rectangular Endplate Cages Through a Posterior Approach: Surgical Techniques and Early Postoperative Outcomes. Oper Neurosurg (Hagerstown) 2020; 18:329-338. [PMID: 31214704 DOI: 10.1093/ons/opz151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Thoracolumbar pathology can result in compression of neural elements, instability, and deformity. Circumferential decompression with anterior column reconstruction is often required to restore biomechanical stability and minimize the risk of implant failure. OBJECTIVE To assess the safety and viability of wide-footprint rectangular cages for vertebral column resection (VCR). METHODS We performed VCR with wide-footprint rectangular endplate cages, which were designed for transthoracic or retroperitoneal approaches. We present our technique using a single-stage posterior approach. RESULTS A total of 45 patients underwent VCR with rectangular endplate cages. Mean age was 58 yr. Diagnoses included 23 tumors (51%), 14 infections (31%), and 8 deformities (18%). VCRs were performed in 10 upper thoracic, 17 middle thoracic, 14 lower thoracic, and 4 lumbar levels. Twenty-four cases involved a single level VCR (53%) with 18 two-level (40%) and 3 three-level (7%) VCRs. Average procedure duration was 264 min with mean estimated blood loss of 1900 ml. Neurological outcomes were stable in 27 cases (60%), improved in 16 (36%), and worse in 2 (4%). There were 7 medical and 7 surgical complications in 11 patients. There were significant decreases in postoperative thoracic kyphosis (47° vs 35°, P = .022) and regional kyphosis (34° vs 10°, P < .001). There were 2 cases of cage subsidence due to intraoperative endplate violation, neither of which progressed on CT scan at 14 and 35 mo. CONCLUSION Posterior VCR with rectangular footprint cages is safe and feasible. This provides improved biomechanical stability without the morbidity of a lateral transthoracic or retroperitoneal approach.
Collapse
Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Murat Pekmezci
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| |
Collapse
|
9
|
Landriel F, Baccanelli M, Hem S, Vecchi E, Bendersky M, Yampolsky C. Intraoperative monitoring for spinal radiculomedullary artery aneurysm occlusion treatment: What, when, and how long? Surg Neurol Int 2017; 8:211. [PMID: 28966818 PMCID: PMC5609436 DOI: 10.4103/sni.sni_385_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 06/15/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Spinal radiculomedullary artery aneurysms are extremely rare. Treatment should be tailored to clinical presentation, distal aneurysm flow, and lesion anatomical features. When a surgical occlusion is planned, it is necessary to evaluate whether intraoperative monitoring (IOM) should be considered as an indispensable tool to prevent potential spinal cord ischemia. METHODS We present a patient with symptoms and signs of spinal subarachnoid hemorrhage resulting from the rupture of a T4 anterior radiculomedullary aneurysm who underwent open surgical treatment under motor evoked potential (MEP) monitoring. RESULTS Due to the aneurysmal fusiform shape and preserved distal flow, the afferent left anterior radiculomedullary artery was temporarily clipped; 2 minutes after the clamping, the threshold stimulation level rose higher than 100 V, and at minute 3, MEPs amplitude became attenuated over 50%. This was considered as a warning criteria to leave the vessel occlusion. The radiculomedullary aneurysm walls were reinforced and wrapped with muscle and fibrin glue to prevent re-bleeding. The patient awoke from general anesthesia without focal neurologic deficit and made an uneventful recovery with complete resolution of her symptoms and signs. CONCLUSION This paper attempts to build awareness of the possibility to cause or worsen a neurological deficit if a radiculomedullary aneurysm with preserved distal flow is clipped or embolized without an optimal IOM control. We report in detail MEP monitoring during the occlusion of a unilateral T4 segmental artery that supplies an anterior radiculomedullary artery aneurysm.
Collapse
Affiliation(s)
- Federico Landriel
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
| | - Matteo Baccanelli
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
| | - Santiago Hem
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
| | - Eduardo Vecchi
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
| | - Mariana Bendersky
- Department of Neurology, Hospital Italiano de Buenos Aires, Argentina
| | - Claudio Yampolsky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
| |
Collapse
|
10
|
Zhao Z, Xie J, Wang Y, Bi N, Li T, Zhang Y, Shi Z. The effect from different numbers of segmental arteries ligation to the spinal cord in the clinical practice of posterior vertebral column resection correction. 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 2017; 26:1937-1944. [PMID: 28364333 DOI: 10.1007/s00586-017-5067-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 03/01/2017] [Accepted: 03/24/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE In using posterior vertebral column resection (PVCR) to treat severe kyphoscoliosis, it is unavoidable to ligate and cut off several segmental arteries (SAs) of the spinal cord for exposure and hemostasis, but which would raise the neurological risks. The aim of this study is to explore the changes of intraoperative spinal cord monitoring (IOM) following ligating different numbers of SAs in PVCR. METHODS Twenty-one consecutive patients with severe kyphoscoliosis were included and treated by PVCR correction. In operation, according to ligate different numbers of SAs, the IOM changes were recorded, respectively. Examinations of the covariance between different numbers of SAs ligations and IOM changes were performed to reveal the effect to the spinal cord by SAs ligations. RESULTS In all the 21 cases, averaging 1.9 pairs of SAs were ligated. With the increased numbers of ligations, SSEP amplitudes and latencies were changed more obviously: from 1 to 3 pairs ligations, the mean decreased percentages of amplitudes were from 53.20 to 78.15%, the mean increased percentages of latency were from 1.23 to 1.40%, and the mean durations of decreased SSEP amplitudes were from 3.23 to 5.2 min; but without abnormal MEP changes. None occurred postoperative or delayed neurological deficit. Correlation analysis identified significant correlations between the number of SAs ligation and decreased percentage of SSEP amplitude (r = 0.945, P < 0.0001), and between the number of SAs being ligated and the duration of SSEP change (r = 0.945, P = 0.0002). CONCLUSIONS Following the increased number of SAs ligation, the amplitude of SSEP is decreased more obviously with a much longer duration of recovery and the risk to spinal cord will be increased greatly. In the PVCR correction on the basis of spinal shortening, the numbers of SAs ligations should be as less as possible for neurological safety.
Collapse
Affiliation(s)
- Zhi Zhao
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Jingming Xie
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China.
| | - Yingsong Wang
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Ni Bi
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Tao Li
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Ying Zhang
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| | - Zhiyue Shi
- Department of Orthopaedics, The 2nd Affiliated Hospital of Kunming Medical University, 374# Dianmian Road, Kunming, Yunnan Province, 650101, People's Republic of China
| |
Collapse
|
11
|
Beckman JM, Vincent B, Park MS, Billys JB, Isaacs RE, Pimenta L, Uribe JS. Contralateral psoas hematoma after minimally invasive, lateral retroperitoneal transpsoas lumbar interbody fusion: a multicenter review of 3950 lumbar levels. J Neurosurg Spine 2016; 26:50-54. [PMID: 27494784 DOI: 10.3171/2016.4.spine151040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Minimally invasive lateral lumbar interbody fusion (LLIF) via the retroperitoneal transpsoas approach is a technically demanding procedure with a multitude of potential complications. A relatively unknown complication is the contralateral psoas hematoma. The authors speculate that injury occurs from segmental vessel injury at the time of contralateral annulus release; however, this is not fully understood. In this multicenter retrospective review, the authors report the incidence of this contralateral complication and its neurological sequelae. METHODS This study was a retrospective chart review of all minimally invasive LLIF performed at participating institutions from 2008 to 2014. Exclusion criteria included an underlying diagnosis of trauma or neoplasia as well as lateral corpectomies or anterior column releases. Single-level, multilevel, and stand-alone constructs were included. All patients underwent preoperative MRI. Follow-up was at least 12 months. All complications and clinical outcomes were self-reported by each surgeon. RESULTS There were 3950 lumbar interbody cages placed via the retroperitoneal transpsoas approach, with 7 cases (0.18% incidence) of symptomatic contralateral psoas hematoma, 3 of which required reoperation for hematoma evacuation. Neurological outcome did not improve after reoperation. Reoperation occurred an average of 1 month after the initial operation due to a delay in diagnosis. In 1 case, segmental artery injury was confirmed at the time of surgery; in the others, segmental vessel injury was suspected, although it could not be confirmed. Neurological deficits persisted in 3 patients while the others remained neurologically intact. Two patients were receiving antiplatelet therapy prior to the procedure. CONCLUSIONS The contralateral psoas hematoma is a rare complication suspected to occur from segmental vessel injury during contralateral annulus release. Detailed review of preoperative imaging for aberrant vessel anatomy may prevent injury and subsequent neurological deficit.
Collapse
Affiliation(s)
- Joshua M Beckman
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
| | - Berney Vincent
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
| | - Michael S Park
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
| | - James B Billys
- Center for Spinal Disorders, Florida Orthopaedic Institute, Tampa, Florida
| | - Robert E Isaacs
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina; and
| | - Luiz Pimenta
- Instituto de Patologia da Coluna, São Paulo, Brazil
| | - Juan S Uribe
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
| |
Collapse
|
12
|
Grelat M, Madkouri R, Tremlet J, Thouant P, Beaurain J, Mourier KL. Aim and indications of spinal angiography for spine and spinal cord surgery: Based on a retrospective series of 70 cases. Neurochirurgie 2016; 62:38-45. [DOI: 10.1016/j.neuchi.2015.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 09/11/2015] [Accepted: 10/10/2015] [Indexed: 11/29/2022]
|
13
|
Spinal Cord Blood Supply and Its Surgical Implications. J Am Acad Orthop Surg 2015; 23:581-91. [PMID: 26377671 DOI: 10.5435/jaaos-d-14-00219] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 01/03/2015] [Indexed: 02/01/2023] Open
Abstract
The blood supply to the spine is based on a predictable segmental vascular structure at each spinal level, but true radiculomedullary arteries, which feed the dominant cord supply vessel, the anterior spinal artery, are relatively few and their locations variable. Under pathologic conditions, such as aortic stent grafting, spinal deformity surgery, or spinal tumor resection, sacrifice of a dominant radiculomedullary vessel may or may not lead to spinal cord ischemia, depending on dynamic autoregulatory or collateral mechanisms to compensate for its loss. Elucidation of the exact mechanisms for this compensation requires further study but will be aided by preoperative, intraoperative, and postoperative comparative angiography. Protocols in place at our center and others minimize the risk of spinal cord ischemia during planned radiculomedullary vessel sacrifice.
Collapse
|
14
|
Walsh KA, Keane D, Fahy GJ. Close relationship of segmental spinal artery to posterior left atrium in patients with osteophyte formation enlarged left atrium and atrial fibrillation. Heart Rhythm 2014; 12:851. [PMID: 25541271 DOI: 10.1016/j.hrthm.2014.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Katie A Walsh
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - David Keane
- Department of Cardiology, St Vincent's University Hospital, Dublin, Ireland
| | - Gerard J Fahy
- Department of Cardiology, Cork University Hospital, Cork, Ireland.
| |
Collapse
|
15
|
Javidan P, Kabirian N, Mundis GM, Akbarnia BA. Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique: case report. J Neurosurg Spine 2013; 19:595-9. [PMID: 24053377 DOI: 10.3171/2013.8.spine121160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up. Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.
Collapse
Affiliation(s)
- Pooya Javidan
- San Diego Center for Spinal Disorders, La Jolla, California
| | | | | | | |
Collapse
|
16
|
Abstract
Anterior open scoliosis surgery using the dual rod system is a safe and rather effective procedure for the correction of scoliosis (50-60 %). Thoracic hypokyphosis and rib hump correction with open anterior rather than posterior instrumentation appear to be the better approaches, although the latter is somewhat controversial with current posterior vertebral column derotation devices. In patients with Risser grade 0, hyperkyphosis and adding-on may occur with anterior thoracic spine instrumentation. Anterior thoracoscopic instrumentation provides a similar correction (65 %) with good cosmetic outcomes, but it is associated with a rather high risk of instrumentation (pull-out, pseudoarthrosis) and pulmonary complications. Approximately 80 % of patients with adolescent idiopathic scoliosis (AIS) curves of >70° have restrictive lung disease or smaller than normal lung volumes. AIS patients undergoing anterior thoracotomy or anteroposterior surgery will demonstrate a significant decrease in percentage of predicted lung volumes during follow-up. The thoracoabdominal approach and thoracoscopic approach without thoracoplasty do not produce similar changes in detrimental lung volume. In patients with severe AIS (>90°), posterior-only surgery with TPS provides similar radiographic correction of the deformity (44 %) with better pulmonary function outcomes than anteroposterior surgery. Vascular spinal cord malfunction after segmental vessel ligation during anterior scoliosis surgery has been reported. Based on the current literature, the main indication for open anterior scoliosis instrumentation is Lenke 5C thoracolumbar or lumbar AIS curve with anterior instrumentation typically between T11 and L3.
Collapse
|
17
|
Chatterjee AD, Hassan K, Grevitt MP. Congenital kypho-scoliosis: a case of thoracic insufficiency syndrome and the limitations of treatment. 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 2011; 21:1043-9. [PMID: 22048403 DOI: 10.1007/s00586-011-2032-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 07/03/2011] [Accepted: 09/16/2011] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Congenital spinal vertebral anomalies may present with deformity resulting in congenital scoliosis and kyphosis. This leads to abnormal spinal growth. The latter when combined with associated rib fusions may impair normal thoracic cage development and resultant pulmonary hypoplasia. Most congenital scoliosis can be detected in utero by ultrasound scan or recognized in the neonatal period, but a few spinal defects can remain undetected. MATERIALS AND METHODS In this Grand Round, we present the case of a 7-year-old girl with a severe scoliosis and thoracic insufficiency syndrome (TIS). 3D CT reconstruction imaging demonstrated a mixed picture of fusion and segmentation abnormalities. A marked kyphoscoliosis was demonstrated at the thoraco-lumbar junction. Via a left thoracotomy, anterior excision of intervertebral discs was performed together with, interbody fusion, and in situ stabilisation of the kyphosis with double allograft (femur) strut grafts. CONCLUSIONS This article highlights the features of congenital kypho-scoliosis and TIS. The difficulties of treating kyphosis when combined with TIS are discussed together with the limitations of current surgical techniques.
Collapse
Affiliation(s)
- A D Chatterjee
- Centre for Spinal Studies and Surgery, Queens Medical Centre, Derby Road, Nottingham, UK.
| | | | | |
Collapse
|
18
|
Arslan M, Comert A, Acar HI, Ozdemir M, Elhan A, Tekdemir I, Tubbs RS, Ugur HC. Surgical view of the lumbar arteries and their branches: an anatomical study. Neurosurgery 2011; 68:16-22; discussion 22. [PMID: 21304330 DOI: 10.1227/neu.0b013e318205e307] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although injury to the lumbar arteries during anterior spinal approaches is often encountered, there are few published articles regarding the relationship between the lumbar arteries and spinal cord ischemia. OBJECTIVE To examine the morphology of the lumbar arteries and to emphasize their clinical importance. METHODS With the aid of a surgical microscope, 80 lumbar arteries in 10 formalin-fixed male cadavers were studied. Measurements of these structures were made and relationships observed. RESULTS The spinal artery was usually the first branch of the lumbar artery. The greatest lumbar artery diameter was at L4 and had a mean diameter of 3.25 mm; the smallest diameter was identified at L2 and had a mean diameter of 2.05 mm. The largest spinal artery diameter was at L3 (mean, 0.56 mm) and the smallest at L1 (mean, 0.42 mm). The largest anastomotic artery diameter was at L4 (mean, 0.42 mm) and the smallest at L1 (mean, 0.32 mm). For the right and left sides, the mean greatest distance between the origin of the lumbar artery and the tendinous arch was at L4 (mean, 40.9 and 31.8 mm, respectively) and the least at L1 (mean, 31.8 and 22.5 mm, respectively). The mean of the greatest distance between the anastomotic branch and the base of the transverse process of the lumbar vertebrae was at L4 (mean, 4.41 and 4.35 mm, respectively) and the smallest at L1 (mean, 4.04 and 4.08 mm, respectively). CONCLUSION These anatomic findings of the lumbar segmental arteries would be useful for emphasizing their surgical importance.
Collapse
Affiliation(s)
- Mehmet Arslan
- Department of Neurosurgery, Yuzuncu Yıl University, Faculty of Medicine, Van, Turkey
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Relevance of the anatomical location of the Adamkiewicz artery in spine surgery. Surg Radiol Anat 2010; 33:3-9. [DOI: 10.1007/s00276-010-0654-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 03/10/2010] [Indexed: 11/26/2022]
|
20
|
Eleraky MA, Setzer M, Papanastassiou ID, Baaj AA, Tran ND, Katsares KM, Vrionis FD. Role of motor-evoked potential monitoring in conjunction with temporary clipping of spinal nerve roots in posterior thoracic spine tumor surgery. Spine J 2010; 10:396-403. [PMID: 20421074 DOI: 10.1016/j.spinee.2010.02.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 01/19/2010] [Accepted: 02/14/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The vascular supply of the thoracic spinal cord depends on the thoracolumbar segmental arteries. Because of the small size and ventral course of these arteries in relation to the dorsal root ganglion and ventral root, they cannot be reliably identified during surgery by anatomic or morphologic criteria. Sacrificing them will most likely result in paraplegia. PURPOSE The goal of this study was to evaluate a novel method of intraoperative testing of a nerve root's contribution to the blood supply of the thoracic spinal cord. STUDY DESIGN/SETTING This is a clinical retrospective study of 49 patients diagnosed with thoracic spine tumors. Temporary nerve root clipping combined with motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring was performed; additionally, postoperative clinical evaluation was done and reported in all cases. METHODS All cases were monitored by SSEP and MEPs. The nerve root to be sacrificed was temporarily clipped using standard aneurysm clips, and SSEP/MEP were assessed before and after clipping. Four nerve roots were sacrificed in four cases, three nerve roots in eight cases, and two nerve roots in 22 cases. Nerve roots were sacrificed bilaterally in 12 cases. RESULTS Most patients (47/49) had no changes in MEP/SSEP and had no neurological deficit postoperatively. One case of a spinal sarcoma demonstrated changes in MEP after temporary clipping of the left T11 nerve root. The nerve was not sacrificed, and the patient was neurologically intact after surgery. In another case of a sarcoma, MEPs changed in the lower limbs after ligation of left T9 nerve root. It was felt that it was a global event because of anesthesia. Postoperatively, the patient had complete paraplegia but recovered almost completely after 6 months. CONCLUSIONS Temporary nerve root clipping combined with MEP and SSEP monitoring may enhance the impact of neuromonitoring in the intraoperative management of patients with thoracic spine tumors and favorably influence neurological outcome.
Collapse
Affiliation(s)
- Mohammed A Eleraky
- H. Lee Moffitt Cancer Center & Research Institute, NeuroOncology Program, University of South Florida College of Medicine, Tampa, FL 33612, USA
| | | | | | | | | | | | | |
Collapse
|
21
|
Stafa A, Barbara C, Boriani S, Simonetti L, Leonardi M. A Little Talk on Adamkiewicz's Artery. Some Practical Considerations on the Pre-Operative Identification of this Artery Starting from a Single Team Experience in Pre-Surgical Selective Embolization of Vascularized Spinal Lesions. Neuroradiol J 2010; 23:225-33. [PMID: 24148543 DOI: 10.1177/197140091002300213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 03/17/2010] [Indexed: 11/15/2022] Open
Abstract
The major radicular artery eponymically named "Adamkiewicz's artery" (AKA) is an important vessel supplying the spinal cord, especially the lumbar enlargement. This report emphasizes the importance of anatomical knowledge of this artery and highlights the concept of the potential risk of neurological complications during different procedures: spine orthopedic/neurosurgery, aortic repair (vascular surgery) and endovascular selective embolizations performed by interventional neuro/radiologists. Anatomical considerations are made on the spinal cord arterial circulation with a special focus on the AKA. Our review of the literature considered this anatomical element essential to compare the potential risk of spinal cord ischemic damage during orthopedic/neurosurgical spine procedures, aortic vascular surgery repair procedures and endovascular selective arterial embolizations. Evaluation of the endovascular selective arterial spine embolization risk was based on our series of 410 embolization procedures. Spinal cord infarction and transient or permanent paraplegia may result from inadvertent interruption of the AKA. The presence of intersegmental collaterals may decrease the risk of spinal cord ischemia: this is an important element to bear in mind that may help in spine surgery or aortic repair procedures performed by vascular surgeons. Nevertheless, during aortic repair (open surgery or stent-graft procedures) interruption of bilateral segmental arteries at multiple consecutive levels including that of the AKA may occur thereby increasing the ischemic spinal cord risk, annulling the benefit of intersegmental collaterals. Accidental embolizations of the AKA during endovascular spine procedures (i.e. selective arterial embolizations) performed by interventional neuro/radiologists will cause an almost certain spinal cord infarction due to the consequent embolizations of the anterior spinal artery (ASA).
Collapse
Affiliation(s)
- A Stafa
- Neuroradiology Unit, Maggiore Hospital; Bologna, Italy -
| | | | | | | | | |
Collapse
|
22
|
Neurologic injury in the surgical treatment of idiopathic scoliosis: guidelines for assessment and management. J Am Acad Orthop Surg 2009; 17:426-34. [PMID: 19571298 DOI: 10.5435/00124635-200907000-00003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Iatrogenic spinal cord injury resulting from surgical treatment of spinal deformity is a relatively uncommon but devastating complication. Publications on the prevalence of spinal cord injury following surgery are numerous, but no definitive review with clinically pertinent treatment guidelines exists. Methods to reduce the risk of neurologic complications with scoliosis surgery include adequate patient evaluation and preoperative planning, intraoperative preparation, intraoperative neuromonitoring, and postoperative management. Treatment algorithms may be useful in the clinical setting to manage intraoperative or postoperative neurologic injury.
Collapse
|
23
|
Current World Literature. Curr Opin Anaesthesiol 2008; 21:684-93. [DOI: 10.1097/aco.0b013e328312c01b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Multimodality monitoring of the central nervous system using motor-evoked potentials. Curr Opin Anaesthesiol 2008; 21:560-4. [DOI: 10.1097/aco.0b013e32830f1fbd] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|