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Marina L, Sanz E, Morillo Balsera MC, Cristobal L, Maldonado AA. Optimizing donor fascicle selection in Oberlin's procedure: A retrospective review of anatomical variability using intraoperative neuromonitoring. Microsurgery 2024; 44:e31178. [PMID: 38661385 DOI: 10.1002/micr.31178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/20/2024] [Accepted: 03/27/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Transfer of the fascicle carrying the flexor carpi ulnaris (FCU) branch of the ulnar nerve (UN) to the biceps/brachialis muscle branch of the musculocutaneous nerve (Oberlin's procedure), is a mainstay technique for elbow flexion restoration in patients with upper brachial plexus injury. Despite its widespread use, there are few studies regarding the anatomic location of the donor fascicle for Oberlin's procedure. Our report aims to analyze the anatomical variability of this fascicle within the UN, while obtaining quantifiable, objective data with intraoperative neuromonitoring (IONM) for donor fascicle selection. METHODS We performed a retrospective review of patients at our institution who underwent an Oberlin's procedure from September 2019 to July 2023. We used IONM for donor fascicle selection (greatest FCU muscle and least intrinsic hand muscle activation). We prospectively obtained demographic and electrophysiological data, as well as anatomical location of donor fascicles and post-surgical morbidities. Surgeon's perception of FCU/intrinsic muscle contraction was compared to objective muscle amplitude during IONM. RESULTS Eight patients were included, with a mean age of 30.5 years and an injury-to-surgery interval of 4 months. Donor fascicle was located anterior in two cases, posterior in two, radial in two and ulnar in two patients. Correlation between surgeon's perception and IONM findings were consistent in six (75%) cases. No long term motor or sensory deficits were registered. CONCLUSIONS Fascicle anatomy within the UN at the proximal arm is highly variable. The use of IONM can aid in optimizing donor fascicle selection for Oberlin's procedure.
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Affiliation(s)
- Lucas Marina
- Department of Plastic and Reconstructive Surgery, Hospital Universitario de Getafe, Madrid, Spain
| | - Elisa Sanz
- Department of Neurophysiology, Hospital Universitario de Getafe, Madrid, Spain
- Department of Medicine, Faculty of Biomedical Science and Health, Universidad Europea de Madrid, Madrid, Spain
| | - M Carmen Morillo Balsera
- Department of Topographic Engineering and Cartography, Universidad Politécnica de Madrid, Madrid, Spain
| | - Lara Cristobal
- Department of Plastic and Reconstructive Surgery, Hospital Universitario de Getafe, Madrid, Spain
- Department of Medicine, Faculty of Biomedical Science and Health, Universidad Europea de Madrid, Madrid, Spain
| | - Andres A Maldonado
- Department of Plastic and Reconstructive Surgery, Hospital Universitario de Getafe, Madrid, Spain
- Department of Medicine, Faculty of Biomedical Science and Health, Universidad Europea de Madrid, Madrid, Spain
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Bakhsheshian J, Lenke LG, Hassan FM, Lewerenz E, Reyes JL, Zuckerman SL. Prospective Validation of the Spinal Cord Shape Classification System in the Prediction of Intraoperative Neuromonitoring Data Loss: Assessing the Risk of Spinal Cord Data Loss During Spinal Deformity Correction. J Bone Joint Surg Am 2024; 106:716-726. [PMID: 38386718 DOI: 10.2106/jbjs.23.00882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND The Spinal Cord Shape Classification System (SCSCS) class has been associated with spinal cord monitoring data loss during spinal deformity surgery. The objective of the current study was to prospectively validate the SCSCS as a predictor of spinal cord monitoring data loss during spinal deformity surgery. METHODS A prospective cohort study of consecutive patients who were undergoing primary deformity surgery at a single institution from 2018 to 2023 and whose major curve was in the spinal cord region was undertaken. Spinal cord morphology at the apex of the major curve on preoperative axial T2-weighted magnetic resonance imaging was used to categorize patients into 3 spinal cord shape types based on the SCSCS. The primary outcome was intraoperative neuromonitoring (IONM) data loss related to spinal cord dysfunction. Demographics and surgical and radiographic variables were compared between patients with IONM data loss and those without loss. Predictors of IONM loss were determined using bivariate and multivariable logistic regression analyses. RESULTS A total of 256 patients (168 adult, 88 pediatric) were included and were separated into 3 SCSCS types: 110 (43.0%) with Type I, 105 (41.0%) with Type II, and 41 (16.0%) with Type III. IONM loss was observed in 30 (11.7%) of the 256 patients, including 7 (6.4%) of 110 with SCSCS Type I, 7 (6.7%) of 105 with Type II, and 16 (39.0%) of 41 with Type III. IONM loss was associated with SCSCS Type III, the preoperative deformity angular ratio, performance of 3-column osteotomies, greater operative time, greater transfusion volume, and greater postoperative sagittal corrections. SCSCS type was the strongest independent predictor of IONM data loss. SCSCS Type III had the greatest odds of IONM loss (odds ratio [OR] = 6.68, 95% confidence interval [CI] = 2.45 to 18.23 compared with Types I and II combined). The overall predictive performance with respect to IONM loss (area under the receiver operating characteristic curve = 0.827) was considered excellent. CONCLUSIONS This prospective cohort study of patients undergoing spinal deformity correction confirmed that patients with a Type-III spinal cord shape had greater odds of IONM loss. Inclusion of the SCSCS in preoperative risk stratification and intraoperative management of spinal deformity corrective surgery is recommended. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joshua Bakhsheshian
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
- New York-Presbyterian Och Spine Hospital, New York, NY
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
- New York-Presbyterian Och Spine Hospital, New York, NY
| | - Fthimnir M Hassan
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Erik Lewerenz
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Justin L Reyes
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Scott L Zuckerman
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
- New York-Presbyterian Och Spine Hospital, New York, NY
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Goel V, Kaizer AM, Jain S, Darrow D, Shankar H. Intraoperative neurophysiological monitoring and spinal cord stimulator implantation. Reg Anesth Pain Med 2024; 49:192-199. [PMID: 37407277 DOI: 10.1136/rapm-2023-104325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION Spinal cord injury (SCI) is one of the most dreaded complications after spinal cord stimulation (SCS) implantation surgery. As a result, intraoperative neurophysiological monitoring (IONM) has been proposed to avoid accidental damage to nervous structures under anesthesia and confirm positioning for optimal stimulation. Our study uses a large administrative claims database to determine the 30-day risk of SCI after SCS implantation. METHODS This retrospective cohort study used the IBM MarketScan Commercial and Medicare Supplemental Databases from 2016 to 2019. Adult patients undergoing SCS surgical procedures with at least 90 days of follow-up, IONM use, the type of sedation used during the procedure, and subsequent SCI were identified using administrative codes. In addition, logistic regression was used to examine the relationship between various risk factors and subsequent SCI. RESULTS A total of 9676 patients underwent SCS surgery (64.7% percutaneous implants) during the study period. Nine hundred and forty-four (9.75%) patients underwent SCS implantation with IONM. Conscious sedation, Monitored Anesthesia Care anesthesia, and general anesthesia were used in patients with 0.9%, 60.2%, and 28.6%, respectively. Eighty-one (0.8%) patients developed SCI within 30 days after SCS implant surgery. The SCI rate was higher in the group that underwent IONM (2% vs 0.7%, p value <0.001) during the implantation procedure, reflecting the underlying risk. After adjustment for other factors, the OR of SCI is 2.39 (95% CI: 1.33 to 4.14, p value=0.002) times higher for those with IONM than those without IONM. CONCLUSIONS Increased SCI risk among patients with IONM likely reflects higher baseline risk, and further research is needed for risk mitigation.
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Affiliation(s)
- Vasudha Goel
- Department of Anesthesia and Pain Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Alexander M Kaizer
- Department of Biostatistics and Infomatics, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Sejal Jain
- Department of Anesthesia and Pain medicine, Department of Pediatrics, UT Southwestern Medical School, Dallas, Texas, USA
| | - David Darrow
- Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Wilkinson MF, Galdino Chaves JP, Arroyo MV, Zarrabian M. Repeated L5 Nerve Root Compromise Detected with Motor Evoked Potentials (MEP), but Not Electromyography (EMG): A Case Report. Neurodiagn J 2024; 64:24-32. [PMID: 38437023 DOI: 10.1080/21646821.2024.2312098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/24/2024] [Indexed: 03/06/2024]
Abstract
We report a case where neuromonitoring, using motor evoked potentials (MEP), detected an intraoperative L5 nerve root deficit during a lumbosacral decompression and instrumented fusion procedure. Critically, the MEP changes were not preceded nor accompanied by any significant spontaneous electromyography (sEMG) activity. Presumptive L5 innervated muscles, including tibialis anterior (TA), extensor hallucis longus (EHL) and gluteus maximus, were targets for nerve root surveillance using combined MEP and sEMG techniques. During a high-grade spondylolisthesis correction procedure, attempts to align a left-sided rod resulted in repeated loss and recovery cycles of MEP from the TA and EHL. No accompanying EMG alerts were associated with any of the MEP changes nor were MEP variations seen from muscles innervated above and below L5. After several attempts, the rod alignment was achieved, but significant MEP signal decrement (72% decrease) remained from the EHL. Postoperatively, the patient experienced significant foot drop on the left side that recovered over a period of 3 months. This case contributes to a growing body of evidence that exclusive reliance on sEMG for spinal nerve root scrutiny can be unreliable and MEP may provide more dependable data on nerve root patency.
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Affiliation(s)
- Marshall F Wilkinson
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Canada
| | - Jennyfer P Galdino Chaves
- Department of Orthopedic Surgery and Winnipeg Spine Program University of Manitoba and Health Sciences Centre, Winnipeg, Canada
| | - Miguel Vega Arroyo
- Department of Orthopedic Surgery and Winnipeg Spine Program University of Manitoba and Health Sciences Centre, Winnipeg, Canada
| | - Mohammed Zarrabian
- Department of Orthopedic Surgery and Winnipeg Spine Program University of Manitoba and Health Sciences Centre, Winnipeg, Canada
- Division of Orthopedic Surgery, McMaster University, Hamilton, Canada
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Ali S, Talha M, Qureshi MA, Afzal W, Shamim B, Inam S. Intraoperative Neurophysiological Monitoring in Corrective Surgery of Scoliosis - Experience at a Tertiary Care Hospital. J Coll Physicians Surg Pak 2024; 34:284-289. [PMID: 38462862 DOI: 10.29271/jcpsp.2024.03.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 01/28/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To evaluate the role of intraoperative neurophysiological monitoring (IONM) in reducing the postoperative neurologic deficit following corrective surgery of scoliosis. STUDY DESIGN Observational Study. Place and Duration of the Study: Spine Surgery Department, Combined Military Hospital, Rawalpindi, from December 2022 to May 2023. METHODOLOGY The study included 170 cases of scoliosis operated under multimodal IONM. Decreased amplitude of ≥50% in SSEP or 70-80% in MEPs were considered warning signs. Cases were divided into two groups: Group 1 (signal drop) and Group 2 (no signal drop). Group 1 was subdivided into Group 1a (true positive), Group 1b (false positive) and Group 1c (intermediate positive). Group 2 was subdivided into Group 2a (true negative) and Group 2b (false negative). RESULTS Evoked potential changes were observed in 27 (15.9%) cases. This includes transient drop of signals in 16 (9.4%) and sustained drop of signals in 11 (6.5%) cases. Among sustained signal drop, 9 (5.29%) cases had exhibited postoperative neurological deficit whereas 2 (1.17%) cases did not show postoperative neurological deficit (false positive). Multimodal IONM in the current study shows sensitivity of 100%, specificity of 98.6%, positive predictive value of 92.6%, and negative predictive value of 100%. CONCLUSION Multimodal IONM reduces the incidence of postoperative neurological deficit in corrective surgery of scoliosis by effectively detecting neurologic injury during surgery. Monitoring events alert surgical team to exercise immediate corrective measures which likely results in recovery of lost signals and predict the favorable outcome. KEY WORDS Intraoperative monitoring, Motor evoked potentials, Neurological deficit, Scoliosis, Somatosensory evoked potentials.
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Affiliation(s)
- Sajid Ali
- Department of Spine Surgery, Combined Military Hospital, Rawalpindi, Pakistan
| | - Muhammad Talha
- Department of Spine Surgery, Combined Military Hospital, Rawalpindi, Pakistan
| | | | - Waseem Afzal
- Department of Spine Surgery, Combined Military Hospital, Rawalpindi, Pakistan
| | - Babar Shamim
- Department of Spine Surgery, Combined Military Hospital, Rawalpindi, Pakistan
| | - Shahzad Inam
- Department of Spine Surgery, Combined Military Hospital, Rawalpindi, Pakistan
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Yoo NY, Kim HS, Yang JW, Park D. Removal of schwannoma from the psoas muscle with intraoperative neurophysiological monitoring: A case report. Medicine (Baltimore) 2024; 103:e37244. [PMID: 38363883 PMCID: PMC10869051 DOI: 10.1097/md.0000000000037244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/23/2024] [Indexed: 02/18/2024] Open
Abstract
RATIONALE The incidence of a schwannoma within the psoas muscle is rare, and only a few cases have been reported. The surgical approach to removing schwannomas present in the psoas muscle is challenging because of its anatomical proximity to the lumbar plexus. PATIENT CONCERNS A 31-year-old man experienced right lower back pain and anterolateral thigh numbness for 2 months. DIAGNOSIS Magnetic resonance imaging of the patient's lumbar spine revealed a mass lesion, which was radiologically diagnosed as a well-demarcated schwannoma. INTERVENTIONS The patient underwent surgery for excision of the schwannoma in the right psoas muscle at the second to fourth lumbar vertebrae levels. During surgery, intraoperative neurophysiological monitoring modalities, free-running and triggered electromyography and evoked potentials, from the target muscles were recorded. OUTCOMES There was no neurotonic discharge corresponding to neuronal injury. Compound motor nerve action potential was detected in the triggered electromyography of muscles around the medial margin of the tumor. However, direct integration of the motor nerve was not observed in the intra-tumor region. LESSONS We report that schwannoma removal in the psoas muscle, which is adjacent to the lumbar plexus, can be safely performed using intraoperative neurophysiological monitoring.
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Affiliation(s)
- Na Yoon Yoo
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Hyoung Seop Kim
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Joong Won Yang
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, South Korea
| | - Dougho Park
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang, South Korea
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Jackson ME, Galambas AK, Bauer JM. Intraoperative Neuromonitoring for Spines at Risk During Nonspine Surgery: A 9-Year Review. J Pediatr Orthop 2024; 44:e197-e202. [PMID: 37728105 DOI: 10.1097/bpo.0000000000002520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Patients with certain spinal anomalies are at risk for rare but devastating spinal cord injuries under anesthesia. We created a Spine at Risk (SAR) program to evaluate and recommend precautions for such patients, including intraoperative neuromonitoring (IONM) use for the highest-risk patients. We aimed to review all monitored nonspine procedures to determine rate of potential spinal cord injuries avoided in those who would otherwise have been unmonitored. METHODS We performed a retrospective review of our institutional SAR program from 2011 to 2019 to analyze the number of nonspine anesthetized procedures that were done under IONM, the characteristics of those that had an IONM alert; and the clinical outcomes. RESULTS Of the 3,453 patients flagged for SAR review, 1121 (33%) received a precaution recommendation, and 359 (10% of all flagged) were given IONM recommendations. Of those, 57 patients (16% of recommendations, 2% of all flagged) had a total of 102 nonspine anesthetized procedures done under IONM. Seven patients had a total of 10 cases with IONM alerts. Two cases were aborted when improved signals could not be obtained after working through a checklist; one of these patients woke with transient neurological deficits. Signals improved to baseline in 7 cases by working through a signal loss checklist. One case was aborted preoperatively when monitorable baseline signals could not be obtained. CONCLUSIONS In the highest-risk spinal anomaly patients, we monitored an average of 11.7 nonspine cases per year, with a 10% rate of IONM alerts, and no permanent neurological deficits. Although the majority of patients remain safe during procedures, in the most critical patients IONM allowed the team to identify and react to alerts that may have otherwise led to permanent neurological injury. This is the largest series of spinal cord-monitored nonspine pediatric cases. It is important for pediatric orthopedic surgeons to evaluate at-risk patients and recommend IONM where appropriate, to protect both patients and our procedural colleagues. LEVEL OF EVIDENCE Case series, level IV.
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Affiliation(s)
| | | | - Jennifer M Bauer
- Department of Orthopaedics and Sports Medicine, University of Washington
- Department of Orthopaedic Surgery, Seattle Children's Hospital, Seattle, WA
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Manohara N, Pinto V, Lobo C, Byrappa V, Lobo FA. Changes in motor evoked potentials after erector spinae block in scoliosis surgery-when to take pre-incision baseline recordings? J Clin Monit Comput 2024; 38:229-234. [PMID: 37460867 DOI: 10.1007/s10877-023-01058-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/06/2023] [Indexed: 02/21/2024]
Abstract
Multimodal intraoperative neurophysiological monitoring (IONM) is highly valuable in scoliosis surgeries for monitoring spinal cord function, particularly during instrumentation. Accurate timing of baseline recordings of TcMEP and SSEP is crucial, as any changes observed during surgery and instrumentation are compared to these baseline recordings. However, the impact of ultrasound-guided erector spinae block (USG-ESPB) on SSEP and TcMEP is not well-studied in scoliosis surgery. In this report, we present two cases of scoliosis surgery where bilateral two-level USG-ESPB using different concentrations of ropivacaine (0.375% and 0.2%) resulted in a transient and significant deterioration of TcMEP, occurring 3 minutes after the block and lasting for 20 minutes. Remarkably, SSEPs remained unchanged during this period. These findings suggest that USG-ESPB may produce TcMEP changes, highlighting the importance of carefully considering the timing of baseline TcMEP acquisition in scoliosis surgery.
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Affiliation(s)
| | - Vania Pinto
- Neurophysiology, Cleveland Clinic, Abu Dhabi, UAE
| | - Clara Lobo
- Anesthesia Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Vinay Byrappa
- Anesthesia Institute, Cleveland Clinic, Abu Dhabi, UAE
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Al-Qudah AM, Ta'ani OA, Thirumala PD, Sultan I, Visweswaran S, Nadkarni N, Kiselevskaya V, Crammond DJ, Balzer J, Anetakis KM, Shandal V, Subramaniam K, Subramanium B, Sadhasivam S. Role of Intraoperative Neuromonitoring to Predict Postoperative Delirium in Cardiovascular Surgery. J Cardiothorac Vasc Anesth 2024; 38:526-533. [PMID: 37838509 DOI: 10.1053/j.jvca.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/20/2023] [Accepted: 09/09/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE Postoperative delirium (POD) can occur in up to 50% of older patients undergoing cardiovascular surgery, resulting in hospitalization and significant morbidity and mortality. This study aimed to determine whether intraoperative neurophysiologic monitoring (IONM) modalities can be used to predict delirium in patients undergoing cardiovascular surgery. DESIGN Adult patients undergoing cardiovascular surgery with IONM between 2019 and 2021 were reviewed retrospectively. Delirium was assessed multiple times using the Intensive Care Delirium Screening Checklist (ICDSC). Patients with an ICDSC score ≥4 were considered to have POD. Significant IONM changes were evaluated based on a visual review of electroencephalography (EEG) and somatosensory evoked potentials data and documentation of significant changes during surgery. SETTING University of Pittsburgh Medical Center hospitals. PARTICIPANTS Patients 18 years old and older undergoing cardiovascular surgery with IONM monitoring. MEASUREMENTS AND MAIN RESULTS Of the 578 patients undergoing cardiovascular surgery with IONM, 126 had POD (21.8%). Significant IONM changes were noted in 134 patients, of whom 49 patients had delirium (36.6%). In contrast, 444 patients had no IONM changes during surgery, of whom 77 (17.3%) patients had POD. Upon multivariate analysis, IONM changes were associated with POD (odds ratio 2.12; 95% CI 1.31-3.44; p < 0.001). Additionally, baseline EEG abnormalities were associated with POD (p = 0.002). CONCLUSION Significant IONM changes are associated with an increased risk of POD in patients undergoing cardiovascular surgery. These findings offer a basis for future research and analysis of EEG and somatosensory evoked potential monitoring to predict, detect, and prevent POD.
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Affiliation(s)
- Abdullah M Al-Qudah
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Omar Al Ta'ani
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Parthasarathy D Thirumala
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shyam Visweswaran
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Neelesh Nadkarni
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Victoria Kiselevskaya
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Donald J Crammond
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey Balzer
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Katherine M Anetakis
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Varun Shandal
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Balachundhar Subramanium
- Department of Anesthesiology, Critical Care & Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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Abdelaal Ahmed Mahmoud Metwally Alkhatip A, Mills KE, Hogue O, Sallam A, Hamza MK, Farag E, Yassin HM, Wagih M, Ahmed AMI, Helmy MH, Elayashy M. The effects of dexmedetomidine on intraoperative neurophysiologic monitoring modalities during corrective scoliosis surgery in pediatric patients: A systematic review. Paediatr Anaesth 2024; 34:112-120. [PMID: 37927199 DOI: 10.1111/pan.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND During scoliosis surgery, motor evoked potentials (MEP), and somatosensory evoked potentials (SSEP) have been reported to be affected by the use of higher doses of anesthetic agents. Dexmedetomidine, a sympatholytic agent, an alpha-2 receptor agonist, has been used as an adjunctive agent to lower anesthetic dose. However, there is conflicting evidence regarding the effects of dexmedetomidine on the intraoperative neurophysiological monitoring of MEP and SSEP during surgery, particularly among pediatric patients. OBJECTIVES This systematic review aimed to determine whether, during spinal fusion surgery in pediatric patients with scoliosis, dexmedetomidine alters MEP amplitude or SSEP latency and amplitude and, if so, whether different doses of dexmedetomidine display different effects (PROSPERO registration number CRD42022300562). METHODS We searched PubMed, Scopus, and Cochrane Library on January 1, 2022 and included randomized controlled trials, observational cohort and case-control studies and case series investigating dexmedetomidine in the population of interest and comparing against a standardized anesthesia regimen without dexmedetomidine or comparing multiple doses of dexmedetomidine. Animal and in vitro studies and conference abstracts were excluded. RESULTS We found substantial heterogeneity in the risk of bias (per Cochrane-preferred tools) of the included articles (n = 5); results are summarized without meta-analysis. Articles with the lowest risk of bias indicated that dexmedetomidine was associated with MEP loss and that higher doses of dexmedetomidine increased risk. In contrast, articles reporting no association between dexmedetomidine and MEP loss suffered from higher risk of bias, including suspected or confirmed problems with confounding, outcome measurement, participant selection, results reporting, and lack of statistical transparency and power. CONCLUSION Given the limitations of the studies available in the literature, it would be advisable to conduct rigorous randomized controlled trials with larger sample sizes to assess the effects of dexmedetomidine use of in scoliosis surgery in pediatric patients.
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Affiliation(s)
| | | | - Olivia Hogue
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amr Sallam
- Department of Anaesthesia, Tallaght University Hospital, Dublin, Ireland
| | | | - Ehab Farag
- Department of Anaesthesia, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Hany Mahmoud Yassin
- Department of Anaesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mohamed Wagih
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | - Mohamed Elayashy
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
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Lu L, Lau M, Akers L, Jones L, Selassie M, Burke M, Barley J, Hillegass M, Gleichgerrcht E. Intraoperative Neurophysiological Monitoring During Lead Placement for Dorsal Root Ganglion Stimulation: A Literature Review and Case Series. Neuromodulation 2024; 27:160-171. [PMID: 37245141 DOI: 10.1016/j.neurom.2023.04.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/23/2023] [Accepted: 04/11/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) is a viable interventional option for intractable pain management. Although systematic data are lacking regarding the immediate neurologic complications of this procedure, intraoperative neurophysiological monitoring (IONM) can be a valuable tool to detect real-time neurologic changes and prompt intervention(s) during DRG-S performed under general anesthesia and deep sedation. MATERIALS AND METHODS In our single-center case series, we performed multimodal IONM, including peripheral nerve somatosensory evoked potentials (pnSSEPs) and dermatomal somatosensory evoked potentials (dSSEPs), spontaneous electromyography (EMG), transcranial motor evoked potentials (MEPs), and electroencephalogram (EEG) for some trials and all permanent DRG-S lead placement per surgeon preference. Alert criteria for each IONM modality were established before data acquisition and collection. An IONM alert was used to implement an immediate repositioning of the lead to reduce any possible postoperative neurologic deficits. We reviewed the literature and summarized the current IONM modalities commonly applied during DRG-S, including somatosensory evoked potentials and EMG. Because DRG-S targets the dorsal roots, we hypothesized that including dSSEP would allow more sensitivity as a proxy for potential sensory changes under generalized anesthesia than would including standard pnSSEPs. RESULTS From our case series of 22 consecutive procedures with 45 lead placements, one case had an alert immediately after DRG-S lead positioning. In this case, dSSEP attenuation was seen, indicating changes in the S1 dermatome, which occurred despite ipsilateral pnSSEP from the posterior tibial nerve remaining at baselines. The dSSEP alert prompted the surgeon to reposition the S1 lead, resulting in immediate recovery of the dSSEP to baseline status. The rate of IONM alerts reported intraoperatively was 4.55% per procedure and 2.22% per lead (n = 1). No neurologic deficits were reported after the procedure, resulting in no postoperative neurologic complications or deficits. No other IONM changes or alerts were observed from pnSSEP, spontaneous EMG, MEPs, or EEG modalities. Reviewing the literature, we noted challenges and potential deficiencies when using current IONM modalities for DRG-S procedures. CONCLUSIONS Our case series suggests dSSEPs offer greater reliability than do pnSSEPs in quickly detecting neurologic changes, and subsequent neural injury, during DRG-S cases. We encourage future studies to focus on adding dSSEP to standard pnSSEP to provide a comprehensive, real-time neurophysiological assessment during lead placement for DRG-S. More investigation, collaboration, and evidence are required to evaluate, compare, and standardize comprehensive IONM protocols for DRG-S.
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Affiliation(s)
- Lei Lu
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.
| | - Martha Lau
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Lindsey Akers
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Lakota Jones
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Meron Selassie
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Martin Burke
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jessica Barley
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Hillegass
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
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López JR, Jaffe RA, López IR, Burbridge MA. Fosaprepitant Does Not Interfere With Commonly Used Intraoperative Neuromonitoring Modalities Under General Anesthesia: A Preliminary Study. J Neurosurg Anesthesiol 2024; 36:74-76. [PMID: 36006662 DOI: 10.1097/ana.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fosaprepitant [Emend®], a neurokinin type-1 [NK-1] receptor antagonist, is a highly effective for the prophylaxis of postoperative nausea and vomiting [PONV] after general anesthesia; it is particularly effective in patients undergoing neurosurgical procedures. Based on the widespread distribution of NK-1 receptors in the central and peripheral nervous systems, we sought to determine whether fosaprepitant administration would interfere with commonly used intraoperative neurophysiologic monitoring modalities during general anesthesia. METHODS Eleven patients having propofol-based general anesthesia for interventional neuroradiology procedures were administered 150 mg fosaprepitant intravenously after baseline electroencephalogram [EEG], transcranial motor evoked potential [TcMEP], and somatosensory evoked potential [SSEP] recordings were obtained. Recordings of these neuromonitoring modalities at 30, 60, and 90 min after fosaprepitant administration were compared to baseline. RESULTS Fosaprepitant did not have a significant effect on SSEP/TcMEP amplitudes or latencies, or on TcMEP morphology. There were also no changes in EEG voltage, frequency, or symmetry. CONCLUSION Fosaprepitant does not appear to markedly interfere with SSEP, TcMEP, or EEG neuromonitoring modalities during propofol-based general anesthesia.
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Affiliation(s)
| | - Richard A Jaffe
- Department of Anesthesiology, Perioperative and Pain Management, Stanford University School of Medicine, Stanford, CA
| | | | - Mark A Burbridge
- Department of Anesthesiology, Perioperative and Pain Management, Stanford University School of Medicine, Stanford, CA
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Lapteva K, Gavrjushin A, Pitskhelauri D, Birg T, Danilov G, Ogurtsova A, Strunina Y, Fomochkina L. Intraoperative Neurophysiologic Monitoring in Predicting Dysphagia After Brainstem and Fourth Ventricle Surgery. World Neurosurg 2023; 180:e334-e340. [PMID: 37757944 DOI: 10.1016/j.wneu.2023.09.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Dysphagia represents the main complication of posterior fossa neurosurgery. Adequate diagnosis of this complication is warranted to prevent untimely extubation with subsequent aspiration. Intraoperative neurophysiologic monitoring (IONM) modalities may be used for this purpose. However, it is not known which IONM modality may be significant for diagnosis. This study aimed to define the most significant IONM modality for dysphagia prognostication after posterior fossa neurosurgery. METHODS The analysis included 46 patients (34 with tumors of the fourth ventricle and 12 with brainstem localization) who underwent surgical excision of the tumor. Neurologic symptoms before and after neurosurgery were noted and magnetic resonance imaging with the subsequent volume estimation of the removed mass was performed, followed by an IONM findings analysis (mapping of the nucleus of the caudal cranial nerves [CN] and corticobulbar motor-evoked potentials [CoMEP]). RESULTS Aggravation of dysphagia was noted in 24% of the patients, more often in patients with tumor localization in the fourth ventricle (26%) than in those with brainstem mass lesions (16%). Mapping of the caudal cranial nerve nuclei did not correlate with the dysfunction of these structures. CoMEP was significantly associated with the neurologic state of the CN. The decrease in CoMEP is a significant prognostic factor for postoperative bulbar symptoms appearance or aggravation. CONCLUSIONS Mapping the CN is an important identification tool. The CoMEP modality should be used intraoperatively to determine the functional state of the CN and predict postoperative dysphagia.
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Affiliation(s)
- Kristina Lapteva
- Department of Clinical Neurophysiology, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation.
| | - Andrey Gavrjushin
- Department of Neuro-oncology, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - David Pitskhelauri
- Department of Neuro-oncology, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Tatiana Birg
- Department of Intensive Care Unit, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Gleb Danilov
- Laboratory of Biomedical Informatics and Artificial Intelligence, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Anna Ogurtsova
- Department of Clinical Neurophysiology, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Yulia Strunina
- Laboratory of Biomedical Informatics and Artificial Intelligence, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Ludmila Fomochkina
- Department of Otorhinolaryngology, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
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Iorio C, Koucheki R, Strantzas S, Vandenberk M, Lewis SJ, Zeller R, Camp M, Rocos B, Lebel DE. Utility of intraoperative neurophysiological monitoring in detecting motor and sensory nerve injuries in pediatric high-grade spondylolisthesis. Spine J 2023; 23:1920-1927. [PMID: 37572881 DOI: 10.1016/j.spinee.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/30/2023] [Accepted: 08/05/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND CONTEXT Intraoperative neuromonitoring (IONM) during surgical correction of spinal deformity has been shown to reduce iatrogenic injury in pediatric and adult populations. Although motor-evoked potentials (MEP), somatosensory-evoked potentials (SSEP), and electromyography (EMG) have been shown to be highly sensitive and specific in detecting spinal cord and nerve root injuries, their utility in detecting motor and sensory nerve root injury in pediatric high-grade spondylolisthesis (HGS) remains unknown. PURPOSE We aim to assess the diagnostic accuracy and therapeutic impact of unimodal and multimodal IONM in the surgical management of HGS. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Pediatric patients undergoing posterior spinal fusion (PSF) for treatment of HGS. OUTCOME MEASURES Data on patient demographics, spinopelvic and spondylolisthesis parameters, and the presence of pre-and postoperative neurological deficits were collected. METHODS Intraoperative MEP, SSEP, and EMG alerts were recorded. Alert criteria were defined as a change in amplitude of more than 50% for MEP and/or SSEP, with or without change in latency, and more than 10 seconds of sustained EMG activity. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each modality and the combination of MEP and SSEP. The 95% confidence intervals (CIs) were calculated using the exact (Clopper-Pearson) method. RESULTS Fifty-four pediatric patients with HGS undergoing PSF between 2003 and 2021 in a single tertiary center were included. Seventy-two percent (39/54) of patients were female; the average age of patients was 13.7±2.3 years. The sensitivity of MEP in detecting new postoperative neurologic deficit was 92.3% (95% CI [64.0-99.8]), SSEP 77.8% (95% CI [40.0-97.2]), EMG 69.2% (95% CI [38.6-90.9]), and combination MEP and SSEP 100% (95% CI [73.5-100]). The specificity of MEP was 80.0% (95% CI [64.4-91.0]), SSEP 95.1% (95% CI [83.5-99.4]), EMG 65.9% (95% CI [49.4-79.9]), and combination MEP and SSEP 82.9% (95% CI [67.9-92.9]). The accuracy of SSEP was 92.0% (95% CI [80.8%-97.8%]), and the combination of MEP and SSEP was 86.8% (95% CI [74.7%-94.5%]). Twelve (22.2%) patients had a new motor or sensory deficit diagnosed immediately postoperatively. Nine patients made a full recovery, and 3 had some neurologic deficit on final follow-up. CONCLUSION Unimodal IONM using SSEP and MEP alone were accurate in diagnosing sensory and motor nerve root injuries, respectively. The diagnostic accuracy in predicting motor and sensory nerve injuries in pediatric HGS improved further with the use of multimodal IONM (combining MEP and SEP). We recommend the utilization of multimodal IONM in all HGS PSF surgeries.
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Affiliation(s)
- Carlo Iorio
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Spine Surgery Unit, Department of Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Robert Koucheki
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Samuel Strantzas
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada
| | - Michael Vandenberk
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen J Lewis
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Reinhard Zeller
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mark Camp
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Brett Rocos
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Orthopedic Surgery, Division of Spine, Duke University, Durham, NC, USA
| | - David E Lebel
- The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Liu W, Li Y, Qiu J, Shi B, Liu Z, Sun X, Qiu Y, Zhu Z. Intra-operative Neurophysiological Monitoring in Patients Undergoing Posterior Spinal Correction Surgery with Pre-operative Neurological Deficit: Its Feasibility and High-risk Factors for Failed Monitoring. Orthop Surg 2023; 15:3146-3152. [PMID: 37853995 PMCID: PMC10693999 DOI: 10.1111/os.13914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVE Considering spinal deformity patients with pre-operative neurological deficit were associated with more intra-operative iatrogenic neurological complications than those without, intra-operative neurophysiological monitoring (IONM) has been used for detecting possible iatrogenic injury timely. However, the IONM waveforms are often unreliable. To analyze the performance of intra-operative neurophysiological monitoring (IONM) including somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) in patients with pre-operative neurological deficit undergoing posterior spinal correction surgery, and to identify the high-risk factors for failed IONM. METHODS Patients with pre-operative neurological deficit undergoing posterior spinal correction surgery between October 2017 and January 2022 were retrospectively reviewed. The presence or absence of SEP and MEP of target muscles were separately recorded. The P37/N50 latency and amplitude of SEP, and the MEP amplitude were measured. Any IONM alerts were also recorded. The IONM performance was compared among patients with different etiologies, levels responsible for neurological deficit, and strength of IONM-target muscles. Patients' demographics were analyzed using the descriptive statistics and were presented with mean ± standard deviation. Comparison analysis was performed using χ2 -test and statistically significant difference was defined as p < 0.05. RESULTS A total of 270 patients (147 males, 123 females) with an average age of 48.4 ± 36.7 years were involved. The SEP records were available in 371 (68.7%) lower extremities while MEP records were available in 418 (77.4%). SEP alerts were reported in 31 lower extremities and MEP alerts in 22, and new neurological deficit at post-operation was observed in 11. The etiologies of neuromuscular and syndromic indicated relatively lower success rates of IONM, which were 44.1% and 40.5% for SEP, and 58.8% and 59.5% for MEP (p < 0.001). In addition, patients with pre-operative neurological deficit caused by cervical spine and muscle strength lower than grade 4 suffered from higher risk of failed IONM waveforms (p < 0.001). CONCLUSION Patients with pre-operative neurological deficit suffered from a higher incidence of failed IONM results. The high-risk for failed IONM waveforms included the neuromuscular and syndromic etiologies, neurological deficit caused by cervical spine, muscle strength lower than grade 4 in patients with pre-operative neurological deficit undergoing posterior spinal correction surgery.
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Affiliation(s)
- Wanyou Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Yinkun Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Junyin Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Benlong Shi
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
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Liu W, Qiu J, Zhu Z, Shi B, Li Y, Liu Z, Sun X, Qiu Y. Intraoperative Neurophysiological Monitoring Alerts During Three-Column Osteotomy: Incidence and Risk Factors. J Clin Neurophysiol 2023; 40:641-645. [PMID: 35044361 DOI: 10.1097/wnp.0000000000000924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PRUPOSE To analyze the incidence and risk factors of intraoperative neurophysiological monitoring (IONM) alerts in patients undergoing three-column osteotomy. METHODS A total of 551 patients (340 males and 211 females) with an average age of 31.9 years undergoing posterior 3-column osteotomy were retrospectively reviewed. The coronal Cobb angle of main curve and sagittal global kyphosis were measured on preoperative standing whole spinal x-rays. The Frankel scores at preoperation, postoperation, and the last follow-up were recorded and applied for assessment of neurologic status. Surgical procedures and other factors associated with IONM alerts were analyzed. RESULTS A total of 98 (17.8%) IONM alerts were reported during surgery, including 82 somatosensory evoked potential alerts and 91 motor evoked potential alerts. Positive wake-up test was revealed in 57 patients (10.3%) even after prompt managements, and new neurologic deficits were observed in 50 patients (9.1%) at immediate postoperation. Of the 50 patients with new neurologic deficits at postoperation, the Frankel scores were A in 5 patients, B in 4, C in 9, and D in 32. The χ 2 test showed that patients with congenital deformities, global kyphosis >90°, vertebral column resection procedure, cervicothoracic/thoracic osteotomy, blood loss >3,000 mL, and preoperative neurologic deficit were at a higher risk of IONM alerts. CONCLUSIONS The incidence of IONM alerts in patients undergoing 3-column osteotomy was 17.8%. Congenital deformities, global kyphosis >90°, vertebral column resection, cervicothoracic/thoracic osteotomy, blood loss >3,000 mL, and preoperative neurologic deficit indicated high risk of IONM alerts.
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Affiliation(s)
- Wanyou Liu
- Department of Spine Surgery, Nanjing Drum Tower Hospital Clinical College of Xuzhou Medical University, Nanjing, China; and
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Junyin Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zezhang Zhu
- Department of Spine Surgery, Nanjing Drum Tower Hospital Clinical College of Xuzhou Medical University, Nanjing, China; and
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Benlong Shi
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yang Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu Sun
- Department of Spine Surgery, Nanjing Drum Tower Hospital Clinical College of Xuzhou Medical University, Nanjing, China; and
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Department of Spine Surgery, Nanjing Drum Tower Hospital Clinical College of Xuzhou Medical University, Nanjing, China; and
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Schlaeppi JA, Schreen R, Seidel K, Pollo C. Intraoperative Neurophysiological Monitoring During Spinal Cord Stimulation Surgery: A Systematic Review. Neuromodulation 2023; 26:1319-1327. [PMID: 37802585 DOI: 10.1016/j.neurom.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVES This study aims to describe the state of literature regarding the use of intraoperative neurophysiological monitoring (IONM) during spinal cord stimulator surgery. MATERIALS AND METHODS A systematic review of the use of IONM during spinal cord stimulation (SCS) surgery was performed using the following three data bases: PubMed, Ovid MEDLINE, and Embase. Research techniques included systematic research following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol by Cochrane, and backward searching. Qualitative analysis of included articles was performed using the methodologic index for nonrandomized studies assessment tool. Direction of effect, consistency across studies, and cost-effectiveness were narratively synthesized. RESULTS A total of 15 records were identified through data base searching. All records used IONM methods under general anesthesia for guidance of epidural lead placement. IONM techniques used for determining lateralization in the found articles were compound muscle action potentials (CMAPs) (n = 8), somatosensory evoked potentials (SSEPs) (n = 3) or both (n = 4). Motor evoked potentials were used in three trials for neuroprotection purposes. Two studies were comparative, and 12 were noncomparative. CONCLUSIONS We found a good body of level II evidence that using IONM during SCS surgery is a valid alternative to awake surgery and may even be superior regarding pain management, cost-effectiveness, and postoperative neurologic deficits. In direct comparison, the found evidence suggested using CMAP provided more consistently favorable results than using SSEP for midline placement of epidural leads under general anesthesia. Selection of IONM modality should be made on the basis of pathophysiology of disease, individual IONM experience, and the individual patient.
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Affiliation(s)
- Janine-Ai Schlaeppi
- Department of Neurosurgery, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Raphael Schreen
- Department of Neurosurgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kathleen Seidel
- Department of Neurosurgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudio Pollo
- Department of Neurosurgery, Bern University Hospital, University of Bern, Bern, Switzerland
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Ushirozako H, Yoshida G, Imagama S, Machino M, Ando M, Kawabata S, Yamada K, Kanchiku T, Fujiwara Y, Taniguchi S, Iwasaki H, Shigematsu H, Tadokoro N, Takahashi M, Wada K, Yamamoto N, Funaba M, Yasuda A, Hashimoto J, Morito S, Takatani T, Kobayashi K, Nakanishi K, Kurosu K, Matsuyama Y. Role of Transcranial Motor Evoked Potential Monitoring During Traumatic Spinal Injury Surgery: A Prospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Spine (Phila Pa 1976) 2023; 48:1388-1396. [PMID: 37000682 DOI: 10.1097/brs.0000000000004652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/14/2023] [Indexed: 04/01/2023]
Abstract
STUDY DESIGN A prospective multicenter observational cohort study. OBJECTIVE This study aimed to investigate the role of transcranial motor evoked potential (TcMEP) monitoring during traumatic spinal injury surgery, the timing of TcMEP alerts, and intervention strategies to avoid intraoperative neurological complications. SUMMARY OF BACKGROUND DATA Intraoperative neuromonitoring, including TcMEP monitoring, is commonly used in high-risk spinal surgery to predict intraoperative spinal cord injury; however, little information is available on its use in traumatic spinal injury surgery. METHODS The TcMEP monitoring data of 350 consecutive patients who underwent traumatic spinal injury surgery (mean age, 69.3 y) between 2017 and 2021 were prospectively reviewed. In this study, a TcMEP amplitude reduction ≥70% was established as a TcMEP alert. A rescue case was defined as a case with the recovery of TcMEP amplitudes after certain procedures and without postoperative neurological complications. RESULTS Among the 350 patients who underwent traumatic spinal injury surgery (TcMEP derivation rate 94%), TcMEP monitoring revealed seven true-positive (TP) (2.0%), three rescues (0.9%; rescue rate 30%), 31 false-positive, one false-negative, and 287 true-negative cases, resulting in 88% sensitivity, 90% specificity, 18% positive predictive value, and 99% negative predictive value. The TP rate in patients with preoperative motor deficits was 2.9%, which was higher than that in patients without preoperative motor deficits (1.1%). The most common timing of TcMEP alerts was during decompression (40%). During decompression, suspension of surgery with intravenous steroid injection was ineffective (rescue rate, 0%), and additional decompression was effective. CONCLUSION Given the low prevalence of neurological complications (2.3%) and the low positive predictive value (18.4%), single usage of TcMEP monitoring during traumatic spinal injury surgery is not recommended. Further efforts should be made to reduce FP alert rates through better interpretation of multimodal Intraoperative neuromonitorings and the incorporation of anesthesiology to improve the positive predictive value. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Muneharu Ando
- Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan
| | - Shigenori Kawabata
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kei Yamada
- Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Tsukasa Kanchiku
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan
| | - Yasushi Fujiwara
- Department of Orthopedic Surgery, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | | | - Hiroshi Iwasaki
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama, Japan
| | - Hideki Shigematsu
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Nobuaki Tadokoro
- Department of Orthopedic Surgery, Kochi University, Kochi, Japan
| | | | - Kanichiro Wada
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Naoya Yamamoto
- Department of Orthopedic Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University, Yamaguchi, Japan
| | - Akimasa Yasuda
- Department of Orthopedic Surgery, National Defense Medical College Hospital, Saitama, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinji Morito
- Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, Nara, Japan
| | | | | | - Kenta Kurosu
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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19
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Angelliaume A, Alhada TL, Parent HF, Royer J, Harper L. Intraoperative neurophysiological monitoring in scoliosis surgery: literature review of the last 10 years. Eur Spine J 2023; 32:3072-3076. [PMID: 37434021 DOI: 10.1007/s00586-023-07837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Patients with spinal deformities undergoing corrective surgery are at risk for iatrogenic spinal cord injury (SCI) and subsequent neurological deficit. Intraoperative neurophysiological monitoring (IONM) allows early detection of SCI which enables early intervention resulting in a better prognosis. The primary aim of this literature review was to search if there are threshold values of TcMEP and SSEP in the literature that are widely accepted as alert during IONM. The secondary aim was to update knowledge concerning IONM during scoliosis surgery. METHOD PubMed/MEDLINE and Cochrane library electronic databases were used to search publication from 2012 to 2022. The following keywords were used: evoked potential, scoliosis, surgery, intraoperative monitoring and neurophysiological. We included all studies dealing with SSEP and TcMEP monitoring during scoliosis surgery. Two authors reviewed all titles and abstracts to identify studies that met the inclusion criteria. RESULTS We included 43 papers. Rates of IONM alert and neurological deficit varied from 0.56 to 64% and from 0.15 to 8.3%, respectively. Threshold values varied from a loss of 50 to 90% for TcMEP amplitude, whereas it seems that a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted for SSEP. Causes of IONM changes most frequently reported were surgical maneuver. CONCLUSION Concerning SSEP, a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted as an alert. For TcMEP, it seems that the use of highest threshold values can avoid unnecessary surgical procedure for the patient without increasing risk of neurological deficit.
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Affiliation(s)
| | - Toul-la Alhada
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | | | - Julia Royer
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Luke Harper
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
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20
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Torres-Carretero L, Otero-Rodríguez Á, Alejos-Herrera MV, Vázquez-Casares G, García-Martín A, Garrido-Ruiz PA. [Utility of the intraoperative neurophysiological monitoring as a prognostic value of postoperative facial paresis in vestibular schwannomas]. Neurocirugia (Astur : Engl Ed) 2023; 34:238-246. [PMID: 36931931 DOI: 10.1016/j.neucie.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/07/2022] [Indexed: 03/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Intraoperative neurophysiological monitoring allows us to predict the functional status of the facial nerve after vestibular schwannoma surgery. Due to the great variability of the neurophysiological protocols used for it, the goal of this study is to determine the prognostic ability of our neurophysiological protocol. MATERIAL AND METHODS We have performed a statistical analysis of the neurophysiological monitoring data collected from patients operated between March 2009 and July 2021 at the Neurosurgery Service of Salamanca according to their functional status, both in the immediate post-surgical period and one year after surgery. RESULTS A number of 51 patients between 46 and 63 years old (median: 54) were analyzed. We have found significant differences studying the threshold value of the stimulation intensity of the facial nerve and the variation of the Cortico-bulbar Evoked Motor Potentials (P=0.043 and P=0.011, respectively) between the patients with good and bad clinical situation after surgery. The most discriminating intensity threshold value was 0.35mA (Sensitivity: 85%; Specificity: 48%). No statistical relationship was found in the study group one year after surgery. CONCLUSIONS Our intraoperative monitoring protocol allows us to predict the clinical situation of patients in the immediate postoperative period and improve information for the patient and her relatives after surgery. We cannot, however, use these parameters to predict the functional situation one year after surgery and make clinical decisions in this regard.
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Affiliation(s)
| | | | | | | | - Andoni García-Martín
- Servicio de Neurocirugía, Hospital Universitario de Salamanca, Salamanca, España
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21
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Fleseriu CM, Sultan I, Brown JA, Mina A, Frenchman J, Crammond DJ, Balzer J, Anetakis KM, Subramaniam K, Shandal V, Navid F, Thirumala PD. Role of Intraoperative Neurophysiological Monitoring in Preventing Stroke After Cardiac Surgery. Ann Thorac Surg 2023; 116:623-629. [PMID: 36634835 DOI: 10.1016/j.athoracsur.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/09/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Perioperative stroke after cardiac surgical procedures carries significant morbidity. Dual intraoperative neurophysiological monitoring with electroencephalography (EEG) and somatosensory-evoked potentials detects cerebral hypoperfusion and predicts postoperative stroke in noncardiac procedures. We further evaluated preoperative risk factors and intraoperative neuromonitoring ability to predict postoperative stroke after cardiac operations. METHODS All patients who underwent cardiac operations with intraoperative neurophysiological monitoring from 2009 to 2020 at a single academic medical center were retrospectively analyzed. Patients with circulatory arrest were excluded. Risks factors analyzed were sex, age, tobacco use, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, prior cerebrovascular accident, cerebrovascular disease, antiplatelet/anticoagulant use, abnormal somatosensory-evoked potentials and EEG baselines, and significant somatosensory-evoked potentials and EEG change as well as their permanence. Patients were divided into 2 groups by 30-day postoperative stroke occurrence. Univariate and multivariate logistical regressions were used for postoperative stroke significant predictors, and Kaplan-Meier curves estimated survival. RESULTS The study included 620 patients (67.6% men), mean age 65.1 ± 14.1 years, with stroke in 5.32%. In univariate analysis, diabetes (odds ratio [OR], 2.62) and permanence of EEG change (OR, 5.35) were each associated with increased postoperative stroke odds. In multivariate analysis, diabetes (OR, 2.64) and permanent EEG change (OR, 4.22) were independently significantly associated with postoperative stroke. Overall survival was significantly better for patients with no intraoperative neurophysiological monitoring changes (P < .005). CONCLUSIONS Permanent EEG change and diabetes were significant postoperative stroke predictors in cardiac operations. Furthermore, overall survival out to 10 years postoperatively was significantly higher in the group without intraoperative neurophysiological monitoring changes, emphasizing its important predictive role.
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Affiliation(s)
- Cara M Fleseriu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amir Mina
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Frenchman
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey Balzer
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katherine M Anetakis
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Varun Shandal
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Parthasarathy D Thirumala
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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22
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Liu X, Zhang X, Shang X, Wang H, Hou W, Sun Z. The TOFr of 0.75 to 0.85 is the optimal timing for IONM during thyroid surgery: a prospective observational cohort study. BMC Anesthesiol 2023; 23:286. [PMID: 37612707 PMCID: PMC10464378 DOI: 10.1186/s12871-023-02224-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUD Recurrent laryngeal nerve (RLN) injury is one of the serious complications of thyroid tumour surgery, surgical treatment of thyroid cancer requires careful consideration of the RLN and its impact on glottis function. There has been no unified standard for precise neuromuscular block monitoring to guide the monitoring of RLN in thyroid surgery. This study aimed to investigate the correlation between Train-of-four stabilization ratio (TOFr) and neural signal values of intraoperative neurophysiological monitoring (INOM) during thyroid operation, and further to determine the optimal timing for INOM during thyroid operation. METHODS Patients scheduled for thyroid tumour resection with INOM and RLN monitoring from April 2018 to July 2018 in our center were recruited. Electromyography (EMG) signals and corresponding TOFr were collected. All nerve stimulation data were included in group VR. Vagus nerve stimulation data were included in Subgroup V. RLN stimulation data were included in Subgroup R. The timing of recording was as follows: Vagus nerve EMG amplitude after opening the lateral space between the thyroid and carotid sheath and before the initiation of thyroid dissection, RLN EMG amplitude at first recognition, RLN EMG amplitude after complete thyroid dissection (Repeat three times), and Vagus nerve EMG amplitude after resection of the thyroid (Repeat three times). Correlation analysis of continuous variables was described by a scatter diagram. Pearson correlation analysis or Spearman correlation analysis was used for the two groups of variables. RESULTS Finally, 134 vagus nerve signals and 143 RLN signals were analysed after matching with TOFr. The EMG amplitude in the VR group and subgroups after nerve stimulation was positively correlated with TOFr (p < 0.05). In the VR, V and R group, the incidence of EMG ≥ 500 µV in the 0.75 < TOFr ≤ 0.85 interval was significantly higher than the 0 < TOFr ≤ 0.75 interval (P = 0.002, P = 0.013 and P = 0.029), and has no statistical difference compared to 0.85 < TOFr ≤ 0.95 interval (P > 0.05). CONCLUSIONS The EMG signals of the RLN and vagus nerve stimulation during thyroid surgery were positively correlated with TOFr. TOFr > 0.75 could reflect more than 50% of the effective nerve electrophysiological signals, 0.75 < TOFr ≤ 0.85 interval was the optimal timing for IONM during thyroid surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR1800015797) Registered on 20/04/2018. https://www.chictr.org.cn .
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Affiliation(s)
- Xi Liu
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Anaesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xue Zhang
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xue Shang
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huihui Wang
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Wenting Hou
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Zhirong Sun
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
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23
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Harris E. Using EEG to Monitor Brain Wave Transitions Could Reduce Postoperative Cognitive Issues. JAMA 2023; 330:586. [PMID: 37494036 DOI: 10.1001/jama.2023.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
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Siller S, Sixta A, Tonn JC, Szelenyi A. Feasibility of multimodal intraoperative neurophysiological monitoring for extramedullary spinal cord tumor surgery in elderly patients. Acta Neurochir (Wien) 2023; 165:2089-2099. [PMID: 37355475 PMCID: PMC10409671 DOI: 10.1007/s00701-023-05682-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/13/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND/PURPOSE Extramedullary spinal cord tumors (EMSCTs) are mostly benign tumors which are increasingly diagnosed and operatively treated in the elderly. While there are hints that multimodal intraoperative neurophysiological monitoring (IONM) could be influenced by age and age-related comorbidities, no study has ever systematically evaluated its feasibility and value for EMSCT surgery in elderly patients. METHODS We retrospectively evaluated all patients with microsurgical EMSCT resection under continuous multimodal IONM with SSEPs, MEPs and electromyography between 2016 and 2020. Epidemiological, clinical, imaging and operative/IONM records as well as detailed individual outcomes were analyzed and compared for the cohort < / ≥ 65 years. RESULTS Mean age was 45 years in cohort < 65 years (n = 109) and 76 years in cohort ≥ 65 years (n = 64), while baseline/operative characteristics did not significantly differ. Mean baseline SSEPs' latencies (left-right average) were significantly higher in the cohort ≥ 65 years for both median (20.9 ms vs. 22.1 ms; p < 0.01) and tibial nerve (42.9 ms vs. 46.1 ms; p < 0.01) without significant differences for SSEPs' amplitudes. Stimulation intensity to elicit intraoperative MEPs was significantly higher in the cohort ≥ 65 years (surrogate-marker: left-right-averaged quotient ID1-muscle/abductor-hallucis-muscle; 1.6 vs. 2.1; p < 0.001). Intraoperatively, SSEP and MEP monitoring were feasible in 99%/100% and 99%/98% for the cohort < / ≥ 65 years without significant differences in rates for significant IONM changes during surgery or postoperatively new sensorimotor deficits. Sensitivity of IONM was 29%/43%, specificity 99%/98%, positive and negative predictive values 67%/75% and 95%/93% for the cohort < / ≥ 65 years. Overall, age was no risk factor for IONM feasibility or rate of significant IONM changes. DISCUSSION Multimodal IONM is feasible/reliable for EMSCT surgery in elderly patients. An age-related prolongation of SSEPs' latencies and demand for higher stimulation intensities for MEPs' elicitation has to be considered.
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Affiliation(s)
- Sebastian Siller
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Akela Sixta
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Andrea Szelenyi
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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25
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Holdefer RN, Seubert CN, Skinner SA, Humbert AT, Edwards ME, MacDonald DB. Analyzing the value of IONM as a complex intervention: The gap between published evidence and clinical practice. Clin Neurophysiol 2023; 151:59-73. [PMID: 37163826 DOI: 10.1016/j.clinph.2023.03.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 02/25/2023] [Accepted: 03/20/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Intraoperative neurophysiological monitoring (IONM) was investigated as a complex intervention (CI) as defined by the United Kingdom Medical Research Council (MRC) in published studies to identify challenges and solutions in estimating IONM's effects on postoperative outcomes. METHODS A scoping review to April 2022 of the influence of setting on what was implemented as IONM and how it influenced postoperative outcomes was performed for studies that compared IONM to no IONM cohorts. IONM complexity was assessed with the iCAT_SR tool. Causal graphs were used to represent this complexity. RESULTS IONM implementation depended on the surgical procedure, institution and/or surgeon. "How" IONM influenced neurologic outcomes was attributed to surgeon or institutional experience with the surgical procedure, surgeon or institutional experience with IONM, co-interventions in addition to IONM, models of IONM service delivery and individual characteristics of the IONM provider. Indirect effects of IONM mediated by extent of tumor resection, surgical approach, changes in operative procedure, shorter operative time, and duration of aneurysm clipping were also described. There were no quantitative estimates of the relative contribution of these indirect effects to total IONM effects on outcomes. CONCLUSIONS IONM is a complex intervention whose evaluation is more challenging than that of a simple intervention. Its implementation and largely indirect effects depend on specific settings that are usefully represented in causal graphs. SIGNIFICANCE IONM evaluation as a complex intervention aided by causal graphs and multivariable analysis could provide a valuable framework for future study design and assessments of IONM effectiveness in different settings.
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Affiliation(s)
- Robert N Holdefer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | - Christoph N Seubert
- Department of Anesthesiology, Division of Neuroanesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Stanley A Skinner
- Intraoperative Monitoring, Department of Neurophysiology, Abbott Northwestern Hospital, 800 E 28th Street, Minneapolis, MN 55407, USA
| | - Andrew T Humbert
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Mary E Edwards
- University of Florida Health Science Center Libraries, University of Florida, Gainesville, FL, USA
| | - David B MacDonald
- Arkana Forum Medical Education Center, Im Hausgrün 29, 79312, Emmendingen, Germany
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Lettieri C, Pauletto G, Valiante G, Ius T, Verriello L, Valente M, Skrap M, Gigli GL, Budai R. Fast or Slow? A Comparison Between Two Transcranial Electrical Stimulation Techniques for Eliciting Motor-Evoked Potentials During Supratentorial Surgery. J Clin Neurophysiol 2023; 40:465-470. [PMID: 35452204 DOI: 10.1097/wnp.0000000000000902] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE During intraoperative neurophysiological monitoring of motor pathways, two types of transcranial electrical stimulation are available, i.e., constant-current and constant-voltage stimulation. Few previous studies, performed only during spinal surgery, analyzed and compared them during intraoperative neurophysiological monitoring. The aim of our study was to compare these two stimulation techniques for eliciting motor-evoked potentials during intraoperative neurophysiological monitoring in a group of patients affected by supratentorial lesions. METHODS Supratentorial lesions from 16 patients were retrospectively collected and analyzed. Motor-evoked potentials were performed only from transcranial electrical stimulation because the inability to place the subdural strip electrodes correctly did not permit to perform direct cortical stimulation. At the beginning of surgery, in each patient, motor-evoked potentials were monitored by using both "fast-charge" constant-voltage and "slow-charge" constant-current stimulation. Several neurophysiological parameters were collected and compared between the two stimulation techniques by means of statistical analysis. RESULTS "Fast-charge" constant-voltage stimulation allowed statistically higher efficiency rates for eliciting motor-evoked potentials compared with "slow-charge" constant-current stimulation, both for upper and lower limbs. We also found that threshold and maximal charge as well as charge density were significantly lower during constant-voltage stimulation, thus lowering the potential tissue damage. CONCLUSIONS "Fast-charge" constant-voltage transcranial electrical stimulation is feasible and safe during intraoperative neurophysiological monitoring for supratentorial surgery and may be preferable to "slow-charge" constant-current stimulation.
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Affiliation(s)
- Christian Lettieri
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Giada Pauletto
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Gabriele Valiante
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Tamara Ius
- Neurosurgery Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Lorenzo Verriello
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy ; and
- Departments of Medicine (DAME) and
| | - Miran Skrap
- Neurosurgery Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Gian L Gigli
- Clinical Neurology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy ; and
- Mathematics, Informatics and Physics (DMIF), University of Udine, Udine, Italy
| | - Riccardo Budai
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
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Allison DW, Hayworth MK, Nader R, Ballman M, Sun D, Ninan R, Southern E. Intraoperative transabdominal MEPs: four case reports. J Clin Monit Comput 2023; 37:689-698. [PMID: 35999343 DOI: 10.1007/s10877-022-00903-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022]
Abstract
Four recent cases utilizing transabdominal motor-evoked potentials (TaMEPs) are presented as illustrative of the monitoring technique during lumbosacral fusion, sciatic nerve tumor resection, cauda equina tumor resection, and lumbar decompression. Case 1: In a high-grade lumbosacral spondylolisthesis revision fusion, both transcranial motor-evoked potentials (TcMEPs) and TaMEPs detected a transient focal loss of left tibialis anterior response in conjunction with L5 nerve root decompression. Case 2: In a sciatic nerve tumor resection, TcMEPs responses were lost but TaMEPs remained unchanged, the patient was neurologically intact postoperatively. Case 3: TaMEPs were acquired during an L1-L3 intradural extramedullary cauda equina tumor resection utilizing a unique TaMEP stimulation electrode. Case 4: TaMEPs were successfully acquired with little anesthetic fade utilizing an anesthetic regimen of 1.1 MAC Sevoflurane during a lumbar decompression. While the first two cases present TaMEPs and TcMEPs side-by-side, demonstrating TaMEPs correlating to TcMEPs (Case 1) or a more accurate reflection of patient outcome (Case 2), no inference regarding the accuracy of TaMEPs to monitor nerve elements during cauda equina surgery (Cases 3) or the lumbar decompression presented in Case 4 should be made as these are demonstrations of technique, not utility.
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Affiliation(s)
- David W Allison
- Department of Neurophysiology, Houston Methodist Hospital, 6565 Fannin St., Houston, TX, 77030, USA.
| | - Miranda K Hayworth
- Department of Neurosurgery, University of Texas Medical Branch, 1005 Harborside Drive, Galveston, TX, 77555, USA
| | - Remi Nader
- Department of Neurosurgery, University of Texas Medical Branch, 1005 Harborside Drive, Galveston, TX, 77555, USA
| | - Melodie Ballman
- Medsurant Health, 100 Front Street, Suite 280, West Conshohoken, PA, 19428, USA
| | - Derrick Sun
- Department of Neurosurgery, Houston Methodist Healthcare System, 6560 Fannin St., Houston, TX, 77030, USA
| | - Rony Ninan
- Department of Neurology, Houston Methodist Healthcare System, 6560 Fannin St., Houston, TX, 77030, USA
| | - Edward Southern
- Department of Orthopedic Surgery, University of Texas Medical Branch, 1005 Harborside Drive, Galveston, TX, 77555, USA
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Oh BH, Kim JY, Lee JB, Kim IS, Hong JT, Sung JH, Lee HJ. Failure to Obtain Baseline Signals of Transcranial Motor-Evoked Potentials in Spine Surgery: Analysis of the Reasons. World Neurosurg 2023; 170:e144-e150. [PMID: 36328164 DOI: 10.1016/j.wneu.2022.10.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Among the various intraoperative neurophysiologic monitoring (IONM) techniques, transcranial motor-evoked potential (Tc-MEP) has recently become the most widely used method to monitor motor function. However, we often find that Tc-MEP is not sufficiently detected at the start of surgery. Therefore, we aimed to analyze the reasons and risk factors for not detecting sufficient baseline signal of Tc-MEP from the beginning of spinal surgery. METHODS We categorized IONM data from 1058 patients who underwent spine surgeries at a single institution from 2014 to 2020 and categorized them into 2 groups: 1) "poor MEP" if Tc-MEP could not be sufficiently obtained and 2) "normal MEP" if Tc-MEP could be sufficiently obtained from the surgery. We analyzed the patient's age, gender, underlying disease, operation type, level numbers, baseline motor function, existence of pathologic reflex, myelopathy, and duration from the onset and clinical diagnosis. RESULTS The rate of failure to obtain sufficient baseline Tc-MEP signals in spine surgery was 21.8% (231/1058). Multivariate analysis showed significant associations of existence of diabetes mellitus, myelopathy, thoracic spine surgery, baseline motor deficit and tumor, and trauma disease with loss of meaningful and interpretable signals in baseline Tc-MEP (P < 0.05). Only 15 of 231 patients (6.4%) showed a trend of signal recovery after decompression procedures. CONCLUSIONS Various factors (myelopathy, diabetes mellitus, thoracic surgery, baseline motor deficit, tumor, and trauma) were closely related to not obtaining sufficient baseline signals for Tc-MEP. When operating on patients with these considerations, we need to consider the efficacy and usefulness of Tc- MEP.
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Affiliation(s)
- Byeong Ho Oh
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jee Yong Kim
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jong Beom Lee
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Il Sup Kim
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jae Taek Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Ho Jin Lee
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea.
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Olmsted ZT, Silverstein JW, Einstein EH, Sowulewski J, Nelson P, Boockvar JA, D'Amico RS. Evolution of flash visual evoked potentials to monitor visual pathway integrity during tumor resection: illustrative cases and literature review. Neurosurg Rev 2023; 46:46. [PMID: 36715828 DOI: 10.1007/s10143-023-01955-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
Flash visual evoked potentials (fVEPs) provide a means to interrogate visual system functioning intraoperatively during tumor resection in which the optic pathway is at risk for injury. Due to technical limitations, fVEPs have remained underutilized in the armamentarium of intraoperative neurophysiological monitoring (IONM) techniques. Here we review the evolution of fVEPs as an IONM technique with emphasis on the enabling technological and intraoperative improvements. A combined approach with electroretinography (ERG) has enhanced feasibility of fVEP neuromonitoring as a practical application to increase safety and reduce error during tumor resection near the prechiasmal optic pathway. The major advance has been towards differentiating true cases of damage from false findings. We use two illustrative neurosurgical cases in which fVEPs were monitored with and without ERG to discuss limitations and demonstrate how ERG data can clarify false-positive findings in the operating room. Standardization measures have focused on uniformity of photostimulation parameters for fVEP recordings between neurosurgical groups.
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Affiliation(s)
- Zachary T Olmsted
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA.
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
- Neuro Protective Solutions, New York, NY, USA
| | - Evan H Einstein
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | | | - Priscilla Nelson
- Department of Anesthesiology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | - John A Boockvar
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
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Hoang L, Jasiukaitis P. Confirming a C5 Palsy with a Motor Evoked Potential Trending Algorithm during Insertion of Cervical Facet Spacers: A Case Study. Neurodiagn J 2022; 62:206-221. [PMID: 36459540 DOI: 10.1080/21646821.2022.2136926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 10/12/2022] [Indexed: 06/17/2023]
Abstract
The use of cervical facet spacers has shown favorable clinical results in the treatment of cervical spondylotic disease; however, there are limited data regarding neurological complications associated with the procedure. This case report demonstrates the specificity of multi-myotomal motor evoked potentials (MEPs) in detecting acute postoperative C5 palsy following placement of facet spacers. A posterior cervical fusion with decompression and instrumentation involving DTRAX (Providence Medical Technology; Lafayette, CA) was used to treat a patient with cervical stenosis and myelopathy. Intraoperative neurophysiological monitoring (IONM) consisting of MEPs, somatosensory evoked potentials (SSEPs), and free-run electromyography (EMG), was used throughout the procedure. Immediately following the placement of the DTRAX spacers at C4-5, a decrease in amplitudes from the right deltoid and biceps MEP recordings (>65%) was detected. All other IONM modalities remained stable; it is noteworthy that there was an absence of mechanically elicited EMG. A novel post-alert regression analysis trending algorithm of MEP amplitudes confirmed the visual alert. This warning along with an intraoperative computed tomography (CT) scan of the cervical spine subsequently resulted in the decision to remove one of the facet spacers. Surgical intervention did not result in recovery of the aforementioned MEP recordings, which remained attenuated at the time of wound closure. Postoperatively, the patient exhibited an immediate right C5 palsy (2/5). A post-surgery application of the trending algorithm demonstrated that it correlated to the visual alert until the end of monitoring.
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Affiliation(s)
- Ly Hoang
- Department of Surgical Neurophysiology University of California - San Francisco (UCSF), San Francisco, California
| | - Paul Jasiukaitis
- Department of Surgical Neurophysiology University of California - San Francisco (UCSF), San Francisco, California
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Funaba M, Kanchiku T, Kobayashi K, Yoshida G, Machino M, Yamada K, Shigematsu H, Tadokoro N, Ushirozako H, Takahashi M, Yamamoto N, Morito S, Kawabata S, Fujiwara Y, Ando M, Taniguchi S, Iwasaki H, Wada K, Yasuda A, Hashimoto J, Takatani T, Ando K, Matsuyama Y, Imagama S. The Utility of Transcranial Stimulated Motor-Evoked Potential Alerts in Cervical Spine Surgery Varies Based on Preoperative Motor Status. Spine (Phila Pa 1976) 2022; 47:1659-1668. [PMID: 35943242 DOI: 10.1097/brs.0000000000004448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/13/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective multicenter observational study. OBJECTIVE The aim was to investigate the validity of transcranial motor-evoked potentials (Tc-MEP) in cervical spine surgery and identify factors associated with positive predictive value when Tc-MEP alerts are occurred. SUMMARY OF BACKGROUND DATA The sensitivity and specificity of Tc-MEP for detecting motor paralysis are high; however, false-positives sometimes occur. MATERIALS AND METHODS The authors examined Tc-MEP in 2476 cases of cervical spine surgeries and compared patient backgrounds, type of spinal disorders, preoperative motor status, surgical factors, and the types of Tc-MEP alerts. Tc-MEP alerts were defined as an amplitude reduction of more than 70% from the control waveform. Tc-MEP results were classified into two groups: false-positive and true-positive, and items that showed significant differences were extracted by univariate analysis and detected by multivariate analysis. RESULTS Overall sensitivity was 66% (segmental paralysis: 33% and lower limb paralysis: 95.8%) and specificity was 91.5%. Tc-MEP outcomes were 33 true-positives and 233 false-positives. Positive predictive value of general spine surgery was significantly higher in cases with a severe motor status than in a nonsevere motor status (19.5% vs . 6.7%, P =0.02), but not different in high-risk spine surgery (20.8% vs . 19.4%). However, rescue rates did not significantly differ regardless of motor status (48% vs . 50%). In a multivariate logistic analysis, a preoperative severe motor status [ P =0.041, odds ratio (OR): 2.46, 95% confidence interval (95% CI): 1.03-5.86] and Tc-MEP alerts during intradural tumor resection ( P <0.001, OR: 7.44, 95% CI: 2.64-20.96) associated with true-positives, while Tc-MEP alerts that could not be identified with surgical maneuvers ( P =0.011, OR: 0.23, 95% CI: 0.073-0.71) were associated with false-positives. CONCLUSION The utility of Tc-MEP in patients with a preoperative severe motor status was enhanced, even in those without high-risk spine surgery. Regardless of the motor status, appropriate interventions following Tc-MEP alerts may prevent postoperative paralysis.
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Affiliation(s)
- Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Tsukasa Kanchiku
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kei Yamada
- Department of Orthopedic Surgery, Kurume University school of medicine, Kurume, Japan
| | - Hideki Shigematsu
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Nobuaki Tadokoro
- Department of Orthopedic Surgery, Kochi University, Kochi, Japan
| | - Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | - Naoya Yamamoto
- Department of Orthopedic Surgery, Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Shinji Morito
- Department of Orthopedic Surgery, Kurume University school of medicine, Kurume, Japan
| | - Shigenori Kawabata
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasushi Fujiwara
- Department of Orthopedic Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Muneharu Ando
- Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan
| | | | - Hiroshi Iwasaki
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama, Japan
| | - Kanichiro Wada
- Department of Orthopedic Surgery, Hirosaki University, Hirosaki, Japan
| | - Akimasa Yasuda
- Department of Orthopedic Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, Nara, Japan
| | - Kei Ando
- Department of Orthopedic 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 Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Yoshida G, Ushirozako H, Machino M, Shigematsu H, Kawabata S, Yamada K, Kanchiku T, Fujiwara Y, Iwasaki H, Ando M, Taniguchi S, Takatani T, Tadokoro N, Takahashi M, Wada K, Yamamoto N, Funaba M, Yasuda A, Hashimoto J, Morito S, Kurosu K, Kobayashi K, Ando K, Takeshita K, Matsuyama Y, Imagama S. Transcranial Motor-evoked Potentials for Intraoperative Nerve Root Monitoring During Adult Spinal Deformity Surgery: A Prospective Multicenter Study. Spine (Phila Pa 1976) 2022; 47:1590-1598. [PMID: 35905314 DOI: 10.1097/brs.0000000000004440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/06/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, multicenter study. OBJECTIVE This study clarified the uses and limitations of transcranial motor-evoked potentials (Tc-MEPs) for nerve root monitoring during adult spinal deformity (ASD) surgeries. SUMMARY OF BACKGROUND DATA Whether Tc-MEPs can detect nerve root injuries (NRIs) in ASD surgeries remains controversial. MATERIALS AND METHODS We prospectively analyzed neuromonitoring data from 14 institutions between 2017 and 2020. The subjects were ASD patients surgically treated with posterior corrective fusion using multichannel Tc-MEPs. An alert was defined as a decrease of ≥70% in the Tc-MEP's waveform amplitude from baseline, and NRI was considered as meeting the focal Tc-MEP alerts shortly following surgical procedures with postoperative nerve root symptoms in the selected muscles. RESULTS A total of 311 patients with ASD (262 women and 49 men) and a mean age of 65.5 years were analyzed. Tc-MEP results revealed 47 cases (15.1%) of alerts, including 25 alerts after 10 deformity corrections, six three-column osteotomies, four interbody fusions, three pedicle screw placements or two decompressions, and 22 alerts regardless of surgical maneuvers. Postoperatively, 14 patients (4.5%) had neurological deterioration considered to be all NRI, 11 true positives, and three false negatives (FN). Two FN did not reach a 70% loss of baseline (46% and 65% loss of baseline) and one was not monitored at target muscles. Multivariate logistic regression analysis revealed that risk factors of NRI were preexisting motor weakness ( P <0.001, odds ratio=10.41) and three-column osteotomies ( P =0.008, odds ratio=7.397). CONCLUSIONS Nerve root injuries in our ASD cohort were partially predictable using multichannel Tc-MEPs with a 70% decrease in amplitude as an alarm threshold. We propose that future research should evaluate the efficacy of an idealized warning threshold (e.g., 50%) and a more detailed evoked muscle selection, in reducing false negatives.
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Affiliation(s)
- Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Shigematsu
- Department of Orthopedic Surgery, Nara Medical University, Nara, 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
| | - Muneharu Ando
- Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan
| | | | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, Nara, Japan
| | - Nobuaki Tadokoro
- Department of Orthopedic Surgery, Kochi University, Kochi, Japan
| | | | - Kanichiro Wada
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Naoya Yamamoto
- Department of Orthopedic Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University, Yamaguchi, Japan
| | - Akimasa Yasuda
- Department of Orthopedic Surgery, National Defense Medical College Hospital, Saitama, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinji Morito
- Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Kenta Kurosu
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsushi Takeshita
- Department of Orthopedic Surgery, Jichi Medical University, Tochigi, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Revilla-Pacheco F, Watanabe S, Rodríguez-Reyes J, Sánchez-Torres C, Shkurovich-Bialik P, Herrada-Pineda T, Rodríguez-Salgado P, Franco-Granillo J, Calderón-Juárez M. Transcranial electric stimulation motor evoked potentials for cervical spine intraoperative monitoring complications: systematic review and illustrative case of cardiac arrest. Eur Spine J 2022; 31:2723-2732. [PMID: 35790650 DOI: 10.1007/s00586-022-07297-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE We show a systematic review of known complications during intraoperative neuromonitoring (IONM) using transcranial electric stimulation motor evoked potentials (TES-MEP) on cervical spine surgery, which provides a summary of the main findings. A rare complication during this procedure, cardiac arrest by cardioinhibitory reflex, is also described. METHODS Findings of 523 scientific papers published from 1995 onwards were reviewed in the following databases: CENTRAL, Cochrane Library, Embase, Google Scholar, Ovid, LILACS, PubMed, and Web of Science. This study evaluated only complications on cervical spine surgery undergoing TES-MEP IONM. RESULTS The review of the literature yielded 13 studies on the complications of TES-MEP IONM, from which three were excluded. Five studies are case series; the rest are case reports. Overall, 169 complications on 167 patients were reported in a total of 38,915 patients, a global prevalence of 0.43%. The most common complication was tongue-bite in 129 cases, (76.3% of all complication events). Tongue-bite had a prevalence of 0.33% (CI 95%, 0.28-0.39%) in all patients on TES-MEP IONM. A relatively low prevalence of severe complications was found: cardiac-arrhythmia, bradycardia and seizure, the prevalence of this complications represents only one case in all the sample. Alongside, we report the occurrence of cardiac arrest attributable to TES-MEP IONM. CONCLUSIONS This systematic review shows that TES-MEP is a safe procedure with a very low prevalence of complications. To our best knowledge, asystole is reported for the first time as a complication during TES-MEP IONM.
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Affiliation(s)
| | - Shoko Watanabe
- Department of Neurosurgery, ABC Medical Center, Mexico City, Mexico
| | | | | | | | | | | | | | - Martín Calderón-Juárez
- Plan de Estudios Combinados en Medicina, Faculty of Medicine, National Autonomous University of Mexico, Circuto Escolar 411A, Coyoacán, 04360, Mexico City, Mexico.
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昝 昕, 方 媛, 周 良, 周 培, 徐 建. [Advances in Intraoperative Neurophysiological Monitoring Techniques in Transnasal Endoscopic Skull Base Surgery]. Sichuan Da Xue Xue Bao Yi Xue Ban 2022; 53:579-582. [PMID: 35871726 PMCID: PMC10409453 DOI: 10.12182/20220760501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Indexed: 06/15/2023]
Abstract
Transnasal endoscopic skull base surgery has been increasing in volume in recent years and its indications are constantly expanding. The potential occurrence of intraoperative and postoperative neurovascular complications deserves special attention from neurosurgeons. Multimodal intraoperative neurophysiological monitoring technology allows neurosurgeons to monitor cerebral perfusion and the functional status of the associated cranial nerves in real time, thereby enabling surgeons to make prompt adjustments in surgical procedures and strategies and reduce the risks of postoperative neurological complications in patients. Based on available literature, we reviewed how appropriate monitoring strategies were optimized for different key components of transnasal endoscopic skull base procedures, intending to provide reference for clinicians.
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Affiliation(s)
- 昕 昝
- 四川大学华西医院 神经外科 (成都 610041)Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 媛 方
- 四川大学华西医院 神经外科 (成都 610041)Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 良学 周
- 四川大学华西医院 神经外科 (成都 610041)Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 培志 周
- 四川大学华西医院 神经外科 (成都 610041)Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 建国 徐
- 四川大学华西医院 神经外科 (成都 610041)Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China
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35
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Silverstein JW, Doron O, Ellis JA. Deliberate Parent Artery Sacrifice Guided by Intraoperative Neurophysiological Monitoring During Complex Surgical Clipping of a Ruptured Anterior Communicating Artery Aneurysm. Neurodiagn J 2022; 62:108-119. [PMID: 35709517 DOI: 10.1080/21646821.2022.2072156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/26/2022] [Indexed: 06/15/2023]
Abstract
Aneurysms arising from the anterior communicating artery (ACOA) are the most common intracranial aneurysms encountered. Most aneurysms can be treated with surgical clipping or endovascular coiling; however, there are times when parent vessel sacrifice (PVS) is necessary such as aneurysms with fragile necks or large/giant aneurysms. Application of intraoperative neurophysiological monitoring (IONM) can assist in guiding permissive temporary vessel occlusion during complex aneurysm clippings. However, to-date there is no literature that describes how IONM can be used as a predictor of post-operative neurological status when PVS is employed or as a guide to determine whether PVS is safe. We present a case where IONM guided the sacrifice of the A1 and anterior communicating arteries after 2 hours and 25 min of temporary vessel occlusion. No attenuation was noted in the IONM at any point during the procedure, and the IONM predicted the patient would awake neurologically intact.
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Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, New York
| | - Omer Doron
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Jason A Ellis
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
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36
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Green R, Mishra A, Schneider D, Najjar S, D'Amico RS, Sciubba DM, Lo SF, Silverstein JW. Subdural Direct Wave Intraoperative Neurophysiological Monitoring in Intramedullary Spinal Cord Tumor Resection: Case Report. Neurodiagn J 2022; 62:87-98. [PMID: 35709516 DOI: 10.1080/21646821.2022.2060011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/26/2022] [Indexed: 06/15/2023]
Abstract
Direct wave (D-wave) intraoperative neurophysiological monitoring (IONM) is used during intramedullary spinal cord tumor (IMSCT) resection to assess corticospinal tract (CST) integrity. There are several obstacles to obtaining consistent and reliable D-wave monitoring and modifications to standard IONM procedures may improve surgical resection. We present the case of a subependymoma IMSCT resection at the T2-T6 spinal levels where subdural D-wave monitoring was implemented. A 47-year-old male was presented with a five-year history of numbness in his right foot eventually worsening to sharp upper back pain with increased lower extremity spasticity. MRI revealed an expansile non-contrast enhancing multi-loculated cystic lesion spanning T2-T6 as well as a separate T1-T2 lesion. A T2-T6 laminoplasty was performed for intramedullary resection of the lesion. A spinal electrode was placed in the epidural space caudal to the surgical site to monitor CST function; however, action potentials could not be obtained. Post durotomy, the electrode was placed in the subdural space under direct visualization. This resulted in a reliable D-wave recording, which assisted surgical decision-making during the procedure upon D-wave and limb motor evoked potential attenuation. Surgical intervention led to the recovery of the D-wave recording. Subdural D-wave monitoring serves as an alternative in patients where reliable D-waves from the epidural space are unable to be obtained. Further investigation is required to improve the recording technique, including exploring various types of contacts and lead placement locations.
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Affiliation(s)
- Ross Green
- Department of Neurosurgery, Northshore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Akash Mishra
- Department of Neurosurgery, Northshore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Daniel Schneider
- Department of Neurosurgery, Northshore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Salem Najjar
- Department of Neurosurgery, Northshore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Daniel M Sciubba
- Department of Neurosurgery, Northshore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Sheng-Fu Lo
- Department of Neurosurgery, Northshore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Justin W Silverstein
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
- Department of Neurology, Northshore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
- Department of Clinical Neurophysiology Neuro Protective Solutions, New York, New York
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37
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Allison DW, Balzer JR. Misconceptions in IONM Part I: Interleaved Intraoperative Somatosensory Evoked Potential Stimulation. Neurodiagn J 2022; 62:6-25. [PMID: 35061974 DOI: 10.1080/21646821.2022.2010471] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
A misconception in the field of intraoperative neurophysiological monitoring (IONM) is that continuous, multi-nerve (four-limb), interleaved somatosensory evoked potential (SSEP) stimulation, while advantageous, is not universally utilized due to variety of misunderstandings regarding this approach to SSEP stimulation. This article addresses the rationale for this misconception. We find that continuous, multi-nerve, interleaved SSEP stimulation is superior to all other stimulation paradigms in most operative scenarios, allowing the fastest acquisition of SSEPs at low stimulation repetition rates, which generate the highest amplitude cortical responses.
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Affiliation(s)
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania
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38
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Pan T, Adeyemo A, Armstrong DG, Petfield JL. Neurophysiological Intraoperative Monitoring in Patients with Cochlear Implant Undergoing Posterior Spinal Fusion: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00016. [PMID: 35050944 DOI: 10.2106/jbjs.cc.21.00609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE Transcranial electric stimulation motor-evoked potentials (tcMEPs) are the most sensitive technique in multimodality intraoperative neuromonitoring (IONM) for posterior spinal fusion (PSF). The presence of a cochlear implant (CI) is considered a contraindication to IONM because of theoretical risk of implant device and local tissue damage from voltages induced by tcMEPs. We present the case of a 10-year-old girl with CI who underwent successful PSF with tcMEP and monopolar electrocautery (MoEC) without perioperative complications or CI damage. CONCLUSION With proper precautions, such as MoEC usage at a minimal voltage, motor-evoked potential monitoring can be safely performed in pediatric patients with CI undergoing PSF.
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Affiliation(s)
- Tommy Pan
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Adeshina Adeyemo
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania
| | - Douglas G Armstrong
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania
| | - Joseph L Petfield
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania
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39
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Abstract
Electrophysiological monitoring of the peripheral nervous system during a variety of surgeries provides useful information that supplements and complements preoperative assessment. Monitoring improves localization and understanding of the underlying pathophysiology of peripheral nerve lesions leading to more rational treatment decisions and improved outcomes. Monitoring is accomplished by adaptation of routine electrodiagnostic techniques (i.e., nerve conduction studies, evoked potentials, and electromyography) with special attention to technical factors including electrical and movement artifact. These techniques have been successfully applied during surgery for entrapment neuropathies, traumatic nerve injury and repair, peripheral nerve tumors, and adjacent structure procedures that risk peripheral nerve injury. A clear understanding of the anatomy and neurophysiology is necessary, as is understanding and performing the difficult technical aspects of these studies to provide accurate information to enhance patient outcome and recovery. As in any intraoperative neurophysiologic monitoring (IONM) setting, constant and accurate communication between the IONM team, surgeon, and anesthesia team is critically important to meet these goals.
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Affiliation(s)
- Jeffrey A Strommen
- Department of Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States.
| | - Stanley Skinner
- Department of Intraoperative Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States.
| | - Brian A Crum
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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Szelényi A, Fernández-Conejero I, Kodama K. Surgery and intraoperative neurophysiologic monitoring for aneurysm clipping. Handb Clin Neurol 2022; 186:375-393. [PMID: 35772896 DOI: 10.1016/b978-0-12-819826-1.00008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This chapter describes the feasibility, utilization, and value of intraoperative neurophysiologic monitoring (IONM) in cerebrovascular cases. Practical advice on the integration of these adjunct methods into the modern neurosurgical operating room is based on our own neurophysiologic and neurosurgical experience. Most IONM is done for anterior circulation aneurysms. Somatosensory and motor evoked potentials are the modalities of choice covering vascular territories of the internal, anterior, and middle cerebral arteries. While monitoring both hemispheres with the unoperated side as control, monitoring focus is laid upon those territories at risk and bearing the aneurysm. The specificity of IONM is close to 1, and sensitivity ranges from 0.2 to 1, depending on the categorization of transient changes. The overall likelihood of worsened neurologic outcome after any intraoperative signal deterioration (transient or permanent) is 0.4.
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Affiliation(s)
- Andrea Szelényi
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany.
| | - Isabel Fernández-Conejero
- Unit of Intraoperative Neurophysiology, Department of Neurology, University Hospital of Bellvitge, Barcelona, Spain
| | - Kunihiko Kodama
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
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Wang Y, Zhao X, Geng B, Sheng X, Zhang K, Cao C, Xia Y, Chen S. Application of Triggered EMG in the Intraoperative Neurophysiological Monitoring of Posterior Percutaneous Endoscopic Cervical Discectomy. Orthop Surg 2021; 13:2236-2245. [PMID: 34668326 PMCID: PMC8654663 DOI: 10.1111/os.13092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To describe the rationale and application of triggered EMG (T-EMG) in intraoperative neurophysiological monitoring, and to explore the efficacy and safety of posterior percutaneous endoscopic cervical discectomy (PPECD) in the treatment of cervical spondylotic radiculopathy (CSR) under multimodal intraoperative neurophysiological monitoring (IOM). METHODS This study was a retrospective cohort control study. The clinical data of 74 patients with single-segment CSR from June 2015 to August 2018 were analyzed retrospectively, of whom 35 underwent IOM-assisted PPECD with triggered EMG (T-EMG group), while 39 were subjected to IOM-assisted PPECD alone (IOM group). Operation time, hospital stay, and complications were recorded for both groups. The curative effect was evaluated according to the Visual Analog Scale (VAS) of neck and arm pain, Japanese Orthopaedic Association (JOA) score, and modified MacNab scale. RESULTS Operations were successful and all patients were followed up for at least 24 (average 31.77 ± 9.51) months with no patient lost to follow-up. No significant difference was found in preoperative baseline data between the T-EMG and the IOM group (P > 0.05). Also, no significant difference was found in the operation time between the T-EMG (108.29 ± 11.44 min) and the IOM (110.13 ± 12.70 min) (P > 0.05) group, but the difference in hospital stay (T-EMG: 5.66 ± 0.99 days; IOM: 7.10 ± 1.43 days) was statistically significant (P < 0.05). The VAS for the neck and upper limbs in the two groups at 1 month post-operation (T-EMG: 2.09 ± 1.07, 2.26 ± 0.92; IOM:2.18 ± 1.05, 2.31 ± 0.77) and the last follow-up (T-EMG: 0.83 ± 0.62, 0.86 ± 0.55; IOM: 0.90 ± 0.50, 0.87 ± 0.61) were significantly different from the preoperative scores (T-EMG: 6.14 ± 1.09, 7.17 ± 1.04; IOM: 6.18 ± 1.28, 7.15 ± 1.23) (P < 0.05). However, no significant difference was found between the two groups (P > 0.05). The 1-month postoperative JOA scores for the two groups (12.69 ± 0.76; 12.59 ± 0.82) and those at the last follow-up (14.60 ± 0.77; 14.36 ± 0.78) were significantly different from the preoperative scores (11.09 ± 0.98; 11.05 ± 0.89) (P < 0.05), but the difference between the two groups was not significant (P > 0.05). One patient in the T-EMG group developed a transient aggravation of symptoms on the first day after surgery. In the IOM group, three patients had intraoperative cerebrospinal fluid leakage, and symptoms of C5 nerve root paralysis were presented in four patients following surgery. Compared with the IOM group, the T-EMG group had fewer complications (1/35; 7/39, P < 0.05). At the last follow-up, the modified MacNab criteria were 91.43% (32/35) and 89.7% (35/39) for the T-EMG group and IOM group, respectively. CONCLUSIONS Triggered EMG prevents the occurrence of neurological complications, which not only aids PPECD for CSR treatment in achieving satisfactory results, but also reduces average hospital stay and complication rates.
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Affiliation(s)
- Yao‐bin Wang
- Department of OrthopaedicsLanzhou University Second HospitalLanzhouChina
- Gansu Provincial Orthopaedic Clinical Medicine Research CenterLanzhouChina
- Key Laboratory of Bone and Joint Disease Research of Gansu ProvinceLanzhouChina
- Department of Spinal and Spinal Cord surgeryHenan Provincial People's HospitalZhengzhouChina
| | - Xiao‐bing Zhao
- Department of OrthopaedicsLanzhou University Second HospitalLanzhouChina
- Gansu Provincial Orthopaedic Clinical Medicine Research CenterLanzhouChina
- Key Laboratory of Bone and Joint Disease Research of Gansu ProvinceLanzhouChina
| | - Bin Geng
- Department of OrthopaedicsLanzhou University Second HospitalLanzhouChina
- Gansu Provincial Orthopaedic Clinical Medicine Research CenterLanzhouChina
- Key Laboratory of Bone and Joint Disease Research of Gansu ProvinceLanzhouChina
| | - Xiao‐yun Sheng
- Department of OrthopaedicsLanzhou University Second HospitalLanzhouChina
- Gansu Provincial Orthopaedic Clinical Medicine Research CenterLanzhouChina
- Key Laboratory of Bone and Joint Disease Research of Gansu ProvinceLanzhouChina
| | - Kai Zhang
- Department of Spinal and Spinal Cord surgeryHenan Provincial People's HospitalZhengzhouChina
| | - Chen Cao
- Department of Spinal and Spinal Cord surgeryHenan Provincial People's HospitalZhengzhouChina
| | - Ya‐yi Xia
- Department of OrthopaedicsLanzhou University Second HospitalLanzhouChina
- Gansu Provincial Orthopaedic Clinical Medicine Research CenterLanzhouChina
- Key Laboratory of Bone and Joint Disease Research of Gansu ProvinceLanzhouChina
| | - Shu‐lian Chen
- Department of Spinal and Spinal Cord surgeryHenan Provincial People's HospitalZhengzhouChina
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Paldor I, Doron O, Peso D, Jubran M, Sviri GE. Intraoperative neuromonitoring during resection of cranial meningiomas and its effect on the surgical workflow. Neurosurg Rev 2021; 45:1481-1490. [PMID: 34632555 DOI: 10.1007/s10143-021-01667-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/15/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Resection of meningiomas adjacent to the central sulcus entails a high rate of morbidity. Explored for intra-axial lesion resection, intraoperative neuromonitoring intraoperative neuromonitoring (IONM) has been shown to decrease neurological deficits. The use of IONM is relatively uncommon and is not considered routine practice in the removal of extra-axial lesions. We sought to characterize IONM's impact on the surgical workflow in supratentorial meningiomas. METHODS We retrospectively analyzed a prospectively collected database, searching cases in which IONM was used for resection of meningioma between 2017 and 2020. We classified the IONM effect on surgical workflow into 5 distinct categories of workflow changes (WFC). RESULTS Forty cases of meningiomas with IONM use were identified. In 1 case (class 1 WFC), the operation was stopped due to IONM input. In 5 cases (class 2 WFC), the tumor was incompletely resected due to input from the IONM. In 14 cases (35%), IONM leads to an alteration of the resection process (alteration of approach, class 3 WFC). In 4 cases (10%), anesthesia care was modified based on IONM input (class 4 WFC). In 16 cases, no changes were made (class 5 WFC). In all patients in whom a change was made (24 cases, WFC 1-4), only 8.3% suffered a temporary deficit, and there were no permanent deficits, whereas when no change was made, there were 18.75% temporary deficit and 6.25% permanent deficit. CONCLUSION IONM has an impact during resection of meningiomas in eloquent areas and may guide the surgical technique, approach to tumor resection, and extent of resection.
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Affiliation(s)
- Iddo Paldor
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
- The Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Omer Doron
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
- Biomedical Engineering department, The Iby and Aladar, Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Dana Peso
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
| | - Muna Jubran
- Surgical Monitoring Services, Beit Shemesh, Israel
| | - Gill E Sviri
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
- The Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Boëx C, Goga C, Bérard N, Al Awadhi A, Bartoli A, Meling T, Bijlenga P, Schaller K. Intraoperative subcortico-cortical evoked potentials of the visual pathway under general anesthesia. Clin Neurophysiol 2021; 132:1381-1388. [PMID: 34023622 DOI: 10.1016/j.clinph.2021.02.399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To assess whether intraoperative subcortical mapping of the visual pathways during brain surgeries was feasible. METHODS Subcortico-cortical evoked potentials (SCEPs: 30 stimulations/site, biphasic single pulse, 1.3 Hz, 0.2 ms/phase, maximum 10 mA; bipolar probe) were measured in 12 patients for stimulation of the optic radiation, Meyer's loop or optic nerve. Recorded sites were bilateral central, parietal, parieto-occipital, occipital (subdermal scalp electrodes, 5-4000 Hz). The minimum distances from the stimulation locations, i.e. the closest border of the resection cavity to the diffusion tensor imaging based visual pathways, were evaluated postoperatively (smallest distance across coronal, sagittal and axial planes). RESULTS Stimulation elicited SCEPs when the visual tracts were close (≤4.5 mm). The responses consisted of a short (P1, 3.0-5.6 ms; 8/8 patients) and of a middle (P2, 15-21.6 ms; 3/8 patients) latency waveforms. In agreement with the neuroanatomy, ipsilateral occipital responses were obtained for temporal or parietal stimulations, and bi-occipital responses for optic nerve stimulations. CONCLUSIONS For the first time to our knowledge, intraoperative SCEPs were observed for stimulations of the optic radiation and of Meyer's loop. Short latency responses were found in agreement with fast conduction of the visual pathway's connecting myelinated fibers. SIGNIFICANCE The mapping of the visual pathways was found feasible for neurosurgeries under general anesthesia.
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Affiliation(s)
- Colette Boëx
- Department of Neurology, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Cristina Goga
- Departement of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Bérard
- Department of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Abdullah Al Awadhi
- Faculty of Medicine, University of Geneva, Geneva, Switzerland; Departement of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Andrea Bartoli
- Departement of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Torstein Meling
- Faculty of Medicine, University of Geneva, Geneva, Switzerland; Departement of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Bijlenga
- Faculty of Medicine, University of Geneva, Geneva, Switzerland; Departement of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Karl Schaller
- Faculty of Medicine, University of Geneva, Geneva, Switzerland; Departement of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
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Lucente G, Martinez-Barenys C, Ramos-Fransi A, Almendrote-Muñoz M, López de Castro P, Deletis V, Coll-Canti J, Martínez-Piñeiro A. A New Methodology for Intraoperative Monitoring of the Functional Integrity of the Phrenic Nerve During Cardiothoracic Surgery. J Clin Neurophysiol 2021; 38:226-230. [PMID: 31895134 DOI: 10.1097/wnp.0000000000000677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The phrenic nerve could be easily injured during cardiothoracic surgeries because of its anatomical relationships. The aim of this study is to describe a new, feasible, and reproducible methodology to achieve a continuous intraoperative neuromonitoring of the phrenic nerve. METHODS Consecutive patients who underwent open-chest surgery were included. The recording active electrode was placed 5 cm superior to the tip of the xiphoid process, and a hook wire inserted at the motor point of the ipsilateral hemidiaphragm was used as the reference electrode. RESULTS We studied 45 patients (92% men, mean age 67 years). Mean height and weight were 167 ± 6.9 cm and 75.6 ± 12.3 kg, respectively. A reproducible compound motor action potential was recorded in 38 (85%) subjects. The mean latency and amplitude values were 9.68 ± 2.40 ms and 1.36 ± 3.83 mV, respectively. No intraoperative events were recorded. CONCLUSIONS We reported a new methodology which allows the assessment of phrenic nerve functional integrity during surgical procedures.
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Affiliation(s)
- Giuseppe Lucente
- Neuromuscular Diseases Unit, Neurosciences Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
- Departamento de Medicina, Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Carlos Martinez-Barenys
- Thoracic Surgery Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
- Departamento de Cirugía, Universitat Autonoma de Barcelona, Bellaterra, Spain ; and
| | - Alba Ramos-Fransi
- Neuromuscular Diseases Unit, Neurosciences Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
| | - Miriam Almendrote-Muñoz
- Neuromuscular Diseases Unit, Neurosciences Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
- Departamento de Medicina, Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Pedro López de Castro
- Thoracic Surgery Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital Dubraya, Zagreb, Croatia
| | - Jaume Coll-Canti
- Neuromuscular Diseases Unit, Neurosciences Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
- Departamento de Medicina, Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Alicia Martínez-Piñeiro
- Neuromuscular Diseases Unit, Neurosciences Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
- Departamento de Medicina, Universitat Autonoma de Barcelona, Bellaterra, Spain
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De la Maza Krzeptowsky LC, San-Juan D, Ximénez Camilli C, Alvarez Perera LÁ, Valdez Ruvalcaba H, Morales Báez JA, Anschel DJ. Neurophysiological Intraoperative Monitoring in the Elderly. J Clin Neurophysiol 2021; 38:231-236. [PMID: 32141983 DOI: 10.1097/wnp.0000000000000689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Intraoperative neurophysiological monitoring (IONM) is widely used to prevent nervous system injury during surgeries in elderly patients. However, there are no studies that describe the characteristics and changes in neurophysiological tests during the IONM of patients aged 60 years and older. The study aims to describe and compare IONM changes during surgeries in adult patients aged 18 to 59 years with those aged 60 years and older. METHODS We performed a comparative retrospective study of patients aged 18 to 59 years versus those 60 aged years and older who underwent IONM during 2013 to 2018 in Mexico City. Sociodemographic characteristics were recorded and compared. Intraoperative neurophysiological monitoring techniques, their changes, and surgical procedures for both groups were analyzed and compared using descriptive statistics, Mann-Whitney U, Fisher, and χ2 tests. The sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS In total, 195 patients were analyzed: 104 patients, 68.63 ± 6.54 years old (elderly group) and 91 patients, 42.3 ± 10.5 years old (younger group). No differences were found in the rates of signal change during IONM between the group of elderly patients and the younger group. The sensitivity, specificity, and positive and negative predictive values were 80%, 99%, 80%, and 99%, respectively. CONCLUSIONS Elderly patients have a similar rate of changes in IONM signals compared with younger patients during heterogeneous surgeries guided by IONM.
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Affiliation(s)
| | - Daniel San-Juan
- Neurophysiology Department, Hospital Ángeles del Pedregal, México City, Mexico
- Neurology Department, National Institute of Neurology, Mexico City, Mexico
| | | | - Luis Á Alvarez Perera
- Neurophysiology Department, Hospital Ángeles del Pedregal, México City, Mexico
- Neurology Department, National Institute of Neurology, Mexico City, Mexico
| | | | | | - David J Anschel
- Comprehensive Epilepsy Center of Long Island, Port Jefferson, New York, U.S.A
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Wasserman D, Valero-Cabré A, Dali M, Stengel C, Boyer A, Rheault F, Bonnetblanc F, Mandonnet E. Axono-cortical evoked potentials as a new method of IONM for preserving the motor control network: a first study in three cases. Acta Neurochir (Wien) 2021; 163:919-935. [PMID: 33161475 DOI: 10.1007/s00701-020-04636-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND White matter stimulation in an awake patient is currently the gold standard for identification of functional pathways. Despite the robustness and reproducibility of this method, very little is known about the electrophysiological mechanisms underlying the functional disruption. Axono-cortical evoked potentials (ACEPs) provide a reliable technique to explore these mechanisms. OBJECTIVE To describe the shape and spatial patterns of ACEPs recorded when stimulating the white matter of the caudal part of the right superior frontal gyrus while recording in the precentral gyrus. METHODS We report on three patients operated on under awake condition for a right superior frontal diffuse low-grade glioma. Functional sites were identified in the posterior wall of the cavity, whose 2-3-mA stimulation generated an arrest of movement. Once the resection was done, axono-cortical potentials were evoked: recording electrodes were put over the precentral gyrus, while stimulating at 1 Hz the white matter functional sites during 30-60 s. Unitary evoked potentials were averaged off-line. Waveform was visually analyzed, defining peaks and troughs, with quantitative measurements of their amplitudes and latencies. Spatial patterns of ACEPs were compared with patients' own and HCP-derived structural connectomics. RESULTS Axono-cortical evoked potentials (ACEPs) were obtained and exhibited complex shapes and spatial patterns that correlated only partially with structural connectivity patterns. CONCLUSION ACEPs is a new IONM methodology that could both contribute to elucidate the propagation of neuronal activity within a distributed network when stimulating white matter and provide a new technique for preserving motor control abilities during brain tumor resections.
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Affiliation(s)
- Demian Wasserman
- Parietal, Inria Saclay Ile-de-France, CEA, Université Paris-Sud, Palaiseau, France
| | | | - Mélissa Dali
- Institut Neuro-PSI - UMR 9197, CNRS, Université Paris-Saclay, Gif-Sur-Yvette, France
- Department of Neurosurgery, Lariboisière Hospital, APHP, 2 rue Ambroise Paré, 75010, Paris, France
| | - Chloé Stengel
- Frontlab, Institut du Cerveau, CNRS UMR 7225, INSERM U1127, Paris, France
| | - Anthony Boyer
- Brain Stimulation and Systems Neuroscience, INSERM U1216, Grenoble, France
| | - François Rheault
- Sherbrooke Connectivity Imaging Lab, Department of Computer Science, Faculty of Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | | | - Emmanuel Mandonnet
- Frontlab, Institut du Cerveau, CNRS UMR 7225, INSERM U1127, Paris, France.
- Department of Neurosurgery, Lariboisière Hospital, APHP, 2 rue Ambroise Paré, 75010, Paris, France.
- Université de Paris, Paris, France.
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Yu T, Wu JP, Zhang J, Yu HC, Yuan TY, Xu DR, Yun ZH, He T, Liu R, Liu QY. Zina percutaneous screw fixation combined with endoscopic lumbar intervertebral fusion under intraoperative neuromonitoring: A case report. Medicine (Baltimore) 2021; 100:e24220. [PMID: 33725928 PMCID: PMC7982225 DOI: 10.1097/md.0000000000024220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 12/16/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Traditional open discectomy and intervertebral fusion surgery is the common strategy for lumbar disc herniation (LDH). However, it has the disadvantages of long recovery time and severe paravertebral soft tissue injury. Zina percutaneous screw fixation combined with endoscopic lumbar intervertebral fusion (ZELIF), as a novel minimally invasive surgical technique for LDH, has the advantages in quicker recovery, less soft tissue destruction, shorter hospital stays and less pain. We report a novel technique of ZELIF under intraoperative neuromonitoring (INM) for the treatment of LDH. PATIENT CONCERNS A 51-year-old male presented to our hospital with left lower extremity pain and numbness for 1 year. DIAGNOSIS Lumbar disc herniation (LDH). INTERVENTIONS This patient was treated with Zina percutaneous screw fixation combined with endoscopic neural decompression, endplate preparation, and intervertebral fusion through Kambin's triangle. Each step of the operation was performed under INM. OUTCOMES The follow-up period lasted 12 months; the hospitalization lasted 4 nights; the blood loss volume was 65 ml, and the time of operation was 266 min. INM showed no neurological damage during the surgery. No surgical complications, including neurological deterioration, cage migration, non-union, instrumentation failure or revision operation, were observed during the follow-up period. Visual Analogue Scale (VAS) score reduced from 7 to 1; the Oswestry Disability Index (ODI) decreased from 43 to 14; the EQ-5D score was 10 preoperatively and 15 at the final follow-up visit; the Physical Component Summary of the 36-Item Short Form Health Survey (SF-36) was 48 preoperatively and 49 at the last follow up visit; the SF-36 Mental Component Summary was 47 before surgery and decreased to 41 postoperatively. CONCLUSION ZELIF under INM may represent a feasible, safe and effective alternative to endoscopic intervertebral fusion and percutaneous screw fixation, for decompressing the lumbar's exiting nerve root directly with minimal invasion in selected patients.
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Park D, Kim DY, Eom YS, Lee SE, Chae SB. Posterior interosseous nerve syndrome caused by a ganglion cyst and its surgical release with intraoperative neurophysiological monitoring: A case report. Medicine (Baltimore) 2021; 100:e24702. [PMID: 33663080 PMCID: PMC7909167 DOI: 10.1097/md.0000000000024702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/21/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Intraoperative neurophysiological monitoring (IONM) has been utilized not only for the rapid detection of neural insults during surgeries, but also to verify the neurophysiological integrity of nerve lesions in the surgical field. PATIENT CONCERNS A 32-year-old woman presented with a wrist and finger drop that had lasted about 3 months. DIAGNOSES The result of the initial electrodiagnostic test was consistent with posterior interosseous nerve (PIN) syndrome. Ultrasonography and magnetic resonance imaging of the proximal forearm showed a cystic mass at the anterolateral aspect of the radial head, which was diagnosed as a ganglion cyst. INTERVENTIONS Surgical release of the ganglion cyst with IONM was performed. During the surgery, we induced nerve action potentials and compound motor action potentials across the ganglion cyst, which demonstrated neural continuity. OUTCOMES Three months after the surgery, the patient showed partial recovery of wrist and finger extensor muscle power. An electrodiagnostic test conducted 3 months after the surgery showed reinnervation potentials in PIN-innervated muscles. LESSONS IONM during peripheral nerve surgeries can support surgical decisions and confirm the location and degree of nerve damage.
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Affiliation(s)
| | - Dong Young Kim
- Department of Orthopedic Surgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang
| | - Yoon Sik Eom
- Department of Orthopedic Surgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang
| | | | - Seung Bum Chae
- Department of Orthopedic Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea
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Carson T, Ghoshal G, Cornwall GB, Tobias R, Schwartz DG, Foley KT. Artificial Intelligence-enabled, Real-time Intraoperative Ultrasound Imaging of Neural Structures Within the Psoas: Validation in a Porcine Spine Model. Spine (Phila Pa 1976) 2021; 46:E146-E152. [PMID: 33399436 PMCID: PMC7787186 DOI: 10.1097/brs.0000000000003704] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/28/2020] [Accepted: 08/13/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Experimental in-vivo animal study. OBJECTIVE The aim of this study was to evaluate an Artificial Intelligence (AI)-enabled ultrasound imaging system's ability to detect, segment, classify, and display neural and other structures during trans-psoas spine surgery. SUMMARY OF BACKGROUND DATA Current methodologies for intraoperatively localizing and visualizing neural structures within the psoas are limited and can impact the safety of lateral lumbar interbody fusion (LLIF). Ultrasound technology, enhanced with AI-derived neural detection algorithms, could prove useful for this task. METHODS The study was conducted using an in vivo porcine model (50 subjects). Image processing and machine learning algorithms were developed to detect neural and other anatomic structures within and adjacent to the psoas muscle while using an ultrasound imaging system during lateral lumbar spine surgery (SonoVision,™ Tissue Differentiation Intelligence, USA). The imaging system's ability to detect and classify the anatomic structures was assessed with subsequent tissue dissection. Dice coefficients were calculated to quantify the performance of the image segmentation. RESULTS The AI-trained ultrasound system detected, segmented, classified, and displayed nerve, psoas muscle, and vertebral body surface with high sensitivity and specificity. The mean Dice coefficient score for each tissue type was >80%, indicating that the detected region and ground truth were >80% similar to each other. The mean specificity of nerve detection was 92%; for bone and muscle, it was >95%. The accuracy of nerve detection was >95%. CONCLUSION This study demonstrates that a combination of AI-derived image processing and machine learning algorithms can be developed to enable real-time ultrasonic detection, segmentation, classification, and display of critical anatomic structures, including neural tissue, during spine surgery. AI-enhanced ultrasound imaging can provide a visual map of important anatomy in and adjacent to the psoas, thereby providing the surgeon with critical information intended to increase the safety of LLIF surgery.Level of Evidence: N/A.
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Affiliation(s)
- Tyler Carson
- NeuroSpine Institute, Palmdale, CA
- Riverside University Health System, Department of Neurosurgery, Moreno Valley, CA
| | | | | | | | | | - Kevin T. Foley
- Semmes-Murphey Clinic & Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN
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Sindou M, Joud A, Georgoulis G. Usefulness of external anal sphincter EMG recording for intraoperative neuromonitoring of the sacral roots-a prospective study in dorsal rhizotomy. Acta Neurochir (Wien) 2021; 163:479-487. [PMID: 33064201 DOI: 10.1007/s00701-020-04610-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In conus medullaris and cauda equina surgery, identification of the sacral nerve roots may be uncertain in spite of their anatomical/radiological landmarks. Mapping the sacral roots by recording the muscular responses to their stimulation may benefit from EMG recording of the External Anal sphincter (EAS) in addition to the main muscular groups of the lower limbs. METHOD In a consecutive series of 27 lumbosacral dorsal rhizotomy (DRh), authors carried out a prospective study on the reliability of the EMG recording of the EAS for identification of the S1 and S2 sacral roots. RESULTS An EAS-response was recorded in all the 27 (bilaterally) explored individuals, testifying good sensitivity and selectivity of the method. EAS-responses were obtained in 96.3% of the 54 stimulated sides of the S2 root versus in only 16.66% for the S1 root, so that an absence of response would indicate S1 rather than S2 level. Furthermore, comparison between myotomal distribution of the S1 and S2 roots showed a significant difference (p < 0.00001), so that myotomal profile may help to identify root level. CONCLUSIONS EMG recording of the EAS can be recommended for current intraoperative neuromonitoring. This simple method also provides-indirectly by extrapolation-information on the sacral motor pathways of the external urethral sphincter (EUS), as the later has the same somatic innervation via the pudendal nerve and related S2, S3, and S4 roots. Method can be helpful not only for DRh, of all varieties, but also for spine surgery, correction of dysraphisms, lipomas and/or tethered cord, and tumor resection.
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Affiliation(s)
- Marc Sindou
- University of Lyon, Lyon, France
- IRR Flavigny, UGECAM Nord-Est, Nancy, France
- Pediatric Neurosurgery Department, CHRU Nancy, Nancy, France
| | - Anthony Joud
- IRR Flavigny, UGECAM Nord-Est, Nancy, France
- Pediatric Neurosurgery Department, CHRU Nancy, Nancy, France
| | - George Georgoulis
- Department of Neurosurgery, General Hospital of Athens "G.Gennimatas", Mesogeion Avenue 154, 11527, Athens, Greece.
- Medical School, University of Athens, Athens, Greece.
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