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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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Shah HA, Chen A, Green R, Ber R, D'Amico RS, Sciubba DM, Lo SFL, Silverstein JW. Direct (D)-Wave Monitoring Enhancement With Subdural Electrode Placement: A Case Series. J Clin Neurophysiol 2024:00004691-990000000-00140. [PMID: 38916920 DOI: 10.1097/wnp.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
PURPOSE Direct-wave (D-wave) neuromonitoring is a direct measure of corticospinal tract integrity that detects potential injury during spinal cord surgery. Epidural placement of electrodes used for D-wave measurements can result in high electrical impedances resulting in substantial signal noise that can compromise signal interpretation. Subdural electrode placement may offer a solution. METHODS Medical records for consecutive patients with epidural and subdural D-wave monitoring were reviewed. Demographic and clinical information including preoperative and postoperative motor strength were recorded. Neuromonitoring charts were reviewed to characterize impedances and signal amplitudes of D-waves recorded epidurally (before durotomy) and subdurally (following durotomy). Nonparametric statistics were used to compare epidural and subdural D-waves. RESULTS Ten patients (50% women, median age 50.5 years) were analyzed, of which five patients (50%) were functionally independent (modified McCormick grade ≤ II) preoperatively. D-waves were successfully acquired by subdural electrodes in eight cases and by epidural electrodes in three cases. Subdural electrode placement was associated with lower impedance values ( P = 0.011) and a higher baseline D-wave amplitude ( P = 0.007) relative to epidural placement. No association was observed between D-wave obtainability and functional status, and no adverse events relating to subdural electrode placement were encountered. CONCLUSIONS Subdural electrode placement allows successful D-wave acquisition with accurate monitoring, clearer waveforms, and a more optimal signal-to-noise ratio relative to epidural placement. For spinal surgeries where access to the subdural compartment is technically safe and feasible, surgeons should consider subdural placement when monitoring D-waves to optimize clinical interpretation.
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Affiliation(s)
- Harshal A Shah
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, U.S.A
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A
| | - Adrian Chen
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, U.S.A
| | - Ross Green
- Department of Neurological Surgery, Northern Westchester Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A
| | - Roee Ber
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, U.S.A
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A
| | - Daniel M Sciubba
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, U.S.A
| | - Sheng-Fu Larry Lo
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, U.S.A
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A
- Department of Neurology, North Shore University Hospital /Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, U.S.A.; and
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, New York, U.S.A
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Hamer RP, Chen A, Gogos A. Bilateral epidural D-wave monitoring during resection of an eccentric cervical astrocytoma with evidence of asymmetrical corticospinal desynchronization. Br J Neurosurg 2024:1-7. [PMID: 38818752 DOI: 10.1080/02688697.2024.2359452] [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: 03/05/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND AND IMPORTANCE The surgical management of intramedullary spinal cord tumours (IMSCT) poses inherent risk to neurologic function. Direct-wave (D-wave) monitoring is routinely reported to be a robust prognostic measure of spinal cord function via midline recording within the epidural or intradural space in a cranial-caudal montage. We explored the feasibility of bilateral epidural D-wave monitoring with routine evoked potentials in promoting safe and maximal resection in a patient with diminished midline D-wave baselines associated with an eccentric intramedullary cervical astrocytoma. CLINICAL PRESENTATION We describe the presentation, surgical management, electrophysiological findings and post-operative outcome of a 46 year-old female patient who underwent two resections for an eccentric intramedullary cervical astrocytoma. During the first procedure we encountered clinically significant motor evoked potential signal change and discontinuation of resection pending further review. Midline D-wave signals showed no change, however peak amplitude was diminutive (7 uV) and overall morphology was characteristic of corticospinal desynchronization. Post-operatively the patient experienced significant but transient left sided weakness. A subsequent revision procedure incorporating ipsilesional and contralesional D-wave monitoring in addition to routinely incorporated evoked potentials was proposed in order to facilitate a safer resection. The ipsilesional D-wave response was considerably lower in amplitude (2.5 uV) in contrast to the contralesional D-wave (20 uV). CONCLUSION To the authors' knowledge this is the first description of bilateral D-wave monitoring as an adjunct to cranial-caudal D-wave montages during IMSCT surgery. In patients with corticospinal desynchronization evidenced by abnormal midline D-wave morphology, bilateral D-wave monitoring in conjunction with routine evoked potentials may be clinically indicated for preservation of motor function and promotion of safe and maximal resection.
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Affiliation(s)
- Ryan P Hamer
- Department of Neurosurgery, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Annie Chen
- Department of Neurosurgery, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Andrew Gogos
- Department of Neurosurgery, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
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Guzzi G, Ricciuti RA, Della Torre A, Lo Turco E, Lavano A, Longhini F, La Torre D. Intraoperative Neurophysiological Monitoring in Neurosurgery. J Clin Med 2024; 13:2966. [PMID: 38792507 PMCID: PMC11122101 DOI: 10.3390/jcm13102966] [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: 04/16/2024] [Revised: 05/08/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Intraoperative neurophysiological monitoring (IONM) is a crucial advancement in neurosurgery, enhancing procedural safety and precision. This technique involves continuous real-time assessment of neurophysiological signals, aiding surgeons in timely interventions to protect neural structures. In addition to inherent limitations, IONM necessitates a detailed anesthetic plan for accurate signal recording. Given the growing importance of IONM in neurosurgery, we conducted a narrative review including the most relevant studies about the modalities and their application in different fields of neurosurgery. In particular, this review provides insights for all physicians and healthcare professionals unfamiliar with IONM, elucidating commonly used techniques in neurosurgery. In particular, it discusses the roles of IONM in various neurosurgical settings such as tumoral brain resection, neurovascular surgery, epilepsy surgery, spinal surgery, and peripheral nerve surgery. Furthermore, it offers an overview of the anesthesiologic strategies and limitations of techniques essential for the effective implementation of IONM.
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Affiliation(s)
- Giusy Guzzi
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | | | - Attilio Della Torre
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | - Erica Lo Turco
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | - Angelo Lavano
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
- Anesthesia and Intensive Care Unit, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
| | - Domenico La Torre
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
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Baig Mirza A, Vastani A, Syrris C, Boardman T, Ghani I, Murphy C, Gebreyohanes A, Vergani F, Mirallave-Pescador A, Lavrador JP, Kailaya Vasan A, Grahovac G. Intraoperative Neurophysiological Monitoring for Intradural Extramedullary Spinal Tumours. Global Spine J 2024; 14:1304-1315. [PMID: 36411068 PMCID: PMC11289564 DOI: 10.1177/21925682221139822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Intraoperative neurophysiological monitoring (IONM) is widely used in spinal neurosurgery, particularly for intramedullary tumours. However, its validity in intradural extramedullary (IDEM) spinal tumours is less clearly defined, this being the focus of this study. METHODS We compared outcomes for patients that underwent resection of IDEM tumours with and without IONM between 2010 and 2020. Primary outcomes were postoperative American Spinal Injury Association (ASIA) scores. Other factors assessed were use of intraoperative ultrasound, drain placement, postoperative complications, postoperative Eastern Cooperative Oncology Group (ECOG) score, extent of resection, length of hospital stay, discharge location and recurrence. RESULTS 163 patients were included, 71 patients in the IONM group and 92 in the non-IONM group. No significant differences were noted in baseline demographics. For preoperative ASIA D patients, 44.0% remained ASIA D and 49.9% improved to ASIA E in the IONM group, compared to 39.7% and 30.2% respectively in the non-IONM group. For preoperative ASIA E patients, 50.3% remained ASIA E and 44.0% deteriorated to ASIA D in the IONM group, compared to 30.2% and 39.7% respectively in the non-IONM group (all other patients deteriorated further). Length of inpatient stay was significantly shorter in the IONM group (P = .043). There were no significant differences in extent of resection, postoperative complications, discharge location or tumour recurrence. CONCLUSIONS Research focusing on the use of IONM in IDEM tumour surgery remains scarce. Our study supports the use of IONM during surgical excision of IDEM tumours.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Amisha Vastani
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Christoforos Syrris
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Timothy Boardman
- GKT School of Medical Education, King’s College London, London, UK
| | - Imran Ghani
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Christopher Murphy
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Axumawi Gebreyohanes
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Francesco Vergani
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Ana Mirallave-Pescador
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
- Department of Clinical Neurophysiology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Jose P. Lavrador
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Ahilan Kailaya Vasan
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Gordan Grahovac
- Department of Neurosurgery, King’s College Hospital NHS Foundation Trust, London, UK
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Li K, Tao X, Liu J, Yang J, Shi J, Wu X, Jia W, Fan X, Qiao H. The application value and improved warning criterion of D-wave monitoring in intramedullary spinal cord tumor surgery. Spine J 2024:S1529-9430(24)00197-9. [PMID: 38679075 DOI: 10.1016/j.spinee.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND CONTEXT The primary treatment method for intramedullary spinal cord tumor (IMSCT) is surgical resection, but this procedure carries a significant risk of neurological damage. Intraoperative neurophysiological monitoring (IONM) has become a necessary adjunctive tool for IMSCT resection. PURPOSE The current study aimed to explore the application value of D-wave monitoring in IMSCT surgery, and tried to investigate a tailored criterion for its early warning. STUDY DESIGN A retrospective clinical study. PATIENT SAMPLE A retrospective analysis was conducted based on the data of patients who underwent IMSCT surgeries performed by the same neurosurgical team at our hospital. IONM was applied in all surgeries. According to inclusion and exclusion criteria, ultimately 90 patients were enrolled in the study. OUTCOME MEASURES The McCormick Scale (MMS) was applied to assess the functional outcome through outpatient visits or telephone follow-up at one month and six months postoperatively. Patients with an MMS grade over II one month after surgery were considered to have newly developed postoperative motor dysfunction (PMD). If the MMS grade could be restored to I or II six months after surgery, it was defined as a short-term PMD. Otherwise, it was defined as a long-term PMD. METHODS The predictive value of different IONM modalities, including somatosensory evoked potential (SEP), muscle motor evoked potential (MEP), and D-wave for PMD, was assessed with sensitivity, specificity, positive predictive value, negative predictive value, and subsequent logistic regression analysis. At last, the cut-off value of the D-wave amplitude reduction ratio for predicting PMD was obtained through the receiver operating characteristic (ROC) curve analysis. RESULTS SEP showed the worst performance in predicting short-term and long-term PMD. Significant MEP changes were indicated as an independent predictive factor for short-term PMD (OR 5.062, 95% CI 1.947-13.166, p=.001), while D-wave changes were demonstrated as an independent predictor for long-term PMD (OR 339.433, 95% CI 11.337-10770.311, p=.001). The optimum cut-off value of the D-wave amplitude reduction ratio for predicting long-term PMD was 42.18%, with a sensitivity of 100% and a specificity of 93.8% (AUC=0.981, p<.001). CONCLUSIONS D-wave monitoring showed extremely high specificity in predicting PMD compared to SEP and MEP monitoring. Moreover, the authors suggested that a D-wave amplitude reduction of over 40% during IMSCT surgery generally indicates long-term PMD for patients.
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Affiliation(s)
- Ke Li
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
| | - Xiaorong Tao
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
| | - Jiajia Liu
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
| | - Jun Yang
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
| | - Jiawei Shi
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
| | - Xiao Wu
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
| | - Wenqing Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
| | - Xing Fan
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China.
| | - Hui Qiao
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, P.R. China
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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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Wang S, Lin X, Guo L, He L, Liu Y, Zhao Y, Zhang J. Validity of evoked potential as biomarker for predicting early neural function changes after thoracic spinal decompression surgery in patients with neurological deficits. 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 2024; 33:924-931. [PMID: 38008871 DOI: 10.1007/s00586-023-07893-0] [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: 12/21/2022] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE To evaluate the validity of intraoperative evoked potential (EP) including motor evoked potential (MEP) and somatosensory evoked potentials (SEP) as a biomarker for predicting neural function changes after thoracic spinal decompression (TSD) surgery. METHOD A consecutive series of 336 TSD surgeries were reviewed between 2010 and 2021 from four spine center. All patients with TSD were divided into 3 groups according to different intraoperative EP results: group 1, EP alerts; group 2, no obvious EP deterioration; group 3, EP improvement compared with baselines. The lower limb Japanese Orthopedic Association (JOA) scores (as well as early and long-term JOA recovery rate) were utilized to quantitatively assess pre- and postoperative neural function change. RESULTS Among the 3 subgroups according to the different EP changes, the early JOA recovery rate (RR%) in the EP improvement group was significantly better than the other two groups (51.3 ± 58.6* vs. 27.5 ± 31.2 and 33.3 ± 43.1; p < 0.01) after 3-month follow-up. The mean MEP and SEP amplitude were from 116 ± 57 µV to 347 ± 71 µV (p < 0.01) and from 1.86 ± 0.24 µV to 2.65 ± 0.29 µV (p < 0.01) between spinal cord pre-decompression and post-decompression. Moreover, multivariate logistic regression analysis revealed that risk factors of EP improvement were duration of symptom (p < 0.001, OR 10.9) and Preop. neurologic deficit degree (p = 0.013, OR 7.46). CONCLUSION The intraoperative EP can predict postoperative neural function changes as a biomarker during TSD. Patient with EP improvement probably has better prognosis for early neural function recovery. The duration of symptom and preoperative neurologic deficit degree may be related to intraoperative EP improvement.
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Affiliation(s)
- Shujie Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Xiangquan Lin
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, People's Republic of China
| | - Lanjun Guo
- Neurophysiological Monitoring Service, University of California, San Francisco, CA, USA
| | - Li He
- Department of Orthopedics, Yinchuan Guolong Hospital, Yinchuan, 750001, People's Republic of China
| | - Yong Liu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Yu Zhao
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.
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9
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Alvi MA, Kwon BK, Hejrati N, Tetreault LA, Evaniew N, Skelly AC, Fehlings MG. Accuracy of Intraoperative Neuromonitoring in the Diagnosis of Intraoperative Neurological Decline in the Setting of Spinal Surgery-A Systematic Review and Meta-Analysis. Global Spine J 2024; 14:105S-149S. [PMID: 38632716 PMCID: PMC10964897 DOI: 10.1177/21925682231196514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES In an effort to prevent intraoperative neurological injury during spine surgery, the use of intraoperative neurophysiological monitoring (IONM) has increased significantly in recent years. Using IONM, spinal cord function can be evaluated intraoperatively by recording signals from specific nerve roots, motor tracts, and sensory tracts. We performed a systematic review and meta-analysis of diagnostic test accuracy (DTA) studies to evaluate the efficacy of IONM among patients undergoing spine surgery for any indication. METHODS The current systematic review and meta-analysis was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis statement for Diagnostic Test Accuracy Studies (PRISMA-DTA) and was registered on PROSPERO. A comprehensive search was performed using MEDLINE, EMBASE and SCOPUS for all studies assessing the diagnostic accuracy of neuromonitoring, including somatosensory evoked potential (SSEP), motor evoked potential (MEP) and electromyography (EMG), either on their own or in combination (multimodal). Studies were included if they reported raw numbers for True Positives (TP), False Negatives (FN), False Positives (FP) and True Negative (TN) either in a 2 × 2 contingency table or in text, and if they used postoperative neurologic exam as a reference standard. Pooled sensitivity and specificity were calculated to evaluate the overall efficacy of each modality type using a bivariate model adapted by Reitsma et al, for all spine surgeries and for individual disease groups and regions of spine. The risk of bias (ROB) of included studies was assessed using the quality assessment tool for diagnostic accuracy studies (QUADAS-2). RESULTS A total of 163 studies were included; 52 of these studies with 16,310 patients reported data for SSEP, 68 studies with 71,144 patients reported data for MEP, 16 studies with 7888 patients reported data for EMG and 69 studies with 17,968 patients reported data for multimodal monitoring. The overall sensitivity, specificity, DOR and AUC for SSEP were 71.4% (95% CI 54.8-83.7), 97.1% (95% CI 95.3-98.3), 41.9 (95% CI 24.1-73.1) and .899, respectively; for MEP, these were 90.2% (95% CI 86.2-93.1), 96% (95% CI 94.3-97.2), 103.25 (95% CI 69.98-152.34) and .927; for EMG, these were 48.3% (95% CI 31.4-65.6), 92.9% (95% CI 84.4-96.9), 11.2 (95% CI 4.84-25.97) and .773; for multimodal, these were found to be 83.5% (95% CI 81-85.7), 93.8% (95% CI 90.6-95.9), 60 (95% CI 35.6-101.3) and .895, respectively. Using the QUADAS-2 ROB analysis, of the 52 studies reporting on SSEP, 13 (25%) were high-risk, 10 (19.2%) had some concerns and 29 (55.8%) were low-risk; for MEP, 8 (11.7%) were high-risk, 21 had some concerns and 39 (57.3%) were low-risk; for EMG, 4 (25%) were high-risk, 3 (18.75%) had some concerns and 9 (56.25%) were low-risk; for multimodal, 14 (20.3%) were high-risk, 13 (18.8%) had some concerns and 42 (60.7%) were low-risk. CONCLUSIONS These results indicate that all neuromonitoring modalities have diagnostic utility in successfully detecting impending or incident intraoperative neurologic injuries among patients undergoing spine surgery for any condition, although it is clear that the accuracy of each modality differs.PROSPERO Registration Number: CRD42023384158.
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Affiliation(s)
- Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
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10
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Duvuru S, Sanker V, Mylavarapu M, Lund S, Jena R, Dave T. Clinical utility of intraoperative direct wave monitoring in patients with pre-operative motor deficits: Case series. Int J Surg Case Rep 2024; 114:109164. [PMID: 38113562 PMCID: PMC10772235 DOI: 10.1016/j.ijscr.2023.109164] [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: 10/24/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE D-wave (Direct waves) are Motor Evoked Potentials (MEPs) generated by a single transcranial stimulation and captured by attaching an epidural recording electrode caudal to the vulnerable area. Intraoperative neurophysiologic monitoring (IONM) is widely used in neurosurgery to recognize important neurological structures but can be challenging in the pediatric population due to incomplete neural development. CASE PRESENTATION Case 1: A 48-year-old female presented to the outpatient department with complaints of difficulty walking for the past six months, numbness and weakness in bilateral lower limbs with recurrent falls for the past 1 month. Case 2: A 12-year-old boy presented to the emergency room with a history of inability to use both upper and lower limbs on the right side with tremulousness. CLINICAL DISCUSSION Magnetic resonance imaging (MRI) Spine in the first case revealed a D9-D10 calcified meningioma with significant spinal cord compression. In the second case, MRI Spine showed C1-C2 Intramedullary Space Occupying Lesion (SOL) and was planned for C1-C2 laminectomy with midline myelotomy. The first case was planned for microsurgical excision of the lesion under IONM guidance. The procedure went smoothly. Microsurgical gross total resection (GTR) of the intramedullary SOL under IONM Guidance was done for the second case. Postoperatively, the first patient showed no neurological compromise or complications. In the second case, following surgery, the child recovered gradually from surgery. CONCLUSION This case series demonstrates the successful surgical management of two cases of spinal cord tumors through an IONM-guided surgery and the effective use of D waves in such challenging cases.
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Affiliation(s)
- Shyam Duvuru
- Department of Neurosurgery, Apollo Specialty Hospitals, Madurai, Tamil Nadu, India
| | - Vivek Sanker
- Department of Neurosurgery, Trivandrum Medical College Hospital, Trivandrum, India
| | | | - Sejal Lund
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, Pakistan
| | - Rahul Jena
- Department of Internal Medicine, Bharati Vidyapeeth Medical College, Pune, India
| | - Tirth Dave
- Bukovinian State Medical University, Chernivtsi, Ukraine.
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11
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Tropeano MP, Rossini Z, Franzini A, Capo G, Olei S, De Robertis M, Milani D, Fornari M, Pessina F. Multimodal Intraoperative Neurophysiological Monitoring in Intramedullary Spinal Cord Tumors: A 10-Year Single Center Experience. Cancers (Basel) 2023; 16:111. [PMID: 38201539 PMCID: PMC10778263 DOI: 10.3390/cancers16010111] [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: 09/20/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery. METHODS Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up. RESULTS Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001). CONCLUSION The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection.
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Affiliation(s)
- Maria Pia Tropeano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Zefferino Rossini
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Andrea Franzini
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Gabriele Capo
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Simone Olei
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
| | - Mario De Robertis
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
| | - Daniela Milani
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Maurizio Fornari
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy (F.P.)
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy (D.M.)
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12
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Shigematsu H, Ando M, Kobayashi K, Yoshida G, Funaba M, Morito S, Takahashi M, Ushirozako H, Kawabata S, Yamada K, Kanchiku T, Fujiwara Y, Taniguchi S, Iwasaki H, Tadokoro N, Wada K, Yamamoto N, Yasuda A, Hashimoto J, Tani T, Ando K, Machino M, Takatani T, Matsuyama Y, Imagama S. Efficacy of D-Wave Monitoring Combined With the Transcranial Motor-Evoked Potentials in High-Risk Spinal Surgery: A Retrospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Global Spine J 2023; 13:2387-2395. [PMID: 35343273 PMCID: PMC10538305 DOI: 10.1177/21925682221084649] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective multicenter cohort study. OBJECTIVES We aimed to clarify the efficacy of multimodal intraoperative neuromonitoring (IONM), especially in transcranial electrical stimulation of motor-evoked potentials (TES-MEPs) with spinal cord-evoked potentials after transcranial stimulation of the brain (D-wave) in the detection of reversible spinal cord injury in high-risk spinal surgery. METHODS We reviewed 1310 patients who underwent TES-MEPs during spinal surgery at 14 spine centers. We compared the monitoring results of TES-MEPs with D-wave vs TES-MEPs without D-wave in high-risk spinal surgery. RESULTS There were 40 cases that used TES-MEPs with D-wave and 1270 cases that used TES-MEPs without D-wave. Before patients were matched, there were significant differences between groups in terms of sex and spinal disease category. Although there was no significant difference in the rescue rate between TES-MEPs with D-wave (2.0%) and TES-MEPs (2.5%), the false-positivity rate was significantly lower (0%) in the TES-MEPs-with-D-wave group. Using a one-to-one propensity score-matched analysis, 40 pairs of patients from the two groups were selected. Baseline characteristics did not significantly differ between the matched groups. In the score-matched analysis, one case (2.5%) in both groups was a case of rescue (P = 1), five (12.5%) cases in the TES-MEPs group were false positives, and there were no false positives in the TES-MEPs-with-D-wave group (P = .02). CONCLUSIONS TES-MEPs with D-wave in high-risk spine surgeries did not affect rescue case rates. However, it helped reduce the false-positivity rate.
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Affiliation(s)
- Hideki Shigematsu
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Muneharu Ando
- Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University, Yamaguchi, Japan
| | - Shinji Morito
- Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | | | - Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shigenori Kawabata
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kei Yamada
- Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Tsukasa Kanchiku
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan
| | - Yasushi Fujiwara
- Department of Orthopedic Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | | | - Hiroshi Iwasaki
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama, Japan
| | - Nobuaki Tadokoro
- Department of Orthopedic Surgery, Kochi University, Kochi, Japan
| | - Kanichiro Wada
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Naoya Yamamoto
- Department of Orthopedic Surgery, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan
| | - Akimasa Yasuda
- Department of Orthopedic Surgery, National Defense Medical College Hospital, Saitama, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshikazu Tani
- Department of Orthopedic Surgery, Kubokawa Hospital, Kochi, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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13
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Costa P, Borio A, Marmolino S, Turco C, Serpella D, Della Cerra E, Cipriano E, Ferlisi S. The role of intraoperative extensor digitorum brevis muscle MEPs in spinal surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3360-3369. [PMID: 37336795 DOI: 10.1007/s00586-023-07811-4] [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: 12/19/2022] [Revised: 04/11/2023] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Intraoperative muscle motor evoked potentials (m-MEPs) are widely used in spinal surgery with the aim of identifying a damage to spinal cord at a reversible stage. Generally, lower limb m-MEPs are recorded from abductor hallucis [AH] and the tibialis anterior [TA]. The purpose of this work is to study an unselected population by recording the m-MEPs from TA, AH and extensor digitorum brevis (EDB), with the aim of identifying the most adjustable and stable muscles responses intraoperatively. METHODS Transcranially electrically induced m-MEPs were intraoperative recorded in a total of 107 surgical procedures. m-MEPs were recorded by a needle electrode placed in the muscle from TA, AH and EDB muscles in the lower extremities. RESULTS Overall monitorability (i.e., at least 1 Lower Limb m-MEP recordable) was 100/107 (93.5%). In the remaining 100 surgeries in 3 cases, the only muscle that could be recorded at baseline was one AH, and in other 2 the EDB. Persistence (i.e., the recordability of m-MEP from baseline to the end of surgery) was 88.7% for TA, 89.8% for AH and 93.8% for EDB. CONCLUSION In our series, EDB m-MEPs have demonstrated a recordability superior to TA and a stability similar to AH. The explanations may be different and range from changes in the excitability of the cortical motor neuron to the different sensitivity to ischemia of the spinal motor neuron. EDB can be used alternatively or can be added to TA and AH as a target muscle of the lower limb in spinal surgery.
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Affiliation(s)
- Paolo Costa
- Department of Neurosciences and Mental Health, Section of Clinical Neurophysiology, Città della Salute e della Scienza, Turin, EU, Italy.
| | - Alessandro Borio
- Department of Neurosciences and Mental Health, Section of Clinical Neurophysiology, Città della Salute e della Scienza, Turin, EU, Italy
| | - Sonia Marmolino
- Department of Neurosciences and Mental Health, Section of Clinical Neurophysiology, Città della Salute e della Scienza, Turin, EU, Italy
| | - Cristina Turco
- Department of Neurosciences and Mental Health, Section of Clinical Neurophysiology, Città della Salute e della Scienza, Turin, EU, Italy
| | - Domenico Serpella
- Department of Neurosciences and Mental Health, Section of Clinical Neurophysiology, Città della Salute e della Scienza, Turin, EU, Italy
| | - Elena Della Cerra
- Department of Neurosciences and Mental Health, Section of Clinical Neurophysiology, Città della Salute e della Scienza, Turin, EU, Italy
| | - Elia Cipriano
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale, Novara, Italy
| | - Salvatore Ferlisi
- Department of Biomedicine, Neurosciences and Advanced Diagnostic (BiND), University of Palermo, Palermo, Italy
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14
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Arima H, Hasegawa T, Yamato Y, Yoshida G, Banno T, Oe S, Mihara Y, Ide K, Watanabe Y, Nakai K, Kurosu K, Matsuyama Y. Postoperative neurological complications in intradural extramedullary tumors: A 10-year experience of a single center. Neurochirurgie 2023; 69:101476. [PMID: 37543192 DOI: 10.1016/j.neuchi.2023.101476] [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: 03/25/2023] [Revised: 06/25/2023] [Accepted: 07/19/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Intradural extramedullary spinal cord tumors (IDEMs) cause neurological symptoms due to compression of the spinal cord and caudal nerves. The purpose of this study was to investigate the incidence of postoperative neurological complications after surgical resection of IDEM and to identify factors associated with such postoperative neurological complications. METHODS We retrospectively analyzed 85 patients who underwent tumor resection for IDEM between 2010 and 2020. We investigated the postoperative worsening of neurological disorders. The patients were divided into two groups: those with and without postoperative neurological complications. Patient demographic characteristics, tumor level, histological type, and surgery-related factors were also compared. RESULTS The mean age at the time of surgery was 57.4 years, and histological analysis revealed 45 cases of schwannoma, 34 cases of meningioma, three cases of myxopapillary ependymoma, one case of ependymoma, one case of hemangioblastoma and one case of lipoma. There were five cases (5.8%) of postoperative neurological complications, and four patients improved within 6 months after surgery, and one patient had residual worsening. There were no statistically significant differences in age, sex, tumor location, preoperative modified McCormick Scale grade, histology, tumor occupancy, or whether fixation was performed in the presence or absence of postoperative neurological complications. All four cases of meningioma with postoperative neurological complications had preoperative neuropathy and meningiomas were located in the anterior or lateral thoracic spine. CONCLUSIONS Neurological complications after surgical resection for IDEM occurred in 5.8% of patients. Meningiomas with postoperative neurological complications located anteriorly or laterally in the thoracic spine.
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Affiliation(s)
- Hideyuki Arima
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan.
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Yu Yamato
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan; Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, 1-20-1 Handayama, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Go Yoshida
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Tomohiro Banno
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Shin Oe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan; Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, 1-20-1 Handayama, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Yuki Mihara
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Koichiro Ide
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Yuh Watanabe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Keiichi Nakai
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Kenta Kurosu
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192 Hamamatsu-city, Shizuoka, Japan
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15
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Gao L, Ye L, Zhang Y, Zhang K, Wang X, Cheng BC, Cheng H. Factors Related to the Deterioration of Postoperative Lower Back Pain in Hemilaminectomy Approach for Lumbar Spinal Schwannoma Resection. J Pain Res 2023; 16:2861-2869. [PMID: 37609360 PMCID: PMC10441654 DOI: 10.2147/jpr.s409773] [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: 02/23/2023] [Accepted: 08/03/2023] [Indexed: 08/24/2023] Open
Abstract
Objective This study aimed to explore the related risk factors in patients who underwent hemilaminectomy for lumbar spinal schwannoma resection and who experienced deterioration of postoperative lower back pain in comparison to preoperative pain levels. Methods This retrospective study recruited 61 patients from the First Affiliated Hospital of An Hui Medical University between January 2018 and June 2019. All data were collected from clinical records and analyzed at 1-month and at 1-year follow-up. The visual analog scale (VAS) was used to evaluate pain, and neurologic function was assessed using the Modified McCormick Scale. Intraoperative neurophysiological monitoring was used to assess neuronal integrity and mitigate injury. Statistical analysis of the data was performed using the SPSS version 19 software. Results Preoperative pain improved dramatically in the 1-year follow-up (VAS: preoperative, 3.84±2.19; 1-year follow-up, 2.13±2.26; P<0.001). The pain-improved group and worsened group showed a significant difference at 1-month (VAS: 1.76±1.56; 5.54±1.26; P<0.05) and at 1-year (VAS: 0.83±1.09; 4.80±1.58; P<0.05) follow-up. The pain-improved and worsened groups had a significant difference in tumor size and hemilaminectomy removal segments at 1-month and 1-year follow-up, but A-train occurrence on electromyography could only be seen as a statistical difference in the 1-month follow-up. Logistic regression analysis revealed that tumor size was an independent risk factor for postoperative lower back pain deterioration. Conclusion The hemilaminectomy approach is a safe and effective method that can dramatically relieve pain in spinal lumbar schwannoma resection. Tumor size is an independent risk factor for postoperative lower back pain. A-train on spontaneous electromyography has been shown to be a reliable predictive factor for the evaluation of postoperative lower back pain. However, further detailed analysis of A-train characteristics can provide a more accurate warning during surgery.
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Affiliation(s)
- Lu Gao
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Lei Ye
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Yiquan Zhang
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Ke Zhang
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Xianxiang Wang
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Bao Chun Cheng
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Hongwei Cheng
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
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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: 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: 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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Wathen CA, Ghenbot YG, Ozturk AK, Cullen DK, O’Donnell JC, Petrov D. Porcine Models of Spinal Cord Injury. Biomedicines 2023; 11:2202. [PMID: 37626699 PMCID: PMC10452184 DOI: 10.3390/biomedicines11082202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/23/2023] [Accepted: 07/29/2023] [Indexed: 08/27/2023] Open
Abstract
Large animal models of spinal cord injury may be useful tools in facilitating the development of translational therapies for spinal cord injury (SCI). Porcine models of SCI are of particular interest due to significant anatomic and physiologic similarities to humans. The similar size and functional organization of the porcine spinal cord, for instance, may facilitate more accurate evaluation of axonal regeneration across long distances that more closely resemble the realities of clinical SCI. Furthermore, the porcine cardiovascular system closely resembles that of humans, including at the level of the spinal cord vascular supply. These anatomic and physiologic similarities to humans not only enable more representative SCI models with the ability to accurately evaluate the translational potential of novel therapies, especially biologics, they also facilitate the collection of physiologic data to assess response to therapy in a setting similar to those used in the clinical management of SCI. This review summarizes the current landscape of porcine spinal cord injury research, including the available models, outcome measures, and the strengths, limitations, and alternatives to porcine models. As the number of investigational SCI therapies grow, porcine SCI models provide an attractive platform for the evaluation of promising treatments prior to clinical translation.
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Affiliation(s)
- Connor A. Wathen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Yohannes G. Ghenbot
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Ali K. Ozturk
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
| | - D. Kacy Cullen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John C. O’Donnell
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Dmitriy Petrov
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
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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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Liu W, Wang C, Wang B, Zhang Y, Jia W. Intramedullary spinal cavernous malformations with high ossification: a case report and review of the literature. Chin Neurosurg J 2023; 9:11. [PMID: 37076925 PMCID: PMC10113117 DOI: 10.1186/s41016-023-00323-6] [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: 11/30/2022] [Accepted: 04/02/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Cavernous malformations of the spinal cord are a rare type of vascular malformation, comprising approximately 5 to 16% of all vascular lesions in the spinal cord. Depending on their origin position, these malformations can be distributed in different locations within the spinal canal. Although intramedullary cavernous malformations have been reported in the literature, they are exceedingly rare. Furthermore, highly calcified or ossified intramedullary cavernous spinal malformations are even rarer. CASE PRESENTATION Here, we present a case report of a 28-year-old woman diagnosed with a thoracic intramedullary cavernous malformation. The patient had been experiencing progressive numbness in her distal limbs for a period of 2 months. During routine lung computed tomography screening for COVID-19, a hyperdense mass was noted in the patient's spinal canal. Magnetic resonance imaging revealed a mulberry-shaped intramedullary mass at the T1-2 level. The patient underwent surgical treatment, during which the entire lesion was successfully removed, resulting in a gradual improvement of her symptoms. Histological examination confirmed the presence of cavernous malformations with calcification. CONCLUSIONS Intramedullary cavernous malformations with calcification are rare and special type that should be treated surgically in the early stage without significant neurological impairment before rebleeding or enlargement of the lesion can occur.
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Affiliation(s)
- Weihao Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Chong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Bo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Yaowu Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Wenqing Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China.
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20
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Morito S, Yamada K, Nakae I, Sato K, Yokosuka K, Yoshida T, Shimazaki T, Hazemoto Y, Saruwatari R, Nishida K, Okazaki S, Hiraoka K. Intradural extramedullary tumor location in the axial view affects the alert timing of intraoperative neurophysiologic monitoring. J Clin Monit Comput 2023; 37:775-782. [PMID: 36635568 DOI: 10.1007/s10877-022-00971-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/28/2022] [Accepted: 12/31/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Intraoperative neurophysiologic monitoring (IONM) reportedly helps prevent postoperative neurological complications following high-risk spinal cord surgeries. There are negative and positive reports about using IONM for intradural extramedullary (IDEM) tumors. We investigated factors affecting alerts of IONM in IDEM tumor surgery. METHODS We analyzed 39 patients with IDEM tumors who underwent surgery using IONM at our hospital between January 2014 and March 2021. Neurological symptoms were evaluated pre- and postoperatively using the manual muscle test (MMT). All patients were evaluated to ascertain the tumor level and location in the axial view, the operative time, intraoperative bleeding volume, and histological type. Additionally, the intraoperative procedure associated with significant IONM changes in transcranial electrical stimulation muscle-evoked potential was investigated. RESULTS There were 11 false-positive and 16 true-negative cases. There was one true-positive case and one false-negative case; the monitoring accuracy achieved a sensitivity of 50%, a specificity of 59%, a positive predictive value of 8%, and a negative predictive value of 94%. In the 22 alert cases, if the tumor was located anterolateral in the axial view, alerts were triggered with a significant difference (p = 0.02) during tumor resection. Alerts were generated for fifteen patients during tumor resection; nine (60%) showed waveform improvement by intervention and were classified as rescue cases. CONCLUSION Alert is probably triggered during tumor resection for anterolaterally located tumors. Alerts during tumor resection procedures were more likely to be rescued than other procedures in IDEM tumor surgery.
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Affiliation(s)
- Shinji Morito
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kei Yamada
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan.
| | - Ichirou Nakae
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kimiaki Sato
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kimiaki Yokosuka
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Tatsuhiro Yoshida
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Takahiro Shimazaki
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Yutaro Hazemoto
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Rikiya Saruwatari
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kota Nishida
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Shingo Okazaki
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Koji Hiraoka
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
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Antkowiak L, Putz M, Sordyl R, Pokora S, Mandera M. Predictive Value of Motor Evoked Potentials in the Resection of Intradural Extramedullary Spinal Tumors in Children. J Clin Med 2022; 12:jcm12010041. [PMID: 36614841 PMCID: PMC9821272 DOI: 10.3390/jcm12010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/04/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
This study aimed to evaluate the predictive value of motor evoked potentials (MEP) in the resection of pediatric intradural extramedullary (IDEM) tumors. Additionally, we aimed to assess the impact of MEP alerts on the extent of tumor resection. Medical records of pediatric patients who underwent resection of IDEM tumors with the assistance of MEP between March 2011 and October 2020 were reviewed. The occurrence of postoperative motor deficits was correlated with intraoperative MEP alerts. Sixteen patients were included. MEP alerts appeared in 2 patients (12.5%), being reflective of new postoperative motor deficits. Among the remaining 14 patients without any intraoperative MEP alerts, no motor decline was found. Accordingly, MEP significantly predicted postoperative motor deficits, reaching sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100% (p < 0.001). In the absence of MEP alerts, 11 out of 14 patients (78.6%) underwent GTR, while no patient with intraoperative IONM alerts underwent GTR (p = 0.025). Although MEP alerts limit the extent of tumor resection, the high sensitivity and PPV of MEP underline its importance in avoiding iatrogenic motor deficits. Concurrently, high specificity and NPV ensure safer tumor excision. Therefore, MEP can reliably support surgical decisions in pediatric patients with IDEM tumors.
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22
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Wang R, Liang Z, Chen Y, Xu X, Chen C. Feasibility and efficacy of spinal microtubular technique for resection of lumbar dumbbell-shaped tumors. Front Oncol 2022; 12:1024877. [DOI: 10.3389/fonc.2022.1024877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
ObjectiveMinimally invasive surgical resection of lumbar dumbbell-shaped tumors is rarely reported. We retrospectively collected clinical data of lumbar dumbbell-shaped tumors treated with the spinal microtubular technique to evaluate the feasibility, complications and efficacy of the surgical methods.MethodsFrom September 2013 to August 2021, clinical data of patients with lumbar dumbbell-shaped tumors that underwent paravertebral approach and micro-tubular tumorectomy (PAMT) were collected; neurological function was assessed using the pain visual analog scale (VAS) and the Japanese Orthopaedic Association (JOA) score.ResultsA total of 46 patients that underwent PAMT were included in this study. In all patients, total resection of the tumor was performed at one stage (100%). The median follow-up period was 27.5 months (P25, P75: 16.5- 57 months). Symptoms such as pain or lower extremity weakness were significantly relieved in 46 patients. The postoperative VAS score and JOA score were significantly higher compared with preoperative scores (p <0.001), and the patients had no tumor recurrence or spinal instability. According to the Eden classification, there were 7 cases of type I, 8 cases of type II, 15 cases of type III, and 16 cases of type IV. In the comparison of the improvement of VAS score at 12 months after PAMT, there were significant differences among different types of tumors (H =15.756, p =0.001); type I was better than type III (Z =2.768, p =0.029) and type IV (Z =2.763, p =0.029), and type II was also better than type III (Z =2.679, p =0.037) and type IV (Z =2.708, p =0.034). With respect to estimated blood loss (Z =-3.041, p =0.013) and postoperative hospital stays (Z =-3.003, p =0.014), type IV was less than type III; and type IV was also less than type II about operation time (Z =-2.653, p =0.040).ConclusionIn small lumbar dumbbell-shaped tumors, PAMT is indicated for Eden types I-IV and different pathological types of tumors, and can achieve complete resection of the tumor (GTR) in one stage with a good prognosis.
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23
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Tumori spinali intradurali. Neurologia 2022. [DOI: 10.1016/s1634-7072(22)46430-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Krafft PR, Peto I, Vakharia KV. Commentary: Resection of an Intradural Extramedullary Capillary Hemangioma in the Lumbar Spine. Oper Neurosurg (Hagerstown) 2022; 23:e137-e138. [PMID: 35838476 DOI: 10.1227/ons.0000000000000286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 01/17/2023] Open
Affiliation(s)
- Paul R Krafft
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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25
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Hersh AM, Patel J, Pennington Z, Porras JL, Goldsborough E, Antar A, Elsamadicy AA, Lubelski D, Wolinsky JP, Jallo G, Gokaslan ZL, Lo SFL, Sciubba DM. Perioperative outcomes and survival after surgery for intramedullary spinal cord tumors: a single-institution series of 302 patients. J Neurosurg Spine 2022; 37:252-262. [PMID: 35213831 DOI: 10.3171/2022.1.spine211235] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intramedullary spinal cord tumors (IMSCTs) are rare neoplasms whose treatment is often technically challenging. Given the low volume seen at most centers, perioperative outcomes have been reported infrequently. Here, the authors present the largest single-institution series of IMSCTs, focusing on the clinical presentation, histological makeup, perioperative outcomes, and long-term survival of surgically treated patients. METHODS A cohort of patients operated on for primary IMSCTs at a comprehensive cancer center between June 2002 and May 2020 was retrospectively identified. Data on patient demographics, tumor histology, neuraxial location, baseline neurological status, functional deficits, and operative characteristics were collected. Perioperative outcomes of interest included length of stay, postoperative complications, readmission, reoperation, and discharge disposition. Data were compared across tumor histologies using the Kruskal-Wallis H test, chi-square test, and Fisher exact test. Pairwise comparisons were conducted using Tukey's honest significant difference test, chi-square test, and Fisher exact test. Long-term survival was assessed across tumor categories and histological subtype using the log-rank test. RESULTS Three hundred two patients were included in the study (mean age 34.9 ± 19 years, 77% white, 57% male). The most common tumors were ependymomas (47%), astrocytomas (31%), and hemangioblastomas (11%). Ependymomas and hemangioblastomas disproportionately localized to the cervical cord (54% and 59%, respectively), whereas astrocytomas were distributed almost equally between the cervical cord (36%) and thoracic cord (38%). Clinical presentation, extent of functional dependence, and postoperative 30-day outcomes were largely independent of underlying tumor pathology, although tumors of the thoracic cord had worse American Spinal Injury Association (ASIA) grades than cervical tumors. Rates of gross-total resection were lower for astrocytomas than for ependymomas (54% vs 84%, p < 0.01) and hemangioblastomas (54% vs 100%, p < 0.01). Additionally, 30-day readmission rates were significantly higher for astrocytomas than ependymomas (14% vs 6%, p = 0.02). Overall survival was significantly affected by the underlying pathology, with astrocytomas having poorer associated prognoses (40% at 15 years) than ependymomas (81%) and hemangioblastomas (66%; p < 0.01) and patients with high-grade ependymomas and astrocytomas having poorer long-term survival than those with low-grade lesions (p < 0.01). CONCLUSIONS The neuraxial location of IMSCTs, extent of resection, and postoperative survival differed significantly across tumor pathologies. However, perioperative outcomes did not vary significantly across tumor cohorts, suggesting that operative details, rather than pathology, may have a stronger influence on the short-term clinical course, whereas pathology appears to have a stronger impact on long-term survival.
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Affiliation(s)
- Andrew M Hersh
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jaimin Patel
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zach Pennington
- 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Jose L Porras
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Earl Goldsborough
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Albert Antar
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Daniel Lubelski
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean-Paul Wolinsky
- 4Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - George Jallo
- 5Department of Neurosurgery, Johns Hopkins Medicine, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Ziya L Gokaslan
- 6Department of Neurosurgery, Brown University, Providence, Rhode Island; and
| | - Sheng-Fu Larry Lo
- 7Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- 7Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York
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Liu T, Yan L, Qi H, Luo Z, Liu X, Yuan T, Dong B, Zhao Y, Zhao S, Li H, Liu Z, Wu X, Wang F, Wang W, Huang Y, Wang G. Diagnostic Value of Multimodal Intraoperative Neuromonitoring by Combining Somatosensory-With Motor-Evoked Potential in Posterior Decompression Surgery for Thoracic Spinal Stenosis. Front Neurosci 2022; 16:879435. [PMID: 35757555 PMCID: PMC9226726 DOI: 10.3389/fnins.2022.879435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Intraoperative neuromonitoring (IONM) has become an increasingly essential technique in spinal surgery. However, data on the diagnostic value of IONM in predicting impending postoperative neurological deficits (PONDs) for patients who underwent posterior decompression surgery for thoracic spinal stenosis (TSS) are limited. Furthermore, patients who are at the highest risk of waveform changes during the surgery remain unknown. Our purpose was to (1) assess the diagnostic accuracy of IONM by combining somatosensory-evoked potential (SSEP) with motor-evoked potential (MEP) in predicting PONDs for patients who underwent the surgery and (2) identify the independent risk factors correlated with IONM changes in our study population. Methods A total of 326 consecutive patients who underwent the surgery were identified and analyzed. We collected the following data: (1) demographic and clinical data; (2) IONM data; and (3) outcome data such as details of PONDs, and recovery status (complete, partial, or no recovery) at the 12-month follow-up visit. Results In total, 27 patients developed PONDs. However, 15, 6, and 6 patients achieved complete recovery, partial recovery, and no recovery, respectively, at the 12-month follow-up. SSEP or MEP change monitoring yielded better diagnostic efficacy in predicting PONDs as indicated by the increased sensitivity (96.30%) and area under the receiver operating characteristic (ROC) curve (AUC) value (0.91). Only one neurological deficit occurred without waveform changes. On multiple logistic regression analysis, the independent risk factors associated with waveform changes were as follows: preoperative moderate or severe neurological deficits (p = 0.002), operating in the upper- or middle-thoracic spinal level (p = 0.003), estimated blood loss (EBL) ≥ 400 ml (p < 0.001), duration of symptoms ≥ 3 months (p < 0.001), and impairment of gait (p = 0.001). Conclusion Somatosensory-evoked potential or MEP change is a highly sensitive and moderately specific indicator for predicting PONDs in posterior decompression surgery for TSS. The independent risks for IONM change were as follows: operated in upper- or middle-thoracic spinal level, presented with gait impairment, had massive blood loss, moderate or severe neurological deficits preoperatively, and had a longer duration of symptoms. Clinical Trial Registration [http://www.chictr.org.cn]; identifier [ChiCTR 200003 2155].
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Affiliation(s)
- Tun Liu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Liang Yan
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Huaguang Qi
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhenguo Luo
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xuemei Liu
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Tao Yuan
- Department of Functional Inspection Section, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Buhuai Dong
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yuanting Zhao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Songchuan Zhao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Houkun Li
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhian Liu
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Institute of Biomedical Engineering, School of Life Sciences and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Xucai Wu
- Department of Anesthesiology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Fei Wang
- Institute of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wentao Wang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yunfei Huang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Gang Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Institute of Biomedical Engineering, School of Life Sciences and Technology, Xi'an Jiaotong University, Xi'an, China
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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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Biodegradable controlled-release polymer containing butylidenephthalide to treat a recurrent cervical spine glioblastoma with promising result. Anticancer Drugs 2022; 33:394-399. [DOI: 10.1097/cad.0000000000001275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Helal A, Alvi M, Everson M, Mikula AL, Cohen Cohen S, Bydon M, Krauss WE, Clarke MJ. Prognostic Factors Independently Associated With Improved Progression-Free Survival After Surgical Resection in Patients With Spinal Cord Astrocytomas: An Institutional Case Series. Oper Neurosurg (Hagerstown) 2022; 22:106-114. [PMID: 35030157 DOI: 10.1227/ons.0000000000000084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spinal astrocytomas are rare tumors in which the extent of resection and adjuvant therapy remain controversial. A number of new molecular markers are used, but their utility in spinal cord tumors remains unclear. OBJECTIVE To determine prognostic indicators of progression-free survival (PFS) in patients with spinal astrocytomas. METHODS A retrospective chart review identified all patients managed at a single institution for spinal cord astrocytomas between 1999 and 2019. Data collected included baseline demographics, presenting signs and symptoms, tumor size, operative outcomes, and adjuvant treatment. Pathological data including histopathological grade, proliferative index, and molecular profile were collected. Duration of follow-up, presence of tumor progression, and status at last follow-up were documented. Univariate and multivariate analyses were performed to determine predictors of PFS. RESULTS Seventy-five patients were included in our study with an average age of 42 ± 17 yr. The thoracic spine was the most commonly involved spinal segment (50 patients), and most patients had grade I or grade II tumors (50 patients). On univariate analysis, gross total resection (GTR), lower tumor grade, and low Ki-67 index were associated with lower tumor progression (P-values .01, .04, and .00013, respectively). On multivariate Cox regression analysis, GTR, adjuvant chemotherapy and radiation, and low Ki-67 index were independent predictors of PFS (P-values .009, .011, and .031, respectively). CONCLUSION In spinal astrocytomas, GTR, adjuvant therapy, and low Ki-67 are independently associated with improved PFS. These data may help guide management of these tumors and provide important prognosticating information.
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Affiliation(s)
- Ahmed Helal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Guo L, Holdefer RN, Kothbauer KF. Monitoring spinal surgery for extramedullary tumors and fractures. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:245-255. [PMID: 35772889 DOI: 10.1016/b978-0-12-819826-1.00006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Meningiomas are the most common intradural extramedullary tumors, followed by nerve sheath tumors that can also grow extradurally. Metastases are the most frequent extradural tumors and most commonly affect the thoracic vertebrae. Spinal fractures with column dislocation and/or instability require surgical fixation. Spine surgery for an extramedullary tumor or fracture usually involves decompression of neural elements and instrumentation for stabilization. These procedures risk spinal cord and nerve root injury. The incidence of nerve root deficits after resection of nerve sheath tumors is particularly high since the tumor grows from the rootlets. Intraoperative neurophysiologic monitoring and mapping techniques have been introduced to prevent iatrogenic neurologic deficits. These include motor and sensory evoked potentials, electromyography, compound muscle action potentials, and the bulbocavernosus reflex. The combination of techniques chosen for a particular procedure depends on the surgical level and the character of the lesion.
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Affiliation(s)
- Lanjun Guo
- Department of Surgical Neuromonitoring, University of California San Francisco, San Francisco, CA, United States.
| | - Robert N Holdefer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Karl F Kothbauer
- Formerly Department of Neurosurgery, University of Basel and Division of Neurosurgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Cardali SM, Ricciardo G, Garufi G, Raffa G, Messineo F, Scalia G, Conti A, Germanò A. Fluorescein-guided surgery for intradural spinal tumors: A single-center experience. BRAIN AND SPINE 2022; 2:100908. [PMID: 36248155 PMCID: PMC9560644 DOI: 10.1016/j.bas.2022.100908] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/14/2022] [Accepted: 06/20/2022] [Indexed: 11/29/2022]
Abstract
Gross total removal has a pivotal role in surgical treatment of intradural spinal tumors. Sodium fluorescein prevents vascular injuries also preserving pial vessels in posterior myelotomy. Fluorescence before the durotomy helps to distinguishing tumor from healthy tissue in intradural lesions. Intraoperative fluorescence is safe and effective, also preserving functional anatomy in tumor removal.
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Affiliation(s)
| | | | - Giada Garufi
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Giovanni Raffa
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | | | - Gianluca Scalia
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy
- Corresponding author. Neurosurgery Unit, Highly Specialized Hospital and of National Importance “Garibaldi”, Piazza Santa Maria di Gesù, 5, 95124, Catania, Italy.
| | - Alfredo Conti
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
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Massaad E, Ha Y, Shankar GM, Shin JH. Clinical Prediction Modeling in Intramedullary Spinal Tumor Surgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 134:333-339. [PMID: 34862557 DOI: 10.1007/978-3-030-85292-4_37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Artificial intelligence is poised to influence various aspects of patient care, and neurosurgery is one of the most uprising fields where machine learning is being applied to provide surgeons with greater insight about the pathophysiology and prognosis of neurological conditions. This chapter provides a guide for clinicians on relevant aspects of machine learning and reviews selected application of these methods in intramedullary spinal cord tumors. The potential areas of application of machine learning extend far beyond the analyses of clinical data to include several areas of artificial intelligence, such as genomics and computer vision. Integration of various sources of data and application of advanced analytical approaches could improve risk assessment for intramedullary tumors.
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Affiliation(s)
- Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Validity of the Alarm Point in Intraoperative Neurophysiological Monitoring of the Spinal Cord by the Monitoring Working Group of the Japanese Society for Spine Surgery and Related Research: A Prospective Multicenter Cohort Study of 1934 Cases. Spine (Phila Pa 1976) 2021; 46:E1069-E1076. [PMID: 34559750 DOI: 10.1097/brs.0000000000004065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective multicenter cohort study. OBJECTIVE The aim of this study was to validate an alarm point of intraoperative neurophysiological monitoring () formulated by the Monitoring Working Group (WG) of the Japanese Society for Spine Surgery and Related Research (JSSR). SUMMARY OF BACKGROUND DATA The Monitoring WG of the JSSR formulated an alarm point of IONM using transcranial electrical stimulation-muscle motor evoked potentials (Tc(E)-MEPs) and has conducted a prospective multicenter study. The validity of the JSSR alarm point of ≥ 70% decreased in Tc(E)-MEPs for each high-risk surgery and any other spine surgeries has not been verified. METHODS Patients who underwent spine and spinal cord surgery with IONM in 16 Japanese spine centers in the Monitoring WG of the JSSR from 2017 to 2018 were enrolled. The patients were divided into the high-risk surgery group (Group HR) and the common surgery group (Group C). Group HR was defined by ossification of the posterior longitudinal ligament (OPLL), spinal deformity, and spinal cord tumor. Group C was classified as other spine surgeries. The alarm point was defined as a ≥70% decrease in the Tc(E)-MEPs. RESULTS In Group HR, the sensitivity and specificity were 94.4% and 87.0%, respectively. In Group C, the sensitivity and specificity were 63.6% and 91.9%. The sensitivity in Group C was statistically lower than that in Group HR (P < 0.05). In Group HR, the sensitivity and specificity in OPLL were 100% and 86.9%, respectively. The sensitivity and specificity in spinal deformity were 87.5% and 84.8%, respectively, and the sensitivity and specificity in spinal cord tumors were 92.9% and 89.9%, respectively. The sensitivity and specificity in each high-risk surgery showed no significant difference. CONCLUSION The alarm point of IONM by the Monitoring WG of the JSSR appeared to be valid for each disease in Group HR. Meanwhile, applying the JSSR alarm point for Group C potentially needed attention.Level of Evidence: 3.
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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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Jokovic M, Somma T, Ilic R, Guizzardi G, Stanimirovic A, Raicevic S, Milicevic M, Grujicic D, Solari D. Primary spinal glioblastoma multiforme. Single center experience and literature review. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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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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Bir M, Gupta U, Jaryal AK, Singh A, Netam R, Kale SS, Chandra SP, Singh M, Rath GP. Predictive value of intraoperative D-wave and m-MEP neurophysiological monitoring in patients with preoperative motor deficits in immediate and late postoperative period. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:26-32. [PMID: 33850378 PMCID: PMC8035592 DOI: 10.4103/jcvjs.jcvjs_76_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 12/26/2020] [Indexed: 11/06/2022] Open
Abstract
Background: Presence of preoperative motor deficits in patients poses a distinct challenge in monitoring the integrity of corticospinal tracts during spinal surgeries. The inconsistency of the motor-evoked potentials is such patients, limits its clinical utility. D-wave is a robust but less utilized technique for corticospinal tract monitoring. The comparative clinical value of these two techniques has not been evaluated in the patients with preoperative deficits. Objectives: The objective of the study was to compare the predictive utility of myogenic Motor Evoked Potentials (m-MEP) and D-wave in terms of recordability and their sensitivity and specificity in predicting transient and permanent new motor deficits. Materials and Methods: Thirty-one patients with preoperative motor deficit scheduled to undergo spinal surgery were included in the study. Intraoperative m-MEP and D-wave changes were identified and correlated with postoperative neurology in the immediate postoperative period and at the time of discharge. Results: The mean preoperative motor power of the patient pool in left and right lower limb was 2.97 ± 1.56 and 3.32 ± 1.49, respectively. The recordability of m-MEPs and D-wave was observed to be 79.4% and 100%, respectively. The m-MEP predicted the motor deterioration in immediate postoperative period with 100% sensitivity and 80% specificity, while D-wave had 14% sensitivity and 100% specificity. At the time of discharge, m-MEPs' specificity reduced to 61%, while D-wave demonstrated 100% specificity. Conclusions: D-wave has a better recordability than m-MEPs in neurologically compromised patients. D-wave predicts development of long-term deficits with 100% specificity, while m-MEPs have a high sensitivity for transient neurological deficit. A combination of D-wave and m-MEP is recommended for monitoring the integrity of the corticospinal tract in patients with preoperative motor deficits.
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Affiliation(s)
- Megha Bir
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Uditi Gupta
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok Kumar Jaryal
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Akanksha Singh
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Netam
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanaesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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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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Kobayashi K, Ando K, Nakashima H, Machino M, Kanbara S, Ito S, Inoue T, Yamaguchi H, Koshimizu H, Imagama S. Poor derivation of Tc-MEP baseline waveforms in surgery for ventral thoracic intradural extramedullary tumor: Efficacy of use of the abductor hallucis in cases with a preoperative non-ambulatory status. J Clin Neurosci 2020; 84:60-65. [PMID: 33485601 DOI: 10.1016/j.jocn.2020.11.045] [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: 05/07/2020] [Revised: 08/18/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
Most thoracic intradural extramedullary tumors (IDEMT) are benign lesions that are treated by gross total resection and spinal cord decompression. Intraoperative transcranial-motor evoked potential (Tc-MEP) monitoring is important for reducing postoperative neurological complications. The purpose of this study is to examine the characteristics of Tc-MEP waveforms in surgery for thoracic IDEMT resection based on location of the tumor relative to the spinal cord. The subjects were 56 patients who underwent surgery for thoracic IDEMT from 2010 to 2018. The waveform derivation rate for each lower muscle was examined at baseline and intraoperatively. 56 patients had a mean age of 61.7 years, and 21 (38%) were non-ambulatory before surgery. The tumors were schwannoma (n = 28, 50%), meningioma (n = 25, 45%), and neurofibroma (n = 3, 5%); and the lesions were dorsal (n = 29, 53%) and ventral (n = 27, 47%). There was a significantly higher rate of undetectable waveforms in all lower limb muscles in the ventral group compared to the dorsal group (15% vs. 3%, p < 0.05). In non-ambulatory cases, the derivation rate at baseline was significantly lower for ventral thoracic IDMETs (47% vs. 68%, p < 0.05). The abductor hallucis (AH) had the highest waveform derivation rate of all lower limb muscles in non-ambulatory cases with a ventral thoracic IDMET. Spinal cord compression by a ventral lesion may be increased, and this may be reflected in greater waveform deterioration. Of all lower limb muscles, the AH had the highest derivation rate, even in non-ambulatory cases with a ventral IDEMT, which suggests the efficacy of multichannel monitoring including the AH.
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Affiliation(s)
- Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shunsuke Kanbara
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Sadayuki Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Taro Inoue
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hiroyuki Koshimizu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
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Cofano F, Giambra C, Costa P, Zeppa P, Bianconi A, Mammi M, Monticelli M, Di Perna G, Junemann CV, Melcarne A, Massaro F, Ducati A, Tartara F, Zenga F, Garbossa D. Management of Extramedullary Intradural Spinal Tumors: The Impact of Clinical Status, Intraoperative Neurophysiological Monitoring and Surgical Approach on Outcomes in a 12-Year Double-Center Experience. Front Neurol 2020; 11:598619. [PMID: 33391161 PMCID: PMC7775672 DOI: 10.3389/fneur.2020.598619] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/19/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: Intradural Extramedullary (IDEM) tumors are usually treated with surgical excision. The aim of this study was to investigate the impact on clinical outcomes of pre-surgical clinical conditions, intraoperative neurophysiological monitoring (IONM), surgical access to the spinal canal, histology, degree of resection and intra/postoperative complications. Methods: This is a retrospective observational study analyzing data of patients suffering from IDEM tumors who underwent surgical treatment over a 12 year period in a double-center experience. Data were extracted from a prospectively maintained database and included: sex, age at diagnosis, clinical status according to the modified McCormick Scale (Grades I-V) at admission, discharge, and follow-up, tumor histology, type of surgical access to the spinal canal (bilateral laminectomy vs. monolateral laminectomy vs. laminoplasty), degree of surgical removal, use and type of IONM, occurrence and type of intraoperative complications, use of Ultrasonic Aspirator (CUSA), radiological follow-up. Results: A total number of 249 patients was included with a mean follow-up of 48.3 months. Gross total resection was achieved in 210 patients (84.3%) mostly in Schwannomas (45.2%) and Meningiomas (40.4%). IONM was performed in 162 procedures (65%) and D-wave was recorded in 64.2% of all cervical and thoracic locations (99 patients). The linear regression diagram for McCormick grades before and after surgery (follow-up) showed a correlation between preoperative and postoperative clinical status. A statistically significant correlation was found between absence of worsening of clinical condition at follow-up and use of IONM at follow-up (p = 0.01) but not at discharge. No associations were found between the choice of surgical approach and the extent of resection (p = 0.79), the presence of recurrence or residual tumor (p = 0.14) or CSF leakage (p = 0.25). The extent of resection was not associated with the use of IONM (p = 0.91) or CUSA (p = 0.19). Conclusion: A reliable prediction of clinical improvement could be made based on pre-operative clinical status. The use of IONM resulted in better clinical outcomes at follow-up (not at discharge), but no associations were found with the extent of resection. The use of minimally invasive approaches such as monolateral laminectomy showed to be effective and not associated with worse outcomes or increased complications.
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Affiliation(s)
- Fabio Cofano
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy.,Ospedale Humanitas Gradenigo, Turin, Italy
| | | | - Paolo Costa
- Section of Clinical Neurophysiology, Centro Traumatologico Ortopedico Hospital, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Andrea Bianconi
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Marco Mammi
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Carola Vera Junemann
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Fulvio Massaro
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | | | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi (ICCS), Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, University Hospital of the City of Health and Science of Turin, Turin, Italy
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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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Park J, Cho YE, Park M, Lee J, Kim D, Park YG. Correlation between preoperative somatosensory evoked potentials and intraoperative neurophysiological monitoring in spinal cord tumors. J Clin Monit Comput 2020; 35:979-991. [PMID: 32990900 DOI: 10.1007/s10877-020-00584-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/21/2020] [Indexed: 11/30/2022]
Abstract
Intraoperative neurophysiological monitoring (IONM) is widely used in spinal cord tumors (SCTs) removal surgery. This study mainly hypothesized that patients with prolonged latency of preoperative somatosensory evoked potentials (preSEPLat) would have more deteriorated intraoperative evoked potentials. Among 506 patients who underwent SCTs removal surgery, 74 underwent both preSEPs and IONM. The correlation between preSEPLat and intraoperative SEPs (ioSEPs) was mainly analyzed, and subgroup analysis according to anatomical type was also conducted. Secondly, whether preSEPLat related to intraoperative motor evoked potentials (ioMEPs) or postoperative motor deterioration (PMD) was analyzed. In addition, risk factors for PMD were examined among anatomical factors, including operation level, tumor-occupying area ratio, and anatomical type, as well as electrophysiological factors, such as preSEPLat, ioSEPs, and ioMEPs. Changes in ioSEP and ioMEP were considered significant even if they were recovered before the end of the monitoring. Patients with prolonged preSEPLat were more likely to have significant ioSEP changes for intradural-extramedullary (IDEM) but not for intramedullary or extradural tumors. The anatomical type and tumor-occupying area ratio were prognostic factors for transient PMD, while the ioSEPs were the only prognostic factor for persisted PMD over 4 weeks after surgery. PreSEPs are helpful in predicting the significant changes in ioSEPs during IDEM tumor removal surgery. The tumor-occupying area ratio and anatomical type are contributing factors for the transient PMD, whereas ioSEPs are prognostic factors in predicting the PMD that persists over 4 weeks after SCTs removal surgery. To our knowledge, this is the first study that mainly focused on the correlations of preoperative and intraoperative evoked potentials.
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Affiliation(s)
- Jinyoung Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mina Park
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joowon Lee
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dawoon Kim
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Rehabilitation Medicine, Gangnam Severance Hospital, Yonsei University, 20, Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, Republic of Korea.
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Chen Y, Li Z, Chen X, Yin Y, Qiao G. Surgical Treatment Outcomes of Patients with Conus Medullaris Teratoma: A Single-Center Experience of 39 Patients. World Neurosurg 2020; 143:e374-e383. [PMID: 32730968 DOI: 10.1016/j.wneu.2020.07.148] [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: 06/22/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Conus medullaris teratomas are extremely rare, and the treatment experience has been limited. The purpose of the present study was to evaluate the clinical characteristics, radiological features, surgical outcomes, and prognosis of patients with conus medullaris teratoma. METHODS We retrospectively reviewed the data from 39 patients who had undergone surgical resection for conus medullaris teratomas from January 2008 to December 2018. All the operations were performed by 1 senior doctor. The clinical features, pre- and postoperative magnetic resonance imaging findings, pathological features, treatment strategies, and outcomes were analyzed. The neurological status was evaluated using the modified Japanese Orthopaedic Association scale score. RESULTS Of the 39 patients, the mean age was 30.9 years. Of the 39 patients, 20 were male and 19 were female. The symptom duration ranged from 0.3 to 252 months (mean, 61.6 months). Bladder and bowel dysfunction was the most common symptom (76.9%). Total resection was achieved in 25 patients (64.1%), subtotal resection in 11 (28.2%), and partial resection in 3 (7.7%). A mature teratoma was confirmed in all 39 patients. The neurological outcomes were improved 16 patients (45.7%), stable in 14 (40.0%), and aggravated in 5 (14.3%) at a mean follow-up of 62.7 months. Recurrence developed in 1 patient who had undergone subtotal resection. A second surgery with total resection was performed, and the patient's neurological symptoms were stable during follow-up. CONCLUSIONS Total surgical resection is the optimal treatment strategy for patients with conus medullaris teratoma. Safe maximum tumor removal and residual tumor inactivation using electrocoagulation are recommended when total resection cannot be achieved. Surgery can provide a low recurrence rate and an acceptable low complication rate.
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Affiliation(s)
- Yakun Chen
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ze Li
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xin Chen
- Department of Pathology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yiheng Yin
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guangyu Qiao
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China.
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Nasi D, Ghadirpour R, Servadei F. Letter to the Editor Regarding "Intraoperative Neuromonitoring in Patients with Intramedullary Spinal Cord Tumor: A Systematic Review, Meta-Analysis, and Case Series". World Neurosurg 2019; 127:662-663. [PMID: 31266115 DOI: 10.1016/j.wneu.2019.03.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy.
| | - Reza Ghadirpour
- Department of Neurosurgery, University Hospital of Parma, Parma, Italy; Department of Neurosurgery, Institute for Scientific and Care Research "ASMN" of Reggio Emilia, Reggio Emilia, Italy
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Institute, Milan, Italy
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Neurophysiological monitoring during neurosurgery: anesthetic considerations based on outcome evidence. Curr Opin Anaesthesiol 2019; 32:580-584. [PMID: 31145200 DOI: 10.1097/aco.0000000000000753] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the recent outcome studies that investigated intraoperative neurophysiological monitoring (IONM) during spine, neurovascular and brain tumor surgery. RECENT FINDINGS Several recent studies have focused on identifying which types of neurosurgical procedures might benefit most from IONM use. Despite conflicting literature regarding its efficacy in improving neurological outcomes, many experts have advocated for the use of IONM in neurosurgery. Several themes have emerged from the recent literature: the entire perioperative team must always work together to ensure adequate communication and intervention; systems and checklists, in which each member of the perioperative team has a clearly defined role, can be useful in the event of a sudden intraoperative changes in electrophysiological signals; regardless of the IONM modality used, any sudden change in electrophysiological signal should prompt an immediate and appropriate intervention; a multimodal IONM approach is often, but not always, advantageous over a single IONM approach. SUMMARY For neurosurgical procedures that can be complicated by neural injury, the use of IONM should be considered according to specific patient and surgical factors. Future studies should focus on improving IONM technology and optimizing sensitivity and specificity for detecting any impending neural damage.
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