Value of Free-Run Electromyographic Monitoring of Lower Cranial Nerves in Endoscopic Endonasal Approach to Skull Base Surgeries

Mohanraj, Santhosh Kumar; Habeych, Miguel; Wichman, Kelley; Chang, Yue‐Fang; Gardner, Paul A.; Snyderman, Carl H.; Crammond, Donald J.; Balzer, Jeffrey

doi:10.1055/s-0032-1312712

Cited by 19 publications

(23 citation statements)

References 25 publications

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“…SSEPs 16 and TcMEPs 15 monitor the dorsal column and the motor pathways in the spinal cord and reduce neurological deficits after spinal surgeries. EMG has been used for placement of pedicle screws 33 , as well the incidence of cranial nerve deficits in during thyroidectomy 34 and skull base tumor removal 35 . The techniques though useful, have not be validated based on the alarms and subsequent surgical interventions used to modify the procedure.…”

Section: Discussionmentioning

confidence: 99%

Value of intraoperative neurophysiological monitoring to reduce neurological complications in patients undergoing anterior cervical spine procedures for cervical spondylotic myelopathy

Muralidharan

Loke

Habeych

et al. 2016

Journal of Clinical Neuroscience

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Abstract:Objective: The primary aim of this study is to conduct a systematic review of reports concerning patients with cervical spondylotic myelopathy to assess the value of intraoperative monitoring (IOM), such as SSEPs, TcMEPs, and EMG, in anterior cervical procedures. Methods: A search strategy was first conducted in order to collect a small database of relevant papers using key words describing both disorders and procedures of interest. The database was then shortlisted using selection criteria and data from these finalized reports was extracted to identify complications as a result of anterior cervical procedures treating cervical spondylotic myelopathy for outcome analysis on a continuous scale. Results: In the 22 studies that matched the screening criteria, only two involved the use of IOM. The 22 studies had an average of 173 patients. In studies with procedures done without IOM a mean change in JOA score of 3.94 points and a mean change in Nurick score by 1.20 points (both less severe post-op) were observed. Within our sub-group analysis, worsening myelopathy and/or quadriplegia had a mean outcome of 2.71% of cases for studies without IOM and a mean outcome of 0.91% of cases for studies with IOM. Conclusions: Based on the review of published studies sufficient evidence does not exist to negate or reinforce the use of IOM in hopes of reducing neurological complications during anterior cervical procedures. There is no standardized evaluation method to measure these complications. In addition, the modalities used for IOM have not been overwhelmingly confirmed.

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Section: Discussionmentioning

confidence: 99%

Value of intraoperative neurophysiological monitoring to reduce neurological complications in patients undergoing anterior cervical spine procedures for cervical spondylotic myelopathy

Muralidharan

Loke

Habeych

et al. 2016

Journal of Clinical Neuroscience

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“…This study was approved by the local institutional review board for retrospective review of the clinical outcomes. The subsequent description of the neurophysiological monitoring techniques has been discussed in detail in earlier publications, [35][36][37][38][39] and a brief overview is given below.…”

Section: Methodsmentioning

confidence: 99%

“…Significant free-run EMG activity, when present for prolonged periods of time (≥ 100 msec) from a CN, was reported to the surgeons as 1 alert and was also recorded in the patient's records. 38,39 Triggered EMG responses were obtained upon request using a constant-current stimulator. All negative and positive responses were communicated to the surgeons.…”

Section: Alarm Criteriamentioning

confidence: 99%

“…36 Neurological complications, including hemiparesis and cranial nerve palsies, can be predicted and prevented by utilizing real-time continuous intraoperative neurophysiological monitoring (IONM). [25][26][27][35][36][37][38][39] IONM using somatosensory evoked potentials (SSEPs), 2 brainstem auditory evoked potentials (BAEPs), and electromyography (both free-run electromyography [EMG] and triggered EMG) 26,27 have been valuable in conventional skull base surgeries. Similarly, the SSEP and BAEP values and free-run EMG of the CNs during EES for skull base tumors in adults have been previously described.…”

mentioning

confidence: 99%

“…Similarly, the SSEP and BAEP values and free-run EMG of the CNs during EES for skull base tumors in adults have been previously described. [35][36][37][38][39] However, to our knowledge, sufficient data to establish the value of IONM in pediatric EES have not been published.…”

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confidence: 99%

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Intraoperative neurophysiological monitoring during endoscopic endonasal surgery for pediatric skull base tumors

Elangovan¹,

Singh²,

Gardner³

et al. 2016

PED

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OBJECT The aim of this study was to evaluate the value of intraoperative neurophysiological monitoring (IONM) using electromyography (EMG), brainstem auditory evoked potentials (BAEPs), and somatosensory evoked potentials (SSEPs) to predict and/or prevent postoperative neurological deficits in pediatric patients undergoing endoscopic endonasal surgery (EES) for skull base tumors. METHODS All consecutive pediatric patients with skull base tumors who underwent EES with at least 1 modality of IONM (BAEP, SSEP, and/or EMG) at our institution between 1999 and 2013 were retrospectively reviewed. Staged procedures and repeat procedures were identified and analyzed separately. To evaluate the diagnostic accuracy of significant free-run EMG activity, the prevalence of cranial nerve (CN) deficits and the sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 129 patients underwent 159 procedures; 6 patients had a total of 9 CN deficits. The incidences of CN deficits based on the total number of nerves monitored in the groups with and without significant free-run EMG activity were 9% and 1.5%, respectively. The incidences of CN deficits in the groups with 1 staged and more than 1 staged EES were 1.5% and 29%, respectively. The sensitivity, specificity, and negative predictive values (with 95% confidence intervals) of significant EMG to detect CN deficits in repeat procedures were 0.55 (0.22–0.84), 0.86 (0.79–0.9), and 0.97 (0.92–0.99), respectively. Two patients had significant changes in their BAEPs that were reversible with an increase in mean arterial pressure. CONCLUSIONS IONM can be applied effectively and reliably during EES in children. EMG monitoring is specific for detecting CN deficits and can be an effective guide for dissecting these procedures. Triggered EMG should be elicited intraoperatively to check the integrity of the CNs during and after tumor resection. Given the anatomical complexity of pediatric EES and the unique challenges encountered, multimodal IONM can be a valuable adjunct to these procedures.

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ICAR: endoscopic skull‐base surgery

Wang

Zanation

Gardner

et al. 2019

Int Forum Allergy Rhinol

152

279

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Background Endoscopic skull‐base surgery (ESBS) is employed in the management of diverse skull‐base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull‐base surgery have produced the International Consensus Statement on Endoscopic Skull‐Base Surgery (ICAR:ESBS). Methods Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence‐based review or evidence‐based review with recommendations format. Subsequently, each topic was written and then reviewed by skull‐base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. Results The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull‐base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. Conclusion A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence‐based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull‐base community to embrace these opportunities and collaboratively address these shortcomings.

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Value of Free-Run Electromyographic Monitoring of Lower Cranial Nerves in Endoscopic Endonasal Approach to Skull Base Surgeries

Cited by 19 publications

References 25 publications

Value of intraoperative neurophysiological monitoring to reduce neurological complications in patients undergoing anterior cervical spine procedures for cervical spondylotic myelopathy

Value of intraoperative neurophysiological monitoring to reduce neurological complications in patients undergoing anterior cervical spine procedures for cervical spondylotic myelopathy

Intraoperative neurophysiological monitoring during endoscopic endonasal surgery for pediatric skull base tumors

ICAR: endoscopic skull‐base surgery

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