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Chen AC, Shah HA, Vilaysom S, Ryan C, Kruse A, D'Amico RS, Silverstein JW. Influence of Preoperative Motor Score and Patient Comorbidities on Transcranial Motor-Evoked Potential Acquisition in Intracranial Surgery: A Retrospective Cohort Study. Neurosurgery 2024; 95:842-848. [PMID: 38639495 DOI: 10.1227/neu.0000000000002943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/12/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intraoperative neurophysiological monitoring plays a pivotal role in modern neurosurgery, aiding in real-time assessment of eloquent neural structures to mitigate iatrogenic neural injury. This study represents the largest retrospective series to date in monitoring corticospinal tract integrity during intracranial surgery with transcranial motor-evoked potentials (TCMEPs), focusing on the influence of demographic factors, comorbidities, and preoperative motor deficits on the reliability of intraoperative neurophysiological monitoring. While the impact of patient-specific factors affecting TCMEP monitoring in spine surgery is well-documented, similar insights for intracranial surgery are lacking. METHODS A total of 420 craniotomy patients were retrospectively analyzed from electronic medical records from December 2017 to February 2023, excluding patients without preoperative Medical Research Council scores or medical histories. Using intrinsic hand muscles as a robust data set, 840 hand TCMEPs acquired during intracranial surgery were assessed. Demographic and clinical factors, including preoperative motor scores, were analyzed to identify associations with TCMEP acquisition and amplitude. Nonparametric statistics and multivariate regression analysis were employed. RESULTS TCMEPs were successfully acquired in 734 (87.7%) patient hands, even in the presence of preoperative motor deficits in 13.9% of total patient hands. Preoperative motor scores did not predict the ability to acquire baseline TCMEPs ( P = .6). Notably, older age ( P < .001) and hypertension ( P = .01) were independent predictors of lower TCMEP acquisition rates. Preoperative motor scores significantly influenced TCMEP amplitudes, with higher scores correlating with higher amplitudes (1771 [SD = 1550] eve vs 882 [SD = 856] μV, P < .0001). Older age ( P < .001) and chronic kidney disease ( P = .04) were also associated with reduced TCMEP amplitudes. CONCLUSION Our investigation into TCMEPs during intracranial surgery demonstrated a notably high acquisition rate in hand muscles, irrespective of preoperative motor deficits. Preoperative motor scores reliably correlated with TCMEP amplitudes in a linear fashion while advanced age and renal disease emerged as independent predictors of lower TCMEP amplitudes.
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Affiliation(s)
- Adrian C Chen
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset , New York , USA
| | - Harshal A Shah
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset , New York , USA
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York , New York , USA
| | | | - Casey Ryan
- Neuro Protective Solutions, New York , New York , USA
| | - Aaron Kruse
- Neuro Protective Solutions, New York , New York , USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York , New York , USA
| | - Justin W Silverstein
- Neuro Protective Solutions, New York , New York , USA
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York , New York , USA
- Department of Neurology, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York , New York , USA
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Liu K, Ma C, Li D, Li H, Dong X, Liu B, Yu Y, Fan Y, Song H. The role of intraoperative neurophysiological monitoring in intramedullary spinal cord tumor surgery. Chin Neurosurg J 2023; 9:33. [PMID: 38031178 PMCID: PMC10685460 DOI: 10.1186/s41016-023-00348-x] [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: 08/29/2022] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Intramedullary tumors are a class of central nervous system tumors with an incidence of 2 to 4%. As they are located very deep and frequently cause postoperative neurological complications, surgical resection is difficult. In recent years, many surgeons have performed electrophysiological monitoring to effectively reduce the occurrence of postoperative neurological complications. Modern electrophysiological monitoring technology has advanced considerably, leading to the development of many monitoring methods, such as SSEPs, MEPs, DCM, and EMG, to monitor intramedullary tumors. However, electrophysiological monitoring in tumor resection is still being studied. In this article, we discussed the different monitoring methods and their role in monitoring intramedullary tumors by reviewing previous studies. Intratumorally tumors need to be monitored for a summary of the condition of the patient. Only by using various monitoring methods flexibly and through clear communication between surgeons and neurophysiological experts can good decisions be made during surgery and positive surgical results be achieved.
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Affiliation(s)
- Kai Liu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Chengyuan Ma
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Dapeng Li
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Haisong Li
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Xuechao Dong
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Bo Liu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Ying Yu
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Yuxiang Fan
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China
| | - Hongmei Song
- Department of Neurosurgery, Bethune First Hospital of Jilin University, Changchun, Jilin, China.
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Shimony N, Fehnel K, Abbott IR, Jallo GI. The evolution of spinal cord surgery: history, people, instruments, and results. Childs Nerv Syst 2023; 39:2687-2700. [PMID: 37658937 DOI: 10.1007/s00381-023-06128-3] [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: 08/01/2023] [Accepted: 08/12/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Spinal cord surgery has and always will be a challenging operation with satisfying results, but also with potentially devastating results. Over the last century, there has been an evolution in the way we perceive and conduct spinal cord surgery. The phenomenal evolution in technology from the very first x-ray pictures helps to localize the spinal pathology through the use of high-resolution MRI and ultrasonography that allows for high precision surgery with relatively minimal exposure. METHODS The advancements in the surgical technique and the utilization of neuromonitoring allow for maximal safe resection of these delicate and intricate tumors. We also are beginning to understand the biology of spinal cord tumors and vascular lesions, as in the recent 2021 WHO classification which identifies specific entities such as spinal ependymomas, MYCN-amplified, as separate entity from the other subtypes of ependymomas. Surgeons have also accepted the importance of maximal safe resection for most of the spinal cord pathologies rather than just performing biopsy and adjuvant treatment. CONCLUSION There have been significant advances since the first resection of an intramedullary tumor including diagnosis, imaging, and surgical technique for children. These advances have improved the prognosis and outcome in these children.
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Affiliation(s)
- Nir Shimony
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
- Semmes-Murphey Clinic, Memphis, TN, USA
| | - Katie Fehnel
- Department of Neurological Surgery, Harvard Medical School, Boston, MA, USA
- Department of Neurological Surgery, Dana Farber Institute, Boston Children's Hospital, Boston, MA, USA
| | - I Rick Abbott
- Division of Pediatric Neurosurgery, Albert Einstein College of Medicine, New York, NY, USA
| | - George I Jallo
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, 600 5Th Street South, St Petersburg, FL, 33701, USA.
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Siller S, Sixta A, Tonn JC, Szelenyi A. Feasibility of multimodal intraoperative neurophysiological monitoring for extramedullary spinal cord tumor surgery in elderly patients. Acta Neurochir (Wien) 2023; 165:2089-2099. [PMID: 37355475 PMCID: PMC10409671 DOI: 10.1007/s00701-023-05682-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/13/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND/PURPOSE Extramedullary spinal cord tumors (EMSCTs) are mostly benign tumors which are increasingly diagnosed and operatively treated in the elderly. While there are hints that multimodal intraoperative neurophysiological monitoring (IONM) could be influenced by age and age-related comorbidities, no study has ever systematically evaluated its feasibility and value for EMSCT surgery in elderly patients. METHODS We retrospectively evaluated all patients with microsurgical EMSCT resection under continuous multimodal IONM with SSEPs, MEPs and electromyography between 2016 and 2020. Epidemiological, clinical, imaging and operative/IONM records as well as detailed individual outcomes were analyzed and compared for the cohort < / ≥ 65 years. RESULTS Mean age was 45 years in cohort < 65 years (n = 109) and 76 years in cohort ≥ 65 years (n = 64), while baseline/operative characteristics did not significantly differ. Mean baseline SSEPs' latencies (left-right average) were significantly higher in the cohort ≥ 65 years for both median (20.9 ms vs. 22.1 ms; p < 0.01) and tibial nerve (42.9 ms vs. 46.1 ms; p < 0.01) without significant differences for SSEPs' amplitudes. Stimulation intensity to elicit intraoperative MEPs was significantly higher in the cohort ≥ 65 years (surrogate-marker: left-right-averaged quotient ID1-muscle/abductor-hallucis-muscle; 1.6 vs. 2.1; p < 0.001). Intraoperatively, SSEP and MEP monitoring were feasible in 99%/100% and 99%/98% for the cohort < / ≥ 65 years without significant differences in rates for significant IONM changes during surgery or postoperatively new sensorimotor deficits. Sensitivity of IONM was 29%/43%, specificity 99%/98%, positive and negative predictive values 67%/75% and 95%/93% for the cohort < / ≥ 65 years. Overall, age was no risk factor for IONM feasibility or rate of significant IONM changes. DISCUSSION Multimodal IONM is feasible/reliable for EMSCT surgery in elderly patients. An age-related prolongation of SSEPs' latencies and demand for higher stimulation intensities for MEPs' elicitation has to be considered.
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Affiliation(s)
- Sebastian Siller
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Akela Sixta
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Andrea Szelenyi
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Yamada S, Kawajiri S, Arishma H, Isozaki M, Yamauchi T, Akazawa A, Kidoguchi M, Kodera T, Shibaike Y, Umeda H, Tsukinowa Y, Hagihara R, Kikuta K. Prediction of Post-operative Long-Term Outcome of the Motor Function by Multimodal Intraoperative Neuromonitoring With Transcranial Motor-Evoked Potential and Spinal Cord-Evoked Potential After Microsurgical Resection for Spinal Cord Tumors. Front Surg 2022; 9:883832. [PMID: 35599809 PMCID: PMC9114470 DOI: 10.3389/fsurg.2022.883832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo examine the effect of multimodal intraoperative neuromonitoring on the long-term outcome of motor function after microsurgical resection for spinal cord tumors.Materials and MethodsConsecutive fourteen patients with spinal tumors who were surgically treated at the University of Fukui Hospital between 2009 and 2020 [M:F = 10:4, ages ranging from 22 to 83 years (mean ± SD = 58 ± 21 years)] were included in this study. There were eight intra-axial tumors and six extra-axial tumors. There were four patients with hypertension, two patients with diabetes mellitus, and four patients with hyperlipidemia. Three patients were under antithrombotic medication, two were under steroid medication, four were current smokers, and four were current drinkers. Manual muscle test (MMT) of the upper and lower extremities of the patients was examined before surgery, 2 weeks after surgery, and at the final follow-up. The mean follow-up period was 38 ± 37 months. McCormick scores were examined before surgery and at the final follow-up. Microsurgical resection of the tumor was underwent through the posterior approach under transcranial motor-evoked potential (TcMEP) monitoring. The MEP of 46 extremities was recorded during the surgery. Gross total resection was achieved in 13 of 14 surgeries. Spinal cord-evoked potential (Sp-SCEP) monitoring was performed in eight of 14 patients.ResultsThe length of peritumoral edema was significantly longer in patients with deterioration of McCormick scores than in patients with preservation of McCormick scores (p = 0.0274). Sp-SCEP could not predict the deterioration. The ratio of MEP at the beginning of the surgery to that at the end of the surgery was the only significant negative factor that predicts deterioration of motor function of the extremity at the final follow-up (p = 0.0374, odds ratio [OR] 1.02E-05, 95% CI 9.13E+01–7.15E+18). A receiver operating characteristic (ROC) analysis revealed that the cutoff value of the ratio of MEP to predict the deterioration at the final follow-up was 0.23 (specificity 100%, specificity 88%, positive predictive value 100%, and negative predictive value 88%) to predict deterioration at the final follow-up.ConclusionsRatio MEP was the most significant negative factor to predict the deterioration of motor weakness at spinal tumor surgery. The setting of the cutoff value should be more strict as compared to the brain surgery and might be different depending on the institutions.
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Feasibility and diagnostic accuracy of intra-operative monitoring of motor evoked potentials in children <2 years of age undergoing tethered cord surgery: results in 100 children. Childs Nerv Syst 2021; 37:2289-2298. [PMID: 33763733 DOI: 10.1007/s00381-021-05128-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study documents the monitorability using different anesthesia regimes and accuracy of muscle motor evoked potentials (mMEPs) in children ≤2 years of age undergoing tethered cord surgery (TCS). METHODS Intraoperative mMEP monitoring was attempted in 100 consecutive children, ≤2 years of age, undergoing TCS. MEP monitoring was done under 4 different anesthetic regimes: (Total intravenous anesthesia (TIVA); balanced anesthesia with sevoflurane and ketamine; balanced anesthesia with isoflurane and ketamine; and balanced anesthesia with sevoflurane). Factors analyzed for their effect on monitorability were: age, neurological deficits, type of anesthesia, and the number of pulses used for stimulation. RESULTS Baseline mMEPs were obtained in 87% children. Monitorability of mMEPs was similar in children ≤1 year and 1-2 years of age (85.7% and 87.5%). In multivariate analysis, anesthesia regime was the only significant factor predicting presence of baseline mMEPs. Children undergoing TIVA (p=0.02) or balanced anesthesia with a combination of propofol, sevoflurane, and ketamine (p=0.05) were most likely to have baseline mMEPs. mMEPs had a sensitivity of 97.4%, specificity of 96.4%, negative predictive value of 98.2% and accuracy of 96.8%. CONCLUSIONS Baseline mMEPs were obtained in >85% of children ≤2 years of age including those who had motor deficits. TIVA and balanced anesthesia with sevoflurane and ketamine are ideal for mMEP monitoring. mMEPs have a high accuracy although, false positive and false negative results can occasionally be experienced.
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Ushirozako H, Yoshida G, Imagama S, Kobayashi K, Ando K, Ando M, Kawabata S, Yamada K, Kanchiku T, Fujiwara Y, Taniguchi S, Iwasaki H, Shigematsu H, Tadokoro N, Takahashi M, Wada K, Yamamoto N, Funaba M, Yasuda A, Hashimoto J, Morito S, Takatani T, Tani T, Matsuyama Y. Efficacy of Transcranial Motor Evoked Potential Monitoring During Intra- and Extramedullary Spinal Cord Tumor Surgery: A Prospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Global Spine J 2021; 13:961-969. [PMID: 34011196 DOI: 10.1177/21925682211011443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Multicenter prospective study. OBJECTIVES Although intramedullary spinal cord tumor (IMSCT) and extramedullary SCT (EMSCT) surgeries carry high risk of intraoperative motor deficits (MDs), the benefits of transcranial motor evoked potential (TcMEP) monitoring are well-accepted; however, comparisons have not yet been conducted. This study aimed to clarify the efficacy of TcMEP monitoring during IMSCT and EMSCT resection surgeries. METHODS We prospectively reviewed TcMEP monitoring data of 81 consecutive IMSCT and 347 EMSCT patients. We compared the efficacy of interventions based on TcMEP alerts in the IMSCT and EMSCT groups. We defined our alert point as a TcMEP amplitude reduction of ≥70% from baseline. RESULTS In the IMSCT group, TcMEP monitoring revealed 20 true-positive (25%), 8 rescue (10%; rescue rate 29%), 10 false-positive, a false-negative, and 41 true-negative patients, resulting in a sensitivity of 95% and a specificity of 80%. In the EMSCT group, TcMEP monitoring revealed 20 true-positive (6%), 24 rescue (7%; rescue rate 55%), 29 false-positive, 2 false-negative, and 263 true-negative patients, resulting in a sensitivity of 91% and specificity of 90%. The most common TcMEP alert timing was during tumor resection (96% vs. 91%), and suspension surgeries with or without intravenous steroid administration were performed as intervention techniques. CONCLUSIONS Postoperative MD rates in IMSCT and EMSCT surgeries using TcMEP monitoring were 25% and 6%, and rescue rates were 29% and 55%. We believe that the usage of TcMEP monitoring and appropriate intervention techniques during SCT surgeries might have predicted and prevented the occurrence of intraoperative MDs.
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Affiliation(s)
- Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Muneharu Ando
- Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan
| | - Shigenori Kawabata
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kei Yamada
- Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Tsukasa Kanchiku
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan
| | - Yasushi Fujiwara
- Department of Orthopedic Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | | | - Hiroshi Iwasaki
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama, Japan
| | - Hideki Shigematsu
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Nobuaki Tadokoro
- Department of Orthopedic Surgery, Kochi University, Kochi, Japan
| | | | - Kanichiro Wada
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Naoya Yamamoto
- Department of Orthopedic Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University, Yamaguchi, Japan
| | - Akimasa Yasuda
- Department of Orthopedic Surgery, National Defense Medical College Hospital, Saitama, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinji Morito
- Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, Nara, Japan
| | - Toshikazu Tani
- Department of Orthopedic Surgery, Kubokawa Hospital, Kochi, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Early- and long-term surgical outcomes in 109 children with lipomyelomeningocele. Childs Nerv Syst 2021; 37:1623-1632. [PMID: 33404713 DOI: 10.1007/s00381-020-05000-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
AIM To determine the functional outcomes and risk factors for outcomes following surgery for lipomyelomeningocele (LMMC). METHODS Data from 109 children with LMMC who underwent surgery from January 2008 to December 2017 were retrospectively studied to evaluate functional outcomes and possible risk factors for early- (at discharge from hospital or within 1 month of surgery) and long-term outcomes after surgery. RESULTS There were 53 boys and 56 girls with median age of 36 months (IQR 12-90 months; range, 4 months to 18 years) at surgery. At presentation, neurological function was normal (asymptomatic group) in 28 (25.7%) children while there was neurological dysfunction (symptomatic group) in 81 (74.3%). Near total or radical excision of lipoma was done in 71 (65.1%) children. Six (5.8%) children had deterioration of neurological function in the post-operative period with recovery of function in three of them. There were no statistically significant risk factors for early outcomes. At a mean follow-up of 62.5 months (IQR 35-82 months; range, 12-146 months), 21 (27.6%) of the 76 symptomatic group children (including 59.3% with incomplete bladder dysfunction) showed improvement, 52 (68.4%) remained the same, while 3 (4%) deteriorated. In 31 children (symptomatic group) who developed symptoms after 1 year of age, early surgery after development of symptoms was associated with better chances of recovery (p = 0.0008). In the asymptomatic group, 23 (88.5%) had normal neurological function at mean follow-up of 57.5 months (IQR 30-77 months; range, 12-141 months) and 3 (11.5%) had neurological deterioration. The mean time to late deterioration (re-tethering) from surgery was 51.3 months (IQR 24-75 months; range, 24-84 months). Presence of syrinx on initial MRI (p = 0.008) and partial resection of the lipoma (p = 0.02) were independent risk factors for delayed deterioration. CONCLUSION Radical resection of LMMC probably helps in preserving neurological function in > 90% of children at long-term follow-up. Fifty-five percent of children > 2 years of age with incomplete bladder dysfunction regained normal function following surgery. In children who develop symptoms after birth, early surgical intervention can reverse the neurological deficits.
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Shim HK, Lee JM, Kim DH, Nam KH, Choi BK, Han IH. Successful Motor Evoked Potential Monitoring in Cervical Myelopathy : Related Factors and the Effect of Increased Stimulation Intensity. J Korean Neurosurg Soc 2020; 64:78-87. [PMID: 33355842 PMCID: PMC7819792 DOI: 10.3340/jkns.2020.0111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Intraoperative neurophysiological monitoring (IONM) has been widely used during spine surgery to reduce or prevent neurologic deficits, however, its application to the surgical management for cervical myelopathy remains controversial. This study aimed to assess the success rate of IONM in patients with cervical myelopathy and to investigate the factors associated with successful baseline monitoring and the effect of increasing the stimulation intensity by focusing on motor evoked potentials (MEPs).
Methods The data of 88 patients who underwent surgery for cervical myelopathy with IONM between January 2016 and June 2018 were retrospectively reviewed. The success rate of baseline MEP monitoring at the initial stimulation of 400 V was investigated. In unmonitorable cases, the stimulation intensity was increased to 999 V, and the success rate final MEP monitoring was reinvestigated. In addition, factors related to the success rate of baseline MEP monitoring were investigated using independent t-test, Wilcoxon rank-sum test, chi-squared test, and Fisher’s exact probability test for statistical analysis. The factors included age, sex, body mass index, diabetes mellitus, smoking history, symptom duration, Torg-Pavlov ratio, space available for the cord (SAC), cord compression ratio (CCR), intramedullary increased signal intensity (SI) on magnetic resonance imaging, SI length, SI ratio, the Medical Research Council (MRC) grade, the preoperative modified Nurick grade and Japanese Orthopedic Association (JOA) score.
Results The overall success rate for reliable MEP response was 52.3% after increasing the stimulation intensity. No complications were observed to be associated with increased intensity. The factors related to the success rate of final MEP monitoring were found to be SAC (p<0.001), CCR (p<0.001), MRC grade (p<0.001), preoperative modified Nurick grade (p<0.001), and JOA score (p<0.001). The cut-off score for successful MEP monitoring was 5.67 mm for SAC, 47.33% for the CCR, 3 points for MRC grade, 2 points for the modified Nurick grade, and 12 points for the JOA score.
Conclusion Increasing the stimulation intensity could significantly improve the success rate of baseline MEP monitoring for unmonitorable cases at the initial stimulation in cervical myelopathy. In particular, the SAC, CCR, MRC grade, preoperative Nurick grade and JOA score may be considered as the more important related factors associated with the success rate of MEP monitoring. Therefore, the degree of preoperative neurological functional deficits and the presence of spinal cord compression on imaging could be used as new detailed criteria for the application of IONM in patients with cervical myelopathy.
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Affiliation(s)
- Hyok Ki Shim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Meen Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Hwan Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Kwan Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - In Ho Han
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Kurokawa R, Kim P, Itoki K, Yamamoto S, Shingo T, Kawamoto T, Kawamoto S. False-Positive and False-Negative Results of Motor Evoked Potential Monitoring During Surgery for Intramedullary Spinal Cord Tumors. Oper Neurosurg (Hagerstown) 2019; 14:279-287. [PMID: 29462450 DOI: 10.1093/ons/opx113] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 04/12/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Motor evoked potential (MEP) recording is used as a method to monitor integrity of the motor system during surgery for intramedullary tumors (IMTs). Reliable sensitivity of the monitoring in predicting functional deterioration has been reported. However, we observed false positives and false negatives in our experience of 250 surgeries of IMTs. OBJECTIVE To delineate specificity and sensitivity of MEP monitoring and to elucidate its limitations and usefulness. METHODS From 2008 to 2011, 58 patients underwent 62 surgeries for IMTs. MEP monitoring was performed in 59 operations using transcranial electrical stimulation. Correlation with changes in muscle strength and locomotion was analyzed. A group undergoing clipping for unruptured aneurysms was compared for elicitation of MEP. RESULTS Of 212 muscles monitored in the 59 operations, MEP was recorded in 150 (71%). Positive MEP warnings, defined as amplitude decrease below 20% of the initial level, occurred in 37 muscles, but 22 of these (59%) did not have postoperative weakness (false positive). Positive predictive value was limited to 0.41. Of 113 muscles with no MEP warnings, 8 muscles developed postoperative weakness (false negative, 7%). Negative predictive value was 0.93. MEP responses were not elicited in 58 muscles (27%). By contrast, during clipping for unruptured aneurysms, MEP was recorded in 216 of 222 muscles (96%). CONCLUSION MEP monitoring has a limitation in predicting postoperative weakness in surgery for IMTs. False-positive and false-negative indices were abundant, with sensitivity and specificity of 0.65 and 0.83 in predicting postoperative weakness.
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Affiliation(s)
- Ryu Kurokawa
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Phyo Kim
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Kazushige Itoki
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Shinji Yamamoto
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Tetsuro Shingo
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Toshiki Kawamoto
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
| | - Shunsuke Kawamoto
- Department of Neurologic Surgery, Dok-kyo University Hospital, Mibu, Tochigi, Japan
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Rijs K, Klimek M, Scheltens-de Boer M, Biesheuvel K, Harhangi BS. Intraoperative Neuromonitoring in Patients with Intramedullary Spinal Cord Tumor: A Systematic Review, Meta-Analysis, and Case Series. World Neurosurg 2019; 125:498-510.e2. [DOI: 10.1016/j.wneu.2019.01.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/01/2019] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
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Park JH, Lee SH, Kim ES, Eoh W. Analysis of Multimodal Intraoperative Monitoring During Intramedullary Spinal Ependymoma Surgery. World Neurosurg 2018; 120:e169-e180. [DOI: 10.1016/j.wneu.2018.07.267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/29/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022]
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Kim JS, Jang MJ, Hyun SJ, Kim KJ, Jahng TA, Kim HJ, Kim SM, Park KS. Failure to generate baseline muscle motor evoked potentials during spine surgery: Risk factors and association with the postoperative outcomes. Clin Neurophysiol 2018; 129:2276-2283. [DOI: 10.1016/j.clinph.2018.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/20/2018] [Accepted: 08/01/2018] [Indexed: 12/01/2022]
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Umemura T, Nishizawa S, Nakano Y, Saito T, Kitagawa T, Miyaoka R, Suzuki K, Yamamoto J. Intraoperative monitoring of motor-evoked potential for parenchymal brain tumor removal: An analysis of false-negative cases. J Clin Neurosci 2018; 57:105-110. [PMID: 30145081 DOI: 10.1016/j.jocn.2018.08.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 07/05/2018] [Accepted: 08/12/2018] [Indexed: 11/18/2022]
Abstract
Transcranial motor-evoked potential (tc-MEP) monitoring is unreliable for brain tumor removal due to its low sensitivity. According to previous literature, this is because transcranial stimulation seems to reach the deep pyramidal tract beyond the operation point and may thus yield false-negative results, where, although MEP recording is stable, postoperative motor deficits are encountered. Therefore, we aimed to analyze the causes for the false-negative results and investigate whether decreasing the stimulation intensity better reflects the operation point and can improve the sensitivity during parenchymal brain tumor removal. We assessed 122 patients with parenchymal brain and intraventricular tumors, who underwent surgery under tc-MEP monitoring in our hospital between 2011 and 2014. In these patients, the stimulation intensity was fixed at 200 mA. We detected 11 false-negative cases, while the sensitivity of tc-MEP monitoring was 33.9% and the specificity was 99.0%. Between 2015 and 2016, we examined 68 patients with parenchymal brain tumors, in whom the stimulation intensity was reduced to an average of 136.5 mA. Only one case was false-negative, while the sensitivity increased to 83.3% and the specificity was 98.4%. From these results, we conclude that the intensity of tc-MEP stimulation should be minimal to precisely reflect the damage to the operated location. Tc-MEP can be an easy and reliable monitor in brain tumor surgery when used at proper, lower intensity.
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Affiliation(s)
- Takeru Umemura
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan.
| | - Shigeru Nishizawa
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Yoshiteru Nakano
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Takeshi Saito
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Takehiro Kitagawa
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Ryo Miyaoka
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Kohei Suzuki
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Junkoh Yamamoto
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
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Transcranial Motor Evoked Potential Alarm Criteria to Predict Foot Drop Injury During Lumbosacral Surgery. Spine (Phila Pa 1976) 2018; 43:E227-E233. [PMID: 28614281 DOI: 10.1097/brs.0000000000002288] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort analysis. OBJECTIVE This study aims to investigate whether waveform alterations in transcranial motor evoked potentials (TCMEPs) can reliably predict postoperative foot drop. SUMMARY OF BACKGROUND DATA Nerve injury leading to foot drop is a potential complication of lumbosacral surgery. Very limited data exist on the use of intraoperative TCMEPs to identify iatrogenic foot drop. METHODS We retrospectively reviewed neuromonitoring data from 130 consecutive spine surgeries with instrumentation involving L4-S1. TCMEP waveform analysis included amplitude (A), area under the curve (AUC), latency (L), and duration (D). Patient outcomes were correlated with neuromonitoring results. Intraoperative alert criteria were established on the basis of observed intraoperative changes. RESULTS Three patients developed severe foot drop with a muscle weakness functional grade ranging from 0/5 to 3/5. Two patients developed a mild foot drop with functional grade 4/5. Twenty-three patients had preoperative weakness in an L5 distribution. One-hundred two patients who had neither preoperative nor postoperative neurological complications served as a control group. Amplitude significantly decreased in patients with a severe postoperative deficit (P = 0.005) as did AUC and duration (P < 0.05). Intraoperative alert criteria defined as a >65% decrease in AUC resulted in a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100%, 91.4%, 12%, and 100%, respectively. When defining an alert criteria as a >50% decrease in amplitude, sensitivity, specificity, PPV, and NPV were 100%, 87.9%, 8.8%, and 100%, respectively. CONCLUSION Reduction of TCMEP waveform associated with postoperative severe foot drop can be detected during lumbar surgery. Other waveform parameters such as AUC may predict foot drop better than the amplitude. Additional examinations in larger samples of foot drops are needed to validate these alert threshold findings. LEVEL OF EVIDENCE 4.
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Scibilia A, Terranova C, Rizzo V, Raffa G, Morelli A, Esposito F, Mallamace R, Buda G, Conti A, Quartarone A, Germanò A. Intraoperative neurophysiological mapping and monitoring in spinal tumor surgery: sirens or indispensable tools? Neurosurg Focus 2017; 41:E18. [PMID: 27476842 DOI: 10.3171/2016.5.focus16141] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal tumor (ST) surgery carries the risk of new neurological deficits in the postoperative period. Intraoperative neurophysiological monitoring and mapping (IONM) represents an effective method of identifying and monitoring in real time the functional integrity of both the spinal cord (SC) and the nerve roots (NRs). Despite consensus favoring the use of IONM in ST surgery, in this era of evidence-based medicine, there is still a need to demonstrate the effective role of IONM in ST surgery in achieving an oncological cure, optimizing patient safety, and considering medicolegal aspects. Thus, neurosurgeons are asked to establish which techniques are considered indispensable. In the present study, the authors focused on the rationale for and the accuracy (sensitivity, specificity, and positive and negative predictive values) of IONM in ST surgery in light of more recent evidence in the literature, with specific emphasis on the role of IONM in reducing the incidence of postoperative neurological deficits. This review confirms the role of IONM as a useful tool in the workup for ST surgery. Individual monitoring and mapping techniques are clearly not sufficient to account for the complex function of the SC and NRs. Conversely, multimodal IONM is highly sensitive and specific for anticipating neurological injury during ST surgery and represents an important tool for preserving neuronal structures and achieving an optimal postoperative functional outcome.
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Affiliation(s)
| | | | | | - Giovanni Raffa
- Divisions of 1 Neurosurgery.,Department of Clinical and Experimental Medicine, University of Messina, Italy
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Kim DG, Jo SR, Park YS, Hyun SJ, Kim KJ, Jahng TA, Kim HJ, Park KS. Multi-channel motor evoked potential monitoring during anterior cervical discectomy and fusion. Clin Neurophysiol Pract 2017; 2:48-53. [PMID: 30214970 PMCID: PMC6123893 DOI: 10.1016/j.cnp.2016.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 10/27/2022] Open
Abstract
Objectives Anterior cervical discectomy and fusion (ACDF) surgery is the most common surgical procedure for the cervical spine with low complication rate. Despite the potential prognostic benefit, intraoperative neurophysiological monitoring (IONM), a method for detecting impending neurological compromise, is not routinely used in ACDF surgery. The present study aimed to identify the potential benefits of monitoring multi-channel motor evoked potentials (MEPs) during ACDF surgery. Methods We retrospectively reviewed 200 consecutive patients who received IONM with multi-channel MEPs and somatosensory evoked potentials (SSEPs). On average, 9.2 muscles per patient were evaluated under MEP monitoring. Results The rate of MEP change during surgery in the multi-level ACDF group was significantly higher than the single-level group. Two patients from the single-level ACDF group (1.7%) and four patients from the multi-level ACDF group (4.9%) experienced post-operative motor deficits. Multi-channel MEPs monitoring during single and multi-level ACDF surgery demonstrated higher sensitivity, specificity, positive predictive and negative predictive value than SSEP monitoring. Conclusions Multi-channel MEP monitoring might be beneficial for the detection of segmental injury as well as long tract injury during single- and multi-level ACDF surgery. Significance This is first large scale study to identify the usefulness of multi-channel MEPs in monitoring ACDF surgery.
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Affiliation(s)
- Dong-Gun Kim
- Department of Neurology, Myung Diagnostic Radiology Clinic, Seoul, Republic of Korea
| | - Seong-Rae Jo
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Seop Park
- Department of Neurosurgery, Spine Center, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Gyeongnam, Republic of Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Verla T, Fridley JS, Khan AB, Mayer RR, Omeis I. Neuromonitoring for Intramedullary Spinal Cord Tumor Surgery. World Neurosurg 2016; 95:108-116. [DOI: 10.1016/j.wneu.2016.07.066] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
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Influence of Tumor Location and Other Variables on Predictive Value of Intraoperative myogenic Motor-Evoked Potentials in Spinal Cord Tumor Surgery. World Neurosurg 2016; 92:264-272. [DOI: 10.1016/j.wneu.2016.04.117] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/27/2016] [Accepted: 04/27/2016] [Indexed: 11/21/2022]
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Lee JM, Kim DH, Kim HS, Choi BK, Han IH. The Applicability of Intraoperative Neuromonitoring in Patients with Preoperative Motor Weakness during Spine Surgery. KOREAN JOURNAL OF SPINE 2016; 13:9-12. [PMID: 27123024 PMCID: PMC4844661 DOI: 10.14245/kjs.2016.13.1.9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of our study is to evaluate the success rate and feasibility of intraoperative neuromonitoring (IONM) focusing on transcranial motor evoked potential (TcMEP) monitoring for patients with preoperative motor weakness in spine surgery. METHODS Between November 2011 and December 2013, TcMEP and somatosensory evoked potential (SSEP) monitoring were attempted in 130 consecutive patients undergoing spine surgeries for cervical or thoracic cord lesions. Patients ranged in age from 14 to 81 years (mean±standard deviation, 56.7±14.8 years), and 84 patients were male. The success rates of both SSEP and MEPs monitoring were assessed according to the preoperative Medical Research Council (MRC) and Nurick grades. RESULTS TcMEP was recorded successfully in 0%, 28.6%, 72.3%, and 100% of patients with MRC grades 1, 2, 3, 4, and 5, respectively. SSEP was obtained from 0%, 37.5%, 21.5%, 61.4%, and 85.4% of patients with MRC grades 1, 2, 3, 4, and 5, respectively. TcMEP was recorded successfully in 84% of patients with Nurick grades 1-3 and 26% of patients with Nurick grades 4-5. SSEPs were recorded successfully in 76.3% of patients with Nurick grades 1-3 and 24% of patients with grades 4-5. CONCLUSION IONM during spine surgery may be useless in patients with MRC grades 1-2, applicable MRC grade 3, and useful MRC grades 4-5. MRC grade 3 is a critical point of indication for application of MEPs. In unmonitorable cases with MRC grade 3, increasing stimulus intensity or facilitation techniques may be considered to improve the usefulness of TcMEP.
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Affiliation(s)
- Jae Meen Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hwan Kim
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Hwan Soo Kim
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Byung Kwan Choi
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - In Ho Han
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
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Girishan S, Rajshekhar V. Rapid-onset paraparesis and quadriparesis in patients with intramedullary spinal dermoid cysts: report of 10 cases. J Neurosurg Pediatr 2016; 17:86-93. [PMID: 26431244 DOI: 10.3171/2015.5.peds1537] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intramedullary dermoid cysts are rare tumors of the spinal cord. Presentation with rapid onset of paraparesis or quadriparesis (onset within 2 weeks) is rarer still. The authors present their experience in the management and outcome of patients with such a presentation. METHODS Patient records between 2000 and 2014 were retrospectively reviewed to identify those with intraspinal dermoid cysts who presented with rapid-onset paraparesis or quadriparesis. Their clinical, radiological, operative, and follow-up data were analyzed. RESULTS Of a total of 50 patients with intraspinal dermoid cysts managed during the study period, 10 (20%) presented with rapid-onset paraparesis or quadriparesis; 9 patients ranged in age from 8 months to 2 years, and 1 patient was 25 years old. A dermal sinus was seen in the lumbar region of 4 patients, the sacral region of 3, and the thoracic region of 1, and in 1 patient no sinus was found. All except 1 patient presented with rapid-onset paraparesis secondary to infection of the intramedullary dermoid cyst. One patient presented with rupture of a dermoid cyst with extension into the central canal up to the medulla. Early surgery was done soon after presentation in all except 2 patients. Among the 9 patients who underwent surgery (1 patient did not undergo surgery), total excision of the intramedullary dermoid cyst was done in 3 patients, near-total excision in 4 patients, and partial excision in 2 patients. Of the 9 patients who underwent surgery, 8 showed significant improvement in their neurological status, and 1 patient remained stable. The 1 patient who did not undergo surgery died as a result of an uncontrolled infection after being discharged to a local facility for management of wound infection. CONCLUSIONS Early recognition of a dermal sinus and the associated intraspinal dermoid cyst and timely surgical intervention can eliminate the chances of acute deterioration of neurological function. Even after an acute onset of paraparesis or quadriparesis, appropriate antibiotic therapy and prompt surgery can provide reasonably good outcomes in these patients.
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Affiliation(s)
- Shabari Girishan
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, India
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Takami T, Naito K, Yamagata T, Ohata K. Surgical management of spinal intramedullary tumors: radical and safe strategy for benign tumors. Neurol Med Chir (Tokyo) 2015; 55:317-27. [PMID: 25797779 PMCID: PMC4628179 DOI: 10.2176/nmc.ra.2014-0344] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Surgery for spinal intramedullary tumors remains one of the major challenges for neurosurgeons, due to their relative infrequency, unknown natural history, and surgical difficulty. We are sure that safe and precise resection of spinal intramedullary tumors, particularly encapsulated benign tumors, can result in acceptable or satisfactory postoperative outcomes. General surgical concepts and strategies, technical consideration, and functional outcomes after surgery are discussed with illustrative cases of spinal intramedullary benign tumors such as ependymoma, cavernous malformation, and hemangioblastoma. Selection of a posterior median sulcus, posterolateral sulcus, or direct transpial approach was determined based on the preoperative imaging diagnosis and careful inspection of the spinal cord surface. Tumor-cord interface was meticulously delineated in cases of benign encapsulated tumors. Our retrospective functional analysis of 24 consecutive cases of spinal intramedullary ependymoma followed for at least 6 months postoperatively demonstrated a mean grade on the modified McCormick functional schema of 1.8 before surgery, deteriorating significantly to 2.6 early after surgery (< 1 month after surgery), and finally returning to 1.7 in the late postoperative period (> 6 months after surgery). The risk of functional deterioration after surgery should be taken into serious consideration. Functional deterioration after surgery, including neuropathic pain even long after surgery, significantly affects patient quality of life. Better balance between tumor control and functional preservation can be achieved not only by the surgical technique or expertise, but also by intraoperative neurophysiological monitoring, vascular image guidance, and postoperative supportive care. Quality of life after surgery should inarguably be given top priority.
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Affiliation(s)
- Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine
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Pratheesh R, Babu KS, Rajshekhar V. Improvement in intraoperative transcranial electrical motor-evoked potentials in tethered cord surgery: an analysis of 45 cases. Acta Neurochir (Wien) 2014; 156:723-31. [PMID: 24452593 DOI: 10.1007/s00701-014-1999-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 01/09/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Improvement of transcranial electrical motor-evoked potentials (TeMEPs) following untethering during tethered cord surgery (TCS) and its clinical significance have not been analyzed in the literature. METHODS Forty-five consecutive cases of tethered cord were operated on with multimodality intraoperative neurophysiological monitoring (IONM) between February 2005 and January 2012. Intraoperative TeMEP change was classified as improvement, worsening or no change. Motor, sensory, bladder and bowel symptoms and signs were evaluated preoperatively, in the first week post-surgery and at the last follow-up (maximum of 2 years). RESULTS Patient age ranged from 5 to 44 years (mean, 16 ± 10 years), with 30 children. Intraoperative MEPs improved in 23 (51 %), remained the same in 21 (46.7 %) and worsened in 1 (2 %) patient. Motor improvement occurred in 7 patients and clinical improvement in 17 patients in the immediate postoperative period. Postoperative neurological worsening occurred in one patient (2.2 %). Improved and stable MEPs correlated with the motor (p = 0.002) and clinical improvement (p = 0.02) in the immediate postoperative period. Follow-up was available in 35 patients (77.7 %), ranging from 5 to 24 months (median, 21 months; mean, 17.7 ± 6.8 months). There was late clinical improvement in 73.5 % of the patients in whom the intraoperative MEP had remained the same or improved. However, there was no statistically significant correlation between MEP change and long-term outcome. CONCLUSIONS Intraoperative MEP improvement occurs in about 50 % of the patients following successful untethering. This finding probably provides support to the ischemic theory of tethered cord syndrome.
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Affiliation(s)
- Ravindran Pratheesh
- Department of Neurological Sciences, Christian Medical College, Vellore, 632004, India
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