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Silverstein JW, Block J, Olmsted ZT, Green R, Pieters T, Babarevech K, Ballas-Williamson A, Skinner SA, Sciubba DM, Larry Lo SF. Intraoperative Monitoring of the External Urethral Sphincter Reflex: A Novel Adjunct to Bulbocavernosus Reflex Neuromonitoring for Protecting the Sacral Neural Pathways Responsible for Urination, Defecation and Sexual Function. J Clin Neurophysiol 2024; 41:558-564. [PMID: 37963332 DOI: 10.1097/wnp.0000000000001019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
PURPOSE Intraoperative bulbocavernosus reflex neuromonitoring has been utilized to protect bowel, bladder, and sexual function, providing a continuous functional assessment of the somatic sacral nervous system during surgeries where it is at risk. Bulbocavernosus reflex data may also provide additional functional insight, including an evaluation for spinal shock, distinguishing upper versus lower motor neuron injury (conus vs. cauda syndromes) and prognosis for postoperative bowel and bladder function. Continuous intraoperative bulbocavernosus reflex monitoring has been utilized to provide the surgeon with an ongoing functional assessment of the anatomical elements involved in the S2-S4 mediated reflex arc including the conus, cauda equina and pudendal nerves. Intraoperative bulbocavernosus reflex monitoring typically includes the electrical activation of the dorsal nerves of the genitals to initiate the afferent component of the reflex, followed by recording the resulting muscle response using needle electromyography recordings from the external anal sphincter. METHODS Herein we describe a complementary and novel technique that includes recording electromyography responses from the external urethral sphincter to monitor the external urethral sphincter reflex. Specialized foley catheters embedded with recording electrodes have recently become commercially available that provide the ability to perform intraoperative external urethral sphincter muscle recordings. RESULTS We describe technical details and the potential utility of incorporating external urethral sphincter reflex recordings into existing sacral neuromonitoring paradigms to provide redundant yet complementary data streams. CONCLUSIONS We present two illustrative neurosurgical oncology cases to demonstrate the utility of the external urethral sphincter reflex technique in the setting of the necessary surgical sacrifice of sacral nerve roots.
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Affiliation(s)
- Justin W Silverstein
- Department of Neurology, North Shore University Hospital/ Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, New York, U.S.A
| | - Jon Block
- Department of Surgical Neurophysiology, ION Intraoperative Neurophysiology, Orinda, California, U.S.A
| | - Zachary T Olmsted
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A.; and
| | - Ross Green
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A.; and
| | - Thomas Pieters
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A.; and
| | - Kristiana Babarevech
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, New York, U.S.A
| | | | - Stanley A Skinner
- Department of Intraoperative Neurophysiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, U.S.A
| | - Daniel M Sciubba
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A.; and
| | - Sheng-Fu Larry Lo
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A.; and
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Silverstein JW, D'Amico RS, Mehta SH, Gluski J, Ber R, Sciubba DM, Lo SFL. The diagnostic accuracy of neuromonitoring for detecting postoperative bowel and bladder dysfunction in spinal oncology surgery: a case series. J Neurooncol 2024; 169:409-422. [PMID: 38884662 DOI: 10.1007/s11060-024-04742-y] [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] [Received: 05/06/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE Postoperative bowel and bladder dysfunction (BBD) poses a significant risk following surgery of the sacral spinal segments and sacral nerve roots, particularly in neuro-oncology cases. The need for more reliable neuromonitoring techniques to enhance the safety of spine surgery is evident. METHODS We conducted a case series comprising 60 procedures involving 56 patients, spanning from September 2022 to January 2024. We assessed the diagnostic accuracy of sacral reflexes (bulbocavernosus and external urethral sphincter reflexes) and compared them with transcranial motor evoked potentials (TCMEP) incorporating anal sphincter (AS) and external urethral sphincter (EUS) recordings, as well as spontaneous electromyography (s-EMG) with AS and EUS recordings. RESULTS Sacral reflexes demonstrated a specificity of 100% in predicting postoperative BBD, with a sensitivity of 73.33%. While sensitivity slightly decreased to 64.71% at the 1-month follow-up, it remained consistently high overall. TCMEP with AS/EUS recordings did not identify any instances of postoperative BBD, whereas s-EMG with AS/EUS recordings showed a sensitivity of 14.29% and a specificity of 97.14%. CONCLUSION Sacral reflex monitoring emerges as a robust adjunct to routine neuromonitoring, offering surgeons valuable predictive insights to potentially mitigate the occurrence of postoperative BBD.
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Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, NY, USA.
| | - Randy S D'Amico
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Shyle H Mehta
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Jacob Gluski
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Roee Ber
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Daniel M Sciubba
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Sheng-Fu Larry Lo
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Toleikis JR, Pace C, Jahangiri FR, Hemmer LB, Toleikis SC. Intraoperative somatosensory evoked potential (SEP) monitoring: an updated position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2024:10.1007/s10877-024-01201-x. [PMID: 39068294 DOI: 10.1007/s10877-024-01201-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: 07/05/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Somatosensory evoked potentials (SEPs) are used to assess the functional status of somatosensory pathways during surgical procedures and can help protect patients' neurological integrity intraoperatively. This is a position statement on intraoperative SEP monitoring from the American Society of Neurophysiological Monitoring (ASNM) and updates prior ASNM position statements on SEPs from the years 2005 and 2010. This position statement is endorsed by ASNM and serves as an educational service to the neurophysiological community on the recommended use of SEPs as a neurophysiological monitoring tool. It presents the rationale for SEP utilization and its clinical applications. It also covers the relevant anatomy, technical methodology for setup and signal acquisition, signal interpretation, anesthesia and physiological considerations, and documentation and credentialing requirements to optimize SEP monitoring to aid in protecting the nervous system during surgery.
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Affiliation(s)
| | | | - Faisal R Jahangiri
- Global Innervation LLC, Dallas, TX, USA
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
| | - Laura B Hemmer
- Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Pojskić M, Bopp M, Saß B, Nimsky C. Single-Center Experience of Resection of 120 Cases of Intradural Spinal Tumors. World Neurosurg 2024; 187:e233-e256. [PMID: 38642835 DOI: 10.1016/j.wneu.2024.04.071] [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] [Received: 04/07/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Our study presents a single-center experience of resection of intradural spinal tumors either with or without using intraoperative computed tomography-based registration and microscope-based augmented reality (AR). Microscope-based AR was recently described for improved orientation in the operative field in spine surgery, using superimposed images of segmented structures of interest in a two-dimensional or three-dimensional mode. METHODS All patients who underwent surgery for resection of intradural spinal tumors at our department were retrospectively included in the study. Clinical outcomes in terms of postoperative neurologic deficits and complications were evaluated, as well as neuroradiologic outcomes for tumor remnants and recurrence. RESULTS 112 patients (57 female, 55 male; median age 55.8 ± 17.8 years) who underwent 120 surgeries for resection of intradural spinal tumors with the use of intraoperative neuromonitoring were included in the study, with a median follow-up of 39 ± 34.4 months. Nine patients died during the follow-up for reasons unrelated to surgery. The most common tumors were meningioma (n = 41), schwannoma (n = 37), myopapillary ependymomas (n = 12), ependymomas (n = 10), and others (20). Tumors were in the thoracic spine (n = 46), lumbar spine (n = 39), cervical spine (n = 32), lumbosacral spine (n = 1), thoracic and lumbar spine (n = 1), and 1 tumor in the cervical, thoracic, and lumbar spine. Four biopsies were performed, 10 partial resections, 13 subtotal resections, and 93 gross total resections. Laminectomy was the common approach. In 79 cases, patients experienced neurologic deficits before surgery, with ataxia and paraparesis as the most common ones. After surgery, 67 patients were unchanged, 49 improved and 4 worsened. Operative time, extent of resection, clinical outcome, and complication rate did not differ between the AR and non-AR groups. However, the use of AR improved orientation in the operative field by identification of important neurovascular structures. CONCLUSIONS High rates of gross total resection with favorable neurologic outcomes in most patients as well as low recurrence rates with comparable complication rates were noted in our single-center experience. AR improved intraoperative orientation and increased surgeons' comfort by enabling early identification of important anatomic structures; however, clinical and radiologic outcomes did not differ, when AR was not used.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, Marburg, Germany.
| | - Miriam Bopp
- Department of Neurosurgery, University of Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
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Squintani G, Basaldella F, Badari A, Rasera A, Tramontano V, Pinna G, Moscolo F, Soda C, Ricci U, Ravenna G, Sala F. Intraoperative Neurophysiological Monitoring in Tethered Cord Syndrome Surgery: Predictive Values and Clinical Outcome. J Clin Neurophysiol 2024:00004691-990000000-00138. [PMID: 38905022 DOI: 10.1097/wnp.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION "Tethered cord syndrome" (TCS) refers to a congenital abnormality associated with neurological signs and symptoms. The aim of surgery is to prevent or arrest their progression. This study reports a retrospective case series of tethered cord syndrome surgeries, supported by intraoperative neurophysiological monitoring. METHODS The case series comprises 50 surgeries for tethered cord syndrome in which multimodal intraoperative neurophysiological monitoring was performed using motor evoked potentials (transcranial motor evoked potentials [TcMEPs]), tibial nerve somatosensory evoked potentials (TNSEPs), and pudendal-anal reflex (PAR). The intraoperative neurophysiological monitoring results are reported and correlated with clinical outcomes. RESULTS Sensitivity, specificity, and negative predictive value were high for TcMEPs and TNSEPs, while PAR exhibited low sensitivity and positive predictive value but high specificity and negative predictive value. Fisher's exact test revealed a significant correlation between changes in TcMEPs, TNSEPs, and clinical outcome ( P < 0.000 and P = 0.049 respectively), but no correlation was detected between PAR and urinary/anal function ( P = 0.497). CONCLUSIONS While TcMEPs and TNSEPs were found to be reliable intraoperative neurophysiological monitoring parameters during tethered cord syndrome surgery, PAR had low sensitivity and positive predictive value probably because the reflex is not directly related to bladder function and because its multisynaptic pathway may be sensitive to anesthetics. New onset muscle weakness and sensory deficits were related to postoperative changes in TcMEPs and TNSEPs, whereas changes in PAR did not predict bladder/urinary impairment. Urinary deficits may be predicted and prevented with other neurophysiological techniques, such as the bladder-anal reflex.
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Affiliation(s)
- Giovanna Squintani
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Andrea Badari
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andrea Rasera
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurology Unit, Ospedale Ca' Foncello, Treviso, Italy
- Neurology and Neurophysiology Unit, Azienda Ospedaliera Universitaria, Modena, Italy
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | - Vincenzo Tramontano
- Neurology and Neurophysiology Unit, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Giampietro Pinna
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Fabio Moscolo
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | - Christian Soda
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Umberto Ricci
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Giorgio Ravenna
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Francesco Sala
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
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Iyer RD, Ramachandran K, Palaninathan P, Shetty T AP, K S SV, Kanna RM, Shanmuganathan R. Neuromonitoring Signal Changes in Degenerative Cervical Myelopathy: An Analysis of Risk Factors for Signal Drops During Posterior Cervical Decompression. World Neurosurg 2024:S1878-8750(24)01015-5. [PMID: 38906464 DOI: 10.1016/j.wneu.2024.06.057] [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: 05/03/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To analyze intraoperative neuromonitoring data of patients with degenerative cervical myelopathy undergoing cervical laminectomy and assess the incidence of signal drops and their risk factors. METHODS This retrospective observational study included patients with degenerative cervical myelopathy who underwent cervical laminectomy with intraoperative neuromonitoring between July 2018 and March 2023. We analyzed the signal changes for any correlation with the type of pathology (ossified posterior longitudinal ligament vs. cervical spondylotic myelopathy [CSM]) and clinical (severity of myelopathy, duration of symptoms) and radiological (length of cord signal changes and K-line) parameters. RESULTS Of 100 degenerative cervical myelopathy cases, 55 were diagnosed as OPLL and 45 as CSM. Signal drops were recorded in 26 patients-14 persistent drops and 12 transient drops. True positive drops were seen in 4 patients (2 OPLL and 2 CSM), 3 of whom had sustained bimodal drops (both somatosensory evoked potentials and motor evoked potentials). Signal drops were significantly more frequent with OPLL compared with CSM (P < 0.01). Ten of 14 persistent signal drops and 9 of 12 transient drops were seen in patients in OPLL. Continuous OPLL, negative K-line, hill type OPLL, severity of myelopathy, and longer duration of symptoms were risk factors for signal drops. CONCLUSIONS Patients with cervical OPLL have a higher incidence of false positive and transient signal drops after decompression compared with patients with CSM. Longer duration of symptoms, high-grade myelopathy, continuous OPLL, hill type OPLL, and negative K-line were risk factors for signal drops.
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Affiliation(s)
- R Dinesh Iyer
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Karthik Ramachandran
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Pranavakumar Palaninathan
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Ajoy Prasad Shetty T
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India.
| | - Sri Vijayanand K S
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Rishi Mugesh Kanna
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Rajasekaran Shanmuganathan
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
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Udayakumaran S, Karthika KS, Nair NS, George M, Gopinath S. Prognostication of the neurological outcome of tethered cord based on intraoperative neuromonitoring findings: how close can we get? Br J Neurosurg 2024; 38:604-612. [PMID: 34459322 DOI: 10.1080/02688697.2021.1940855] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the correlation of intraoperative neuromonitoring (IONM) data in surgery for tethered cord syndrome (TCS) in children to the neurological outcome at 1-year follow-up. METHODS 208 consecutive patients operated on for TCS, between January 2011 to February 2020, under electrophysiological monitoring in the Division of Paediatric Neurosurgery, AIMS, Kochi, India, were included. Their preoperative neurological, urological and orthopaedic status were compared with the postoperative status at 1 year follow-up. RESULTS Our study prospectively collected the IONM data and retrospectively correlated it to the children's neurological outcome on follow-up. Out of 208 children, 28% (n = 59/208) had motor, 35% (n = 73/208) had bladder and 26% (n = 54/208) had bowel disturbances. Postsurgery, at one-year follow-up, 91% (n = 52/57) of the patients who had motor deficits had improvement, 82.3% (n = 51/62) of patients who had bladder deficits showed an improvement, and 88.8% (n = 48/54) with bowel deficits showed improvement. The monitorability for motor and sphincter potentials were 99.4% and 89.3%, respectively. Except for four patients (3 with bladder and 1 with motor worsening), all the patients who were monitorable with no deficits remained intact except for four patients, all the patients who had deficits and were monitorable improved after detethering (at 1 year). Clinical worsening corresponded to those who had a drop in amplitude of baseline TcMEP (n = 4). 18 events showed an increase in amplitude compared to the baseline TcMEP. These patients improved clinically on follow-up (at 1 year). CONCLUSIONS IONM complements the preoperative clinical details in predicting immediate and long-term outcomes.
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Affiliation(s)
- Suhas Udayakumaran
- Division of Paediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - K S Karthika
- Division of Paediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Nivedita S Nair
- Department of Neurology, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Mathew George
- Department of Anaesthesia, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Siby Gopinath
- Department of Neurology, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
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Mishra MK, Pandey N, Sharma HB, Prasad RS, Sahu A, Pradhan RS, Yadav V. Diagnostic Accuracy of Somatosensory Evoked Potential and Transcranial Motor Evoked Potential in Detection of Neurological Injury in Intradural Extramedullary Spinal Cord Tumor Surgeries: A Short-Term Follow-Up Prospective Interventional Study Experience from Tertiary Care Center of India. Asian J Neurosurg 2024; 19:210-220. [PMID: 38974440 PMCID: PMC11226304 DOI: 10.1055/s-0044-1787052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Objective Intraoperative neuromonitoring (IONM) is an acknowledged tool for real-time neuraxis assessment during surgery. Somatosensory evoked potential (SSEP) and transcranial motor evoked potential (MEP) are commonest deployed modalities of IONM. Role of SSEP and MEP in intradural extramedullary spinal cord tumor (IDEMSCT) surgery is not well established. The aim of this study was to evaluate sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and transcranial MEP, in detection of intraoperative neurological injury in IDEMSCT patients as well as their postoperative limb-specific neurological improvement assessment at fixed intervals till 30 days. Materials and Methods Symptomatic patients with IDEMSCTs were selected according to the inclusion criteria of study protocol. On modified McCormick (mMC) scale, their sensory-motor deficit was assessed both preoperatively and postoperatively. Surgery was done under SSEP and MEP (transcranial) monitoring using appropriate anesthetic agents. Gross total/subtotal resection of tumor was achieved as per IONM warning alarms. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP were calculated considering postoperative neurological changes as "reference standard." Patients were followed up at postoperative day (POD) 0, 1, 7, and 30 for convalescence. Statistical Analysis With appropriate tests of significance, statistical analysis was carried out. Receiver-operating characteristic curve was used to find cutoff point of mMC for SSEP being recordable in patients with higher neurological deficit along with calculation of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP for prediction of intraoperative neurological injury. Results Study included 32 patients. Baseline mean mMC value was 2.59. Under neuromonitoring, gross total resection of IDEMSCT was achieved in 87.5% patients. SSEP was recordable in subset of patients with mMC value less than or equal to 2 with diagnostic accuracy of 100%. MEP was recordable in all patients and it had 96.88% diagnostic accuracy. Statistically significant neurological improvement was noted at POD-7 and POD-30 follow-up. Conclusion SSEP and MEP individually carry high diagnostic accuracy in detection of intraoperative neurological injuries in patients undergoing IDEMSCT surgery. MEP continues to monitor the neuraxis, even in those subsets of patients where SSEP fails to record.
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Affiliation(s)
- Manish Kumar Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Nityanand Pandey
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Hanjabam Barun Sharma
- Department of Physiology, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Ravi Shankar Prasad
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Anurag Sahu
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Ravi Shekhar Pradhan
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Vikrant Yadav
- Department of Neurosurgery, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
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Ricciuti RA, Mancini F, Guzzi G, Marruzzo D, Dario A, Puppa AD, Ricci A, Barbanera A, Talacchi A, Schwarz A, Germanò A, Raco A, Colamaria A, Santoro A, Boccaletti R, Conti C, Conti C, Cenci N, Cossandi C, Bernucci C, Lucantoni C, Costella GB, Garbossa D, Zotta DC, De Gonda F, Esposito F, Giordano F, D'Andrea G, Piatelli G, Zona G, Spena G, Tringali G, Barbagallo G, Giussani C, Gladi M, Landi A, Lavano A, Morabito L, Mastronardi L, Locatelli M, D'Agruma M, Lanotte MM, Montano N, Santonocito OS, Pompucci A, de Falco R, Randi F, Bruscella S, Sartori I, Signorelli F, Tosatto L, Trignani R, Esposito V, Innocenzi G, Paolini S, Vitiello V, Cavallo MA, Sala F. The "state of the art" of intraoperative neurophysiological monitoring: An Italian neurosurgical survey. BRAIN & SPINE 2024; 4:102796. [PMID: 38698806 PMCID: PMC11063224 DOI: 10.1016/j.bas.2024.102796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/25/2024] [Accepted: 03/30/2024] [Indexed: 05/05/2024]
Abstract
Introduction Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers. Research question The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy. Materials and methods A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers. Results A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10-20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request. Discussion and conclusions The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.
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Affiliation(s)
| | | | - Giusy Guzzi
- Neurosurgery, AOU Ospedaliero Mater Domini di Catanzaro, Italy
| | | | | | | | | | - Andrea Barbanera
- Department of Neurosurgery, AON SS. Antonio e Biagio e Cesare Arrigo H, Alessandria, Italy
| | - Andrea Talacchi
- Unit of Neurosurgery, AO San Giovanni Addolorata, Roma, Italy
| | | | - Antonino Germanò
- Unit of Neurosurgery, AOU Policlinico G. Martino di Messina, Italy
| | - Antonino Raco
- Neurosurgery Clinic, Azienda Ospedaliera Sant’Andrea, Roma, Italy
| | - Antonio Colamaria
- Unit of Neurosurgery, Azienda Ospedaliera Policlinico Riuniti Foggia, Foggia, Italy
| | - Antonio Santoro
- Neurosurgery Clinic, Azienda Ospedaliera Universitaria, La Sapienza Policlinico Umberto I° Roma, Roma, Italy
| | | | - Carlo Conti
- Unit of Neurosurgery, Azienda Ospedaliera S. Maria, Terni, Italy
| | - Carlo Conti
- Unit of Neurosurgery, ARNAS G.Brotzu, Cagliari, Italy
| | - Nunzia Cenci
- Neurosurgery, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Christian Cossandi
- Unit of Neurosurgery, AOU Maggiore Della Carità di Novara, Novara, Italy
| | | | | | | | - Diego Garbossa
- Neurosurgery Clinic, AOU Città Della Salute e Della Scienza di Torino, Italy
| | | | | | - Felice Esposito
- Neurosurgery Clinic, A.O.U. Policlinico Federico II - Università Degli Studi di Napoli, Italy
| | - Flavio Giordano
- Unit of Pediatric Neurosurgery, Meyer Children's Hospital IRCCS, Firenze, Italy
- University of Florence, Italy
| | | | | | - Gianluigi Zona
- Neurosurgery Clinic, IRCCS Policlinico San Martino, Genova, Italy
| | | | | | | | - Carlo Giussani
- Neurosurgery Clinic, IRCCS Fondazione Ospedale San Gerardo Dei Tintori di Monza, Università Bicocca, Milano, Italy
| | - Maurizio Gladi
- Neurosurgery Clinic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Italy
| | - Andrea Landi
- Neurosurgery Clinic, Azienda Ospedaliera Universitaria di Padova, Italy
| | - Angelo Lavano
- Neurosurgery, AOU Ospedaliero Mater Domini di Catanzaro, Italy
| | | | | | - Marco Locatelli
- Neurosurgery Clinic, Fondazione IRCCS Ospedale Maggiore Policlinico di Milano, Università Degli Studi di Milano, Italy
| | | | - Michele Maria Lanotte
- Unit of Functional Neurosurgery, AOU Città Della Salute e Della Scienza di Torino, Italy
| | - Nicola Montano
- Neurosurgery Clinic, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | | | | | - Raffaele de Falco
- Neurosurgery, Ospedale Santa Maria Delle Grazie di Pozzuoli, Napoli, Italy
| | - Franco Randi
- Neurosurgery, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Sara Bruscella
- Neurosurgery, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Ivana Sartori
- Unit of Epilepsy Neurosurgery, ASST GOM Niguarda, Milano, Italy
| | | | | | | | | | | | | | | | | | - Francesco Sala
- Neurosurgery Clinic, Azienda Ospedaliera Universitaria di Verona, Verona, Italy
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10
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Dang DD, Mugge LA, Awan OK, Gong AD, Fanous AA. Spinal Meningiomas: A Comprehensive Review and Update on Advancements in Molecular Characterization, Diagnostics, Surgical Approach and Technology, and Alternative Therapies. Cancers (Basel) 2024; 16:1426. [PMID: 38611105 PMCID: PMC11011121 DOI: 10.3390/cancers16071426] [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: 02/04/2024] [Revised: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024] Open
Abstract
Spinal meningiomas are the most common intradural, extramedullary tumor in adults, yet the least common entity when accounting for all meningiomas spanning the neuraxis. While traditionally considered a benign recapitulation of their intracranial counterpart, a paucity of knowledge exists regarding the differences between meningiomas arising from these two anatomic compartments in terms of histopathologic subtypes, molecular tumor biology, surgical principles, long-term functional outcomes, and recurrence rates. To date, advancements at the bench have largely been made for intracranial meningiomas, including the discovery of novel gene targets, DNA methylation profiles, integrated diagnoses, and alternative systemic therapies, with few exceptions reserved for spinal pathology. Likewise, evolving clinical research offers significant updates to our understanding of guiding surgical principles, intraoperative technology, and perioperative patient management for intracranial meningiomas. Nonetheless, spinal meningiomas are predominantly relegated to studies considering non-specific intradural extramedullary spinal tumors of all histopathologic types. The aim of this review is to comprehensively report updates in both basic science and clinical research regarding intraspinal meningiomas and to provide illustrative case examples thereof, thereby lending a better understanding of this heterogenous class of central nervous system tumors.
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Affiliation(s)
- Danielle D. Dang
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Luke A. Mugge
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Omar K. Awan
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Andrew D. Gong
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Andrew A. Fanous
- Department of Neurosurgery, Inova Alexandria Hospital, Alexandria, VA 22304, USA
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11
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Motiei-Langroudi R, Ekanem UO. Utility of Decremental Triggered Electromyogram for Intraoperative Neuromonitoring to Identify Midline in Posterior Myelotomy for Spinal Cord Intramedullary Lesions: Technical Note of a Novel Method. Oper Neurosurg (Hagerstown) 2024; 26:463-467. [PMID: 37976147 DOI: 10.1227/ons.0000000000000989] [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: 08/02/2023] [Accepted: 09/26/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Intramedullary spinal cord lesions are eloquent lesions that are surgically resected via posterior midline myelotomy (PMM). This treatment method carries the risk of postoperative neurological deficits. Various intraoperative neuromonitoring techniques have been used to address this concern. Our study aimed to highlight a newly developed monitoring technique (decremental-triggered electromyogram [dtEMG]) as a novel method to identify the spinal cord midline during PMM. CLINICAL PRESENTATION Seven patients in prone position underwent PMM for an intramedullary lesion using dtEMG for neuromonitoring. dtEMG was used to determine the threshold amplitude (ie, the lowest amplitude to elicit an EMG response) as well as a silent zone, which was determined to be the midline. The age range was 26-73 years. dtEMG detected a silent zone in 6/7 patients. The only patient in whom dtEMG was not useful was a patient with complete paraplegia and sensory loss before surgery. There were no motor evoked or somatosensory evoked potential changes related to PMM in these patients. DISCUSSION Although the commonly used neuromonitoring techniques, including motor and sensory evoked potentials and free-run electromyograms are of utmost importance in spinal cord surgery, they lack the potential to identify midline in such cases. The currently available tools, including dorsal column mapping, are more cumbersome to use. CONCLUSION The newly proposed dtEMG technique can safely and efficiently identify the midline when used as an intraoperative neuromonitoring technique in PMM for spinal cord intramedullary lesion resection.
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Abu-Ata MM, Pasquali C, Sala F. Intraoperative Neuromonitoring in Tethered Cord Surgery in Children. J Clin Neurophysiol 2024; 41:123-133. [PMID: 38306220 DOI: 10.1097/wnp.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Affiliation(s)
- Mahmoud M Abu-Ata
- Center of Neurosciences, King Faisal Specialty Hospital and Research Center, Riyadh, Saudi Arabia; and
| | - Claudia Pasquali
- Department of Neurosciences, Institute of Neurosurgery, University Hospital, Verona, Italy
| | - Francesco Sala
- Department of Neurosciences, Institute of Neurosurgery, University Hospital, Verona, Italy
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13
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Harada N, Sakaeyama Y, Fuchinoue Y, Abe M, Terazono S, Matsuura C, Kubota S, Mikai M, Sugo N, Sugiyama K, Kondo K, Nemoto M. Differentiation between Anterior and Posterior Roots Using Compound Muscle Action Potential in Intradural Extramedullary Spinal Tumor Surgery. Neurol Med Chir (Tokyo) 2024; 64:36-42. [PMID: 38030261 PMCID: PMC10835576 DOI: 10.2176/jns-nmc.2023-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
This study aims to determine the cutoff values for the compound muscle action potential (CMAP) stimulus in anatomically identified anterior (motor nerve) and posterior roots (sensory nerve) during cervical intradural extramedullary tumor surgery. The connection between CMAP data from nerve roots and postoperative neurological symptoms in thoracolumbar tumors was compared with data from cervical lesions. The participants of the study included 22 patients with intradural extramedullary spinal tumors (116 nerve roots). The lowest stimulation intensity to the nerve root at which muscle contraction occurs was defined as the minimal activation intensity (MAI) in the CMAP. In cervical tumors, the MAI was measured after differentiating between the anterior and posterior roots based on the anatomical placement of the dentate ligament and nerve roots. The MAIs for 20 anterior roots in eight cervical tumors were between 0.1 and 0.3 mA, whereas those for 19 posterior roots were between 0.4 and 2.0 mA. The cutoff was <0.4 mA for both the anterior and posterior roots, and sensitivity and specificity were both 100%. In thoracolumbar tumors, the nerve root was severed in 12 of 14 cases. All MAIs were determined to be at the dorsal roots as their scores were higher than the cutoff and did not indicate motor deficits. The MAIs of the anatomically identified anterior and posterior root CMAPs were found to have a cutoff value of <0.4 mA in the cervical lesions. Similar MAI cutoffs were also applicable to thoracolumbar lesions. Thus, CMAP may be useful in detecting anterior and posterior roots in spinal tumor surgery.
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Affiliation(s)
- Naoyuki Harada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Yuki Sakaeyama
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Yutaka Fuchinoue
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Mitsuyoshi Abe
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Sayaka Terazono
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Chie Matsuura
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Shuhei Kubota
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Masataka Mikai
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Nobuo Sugo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Kunio Sugiyama
- Department of Clinical Functional Physiology, Toho University Medical Center Omori Hospital
| | - Kosuke Kondo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
| | - Masaaki Nemoto
- Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University
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14
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Chanbour H, Dewan MC, Zuckerman SL. Commentary: Exoscopic Removal of a Symptomatic Vth Ventricle Cyst (Kraus' Ventriculus Terminalis) Under Ultrasonography and Neurophysiological Assistance: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:121-122. [PMID: 37832025 DOI: 10.1227/ons.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
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15
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Sala F. Intraoperative neurophysiology in pediatric neurosurgery: a historical perspective. Childs Nerv Syst 2023; 39:2929-2941. [PMID: 37776333 PMCID: PMC10613152 DOI: 10.1007/s00381-023-06155-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Intraoperative neurophysiology (ION) has been established over the past three decades as a valuable discipline to improve the safety of neurosurgical procedures with the main goal of reducing neurological morbidity. Neurosurgeons have substantially contributed to the development of this field not only by implementing the use and refinement of ION in the operating room but also by introducing novel techniques for both mapping and monitoring of neural pathways. METHODS This review provides a personal perspective on the evolution of ION in a variety of pediatric neurosurgical procedures: from brain tumor to brainstem surgery, from spinal cord tumor to tethered cord surgery. RESULTS AND DISCUSSION The contribution of pediatric neurosurgeons is highlighted showing how our discipline has played a crucial role in promoting ION at the turn of the century. Finally, a view on novel ION techniques and their potential implications for pediatric neurosurgery will provide insights into the future of ION, further supporting the view of a functional, rather than merely anatomical, approach to pediatric neurosurgery.
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Affiliation(s)
- Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
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16
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Yu B, Xiao Y, Dai H, Yu Y, Lin Y, Xu J. Spinal intradural extramedullary tumors: microscopic keyhole resection with the focus on intraoperative neurophysiological monitoring and long-term outcome. J Orthop Surg Res 2023; 18:598. [PMID: 37574567 PMCID: PMC10424432 DOI: 10.1186/s13018-023-04074-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023] Open
Abstract
OBJECTIVE Spinal schwannomas (SS) and spinal meningiomas (SM) account for most intradural extramedullary (IDEM) tumors. These tumors are usually benign lesions, which generally respond favorably to surgical excision. Few studies up to now tried to determine the long-term outcome after minimally invasive surgery (MIS) with multimodal intraoperative neurophysiological monitoring (IONM) for IDEM tumors. The aim of this study was to present one of the largest case series with special regard to IONM findings and long-term outcome after MIS-keyhole surgery with a tubular retractor system. METHODS Between January 2013 and August 2018, 87 patients with IDEM tumors who underwent tumor removal surgery via MIS-keyhole approach under multimodal IONM were retrospectively reviewed. The neurological status was assessed using a modified McCormick grading scale pre- and postoperatively. Multimodal IONM consisted of motor evoked potentials (MEP), somatosensory evoked potentials (SEP), and electromyography (EMG). Both short-term and long-term clinical evaluations as well as patients' medical files were retrospectively analyzed. RESULTS Surgeries were performed for resection of SS in 49 patients and SM in 38 patients. Tumor locations were cervical in 16.1%, thoracic in 48.3%, thoracolumbar in 4.6%, lumbar 31%. Critical IONM changes were detected in 9 operations (10.3%) in which there were 2 SEPs, 5 MEPs, and 2 EMG events. Three IONM changes (2 MEPs, 1 EMG) were turned out to be transient change in nature since they were resolved in a short time when immediate corrective actions were initiated. Six patients with permanent IONM changes (2SEPs, 3MEPs, 1EMG event), all deficits had resolved during hospitalization or on short -term follow-up evaluation. Sensitivity, specificity, and positive and negative predicted values of IONM were 100, 96, 67, and 100%, respectively. Gross total resection rate was 100%, and a stable or improved McCormick grade exhibited in all patients. No tumor recurrence and no spinal instability were found in the long-term follow-up evaluation (mean 5.2 ± 2.9 years postoperatively). Overall, 94% of patients were either satisfied or very satisfied with their operation, and 93% patients reported excellent or good general clinical outcome according to Odom's criteria. CONCLUSION MIS-keyhole surgery with multimodal IONM for IDEM tumors enables a high level of satisfaction and a satisfying long-term clinical and surgical outcome.
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Affiliation(s)
- Bofei Yu
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Yuhua Xiao
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Hanhao Dai
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Yunlong Yu
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Yuan Lin
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Jie Xu
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China.
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17
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Sánchez Roldán MÁ, Moncho D, Rahnama K, Santa-Cruz D, Lainez E, Baiget D, Chocrón I, Gándara D, Bescós A, Sahuquillo J, Poca MA. Intraoperative Neurophysiological Monitoring in Syringomyelia Surgery: A Multimodal Approach. J Clin Med 2023; 12:5200. [PMID: 37629243 PMCID: PMC10455553 DOI: 10.3390/jcm12165200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/20/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Syringomyelia can be associated with multiple etiologies. The treatment of the underlying causes is first-line therapy; however, a direct approach to the syrinx is accepted as rescue treatment. Any direct intervention on the syrinx requires a myelotomy, posing a significant risk of iatrogenic spinal cord (SC) injury. Intraoperative neurophysiological monitoring (IONM) is crucial to detect and prevent surgically induced damage in neural SC pathways. We retrospectively reviewed the perioperative and intraoperative neurophysiological data and perioperative neurological examinations in ten cases of syringomyelia surgery. All the monitored modalities remained stable throughout the surgery in six cases, correlating with no new postoperative neurological deficits. In two patients, significant transitory attenuation, or loss of motor evoked potentials (MEPs), were observed and recovered after a corrective surgical maneuver, with no new postoperative deficits. In two cases, a significant MEP decrement was noted, which lasted until the end of the surgery and was associated with postoperative weakness. A transitory train of neurotonic electromyography (EMG) discharges was reported in one case. The surgical plan was adjusted, and the patient showed no postoperative deficits. The dorsal nerve roots were stimulated and identified in the seven cases where the myelotomy was performed via the dorsal root entry zone. Dorsal column mapping guided the myelotomy entry zone in four of the cases. In conclusion, multimodal IONM is feasible and reliable and may help prevent iatrogenic SC injury during syringomyelia surgery.
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Affiliation(s)
- M. Ángeles Sánchez Roldán
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Dulce Moncho
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Kimia Rahnama
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Daniela Santa-Cruz
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Elena Lainez
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Daniel Baiget
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (K.R.); (D.S.-C.); (D.B.)
| | - Ivette Chocrón
- Department of Anesthesiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Darío Gándara
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
| | - Agustín Bescós
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
| | - Juan Sahuquillo
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - María A. Poca
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.G.); (A.B.)
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18
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Prabhuraj AR, Mehta S, Sadashiva N, Pruthi N, Arima A, Rao KN, Vazhayil V, Beniwal M, Shashidhar A, Birua GJS, Somanna S. Factors predicting recurrence in benign spinal nerve sheath tumors: A retrospective study of 457 patients from a single institution. J Clin Neurosci 2023; 114:158-165. [PMID: 37441931 DOI: 10.1016/j.jocn.2023.06.019] [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: 05/01/2023] [Revised: 06/25/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Benign Nerve sheath tumors (NST) comprise almost one-third of primary spinal tumours. The majority are sporadic. They have low rates of recurrence but an occasional recurrence may need re-surgery. The present study was designed to identify the variables that can predict the risk of their recurrence. METHODS A retrospective chart review was done including all the histologically proven benign spinal NSTs operated between 2001 and 2019 in our institute. Demographic, operative and postoperative follow-up data were recorded. Recurrence was defined as local reappearance after definite surgical excision or symptomatic increase in size of a residual tumour on follow-up imaging studies. Statistical analysis was done to determine the significant variables associated with local recurrence. RESULTS 457 patients with a median age of 38 years operated for 459 NSTs qualified for the study. The most frequent location of occurrence of tumours was found to be Low Cervical level (C3-C7 levels). Majority of Schwannoma were located intradurally while Neurofibroma were dumb-bell shaped and extradural. Most of the tumours had solid consistency. Post operatively, 7.7% patients developed complications. 7.8% tumours developed local recurrence after median period of 12 months. The patients developing recurrence were younger compared to nonrecurring tumors. On univariate analysis, male gender, Low cervical and Cervicothoracic junction location were associated with higher recurrence. On multivariate analysis, location at Cervicothoracic junction reached significance. CONCLUSION Overall recurrence risk among all NST was 7.8% with a median progression free survival of 36 months. The location of tumour at cervicothoracic location was the significant risk factors for recurrence of tumour in our study.
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Affiliation(s)
- A R Prabhuraj
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Sarthak Mehta
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Arivazhagan Arima
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Kannepalli Narasingha Rao
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Vikas Vazhayil
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Manish Beniwal
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Abhinith Shashidhar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Gyani Jail Singh Birua
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
| | - Sampath Somanna
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
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D'Ercole M, D'Alessandris QG, Di Domenico M, Burattini B, Menna G, Izzo A, Polli FM, Della Pepa GM, Olivi A, Montano N. Is There a Role for Intraoperative Neuromonitoring in Intradural Extramedullary Spine Tumors? Results and Indications from an Institutional Series. J Pers Med 2023; 13:1103. [PMID: 37511716 PMCID: PMC10381312 DOI: 10.3390/jpm13071103] [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: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
While intraoperative neurophysiological monitoring (IONM) is considered a standard for intramedullary spinal cord tumor surgery, the effective role of IONM in intradural extramedullary (IDEM) tumors is still debated. We present the results of 60 patients affected by IDEM tumors undergoing surgery with the aid of IONM. Each patient was evaluated according to the modified McCormick scale (MMS) at admission, discharge and at follow-up. During surgery, motor evoked potentials (MEPs) and somatosensory evoked potentials (SEPs) were studied using the Medtronic NIM-eclipse® 32-channel system (Medtronic Xomed, Inc. 6743 Southpoint Drive North Jacksonville FL USA). Patients' age, gender and tumor location did not affect MMS modifications. Tumors involving more than three levels had an increased likelihood of MMS worsening, while meningioma pathology was associated with worse preoperative and 1-year follow-up MMS. No MEP amplitude ratio was able to predict clinical variations, while intraoperative SEP worsening was associated with 100% risk of poor MMS at discharge and with 50% risk of poor MMS at long-term follow-up. In our opinion, SEP monitoring is a valid tool that may contribute to the preservation of the patient's neurological status. MEP monitoring is not mandatory in IDEM surgery while more studies are required to explore the feasibility and the role of D-wave in this kind of surgery.
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Affiliation(s)
- Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Neurosurgery Section, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Benedetta Burattini
- Department of Neuroscience, Neurosurgery Section, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Grazia Menna
- Department of Neuroscience, Neurosurgery Section, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Filippo Maria Polli
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Neurosurgery Section, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Neurosurgery Section, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Zhang D, Fan T, Fan W, Zhao X, Liang C, Wang Y, Wu K. Clinical Characteristics and Treatment Outcomes of Long-Level Intramedullary Spinal Cord Tumors: A Consecutive Series of 43 Cases. Neurospine 2023; 20:231-239. [PMID: 37016869 PMCID: PMC10080416 DOI: 10.14245/ns.2244648.324] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 12/10/2022] [Indexed: 04/03/2023] Open
Abstract
Objective: Long-level intramedullary spinal cord tumors (LIMSCTs) cause complex treatment issues. However, LIMSCTs have rarely been analyzed separately. The authors reported a large case series of LIMSCTs and analyzed the clinical characteristics and treatment outcomes.Methods: The medical data of patients with LIMSCTs at our institution between January 2015 and December 2019 were retrospectively reviewed. Demographics, tumor size and location, pathology, extent of resection, and neurological functional status were collected.Results: A total of 43 consecutive cases were included. Twenty-three cases (53.5%) of LIMSCTs were ependymal tumors. All patients with ependymal tumors achieved gross total resection (GTR). In ependymal tumor cases, 3 cases (13%) of ependymal tumors experienced postoperative neurological deterioration, and 66% of them showed an improvement at follow-up; 25.6% were low-grade astrocytic tumors. The rates of GTR, subtotal resection (STR) and partial resection (PR) were 63.6%, 27.3%, and 9.1%, respectively. Twenty-seven percent cases showed postoperative neurological worsening, and 33% of them had an improvement at follow-up; 20.9% were high-grade astrocytic tumors. The excision rates were 44.4% for GTR, 44.4% for STR, and 11% for PR, respectively. Fifty-five percent cases showed postoperative neurological worsening, and none of them had an improvement at follow-up.Conclusion: In this series, all LIMSCTs were gliomas. Aggressive tumor resection did not increase the risk of long-term functional deterioration in ependymal tumors and low-grade astrocytic tumors, but in high-grade astrocytic tumors, patients had a higher risk of neurological deterioration and difficulty in recovery. In ependymal tumors and low-grade astrocytic tumors, patients can achieve long-time survival after performing aggressive tumor resection.
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Affiliation(s)
- Dongao Zhang
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tao Fan
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Corresponding Author Tao Fan Spine Center, Sanbo Brain Hospital, Capital Medical University, NO. 50 XiangshanYikesong Road, Haidian District, Beijing, China
| | - Wayne Fan
- Faculty of Science, University of British Columbia, Vancouver, BC, Canada
| | - Xingang Zhao
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Cong Liang
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yinqian Wang
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Kun Wu
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
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21
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Gamblin AS, Awad AW, Karsy M, Guan J, Mazur MD, Bisson EF, Bican O, Dailey AT. Efficacy of Intraoperative Neuromonitoring during the Treatment of Cervical Myelopathy. INDIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1055/s-0043-1764455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Objective The accuracy of intraoperative neuromonitoring (IONM) during surgery for cervical spondylotic myelopathy (CSM) to detect iatrogenic nervous system injuries while they are reversible remains unknown. We evaluated a cohort of patients who had IONM during surgery to assess accuracy.
Methods Patients who underwent surgical treatment of CSM that included IONM from January 2018 through August 2018 were retrospectively identified. A standardized protocol was used for operative management. Clinical changes and postoperative neurological deficits were evaluated.
Results Among 131 patients in whom IONM was used during their procedure, 42 patients (age 58.2 ± 16.3 years, 54.8% males) showed IONM changes and 89 patients had no change. The reasons for IONM changes varied, and some patients had changes detected via multiple modalities: electromyography (n = 25, 59.5%), somatosensory-evoked potentials (n = 14, 33.3%), motor evoked potentials (n = 13, 31.0%). Three patients, all having baseline deficits before surgery, had postoperative deficits. Among the 89 patients without an IONM change, 4 showed worsened postoperative deficits, which were also seen at last follow-up. The sensitivity of IONM for predicting postoperative neurological change was 42.86% and the specificity was 68.55%. However, most patients (124, 94.7%) in whom IONM was used showed no worsened neurological deficit.
Conclusions IONM shows potential in ensuring stable postoperative neurological outcomes in most patients; however, its clinical use and supportive guidelines remain controversial. In our series, prediction of neurological deficits was poor in contrast to some previous studies. Further refinement of clinical and electrophysiological variables is needed to uniformly predict postoperative neurological outcomes.
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Kapadia T, Sahu A, Mahajan A, Ahuja A, Chatterjee A, Sahu A, Warade A, Padashetty S, Vijan A, Chidambaranthan N, Dasgupta A, Sridhar E, Sahay A, Shetty P, Prasad M, Chinnaswamy G, Moiyadi A, Gupta T, Gala F, Sankhe S. Imaging Guidelines and Recommendations for Diagnosis, Surveillance, and Management of Pediatric CNS and Spinal Tumors. Indian J Med Paediatr Oncol 2023. [DOI: 10.1055/s-0042-1759716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
AbstractCentral nervous system (CNS) tumors are the second most common cause of cancer in children when incidence rates of cancer are estimated according to the Indian population dynamics based on 2011 consensus. As per the estimates, CNS tumors account for 20.1% of cancer burden in children aged between 0 and 14 years and 16.8% when 0 to 19 years age group is considered. The most common pediatric brain tumors are astrocytoma and medulloblastoma followed by other embryonal tumors, craniopharyngioma, and ependymal tumors. The incidence of CNS tumors in children from India is similar to the western high-income countries, other than slightly higher incidence of craniopharyngioma in Indian children.
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Affiliation(s)
- Tejas Kapadia
- Children's X-Ray Department/Academic Unit of Paediatric Radiology, Royal Manchester Children's Hospital, United Kingdom
| | - Arpita Sahu
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Abhishek Mahajan
- Department of Radiology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | | | - Abhishek Chatterjee
- Department of Radiation Oncology, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Amit Sahu
- Lilavati Hospital, Mumbai, Maharashtra, India
| | | | - Shubham Padashetty
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Antariksh Vijan
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - Archya Dasgupta
- Department of Radiation Oncology, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Epari Sridhar
- Department of Pathology, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ayushi Sahay
- Department of Pathology, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prakash Shetty
- Department of Neurosurgery, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Maya Prasad
- Department of Paediatric Oncology, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy
- Department of Paediatric Oncology, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Aliasgar Moiyadi
- Department of Neurosurgery, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tejpal Gupta
- Department of Radiation Oncology, Tata Memorial Hospital; TMC &Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Foram Gala
- Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India
| | - Shilpa Sankhe
- King Edward Memorial Hospital, Mumbai, Maharashtra, India
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Olmsted ZT, Silverstein JW, Einstein EH, Sowulewski J, Nelson P, Boockvar JA, D'Amico RS. Evolution of flash visual evoked potentials to monitor visual pathway integrity during tumor resection: illustrative cases and literature review. Neurosurg Rev 2023; 46:46. [PMID: 36715828 DOI: 10.1007/s10143-023-01955-z] [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] [Received: 04/02/2022] [Revised: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
Flash visual evoked potentials (fVEPs) provide a means to interrogate visual system functioning intraoperatively during tumor resection in which the optic pathway is at risk for injury. Due to technical limitations, fVEPs have remained underutilized in the armamentarium of intraoperative neurophysiological monitoring (IONM) techniques. Here we review the evolution of fVEPs as an IONM technique with emphasis on the enabling technological and intraoperative improvements. A combined approach with electroretinography (ERG) has enhanced feasibility of fVEP neuromonitoring as a practical application to increase safety and reduce error during tumor resection near the prechiasmal optic pathway. The major advance has been towards differentiating true cases of damage from false findings. We use two illustrative neurosurgical cases in which fVEPs were monitored with and without ERG to discuss limitations and demonstrate how ERG data can clarify false-positive findings in the operating room. Standardization measures have focused on uniformity of photostimulation parameters for fVEP recordings between neurosurgical groups.
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Affiliation(s)
- Zachary T Olmsted
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA.
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
- Neuro Protective Solutions, New York, NY, USA
| | - Evan H Einstein
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | | | - Priscilla Nelson
- Department of Anesthesiology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | - John A Boockvar
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
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Pasquali C, Basaldella F, Sala F. Updates on Intraoperative Neurophysiology During Surgery for Spinal Dysraphism. Adv Tech Stand Neurosurg 2023; 47:235-272. [PMID: 37640878 DOI: 10.1007/978-3-031-34981-2_9] [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: 08/31/2023]
Abstract
Spinal dysraphism is a group of disorders resulting from an embryologic failure of spinal cord development which can lead to a radicular-medullary mechanical stretch that generates vascular compromise and hypoxic-ischemic damage to the nervous structures of the conus-cauda region.Thus, the clinical relevance of the different types of spinal dysraphism is related to the possible neurologic deficits resulting from spinal cord tethering. The clinical presentation is heterogenous: from asymptomatic to very compromised patients. The indications and the time of a detethering surgery are still subject of debate, although there is an agreement on the high standards of treatment that have to be offered by the surgery. Intraoperative neurophysiology (ION) contributes to the safety of tethered cord surgery in reducing the risks of iatrogenic neurological damages.
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Affiliation(s)
- Claudia Pasquali
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Federica Basaldella
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
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25
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Revilla-Pacheco F, Watanabe S, Rodríguez-Reyes J, Sánchez-Torres C, Shkurovich-Bialik P, Herrada-Pineda T, Rodríguez-Salgado P, Franco-Granillo J, Calderón-Juárez M. Transcranial electric stimulation motor evoked potentials for cervical spine intraoperative monitoring complications: systematic review and illustrative case of cardiac arrest. 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 2022; 31:2723-2732. [PMID: 35790650 DOI: 10.1007/s00586-022-07297-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE We show a systematic review of known complications during intraoperative neuromonitoring (IONM) using transcranial electric stimulation motor evoked potentials (TES-MEP) on cervical spine surgery, which provides a summary of the main findings. A rare complication during this procedure, cardiac arrest by cardioinhibitory reflex, is also described. METHODS Findings of 523 scientific papers published from 1995 onwards were reviewed in the following databases: CENTRAL, Cochrane Library, Embase, Google Scholar, Ovid, LILACS, PubMed, and Web of Science. This study evaluated only complications on cervical spine surgery undergoing TES-MEP IONM. RESULTS The review of the literature yielded 13 studies on the complications of TES-MEP IONM, from which three were excluded. Five studies are case series; the rest are case reports. Overall, 169 complications on 167 patients were reported in a total of 38,915 patients, a global prevalence of 0.43%. The most common complication was tongue-bite in 129 cases, (76.3% of all complication events). Tongue-bite had a prevalence of 0.33% (CI 95%, 0.28-0.39%) in all patients on TES-MEP IONM. A relatively low prevalence of severe complications was found: cardiac-arrhythmia, bradycardia and seizure, the prevalence of this complications represents only one case in all the sample. Alongside, we report the occurrence of cardiac arrest attributable to TES-MEP IONM. CONCLUSIONS This systematic review shows that TES-MEP is a safe procedure with a very low prevalence of complications. To our best knowledge, asystole is reported for the first time as a complication during TES-MEP IONM.
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Affiliation(s)
| | - Shoko Watanabe
- Department of Neurosurgery, ABC Medical Center, Mexico City, Mexico
| | | | | | | | | | | | | | - Martín Calderón-Juárez
- Plan de Estudios Combinados en Medicina, Faculty of Medicine, National Autonomous University of Mexico, Circuto Escolar 411A, Coyoacán, 04360, Mexico City, Mexico.
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26
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Feng X, Deng L, Feng H, Hu Y, Tian J, Sun L. Intraoperative neurophysiologic monitoring alteration during en bloc laminectomy surgery for thoracic ossification of ligamentum flavum. Front Surg 2022; 9:1019112. [PMID: 36238860 PMCID: PMC9551274 DOI: 10.3389/fsurg.2022.1019112] [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: 08/14/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background There is real risk during en bloc resection for the treatment of thoracic ossification of ligamentum flavum (TOLF). Intraoperative neurophysiologic monitoring (IONM) has been applied to monitor neurologic functional integration of the spinal cord during surgery. However, the IONM outcome and its relationship with clinical results still needs to be investigated. The purpose of this study is to evaluate the effectiveness and usefulness of IONM in en bloc laminectomy for TOLF. Methods Data from a total of 68 patients with TOLF who received en bloc resection was collected for this retrospective study. IONM of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) were analyzed in different patterns of signal alerts, i.e. alert in either MEPs or SSEPs, alert in both MEPs and SSEPs, permanent alert, or recovery during surgery. Postoperative motor and sensory neurological function was evaluated in each patient immediately after surgery and at 12-month follow-up after surgery. The relationship of IONM outcomes and postoperative neurologic function were observed. Results Fifty of 68 patients did not present significant changes over alert criteria of IONM, neither SSEPs nor MEPs. Those 50 patients without IONM alerts did not show post-operative neurologic deterioration. Four patients presented alert of IONM in a single modality, while 2 patients showed only SSEP alert and 2 patients showed only MEP alert. Fourteen patients showed alerts in both SSEP and MEP, while 8 patients showed one or both signals return to normal during surgery and other 6 showed permanent abnormal electrophysiologic signals to the end of surgery. In the follow-up neurologic test, 3 patients presented transient neurologic complications from among 8 patients with both SSEP and MEP alerts and recovery during surgery. Six patients without recovery of IONM showed permanent neurologic complications after surgery. Conclusions Results of this study prove the effectiveness and usefulness of IONM in in en bloc laminectomy surgery for TOLF. The patterns of IONM changes correlated with postoperative neurologic functions. Special attention must be paid to the rapid loss of IONM without recovery during spinal decompression.
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Affiliation(s)
- Xiaoning Feng
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Li Deng
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Haoyu Feng
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Yong Hu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Jianghua Tian
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Lin Sun
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Correspondence: Lin Sun
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27
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Sadeh M, Farhat H. Severe High Cervical Cord Compression Due to Large Bilateral Neurofibromas in a Patient With Neurofibromatosis Type 1: A Case Report and Review of Literature. Cureus 2022; 14:e27211. [PMID: 36035059 PMCID: PMC9398895 DOI: 10.7759/cureus.27211] [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] [Accepted: 07/24/2022] [Indexed: 11/15/2022] Open
Abstract
Spinal neurofibromas are rare benign lesions associated with neurofibromatosis Type 1. They can often cause compression on nerve roots and the spinal cord. In this rare case, there are bilateral large neurofibromas with severe cord compression presenting as progressive myelopathy. We illustrate the surgical management as well as post-operative care along with a detailed literature review of similar cases. To our knowledge, this is the first report, in English literature, of spinal neurofibroma with large size, bilateral high cervical cord compression.
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Dauleac C, Boulogne S, Barrey CY, Guyotat J, Jouanneau E, Mertens P, Berhouma M, Jung J, André-Obadia N. Predictors of functional outcome after spinal cord surgery: Relevance of intraoperative neurophysiological monitoring combined with preoperative neurophysiological and MRI assessments. Neurophysiol Clin 2022; 52:242-251. [PMID: 35396150 DOI: 10.1016/j.neucli.2022.03.004] [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: 12/13/2021] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES To assess the accuracy of intraoperative neurophysiological monitoring (IONM) in predicting immediate and 3-month postoperative neurological new deficit (or deterioration) in patients benefiting from spinal cord (SC) surgery; and to identify factors associated with a higher risk of postoperative clinical worsening. METHODS Consecutive patients who underwent SC surgery with IONM were included. Pre and postoperative clinical (modified McCormick scale), radiological (lesion-occupying area ratio), and electrophysiological features were collected. RESULTS A total of 99 patients were included: 14 (14.1%) underwent extradural surgery, 50 (50.5%) intradural extramedullary surgery, and 35 (35.4%) intramedullary surgery. Cumulatively, multimodal IONM (motor and somatosensory evoked potentials, D-wave whenever possible) significantly predicted postoperative deficits (p<0.001), with a sensitivity, specificity, positive predictive value, and negative predictive value of 0.81, 0.93, 0.83, and 0.92, respectively. Sixty (60.6%) patients displayed no IONM change, whereas 39 (39.4%) displayed IONM worsening. In multivariate analysis, predictors for postoperative clinical worsening were: abnormal preoperative electrophysiological assessment (p=0.03), intramedullary tumor (p<0.001), lesion-occupying area ratio ≥0.7 (p<0.001), and IONM alterations (p<0.001). Three months after the surgical procedure, in patients presenting at least one of the risk factors described above, 45/81 (55.6%) and 19/81 (23.5%) were clinically and electrophysiologically improved, respectively; while 13/81 (16.0%) and 10/81 (12.3%) were clinically and electrophysiologically worsened. CONCLUSION Multimodal IONM is an essential tool to guide SC surgery, and enables the accurate prediction of postoperative neurological outcome. Specific attention should be given to patients presenting with preoperative electrophysiological abnormalities, large tumor volume, and intramedullary tumor location.
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Affiliation(s)
- Corentin Dauleac
- Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurologie Fonctionnelle et Epileptologie, Lyon, France; Université Lyon I, Université Claude Bernard, Lyon, France; Laboratoire CREATIS, CNRS UMR5220, Inserm U1206, INSA-Lyon; Université de Lyon I, Lyon, France.
| | - Sébastien Boulogne
- Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurologie Fonctionnelle et Epileptologie, Lyon, France; Université Lyon I, Université Claude Bernard, Lyon, France; Centre de Recherche de Neurosciences de Lyon, INSERM UMRS 1028, CNRS UMR 5292, Université Claude Bernard Lyon 1, Université de Lyon, F-69000 Lyon, France
| | - Cédric Y Barrey
- Université Lyon I, Université Claude Bernard, Lyon, France; Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurochirurgie C, Lyon, France
| | - Jacques Guyotat
- Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurochirurgie D, Lyon, France
| | - Emmanuel Jouanneau
- Université Lyon I, Université Claude Bernard, Lyon, France; Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurochirurgie B, Lyon, France
| | - Patrick Mertens
- Université Lyon I, Université Claude Bernard, Lyon, France; Centre de Recherche de Neurosciences de Lyon, INSERM UMRS 1028, CNRS UMR 5292, Université Claude Bernard Lyon 1, Université de Lyon, F-69000 Lyon, France; Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurochirurgie A, Lyon, France
| | - Moncef Berhouma
- Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurologie Fonctionnelle et Epileptologie, Lyon, France; Laboratoire CREATIS, CNRS UMR5220, Inserm U1206, INSA-Lyon; Université de Lyon I, Lyon, France; Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurochirurgie D, Lyon, France
| | - Julien Jung
- Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurologie Fonctionnelle et Epileptologie, Lyon, France; Université Lyon I, Université Claude Bernard, Lyon, France; Centre de Recherche de Neurosciences de Lyon, INSERM UMRS 1028, CNRS UMR 5292, Université Claude Bernard Lyon 1, Université de Lyon, F-69000 Lyon, France
| | - Nathalie André-Obadia
- Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Service de Neurologie Fonctionnelle et Epileptologie, Lyon, France; Université Lyon I, Université Claude Bernard, Lyon, France; Centre de Recherche de Neurosciences de Lyon, INSERM UMRS 1028, CNRS UMR 5292, Université Claude Bernard Lyon 1, Université de Lyon, F-69000 Lyon, France
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Chatain GP, Kortz MW, Serva S, Shrestha K, Hosokawa P, Ung TH, Finn M. Long-term Neurologic Outcome After Spinal Ependymoma Resection With Multimodal Intraoperative Electrophysiological Recording: Cohort Study and Review of the Literature. Neurospine 2022; 19:118-132. [PMID: 35378586 PMCID: PMC8987544 DOI: 10.14245/ns.2143200.600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/06/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate how multimodal intraoperative neuromonitoring (IONM) changes during spinal ependymoma (SE) resection correlate with long-term neuro-functional outcomes.
Methods A retrospective analysis of patients aged 18 years or older who underwent surgical resection for SE over a 10-year period was conducted. IONM changes were defined as sustained transcranial motor evoked potential (TcMEP) and/or somatosensory evoked potential (SSEP) signal decrease of 50% or greater from baseline. Primary endpoints were postoperative modified McCormick Neurologic Scale (MNS) scores at postoperative day (POD) < 2, 6 weeks, 1 year, and 2 years. Univariate and multivariate analyses were performed. Results Twenty-nine patients were identified. Average age was 44.2±15.4 years. Sixteen (55.2%) were male and 13 (44.8%) were female. Tumor location was 10 cervical-predominant (34.5%), 13 thoracic-predominant (44.8%), and 6 lumbar/conus-predominant (20.7%). A majority (69.0%) were World Health Organization grade 2 tumors. Twentyfour patients (82.8%) achieved gross total resection. Thirteen patients (44.8%) had a sustained documented IONM signal change and 10 (34.5%) had a TcMEP change with or without derangement in SSEP. At POD < 2, 6 weeks, 1 year, and 2 years, MNS was significantly higher for those when analyzing subgroups with either any sustained IONM or TcMEP±SSEP signal attenuation > 50% below baseline (all p<0.05).
Conclusion Sustained IONM derangements > 50% below baseline, particularly for TcMEP, are significantly associated with higher MNS postoperatively out to 2 years. Intraoperative and postoperative management of these patients warrant special consideration to limit neurologic morbidity.
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Affiliation(s)
- Grégoire P. Chatain
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
- Corresponding Author Grégoire P. Chatain https://orcid.org/0000-0002-7770-3009 Department of Neurosurgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO 80045, USA
| | - Michael W. Kortz
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephanie Serva
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Keshari Shrestha
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patrick Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO, USA
| | - Timothy H. Ung
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael Finn
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
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Kiang L, Woodington B, Carnicer-Lombarte A, Malliaras G, Barone DG. Spinal cord bioelectronic interfaces: opportunities in neural recording and clinical challenges. J Neural Eng 2022; 19. [PMID: 35320780 DOI: 10.1088/1741-2552/ac605f] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/23/2022] [Indexed: 11/11/2022]
Abstract
Bioelectronic stimulation of the spinal cord has demonstrated significant progress in restoration of motor function in spinal cord injury (SCI). The proximal, uninjured spinal cord presents a viable target for the recording and generation of control signals to drive targeted stimulation. Signals have been directly recorded from the spinal cord in behaving animals and correlated with limb kinematics. Advances in flexible materials, electrode impedance and signal analysis will allow SCR to be used in next-generation neuroprosthetics. In this review, we summarize the technological advances enabling progress in SCR and describe systematically the clinical challenges facing spinal cord bioelectronic interfaces and potential solutions, from device manufacture, surgical implantation to chronic effects of foreign body reaction and stress-strain mismatches between electrodes and neural tissue. Finally, we establish our vision of bi-directional closed-loop spinal cord bioelectronic bypass interfaces that enable the communication of disrupted sensory signals and restoration of motor function in SCI.
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Affiliation(s)
- Lei Kiang
- Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore, 169608, SINGAPORE
| | - Ben Woodington
- Department of Engineering, University of Cambridge, Electrical Engineering Division, 9 JJ Thomson Ave, Cambridge, Cambridge, CB2 1TN, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Alejandro Carnicer-Lombarte
- Clinical Neurosciences, University of Cambridge, Bioelectronics Laboratory, Cambridge, CB2 0PY, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - George Malliaras
- University of Cambridge, University of Cambridge, Cambridge, CB2 1TN, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Damiano G Barone
- Department of Engineering, University of Cambridge, Electrical Engineering Division, 9 JJ Thomson Ave, Cambridge, Cambridge, Cambridgeshire, CB2 1TN, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
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Soon WC, Fisher B, Chowdhury YA, Hodson J, Fashola E, Egbuji O, Leung A, Czyz M, Furtado N, Dhir J. Factors Influencing Surgical Outcomes for Intradural Spinal Tumours: A Single-Centre Retrospective Cohort Study. Cureus 2022; 14:e21815. [PMID: 35261834 PMCID: PMC8893976 DOI: 10.7759/cureus.21815] [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] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Intradural spinal tumours are relatively uncommon tumours of the central nervous system. In this study, we sought to assess our current practice and determine the factors which affect the surgical outcomes of intradural spinal tumour resection. Methods All consecutive patients who underwent surgical resection of intradural spinal tumours from December 2011 to November 2018 were retrospectively reviewed. The Modified McCormick Scale (MMS) was used to grade patients’ neurological status both pre-operatively and at the latest follow-up. The associations between changes in MMS and variables such as patient demographics, tumour location, number and experience of consultants involved in the procedure, use of intraoperative neuro-monitoring, bony spinal exposure and dural closure methods were assessed. A multivariable binary logistic regression model was performed to identify independent predictors of improvements in MMS. All analyses were performed using IBM SPSS 22 (IBM Corp. Armonk, NY), with p<0.05 deemed to be indicative of statistical significance throughout. Results A total of 145 patients met the inclusion criteria, with a median age of 56.5 years; of whom 119 had extramedullary tumours and 26 had intramedullary tumours. Methods of dural closure were variable, and there was an increasing trend over time towards using the laminoplasty approach for bony exposure. Neither the experience of consultants (p=0.991) nor the number of consultants involved (p=0.084) was found to be significantly associated with the change in MMS, with the strongest predictor being the baseline MMS (p<0.001). Patients who had adjuvant therapy were also significantly more likely to have a poorer neurological outcome (p=0.001). Conclusion A good neurological baseline is a significant positive predictor of an improved functional outcome. The number and seniority of consultant surgeons involved in intradural spinal tumour resections did not significantly alter the postoperative outcomes of patients in our single-unit retrospective study.
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Giammalva GR, Costanzo R, Paolini F, Benigno UE, Porzio M, Brunasso L, Basile L, Gulì C, Pino MA, Gerardi RM, Messina D, Umana GE, Palmisciano P, Scalia G, Graziano F, Visocchi M, Iacopino DG, Maugeri R. Management of Spinal Bone Metastases With Radiofrequency Ablation, Vertebral Reinforcement and Transpedicular Fixation: A Retrospective Single-Center Case Series. Front Oncol 2022; 11:818760. [PMID: 35127531 PMCID: PMC8814334 DOI: 10.3389/fonc.2021.818760] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/28/2021] [Indexed: 11/28/2022] Open
Abstract
Spine is a frequent site of bone metastases, with a 8.5 months median survival time after diagnosis. In most cases treatment is only palliative. Several advanced techniques can ensure a better Quality of Life (QoL) and increase life expectancy. Radiofrequency ablation (RFA) uses alternating current to produce local heating and necrosis of the spinal lesion, preserving the healthy bone. RFA is supported by vertebral reinforcement through kyphoplasty and vertebroplasty in order to stabilize the fracture with polymethylmethacrylate (PMMA) injection, restoring vertebral body height and reducing the weakness of healthy bone. The aim of this study is to demonstrate the efficacy and advantages of RFA plus vertebral reinforcement through PMMA vertebroplasty and fixation in patients affected by bone spinal metastases. We retrospectively analyzed 54 patients with thoraco-lumbar metastatic vertebral fractures admitted to our Unit between January 2014 and June 2020. Each patient underwent RFA followed by PMMA vertebroplasty and transpedicle fixation. We evaluated pain relief through the Visual Analogue Scale (VAS) Score and PMMA vertebral filling based on the mean Saliou filling score. Analysis of variance (ANOVA) was used to test pain relief with statistical significance for p<0.05. A total of 54 patients (median age 63,44 years; range 34-86 years), with a total of 63 infiltrated vertebrae, were treated with RFA, PMMA vertebroplasty and transpedicular screw fixation; average operative time was 60.4 min (range 51–72). The preoperative average VAS score decreased significantly from 7.81 to 2.50 (p < 0.05) after 12 months. Based on Saliou filling score, filling was satisfactory (12–18) in 20 vertebrae (31,7%), mediocre (6–11) in 33 vertebrae (52,4%), inadequate (0–5) in 10 vertebrae (15,9%). A consistent PMMA filling of vertebral bodies was successfully achieved with significant pain relief. Concomitant RFA, PMMA vertebroplasty and pedicle screw fixation represent a safe and effective technique for the management of spinal metastases, improving clinical outcome and pain control.
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Affiliation(s)
- Giuseppe Roberto Giammalva
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Roberta Costanzo
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Federica Paolini
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Umberto Emanuele Benigno
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Massimiliano Porzio
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Lara Brunasso
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Luigi Basile
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Carlo Gulì
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Maria Angela Pino
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosa Maria Gerardi
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Domenico Messina
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Emmanuele Umana
- Department of Neurosurgery, Cannizzaro Hospital Trauma Center Gamma Knife Center, Catania, Italy
| | - Paolo Palmisciano
- Department of Neurosurgery, Cannizzaro Hospital Trauma Center Gamma Knife Center, Catania, Italy
| | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy
| | - Francesca Graziano
- Department of Neurosurgery, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy
| | - Massimiliano Visocchi
- Institute of Neurosurgery, Catholic University School of Medicine, Policlinico “A. Gemelli”, Rome, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
- *Correspondence: Rosario Maugeri,
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Intramedullary spinal cord cavernous malformations-association between intraoperative neurophysiological monitoring changes and neurological outcome. Acta Neurochir (Wien) 2022; 164:2595-2604. [PMID: 36066749 PMCID: PMC9519689 DOI: 10.1007/s00701-022-05354-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Microsurgical resection of spinal cord cavernous malformations can be assisted by intraoperative neurophysiological monitoring (IONM). While the clinical outcome after surgical resection has been discussed in several case series, the association of intraoperative IONM changes and detailed neurological outcome, however, has not been analyzed so far. METHODS Seventeen patients with spinal cavernomas underwent surgery between 02/2004 and 06/2020. Detailed neurological and clinical outcome as well as IONM data including motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring were retrospectively analyzed. Intraoperative IONM changes were compared to outcome at 3-month and 1-year follow-up in order to identify surrogate parameters for an impending neurological deficit. RESULTS Compared to the preoperative state, McCormick score at 1-year follow-up remained unchanged in 12 and improved in five patients, none worsened, while detailed neurological examination revealed a new or worsened sensorimotor deficit in 4 patients. The permanent 80% amplitude reduction of MEP and 50% amplitude reduction of SSEP showed the best diagnostic accuracy with a sensitivity of 100% and 67% respectively and a specificity of 73% and 93% respectively. The relative risk for a new neurological deficit at 1-year follow-up, when reversible IONM-deterioration was registered compared to irreversible IONM deterioration, was 0.56 (0.23-1.37) for MEP deterioration and 0.4 (0.18-0.89) for SSEP deterioration. CONCLUSIONS Reversible IONM changes were associated with a better neurological outcome at follow-up compared to irreversible IONM deterioration during SCCM surgery. Our study favors the permanent 80% amplitude reduction criterion for MEP and 50% amplitude reduction criterion for SSEP for further prospective evaluation of IONM significance and the effectiveness of corrective maneuvers during SCCM surgeries.
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Feletti A, Boaro A, Giampiccolo D, Casoli G, Moscolo F, Ferrara M, Sala F, Pavesi G. Spinal hemangioblastomas: analysis of surgical outcome and prognostic factors. Neurosurg Rev 2021; 45:1645-1661. [PMID: 34825301 DOI: 10.1007/s10143-021-01696-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/02/2021] [Accepted: 11/11/2021] [Indexed: 11/29/2022]
Abstract
The prognostic factors for surgically removed spinal hemangioblastomas, the impact of VHL disease on outcome, and the role of intraoperative neuromonitoring are still not completely clear. The aim of this study was to review our experience with spinal hemangioblastomas in order to assess potential predictors of neurological outcome after surgery. All cases of spinal hemangioblastomas removed at two Italian academic institutions from 1985 to 2020 were reviewed. Data about clinical presentation and symptom duration, diagnosis of VHL, surgical approach, use of IONM, duration of hospital stay, follow-up, and modified McCormick grade before and after surgery were extracted. Sixty-one patients (31 F, 30 M) underwent 69 surgeries to remove 74 spinal hemangioblastomas (37 cervical, 32 thoracic, 5 lumbar). Improvement was found in 32.3% of cases, neurological condition remained stable in 51.6% of cases, and deteriorated in 16.1% of patients. A worsening trend in VHL patients and an improvement trend in non-VHL patients were detected, despite the lack of statistical significance. Laminotomy and use of IONM were found to be associated with better outcome, although no association was found between surgery without IONM and worse outcome. In most cases, patients affected by spinal hemangioblastomas can expect a good long-term outcome. In our experience, laminotomy seems to be associated with better outcome compared to laminectomy. While its absence is not associated with worse outcome, IONM seems to be associated with a better neurological outcome. Our study suggests that the more impaired the preoperative neurological condition, the worse the outcome.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Polo Chirurgico "P. Confortini", P.le Stefani 1, 37126, Verona, Italy.
| | - Alessandro Boaro
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Polo Chirurgico "P. Confortini", P.le Stefani 1, 37126, Verona, Italy
| | - Davide Giampiccolo
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Polo Chirurgico "P. Confortini", P.le Stefani 1, 37126, Verona, Italy
| | - Giorgio Casoli
- Unit of Neurosurgery, Department of Biomedicine, Metabolic Sciences and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Moscolo
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Polo Chirurgico "P. Confortini", P.le Stefani 1, 37126, Verona, Italy
| | - Massimiliano Ferrara
- Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IOV-IRCCS, Padova, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Polo Chirurgico "P. Confortini", P.le Stefani 1, 37126, Verona, Italy
| | - Giacomo Pavesi
- Unit of Neurosurgery, Department of Biomedicine, Metabolic Sciences and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
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Raffa G, Quattropani MC, Marzano G, Curcio A, Rizzo V, Sebestyén G, Tamás V, Büki A, Germanò A. Mapping and Preserving the Visuospatial Network by repetitive nTMS and DTI Tractography in Patients With Right Parietal Lobe Tumors. Front Oncol 2021; 11:677172. [PMID: 34249716 PMCID: PMC8268025 DOI: 10.3389/fonc.2021.677172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The goal of brain tumor surgery is the maximal resection of neoplastic tissue, while preserving the adjacent functional brain tissues. The identification of functional networks involved in complex brain functions, including visuospatial abilities (VSAs), is usually difficult. We report our preliminary experience using a preoperative planning based on the combination of navigated transcranial magnetic stimulation (nTMS) and DTI tractography to provide the preoperative 3D reconstruction of the visuospatial (VS) cortico-subcortical network in patients with right parietal lobe tumors. MATERIAL AND METHODS Patients affected by right parietal lobe tumors underwent mapping of both hemispheres using an nTMS-implemented version of the Hooper Visual Organization Test (HVOT) to identify cortical areas involved in the VS network. DTI tractography was used to compute the subcortical component of the network, consisting of the three branches of the superior longitudinal fasciculus (SLF). The 3D reconstruction of the VS network was used to plan and guide the safest surgical approach to resect the tumor and avoid damage to the network. We retrospectively analyzed the cortical distribution of nTMS-induced errors, and assessed the impact of the planning on surgery by analyzing the extent of tumor resection (EOR) and the occurrence of postoperative VSAs deficits in comparison with a matched historical control group of patients operated without using the nTMS-based preoperative reconstruction of the VS network. RESULTS Twenty patients were enrolled in the study (Group A). The error rate (ER) induced by nTMS was higher in the right vs. the left hemisphere (p=0.02). In the right hemisphere, the ER was higher in the anterior supramarginal gyrus (aSMG) (1.7%), angular gyrus (1.4%) superior parietal lobule (SPL) (1.3%), and dorsal lateral occipital gyrus (dLoG) (1.2%). The reconstruction of the cortico-subcortical VS network was successfully used to plan and guide tumor resection. A gross total resection (GTR) was achieved in 85% of cases. After surgery no new VSAs deficits were observed and a slightly significant improvement of the HVOT score (p=0.02) was documented. The historical control group (Group B) included 20 patients matched for main clinical characteristics with patients in Group A, operated without the support of the nTMS-based planning. A GTR was achieved in 90% of cases, but the postoperative HVOT score resulted to be worsened as compared to the preoperative period (p=0.03). The comparison between groups showed a significantly improved postoperative HVOT score in Group A vs. Group B (p=0.03). CONCLUSIONS The nTMS-implemented HVOT is a feasible approach to map cortical areas involved in VSAs. It can be combined with DTI tractography, thus providing a reconstruction of the VS network that could guide neurosurgeons to preserve the VS network during tumor resection, thus reducing the occurrence of postoperative VSAs deficits as compared to standard asleep surgery.
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Affiliation(s)
- Giovanni Raffa
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | | | - Giuseppina Marzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonello Curcio
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Vincenzo Rizzo
- Division of Neurology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gabriella Sebestyén
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Viktória Tamás
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - András Büki
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
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A case of chronic dysaesthesia in the torso and upper limbs: lessons from a cervical spinal cord subependymoma. Spinal Cord Ser Cases 2021; 7:52. [PMID: 34168112 DOI: 10.1038/s41394-021-00416-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Subependymomas are slow growing WHO grade 1 tumours, typically attached to the ventricular wall of the fourth or lateral ventricles. Spinal subependymomas are rarer still and experience of their biological characteristics remains limited. CASE PRESENTATION A 29-year-old lady presented with chronic attacks of itchy dysaesthesia involving the left hand, neck and trunk, and associated with ipsilateral leg spasms. Recent symptomatic change involved occasional limping and left sided facial numbness but no pain. MRI showed an intradural mass surrounding most of the cervical spinal cord, which appeared scalloped extrinsically, rather than diffusely expanded, by a seemingly extramedullary lesion. At operation, the cord appeared expanded, with no clear margin or distinction between tumour and cord tissue; and the tumour was found to be intramedullary with an exophytic component, rather than extramedullary. Moderate reduction of the left abductor pollicis brevis evoked potential led to a pause in surgery. There was transient hand weakness postoperatively with full recovery, and no radiological change in the tumour morphology for a further 6 years. DISCUSSION An intramedullary tumour such as a spinal cord subependymoma can be mistaken radiologically for an extramedullary tumour, such as an epidermoid. If a subependymoma is suspected, given its indolent course and long-term survival, caution in the extent of surgical resection is advisable in order to avoid surgical morbidity.
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Lee S, Cho DC, Rhim SC, Lee BJ, Hong SH, Koo YS, Park JH. Intraoperative Monitoring for Cauda Equina Tumors: Surgical Outcomes and Neurophysiological Data Accrued Over 10 Years. Neurospine 2021; 18:281-289. [PMID: 34218610 PMCID: PMC8255760 DOI: 10.14245/ns.2040660.330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/27/2020] [Accepted: 12/10/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Cauda equina tumors affect the peripheral nervous system, and the validities of triggered electromyogram (tEMG) and intraoperative neurophysiologic monitoring (IOM) are unclear. We sought to evaluate the accuracy and relevance of tEMG combined with IOM during cauda equina tumor resection. METHODS Between 2008 and 2018, an experienced surgeon performed cauda equina tumor resections using tEMG at a single institution. A cauda equina tumor was defined as an intradural-extramedullary or intradural-extradural tumor at the level of L2 or lower. The clinical presentation, extent of resection, pathology, recurrence, postoperative neurological outcomes, and intraoperative tEMG mapping and IOM data were retrospectively analyzed. RESULTS One hundred three patients who underwent intraoperative tEMG were included; 38 underwent only tEMG (tEMG-only group), and 65 underwent a combination of tEMG and multimodal IOM (MIOM group). There were no significant differences between the neurologic outcomes, extents of resection, or recurrence rates of the 2 groups. No significant therapeutic benefit was observed; however, the accuracy of intraoperative predetection improved with the combination of IOM and tEMG (accuracy: tEMG-only group, 86.8%; MIOM group, 92.3%). When the involved rootlet was resected despite the positive tEMG result, motor function worsened in 3 of 8 cases. The sensitivity and specificity of tEMG were 37.5% and 94.7%, respectively. CONCLUSION tEMG is an essential adjunctive surgical tool for deciding on and planning for rootlet resection. If the tEMG finding is negative, complete resection, involving the rootlet, may be safe. The accuracy may be further improved by using a combination of tEMG and IOM.
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Affiliation(s)
- Subum Lee
- Department of Neurosurgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Dae-Chul Cho
- Department of Neurosurgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Chul Rhim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Neuroscience & Radiosurgery Hybrid Research Center, College of Medicine, Goyang, Korea
| | - Seok Ho Hong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Seo Koo
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sugiyama K, Harada N, Kondo K, Wada A, Takahashi H, Sugo N. Relationship between Preoperative Neuroradiological Findings and Intraoperative Bulbocavernosus Reflex Amplitude in Patients with Intradural Extramedullary Tumors. Neurol Med Chir (Tokyo) 2021; 61:484-491. [PMID: 34078828 PMCID: PMC8365236 DOI: 10.2176/nmc.oa.2020-0425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The current study aimed to evaluate the relationship between preoperative neuroradiological findings and intraoperative bulbocavernosus reflex (BCR) amplitude in patients with intradural extramedullary tumors. A total of 24 patients with lesions below the 12th thoracic vertebra were included in the analysis. Objective and subjective urinary symptoms were investigated using data obtained from medical records and the core lower urethral symptom score (CLSS) questionnaire. The lesion compression rate was evaluated with MRI. In the epiconus-to-conus medullaris (Epi-CM) group, BCR amplitude changes were found to be correlated with the compression rate (p <0.05). The preoperative CLSS of the group with a BCR amplitude of <50% was worse than that of the group with ≥50% (p <0.01). The group did not experience symptom improvement 6 months postoperatively based on the CLSS. The preoperative CLSS of the group with compression rate of ≥80% on imaging was worse than that of the group with <80% (p <0.05). In the group with preoperative compression rate of ≥80%, CLSS at 1 month and 6 months postoperatively was improved as compared to preoperative CLSS (p <0.01, p <0.05). Hence, BCR amplitude changes are associated with the degree of lesion compression on preoperative images and pre- and postoperative urinary symptoms. Patients with intradural extramedullary Epi-CM lesions with strong compression are likely to present with low BCR amplitude and worsened postoperative symptoms. It is considered that the risk of postoperative urinary symptoms increases even with careful surgical manipulation under these conditions.
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Affiliation(s)
- Kunio Sugiyama
- Department of Neurosurgery, Toho University Graduate School of Medicine
| | - Naoyuki Harada
- Department of Neurosurgery, School of Medicine, Faculty of Medicine, Toho University
| | - Kosuke Kondo
- Department of Neurosurgery, School of Medicine, Faculty of Medicine, Toho University
| | - Akihito Wada
- Department of Orthopedic Surgery, Toho University School of Medicine
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Toho University School of Medicine
| | - Nobuo Sugo
- Department of Neurosurgery, Toho University Graduate School of Medicine.,Department of Neurosurgery, School of Medicine, Faculty of Medicine, Toho University
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Ruschel LG, Aragão A, de Oliveira MF, Milano JB, Neto MC, Ramina R. Correlation of Intraoperative Neurophysiological Parameters and Outcomes in Patients with Intramedullary Tumors. Asian J Neurosurg 2021; 16:243-248. [PMID: 34268146 PMCID: PMC8244684 DOI: 10.4103/ajns.ajns_234_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/09/2020] [Accepted: 10/05/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Intramedullary spinal cord tumors (IMSCT) account for about 2%-4% of all central nervous system tumors. Surgical resection is the main treatment step, but might cause damage to functional tissues. Intraoperative neuromonitoring (IONM) is an adopted measure to decrease surgical complications. Below, we describe the results of IMSCT submitted to surgery under IONM at a tertiary institution. Methods The sample consisted of consecutive patients with IMSCT admitted to the Neurological Institute of Curitiba from January 2007 to November 2016. A total of 47 patients were surgically treated. Twenty-three were male (48.9%) and 24 were female (51.1%). The mean age was 42.77 years. The mean follow-up time was 42.7 months. Results Neurological status improved in 29 patients (62%), stable in 6 (13%), and worse in 12 (25%). Patients who presented with motor symptoms at initial diagnosis had a worse outcome compared to patients with sensory impairment and pain (P = 0.026). Patients with a change in electromyography had worse neurological outcomes compared to patients who did not show changes in monitoring (P = 0.017). Discussion and Conclusion No prospective randomized high evidence study has been performed to date to compare clinical evolution after surgery with or without monitoring. In our sample, surgical resection was well succeeded mainly in oligosymptomatic patients with low preoperative McCormick classification and no worsening of IONM during surgery. We believe that microsurgical resection of IMSCT with simultaneous IONM is the gold standard treatment and achieved with good results.
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Affiliation(s)
- Leonardo Gilmone Ruschel
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil.,DFV Neuro, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Afonso Aragão
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil
| | - Matheus Fernandes de Oliveira
- DFV Neuro, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.,Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | | | - Mauricio Coelho Neto
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil
| | - Ricardo Ramina
- Department of Neurosurgery, Neurological Institute of Curitiba, Curitiba, Paraná, Brazil
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Gembruch O, Ahmadipour Y, Chihi M, Dinger TF, Rauschenbach L, Pierscianek D, Jabbarli R, Sure U, Wrede KH, Uerschels AK. Lipomas as an Extremely Rare Cause for Brachial Plexus Compression: A Case Series and Systematic Review. J Brachial Plex Peripher Nerve Inj 2021; 16:e10-e16. [PMID: 33868454 PMCID: PMC8043811 DOI: 10.1055/s-0041-1726087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction
Brachial plexus lipomas are extremely rare benign tumors that may cause slow progression of neurological deficits leading to thoracic outlet syndrome. Up to now, surgery remains challenging. The aim of this study is to present our surgical treatment regime and long-term neurological outcome in three cases of giant brachial plexus lipomas and to show results of systematic review.
Patients and Methods
Retrospective analysis of our database “peripheral nerve lesion” to identify patients suffering from brachial plexus lipomas between January 1, 2012, and December 31, 2019. Systematic review was performed for literature published until March 31, 2020, analyzing PubMed, Google Scholar, Scopus, and the Cochrane Collaboration Library independently by two authors.
Results
Over the past years, three patients suffering from giant brachial plexus lipomas attended to our neurosurgical department. All patients underwent preoperative magnetic resonance imaging (MRI), ultrasound examinations, and electrophysiological testing. Tumors were removed microsurgically via anterior/posterior, supraclavicular/infraclavicular, and combined approaches. The patients were accessed postoperatively by MRI and clinical follow-up. Systematic review of the literature revealed 22 cases, which were analyzed in regard to demographics, surgical treatment, and neurological outcome.
Conclusion
Brachial plexus lipomas are an extremely rare cause for brachial plexus compression. Total microsurgical removal with intraoperative electrophysiological monitoring is the treatment of choice with excellent long-term MRI and clinical outcome.
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Affiliation(s)
- Oliver Gembruch
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Toll BJ, Samdani AF, Pahys JM, Franco A, Yezdani SG, Hwang SW. Single-Staged Management of Pediatric Neuropathic Scoliosis with Intradural-Extramedullary Schwannoma and Improvement in Intraoperative Neuromonitoring: A Case Report. JBJS Case Connect 2021; 10:e0352. [PMID: 32649096 DOI: 10.2106/jbjs.cc.19.00352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 16-year-old girl with lumbar prominence presented to our outpatient clinic complaining of sporadic back pain without paresthesia. Radiographic investigation revealed a 68° left thoracolumbar curve with the apex at L1. Preoperative magnetic resonance imaging identified a mass at T10-11, subsequently confirmed by pathology as a schwannoma. She was treated surgically with resection and posterior spinal fusion in a single-staged procedure under neuromonitoring guidance. Intraoperative improvement in motor evoked potentials after resection informed the decision to perform simultaneous deformity correction. CONCLUSION We discuss the unusual coincidence of a schwannoma with scoliosis and our management algorithm based on operative changes in neuromonitoring.
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Affiliation(s)
- Brandon J Toll
- 1Departments of Orthopaedic Surgery and Neurosurgery, Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania 2Division of Intraoperative Neuromonitoring, SpecialtyCare, Brentwood, Tennessee
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Scibilia A, Cebula H, Esposito F, Angileri FF, Raffa G, Todeschi J, Koch G, Clavert P, Debry C, Germanò A, Proust F, Chibbaro S. Endoscopic Endonasal Approach to the Ventral-Medial Portion of Posterior Paramedian Skull Base: A Morphometric Perspective of Surgical and Radiologic Anatomy. World Neurosurg 2021; 149:e687-e695. [PMID: 33540106 DOI: 10.1016/j.wneu.2021.01.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 01/24/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study aims to provide morphometric analysis of endoscopic endonasal approach (EEA) to the ventral-medial portion of posterior paramedian skull base. Furthermore, it aims to investigate the surgical exposure obtained through EEA with and without eustachian tube (ET) removal, emphasizing the role of contralateral nostril (CN) access. METHODS Five fresh adult head specimens were prepared for dissection. A predissection and a postdissection computed tomography study was performed. A surgically oriented classification into 4 regions was used: 1) tubercular region; 2) occipital condyle region; 3) parapharyngeal space (PPhS) region; and 4) jugular foramen (JF) region. The Student t-test was used to compare angulations and measures of EEA with access from the ipsilateral and CN, respectively, with and without ET removal. RESULTS EEA to the ventral-medial portion of posterior paramedian skull base encompasses 2 medial trajectories (transtubercular and transcondylar) and 2 lateral pathways to the PPhS and JF. The CN access, without removal of the ET, allows a complete exposure of the petrous and intrajugular portion of the JF and superior PPhS without exposition of the parapharyngeal segment of internal carotid artery. The ipsilateral nostril approach with ET removal allows to obtain a wider exposure, reaching the medial sigmoid part of the JF. No significant differences exist in regard to transtubercular and transcondylar approaches. CONCLUSIONS This study suggests that EEA to posterior paramedian skull base allows the realization of a corridor directed to the jugular tubercle, occipital condyle, medial PPhS, and ventral-medial JF. The CN approach with ET preservation can expose the petrous and intrajugular parts of the JF and PPhS. Case series are needed to demonstrate benefits and drawbacks of these approaches.
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Affiliation(s)
- Antonino Scibilia
- Division of Neurosurgery, University of Messina, Messina, Italy; Division of Neurosurgery, University of Strasbourg, Strasbourg, France
| | - Hélène Cebula
- Division of Neurosurgery, University of Strasbourg, Strasbourg, France
| | - Felice Esposito
- Division of Neurosurgery, University of Messina, Messina, Italy; Division of Neurosurgery, Federico II University of Naples, Naples, Italy.
| | | | - Giovanni Raffa
- Division of Neurosurgery, University of Messina, Messina, Italy
| | - Julien Todeschi
- Division of Neurosurgery, University of Strasbourg, Strasbourg, France
| | - Guillame Koch
- Department of Normal Human Anatomy, University of Strasbourg, Strasbourg, France
| | - Philippe Clavert
- Department of Normal Human Anatomy, University of Strasbourg, Strasbourg, France
| | - Christian Debry
- Division of ENT Surgery, University of Strasbourg, Strasbourg, France
| | | | - François Proust
- Division of Neurosurgery, University of Strasbourg, Strasbourg, France
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Olguner SK, Arslan A, Açık V, İstemen İ, Can M, Gezercan Y, Ökten Aİ. Sodium Fluorescein for Spinal Intradural Tumors. Front Oncol 2021; 10:618579. [PMID: 33585245 PMCID: PMC7877540 DOI: 10.3389/fonc.2020.618579] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/11/2020] [Indexed: 01/11/2023] Open
Abstract
Technological innovations in spinal intradural tumor surgery simplify treatment. Surgical treatment of cranial benign and malignant pathologies under microscope with sodium (Na)-fluorescein guidance has often been reported, but few studies have focused on spinal intradural tumors. We aimed to investigate the usefulness of Na-fluorescein under yellow filter in intradural spinal tumor surgery by retrospectively reviewing cases involving intramedullary and extramedullary tumors operated under the guidance of Na-fluorescein. Forty-nine adult patients with a diagnosis of spinal intradural tumor operated under a yellow filter (560 nm) microscope using Na-fluorescein dye were included in the study. Demographic data, such as age and sex, neurological status, extent of tumor resection, histopathological diagnosis, Na-fluorescein staining pattern, and its usefulness during surgery were noted and statistically analyzed. Of all recruited patients, 26 women (53.1%) and 23 men (46.9%), were included for analysis. The age range of the patients was 18–64 years, with a mean age of 41.6 ± 13.9. An intradural intramedullary mass was found in 30.6% (n = 15) of the patients, and an intradural extramedullary mass in 69.4% (n: 34). While Na-fluorescein staining was homogeneous in all intradural extramedullary tumors, 73.3% (n: 11) of intradural intramedullary tumors were homogeneous, and 13.3% (n: 2) moderately heterogeneous. In the whole study group, the Na-fluorescein staining pattern was helpful in surgical resection in 47 cases (95.9%). While 34/34 (100%) found it helpful for extramedullary tumors, 13/15 (86.7%) did in intramedullary tumors, and for 2/15 (13.3%) it was not. In conclusion, Na-fluorescein helps in distinguishing tumor from healthy tissue in intradural extramedullary and intramedullary tumor surgery under a yellow filter microscope in most cases, thus providing convenient assistance to surgeons.
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Affiliation(s)
- Semih Kivanc Olguner
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Ali Arslan
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Vedat Açık
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - İsmail İstemen
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Mehmet Can
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Yurdal Gezercan
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Ali İhsan Ökten
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
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Frazzetta JN, Hofler RC, Adams W, Schneck MJ, Jones GA. The Significance of Motor Evoked Potential Changes and Utility of Multimodality Intraoperative Monitoring in Spinal Surgery: A Retrospective Analysis of Consecutive Cases at a Single Institution. Cureus 2020; 12:e12065. [PMID: 33489485 PMCID: PMC7806190 DOI: 10.7759/cureus.12065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2020] [Indexed: 11/05/2022] Open
Abstract
Objective The objective of the study is to identify specific population groups that may benefit from intraoperative motor evoked potentials (MEP) and to assess positive predictive value (PPV) and negative predictive value (NPV) changes during operation by correlating these with postoperative motor outcomes. Methods We retrospectively reviewed 1,043 consecutive patient cases undergoing spine surgery with and without intraoperative monitoring (IOM) at a single institution from January 1, 2016 to December 31, 2017. Demographic and clinical outcome data were collected at multiple time points. An MEP amplitude decrease of 50% or greater was correlated with a motor deficit for this study. Results On multivariate analysis, patients with coronary artery disease and who received IOM were more likely to experience no new deficit (p=0.047) than those who did not receive IOM. Additionally, patients with hyperlipidemia and coronary artery disease (CAD) were less likely than those without to experience no new deficit (p=0.001 and p=0.02, respectively). MEP accounted for 244 cases, of which 15 had alert MEP criteria but no deficit for a PPV of 21.05% at day 1 post-operation. Day 7-30 PPV declined to 14.29%, and by day 90, there was no association. Conclusion Among patients in our study with CAD, IOM use was associated with significantly better outcomes. Patients with higher intraoperative blood loss, hyperlipidemia, and those with CAD were at increased risk of new neurological deficit. The use of motor evoked potentials was associated with low sensitivity and low PPV.
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Affiliation(s)
- Joseph N Frazzetta
- Neurosurgery, Loyola University Stritch School of Medicine, Maywood, USA
| | - Ryan C Hofler
- Neurosurgery, Loyola University Medical Center, Maywood, USA
| | - William Adams
- Neurosurgery, Loyola University Stritch School of Medicine, Maywood, USA
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Intraspinal epidermoid and dermoid cysts-tumor resection with multimodal intraoperative neurophysiological monitoring and long-term outcome. Acta Neurochir (Wien) 2020; 162:2895-2903. [PMID: 32524245 DOI: 10.1007/s00701-020-04446-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intraspinal epidermoid/dermoid cysts are very rare, benign tumors arising from pathological displacement of epidermal cells into the spinal canal. Literature data about the long-term outcome after microsurgical resection with multimodal intraoperative neurophysiological monitoring (IONM) are lacking. We analyzed one of the largest case series with special regard to intraoperative characteristics and long-term outcome after IONM-aided surgery. METHOD All 12 patients (m:f = 1.4:1) who underwent microsurgical tumor resection with multimodal IONM for intraspinal epidermoid/dermoid tumors between 1998 and 2019 in our university hospital were included. We retrospectively investigated the patients' characteristics, imaging/surgical parameters, and postoperative long-term outcomes. RESULTS Symptomatic tumor manifestation was seen during adulthood in 4 patients (median age 33.0 years) and during childhood in 8 patients (median age 4.3 years). Spinal dysraphism was the most often comorbidity (75%). The most frequent symptoms at diagnosis were spastic pareses (75%), ataxia (58%), and vegetative disorders (42%). Tumors were most often lumbosacral (L1-L5 42%, L5-S3 50%) and intradural-extramedullary (92%). For microsurgical resection, IONM with EMG, SSEPs, and TcMEPs of the limbs and pudendal nerve/anal sphincter was always applied and feasible; intraoperative corrective actions were initiated in three cases due to transient IONM deterioration. None of the patients showed a postoperative deterioration of the neurological status with a gross total resection rate of 92%. Pain situation, McCormick grade, and mJOA Score were improved at long-term follow-up (median 4.8 years). CONCLUSIONS IONM-aided resection of intraspinal epidermoid/dermoid tumors is feasible both in adult and pediatric cases and enables a satisfying clinical and surgical outcome.
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García Pérez F, Vargas López AJ, Velasco Albendea FJ, Narro Donate JM, Villalobos López P, Masegosa González J. Mature filum terminale teratoma. Excision guided by direct stimulation of nerve roots. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30104-4. [PMID: 33097420 DOI: 10.1016/j.neucir.2020.08.005] [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: 05/18/2020] [Revised: 07/30/2020] [Accepted: 08/21/2020] [Indexed: 11/19/2022]
Abstract
A 45-year-old male patient, with no history of interest, consulted in emergency department due to a progressive loss of strength in the lower limbs at the distal level with impossibility for dorsal flexion of the left foot, as well as neurogenic bladder. The MRI revealed a mass at the filum terminale with completed occupation of transverse diameter of the dural sac. The radiological diagnosis was lipoma of filum terminale. The patient underwent surgery with intraoperative neurophysiological monitoring using direct stimulation of nerve roots, which allowed the removal of a tumour composed of sebaceous material, fat and hair. The anatomopathological study classified it as a mature cystic teratoma. Postoperative evolution was favorable.
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Sudden onset temporary loss of SSEP and MEP as a result to positional neck changes in an intradural extramedullary cervical spine schwannoma: A case report. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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WITHDRAWN:The significance of motor evoked potential changes in spinal surgery: A retrospective analysis of consecutive cases at a single institution. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Raffa G, Picht T, Scibilia A, Rösler J, Rein J, Conti A, Ricciardo G, Cardali SM, Vajkoczy P, Germanò A. Surgical treatment of meningiomas located in the rolandic area: the role of navigated transcranial magnetic stimulation for preoperative planning, surgical strategy, and prediction of arachnoidal cleavage and motor outcome. J Neurosurg 2020; 133:107-118. [PMID: 31200378 DOI: 10.3171/2019.3.jns183411] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/15/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Surgical treatment of convexity meningiomas is usually considered a low-risk procedure. Nevertheless, the risk of postoperative motor deficits is higher (7.1%-24.7% of all cases) for lesions located in the rolandic region, especially when an arachnoidal cleavage plane with the motor pathway is not identifiable. The authors analyzed the possible role of navigated transcranial magnetic stimulation (nTMS) for planning resection of rolandic meningiomas and predicting the presence or lack of an intraoperative arachnoidal cleavage plane as well as the postoperative motor outcome. METHODS Clinical data were retrospectively collected from surgical cases involving patients affected by convexity, parasagittal, or falx meningiomas involving the rolandic region, who received preoperative nTMS mapping of the motor cortex (M1) and nTMS-based diffusion tensor imaging (DTI) fiber tracking of the corticospinal tract before surgery at 2 different neurosurgical centers. Surgeons' self-reported evaluation of the impact of nTMS-based mapping on surgical strategy was analyzed. Moreover, the nTMS mapping accuracy was evaluated in comparison with intraoperative neurophysiological mapping (IONM). Lastly, we assessed the role of nTMS as well as other pre- and intraoperative parameters for predicting the patients' motor outcome and the presence or absence of an intraoperative arachnoidal cleavage plane. RESULTS Forty-seven patients were included in this study. The nTMS-based planning was considered useful in 89.3% of cases, and a change of the surgical strategy was observed in 42.5% of cases. The agreement of nTMS-based planning and IONM-based strategy in 35 patients was 94.2%. A new permanent motor deficit occurred in 8.5% of cases (4 of 47). A higher resting motor threshold (RMT) and the lack of an intraoperative arachnoidal cleavage plane were the only independent predictors of a poor motor outcome (p = 0.04 and p = 0.02, respectively). Moreover, a higher RMT and perilesional edema also predicted the lack of an arachnoidal cleavage plane (p = 0.01 and p = 0.03, respectively). Preoperative motor status, T2 cleft sign, contrast-enhancement pattern, and tumor volume had no predictive value. CONCLUSIONS nTMS-based motor mapping is a useful tool for presurgical assessment of rolandic meningiomas, especially when a clear cleavage plane with M1 is not present. Moreover, the RMT can indicate the presence or absence of an intraoperative cleavage plane and predict the motor outcome, thereby helping to identify high-risk patients before surgery.
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Affiliation(s)
- Giovanni Raffa
- 1Division of Neurosurgery, University of Messina, Italy; and
| | - Thomas Picht
- 2Department of Neurosurgery, Charité Universitätsmedizin Berlin, Germany
| | | | - Judith Rösler
- 2Department of Neurosurgery, Charité Universitätsmedizin Berlin, Germany
| | - Johannes Rein
- 2Department of Neurosurgery, Charité Universitätsmedizin Berlin, Germany
| | - Alfredo Conti
- 1Division of Neurosurgery, University of Messina, Italy; and
- 2Department of Neurosurgery, Charité Universitätsmedizin Berlin, Germany
| | | | | | - Peter Vajkoczy
- 2Department of Neurosurgery, Charité Universitätsmedizin Berlin, Germany
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Greve T, Stoecklein VM, Dorn F, Laskowski S, Thon N, Tonn JC, Schichor C. Introduction of intraoperative neuromonitoring does not necessarily improve overall long-term outcome in elective aneurysm clipping. J Neurosurg 2020; 132:1188-1196. [PMID: 30925469 DOI: 10.3171/2018.12.jns182177] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative neuromonitoring (IOM), particularly of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs), evolved as standard of care in a variety of neurosurgical procedures. Case series report a positive impact of IOM for elective microsurgical clipping of unruptured intracranial aneurysms (ECUIA), whereas systematic evaluation of its predictive value is lacking. Therefore, the authors analyzed the neurological outcome of patients undergoing ECUIA before and after IOM introduction to this procedure. METHODS The dates of inclusion in the study were 2007-2014. In this period, ECUIA procedures before (n = 136, NIOM-group; 2007-2010) and after introduction of IOM (n = 138, IOM-group; 2011-2014) were included. The cutoff value for SSEP/MEP abnormality was chosen as an amplitude reduction ≥ 50%. SSEP/MEP changes were correlated with neurological outcome. IOM-undetectable deficits (bulbar, vision, ataxia) were not included in risk stratification. RESULTS There was no significant difference in sex distribution, follow-up period, subarachnoid hemorrhage risk factors, aneurysm diameter, complexity, and location. Age was higher in the IOM-group (57 vs 54 years, p = 0.012). In the IOM group, there were 18 new postoperative deficits (13.0%, 5.8% permanent), 9 hemisyndromes, 2 comas, 4 bulbar symptoms, and 3 visual deficits. In the NIOM group there were 18 new deficits (13.2%; 7.3% permanent, including 7 hemisyndromes). The groups did not significantly differ in the number or nature of postoperative deficits, nor in their recovery rate. In the IOM group, SSEPs and MEPs were available in 99% of cases. Significant changes were noted in 18 cases, 4 of which exhibited postoperative hemisyndrome, and 1 suffered from prolonged comatose state (5 true-positive cases). Twelve patients showed no new detectable deficits (false positives), however 2 of these cases showed asymptomatic infarction. Five patients with new hemisyndrome and 1 comatose patient did not show significant SSEP/MEP alterations (false negatives). Overall sensitivity of SSEP/MEP monitoring was 45.5%, specificity 89.8%, positive predictive value 27.8%, and negative predictive value 95.0%. CONCLUSIONS The assumed positive impact of introducing SSEP/MEP monitoring on overall neurological outcome in ECUIA did not reach significance. This study suggests that from a medicolegal point of view, IOM is not stringently required in all neurovascular procedures. However, future studies should carefully address high-risk patients with complex procedures who might benefit more clearly from IOM than others.
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Affiliation(s)
| | | | - Franziska Dorn
- 2Neuroradiology, Ludwig-Maximilians-University, Campus Grosshadern, Munich, Germany
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