Multimodality Intraoperative Neurophysiologic Monitoring Findings During Surgery for Adult Tethered Cord Syndrome: Analysis of a Series of 44 Patients With Long-Term Follow-up

Paradiso, Guillermo; Lee, Gabriel Y F; Sarjeant, Roger; Hoang, Ly; Massicotte, Eric M.; Fehlings, Michael G.

doi:10.1097/01.brs.0000231687.02271.b6

Cited by 83 publications

(46 citation statements)

References 40 publications

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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%

“…The same group reported similar results and utility of neurophysiological monitor ing for tethered cord release in 15 adults with a diverse number of causes of tethered cord, including thick filum, spinal cord malformations, and lowlying conus. 17 Parad iso and colleagues 14 have also reported success with iden tifying viable tissue intraoperatively based on stimulation thresholds. Although the pathophysiological mechanisms of neurological deterioration are probably similar across causes for tethered cord syndromes, the techniques used for untethering cannot necessarily be extrapolated to pa tients with STCSs, in which the filum may not be readily visually identifiable, and in which little normal compara tive anatomy is available.…”

Section: Neurophysiological Monitoring For Cord Untetheringmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Neurophysiological Monitoring For Cord Untetheringmentioning

confidence: 99%

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

Pouratian¹,

Elias²,

Phillips

et al. 2010

FOC

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“…However, if tethering pathology is confirmed through a radiologic investigation, it might be recommended that the patient is limited in exercise or work, and performed an operation for prophylactic spinal cord release. The operative results for pain are most gratifying 20,23) . Most of our patients had no pain after surgery, and sensorimotor deficits also responded favorably with surgical release of the conus.…”

Section: Discussionmentioning

confidence: 99%

Surgical Management and Outcome of Tethered Cord Syndrome in School-Aged Children, Adolescents, and Young Adults

Kang

Yoon

et al. 2009

J Korean Neurosurg Soc

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Objective :The adolescent presentation of tethered cord syndrome (TCS) is well-recognized, but continues to pose significant diagnostic and management controversies. The authors conducted a retrospective study of clinical outcomes after surgical intervention in 24 school-aged children, adolescents, and young adults with TCS. Methods : All 83 patients with a lipomyelomeningocele (LMMC) underwent untethering surgery for caudal cord tethering between 1987 and 2007. The clinical charts and follow-up data were reviewed. Of these patients, 24 school-aged children, adolescents, and young adults with TCS were studied with respect to the clinical, radiologic, pathologic features, and surgical outcomes. Results : Untethering procedures were performed in 24 patients (age range, 7-25 years) for TCS of various origins (lipoma, lipomyelomeningocele, and tight filum terminale). Specific circumstances involving additional tugging of the already tight conus, and direct trauma to the back precipitated the onset of symptom in 50% of the patients. Diffuse and non-dermatomal leg pain, often referred to the anorectal region, was the most common presenting symptom. Progressive sensorimotor deficits in the lower extremities, as well as bladder and bowel dysfunction, were also common findings, but progressive foot and spinal deformities were noted less frequently. The most common tethered lesions were intradural lipomas, thickened filum and fibrous band adhesions into the placode sac. The surgical outcome was gratifying in relation to pain and motor weakness, but disappointing with respect to resolution of bowel and bladder dysfunction. Of the 24 patients with TCS, pre-operative deficits improved after surgery in 14 (58.3%), remained stable in 8 (33.4%), and worsened in 2 (8.3%). Conclusion :The pathologic lesions of tethered cord syndrome in school-aged children, adolescents, and young adults, are mostly intradural lipomas and tight filum. It is suggested that the degree of cord traction results in neurologic dysfunction in late life due to abnormal tension, aggravated by trauma or repeated tugging of the conus during exercise. Early diagnosis and adequate surgical release might be the keys to the successful outcome in school-aged children, adolescents, and young adults with

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“…Similar 'mis-targeting' of SSEP for postoperative neurological deficit can be resulted from applied spinal level as SSEP can hardly monitor the integrity of sensory pathway at lumbosacral level [22]. Paradiso et al [23] performed untethering of 44 cases of adult tethered cord syndrome under monitoring of SSEP and EMG. Two patients developed new postoperative deficit but only one patient showed SSEP changes.…”

Section: Predictability Of Mep and Ssep For Postoperative Motor Deficitmentioning

confidence: 99%

Feasibility and Predictability of Intraoperative Monitoring in Patients with Intradural Extramedullary and Epidural Metastatic Spinal Tumors

Kang¹,

Gwak²,

Shin³

et al. 2016

J Spine

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Objectives: To evaluate the feasibility, sensitivity and specificity of IOM for IDEM and ED metastatic spinal tumours, and to assess usefulness of SSEP for patients in whom MEP was not measurable. Methods and materials:One hundred and one consecutive patients with IDEM and ED metastatic spinal tumours at the cord level (C1 to L1) received surgery under SSEP and/or MEP was included. Feasibility of IOM was defined to be negative in case of no measurable MEP or SSEP under general anaesthesia after confirmation of reversal of neuromuscular block. More than 50% change of MEP or SSEP amplitude and more than 10% delay of SSEP latency were evaluated as positive signs of IOM change.Results: MEP was measurable in 74 out of 101 trials, thus feasibility is 73%. Patient with normal motor power showed higher feasibility than those with motor power 3 or less. (93% vs. 39%) Among 74 patients with measurable MEP, 19 patients showed positive MEP change and 14 patients got worse of their motor power postoperatively.

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Multimodality Intraoperative Neurophysiologic Monitoring Findings During Surgery for Adult Tethered Cord Syndrome: Analysis of a Series of 44 Patients With Long-Term Follow-up

Cited by 83 publications

References 40 publications

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

Surgical Management and Outcome of Tethered Cord Syndrome in School-Aged Children, Adolescents, and Young Adults

Feasibility and Predictability of Intraoperative Monitoring in Patients with Intradural Extramedullary and Epidural Metastatic Spinal Tumors

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