Multi-modality neurophysiological monitoring during surgery for adult tethered cord syndrome

Paradiso, Guillermo; Lee, Gabriel Y F; Sarjeant, Roger; Fehlings, Michael G.

doi:10.1016/j.jocn.2005.03.012

Cited by 25 publications

(8 citation statements)

References 20 publications

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“…2 Neurophysiological monitoring techniques have been developed for intraoperative monitoring. 3,4 Sutter et al in a prospective study of 409 lumbosacral surgical procedures reported that intraoperative spinal-evoked and cortical-evoked potentials combined with continuous EMG-and motor-evoked potentials of the muscles decrease the postoperative surgical-related complications and thus improve the long-term results. 5 Bose et al also reported that intraoperative electromyographic monitoring provided a real-time measure of impending spinal nerve root injury during instrumented posterior lumbar fusion, allowing for timely intervention and minimization of negative postoperative results.…”

Section: Discussionmentioning

confidence: 99%

Continuous intraoperative electromyographic and transcranial motor evoked potential recordings in spinal stenosis surgery

Voulgaris¹,

Karagiorgiadis²,

Alexiou³

et al. 2010

Journal of Clinical Neuroscience

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Section: Discussionmentioning

confidence: 99%

Continuous intraoperative electromyographic and transcranial motor evoked potential recordings in spinal stenosis surgery

Voulgaris¹,

Karagiorgiadis²,

Alexiou³

et al. 2010

Journal of Clinical Neuroscience

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“…Although others have reported the use of neurophysiological monitoring for tethered cord release, this is the largest series specifically analyzing the utility and outcomes of this technique in STCS. 1,13,14,17,22 …”

Section: Discussionmentioning

confidence: 99%

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

Pouratian¹,

Elias²,

Phillips

et al. 2010

FOC

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Object Many patients develop neurological symptoms related to spinal cord tethering after perinatal repair of myelomeningocele. This is referred to as secondary tethered cord syndrome (STCS). The authors describe their methodology and evaluate the intraoperative utility and postoperative outcomes of electrophysiologically guided untethering for STCS. In addition, the authors describe the use of electrophysiological guidance to identify an “autonomous placode” in the untethering of the cord in STCS. Methods The authors retrospectively identified 46 untethering procedures in 38 patients who had undergone perinatal myelomeningocele repair and in whom the index surgery was for tethered cord release at the site of the repair. In all cases, both passive (electromyography) and active (detection of compound muscle action potentials) electrophysiological monitoring was used. The proximity to neural elements was determined based on the current used; eliciting compound muscle action potentials with a ≤ 10-mA stimulation was assumed to represent direct neural stimulation. Clinical records were reviewed to evaluate the utility of electrophysiological guidance and patient outcomes. Results The median age at the time of untethering was 9.5 years (range 0.5–54 years). The median follow-up time was 42 months (range 3–172 months). Progressive bowel and bladder dysfunction, diagnosed either clinically or by cystometrogram, and low-back pain were the most common presenting symptoms. Intraoperative findings indicated that the most common causes of tethering were dense scar (76%) and a tethered placode (39%). Electrophysiological monitoring identified functional neural tissue near tethered elements and provided intraoperative guidance in all cases. In 41% of cases (19 cases), the untethering plan was noted to have been significantly influenced by intraoperative neurophysiological findings. Moreover, an autonomous placode was identified in 6 patients who were nonambulatory preoperatively and had presented with increasing pain and spasticity. In electrophysiologically silent areas, more aggressive dissection and untethering were possible. Symptoms of low-back pain, lower-extremity paresthesia, and lower-extremity spasticity were most likely to improve after untethering surgery (91, 88, and 82%, respectively). Sectioning above the electrophysiologically defined autonomous placode resulted in significant improvement in back pain and lower-extremity spasticity in 5 of 6 patients. There was 1 case of immediate postoperative neurological deterioration (fecal incontinence). All patients remained clinically stable or improved on long-term follow-up, except for 6 (16% of patients) who required a total of 7 additional procedures for recurrent symptoms (median time to repeat surgery 36 months). Complications were noted in 8 cases, including infections and CSF leaks. Conclusions Surgical untethering of STCS halts progression and often improves preoperative symptoms. Electrophysiological monitoring, using both a threshold-based interpretation system and continuous electromyography monitoring, provides an efficient, effective, and reliable method for intraoperative guidance, thereby limiting iatrogenic injury and providing a means to identify and untether autonomous placodes. Electrophysiological monitoring also allows for more aggressive dissection and untethering in functionally silent regions, possibly decreasing retethering rates.

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“…16,17,21 Furthermore, the surgery is associated with increased perioperative risks, including CSF leak, pseudomeningocele, neurological injury, wound complications, and spinal cord retethering. 17,21,26 Vertebral column shortening by subtraction osteotomy provides an alternative surgical treatment for recurrent TCS. In their cadaveric study, Grande el al.…”

Section: Discussionmentioning

confidence: 99%

Posterior vertebral column subtraction osteotomy: a novel surgical approach for the treatment of multiple recurrences of tethered cord syndrome

Hsieh

Ondra

Grande

et al. 2009

SPI

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Recurrent tethered cord syndrome (TCS) has been reported to develop in 5–50% of patients following initial spinal cord detethering operations. Surgery for multiple recurrences of TCS can be difficult and is associated with significant complications. Using a cadaveric tethered spinal cord model, Grande and colleagues demonstrated that shortening of the vertebral column by performing a 15–25-mm thoracolumbar osteotomy significantly reduced spinal cord, lumbosacral nerve root, and terminal filum tension. Based on this cadaveric study, spinal column shortening by a thoracolumbar subtraction osteotomy may be a viable alternative treatment to traditional surgical detethering for multiple recurrences of TCS. In this article, the authors describe the use of posterior vertebral column subtraction osteotomy (PVCSO) for the treatment of 2 patients with multiple recurrences of TCS. Vertebral column resection osteotomy has been widely used in the surgical correction of fixed spinal deformity. The PVCSO is a novel surgical treatment for multiple recurrences of TCS. In such cases, PVCSO may allow surgeons to avoid neural injury by obviating the need for dissection through previously operated sites and may reduce complications related to CSF leakage. The novel use of PVCSO for recurrent TCS is discussed in this report, including surgical considerations and techniques in performing PVCSO.

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Multi-modality neurophysiological monitoring during surgery for adult tethered cord syndrome

Cited by 25 publications

References 20 publications

Continuous intraoperative electromyographic and transcranial motor evoked potential recordings in spinal stenosis surgery

Continuous intraoperative electromyographic and transcranial motor evoked potential recordings in spinal stenosis surgery

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

Posterior vertebral column subtraction osteotomy: a novel surgical approach for the treatment of multiple recurrences of tethered cord syndrome

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