Monitoring of motor pathways during brain stem surgery: What we have achieved and what we still miss?

Sala, Francesco; Manganotti, Paolo; Tramontano, Vincenzo; Bricolo, Albino; Gerosa, Massimo

doi:10.1016/j.neucli.2007.09.013

Cited by 104 publications

(84 citation statements)

References 30 publications

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“…This choice must be based on anatomical and functional data, location and extension of the lesion, and the patient's clinical condition. 1,26,32,[39][40][41] Wide resection of bone may be required for the related craniotomy since nervous tissue retraction must be avoided even more than in other parts of the encephalon. 1,18,22,[26][27][28] For all this, a deep and precise knowledge of the topographic and functional anatomy of the brainstem is mandatory in order for the neurosurgeon to have in mind a 3D framework of the internal architecture of the brainstem, which will guide him or her throughout the surgical procedure.…”

Section: Discussion Surgical Considerationsmentioning

confidence: 99%

Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations

Párraga

Possatti

Alves

et al. 2016

JNS

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T he brainstem forms the central axis of the brain and comprises the midbrain, pons, and medulla oblongata; it occupies the anterior portion of the cranial posterior fossa (Fig. 1). It is composed of neurons aggregated into nuclei and nerve fibers grouped into bundles called tracts, fasciculi, or lemnisci. These elements of the internal structure may be related to prominences or depressions on the surface, which must be identified by the surgeon. The brainstem is basically composed of 4 types of structures: 1) ascending and descending pathways that connect the spinal cord with the prosencephalon; 2) reflex centers associated with control of breathing, the cardiovascular system, and also consciousness, along the reticular formation; 3) most of the nuclei of the cranial nerves (from CN III to XII); and 4) cerebellar peduncles. 23,36,41,43,49 Brainstem surgery remains a challenge for the neurosurgeon. Recent improvements in neuroimaging, microsurgical techniques, and electrophysiological monitoring, in association with detailed knowledge of regional and functional anatomy, have allowed surgical procedures at this region to become safer and more likely to be successful. To plan the most appropriate approaches, to choose the safest entry zones, and to minimize possible surgical complications, 14,41 it is important for the neurosurgeon to keep in mind both the surface anatomy and the internal architecture of the brainstem. obJective Brainstem surgery remains a challenge for the neurosurgeon despite recent improvements in neuroimaging, microsurgical techniques, and electrophysiological monitoring. A detailed knowledge of the microsurgical anatomy of the brainstem surface and its internal architecture is mandatory to plan appropriate approaches to the brainstem, to choose the safest point of entry, and to avoid potential surgical complications. methods An extensive review of the literature was performed regarding the brainstem surgical approaches, and their correlations with the pertinent anatomy were studied and illustrated through dissection of human brainstems properly fixed with 10% formalin. The specimens were dissected using the fiber dissection technique, under ×6 to ×40 magnification. 3D stereoscopic photographs were obtained (anaglyphic 3D) for better illustration of this study. results The main surgical landmarks and their relationship with the cerebellum and vascular structures were identified on the surface of the brainstem. The arrangements of the white matter (ascending and descending pathways as well as the cerebellar peduncles) were demonstrated on each part of the brainstem (midbrain, pons, and medulla oblongata), with emphasis on their relationships with the surface. The gray matter, constituted mainly by nuclei of the cranial nerves, was also studied and illustrated. coNclusioNs The objective of this article is to review the microsurgical anatomy and the surgical approaches pertinent to the brainstem, providing a framework of its external and internal architecture to guide the neurosurgeon during its ...

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Section: Discussion Surgical Considerationsmentioning

confidence: 99%

Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations

Párraga

Possatti

Alves

et al. 2016

JNS

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“…With intraoperative monitoring, structures such as the corticospinal tract in the cerebral peduncle, CN nuclei (CNs VII, IX, X, and XII), the facial colliculus, and hypoglossal and vagal trigones on the floor of the fourth ventricle can be identified. 51 Frameless stereotaxy registered to the focus of the surgical microscope is also very helpful, especially when the CM is hidden under a very thin layer of normalappearing parenchyma.…”

Section: General Clinical and Surgical Considerationsmentioning

confidence: 99%

Brainstem cavernous malformations: anatomical, clinical, and surgical considerations

Giliberto

Lanzino²,

Diehn

et al. 2010

FOC

110

103

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Symptomatic brainstem cavernous malformations carry a high risk of permanent neurological deficit related to recurrent hemorrhage, which justifies aggressive management. Detailed knowledge of the microscopic and surface anatomy is important for understanding the clinical presentation, predicting possible surgical complications, and formulating an adequate surgical plan. In this article the authors review and illustrate the surgical and microscopic anatomy of the brainstem, provide anatomoclinical correlations, and illustrate a few clinical cases of cavernous malformations in the most common brainstem areas.

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“…18) However, direct stimulation methods are not necessarily used often in the treatment of spinal lesions. In spinal surgeries, direct stimulation of the nerve root is mainly used to identify structures at the level of the cauda equina and to assess the integrity of nervous structures in spinal tumor surgery.…”

Section: Discussionmentioning

confidence: 99%

Utility of Direct Stimulation of Roots in Spinal Surgery

Takeda

Yamaguchi

Morishige

et al. 2011

Neurol. Med. Chir.(Tokyo)

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Prevention of postoperative neurological deficits is a major concern of spinal surgeons and has led to the introduction and current development of intraoperative neurophysiological monitoring. We have used motor evoked potentials and somatosensory evoked potentials as routine monitoring techniques and, in some cases, added optional methods such as direct stimulation of nerve roots and spinal evoked potentials. We report our experience of direct nerve root stimulation as an optional monitoring method during spinal surgeries in 7 patients with lesions affecting the proximal nerve roots aged from 1 day to 78 years (mean 23.5 years). Four patients had anomalous lesions, two had spinal nerve root schwannomas, and one had a far-lateral lumbar disc herniation. Direct stimulation was used for detection of motor nerve roots in the anomalous lesions and schwannomas, and to distinguish the nerve root from the paraspinal soft tissues in the case of a far-lateral herniated disc at the L5-S1 level. Although some patients had slight transient neurological symptoms such as motor weakness and sensory disturbance, none developed severe permanent neurological impairment. Direct stimulation allows detection of the motor nerve during spinal surgery in real time. Our limited experience suggests that the direct stimulation technique could reduce the risk of motor or vesicorectal disturbance after surgery of lesions affecting or involving the spinal nerve roots.

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Monitoring of motor pathways during brain stem surgery: What we have achieved and what we still miss?

Cited by 104 publications

References 30 publications

Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations

Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations

Brainstem cavernous malformations: anatomical, clinical, and surgical considerations

Utility of Direct Stimulation of Roots in Spinal Surgery

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