C4-T3 Replacement Laminoplasty and Microsurgical Resection of Ependymoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Vincent N Nguyen ◽  
Mustafa Motiwala ◽  
Larry Ha ◽  
Alan D Boom ◽  
Frederick A Boop
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Sensory Level ◽  
Glial Tumor ◽  
Intramedullary Spinal Cord ◽  
Spinal Ependymoma ◽  
Pin Fixation ◽  
Microsurgical Techniques ◽  
Normal White Matter

Abstract Spinal ependymomas are the most common intramedullary spinal cord tumors in adults.1-4 They are benign histologically, and maximum safe surgical resection should be pursued with the goal of maintaining neurological integrity.4 Spinal ependymoma resections have been described in the operative video literature, including those using techniques of laminoplasty to prevent postlaminectomy kyphosis.1-3,5 Defining the planes between tumor and normal spinal cord is critical to achieving safe maximum resection.3 This video will illustrate the microsurgical techniques used in the resection of a large spinal cord ependymoma in a patient who presented with progressive lower extremity paraparesis and incontinence and was found to have a large intradural, intramedullary C4-T3 lesion with a rostral glial tumor cyst. The patient consented to surgical intervention.  The patient was placed prone in MAYFIELD 3-point pin fixation (Integra LifeSciences, Plainsboro Township, New Jersey). Intraoperative neurophysiological electrodes were placed for somatosensory evoked potentials, motor evoked potentials, and D-wave monitoring of corticospinal tracts.6,7 C3-T4 replacement laminoplasties were performed. A midline dural incision spanning C4-T4 was made. A midline myelotomy preserving the pial venous plexus was performed with a 69 Beaver blade.2 The attachments of the tumor to the normal white matter of the spinal cord were microsurgically defined, coagulated, and divided. Tumor debulking was performed with an ultrasonic aspirator. Once gross total resection was achieved, the pial edges of the spinal cord were reapproximated. The dura was closed in a watertight fashion. The patient recovered from surgery well with preservation of her motor function with a continued T7 sensory level.

scholarly journals High-resolution direct microstimulation mapping of spinal cord motor pathways during resection of an intramedullary tumor

2015 ◽  
Vol 22 (2) ◽  
pp. 205-210 ◽  
Author(s):  
Ravi Gandhi ◽  
Corinne M. Curtis ◽  
Aaron A. Cohen-Gadol
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Spinal Cord Tumor ◽  
Tumor Resection ◽  
Intramedullary Tumor ◽  
Intramedullary Tumors ◽  
Intramedullary Spinal Cord ◽  
Supratentorial Gliomas ◽  
Microsurgical Techniques

Despite the use of advanced microsurgical techniques, resection of intramedullary tumors may result in significant postoperative deficits because of the vicinity or invasion of important functional tracts. Intraoperative monitoring of somatosensory evoked potentials and transcranial electrical motor evoked potentials has been used previously to limit such complications. Electromyography offers an opportunity for the surgeon to map the eloquent tissue associated with the tumor using intraoperative motor fiber stimulation. Similar to the use of cortical simulation in the resection of supratentorial gliomas, this technique can potentially advance the safety of intramedullary spinal cord tumor resection. The authors describe the use of intraoperative motor fiber tract stimulation to map the corticospinal tracts associated with an intramedullary tumor. This technique led to protection of these tracts during resection of the tumor.

The Role of Motor Evoked Potentials during Surgery for Intramedullary Spinal Cord Tumors

Neurosurgery ◽  
1997 ◽  
Vol 41 (6) ◽  
pp. 1327-1336 ◽  
Author(s):  
Nobu Morota ◽  
Vedran Deletis ◽  
Shlomi Constantini ◽  
Markus Kofler ◽  
Henry Cohen ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Spinal Cord Tumors ◽  
Intramedullary Spinal Cord

The Initial Use of Free-running Electromyography to Detect Early Motor Tract Injury during Resection of Intramedullary Spinal Cord Lesions

2005 ◽  
Vol 56 (suppl_4) ◽  
pp. ONS-299-ONS-314 ◽  
Author(s):  
Stanley A. Skinner ◽  
Mahmoud Nagib ◽  
Thomas A. Bergman ◽  
Robert E. Maxwell ◽  
Gaspar Msangi
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
False Negative ◽  
Neurological Deficits ◽  
Motor Deficit ◽  
Spinal Cord Lesions ◽  
Blood Pressure Elevation ◽  
Intramedullary Spinal Cord ◽  
Free Running

Abstract OBJECTIVE: The resection of intramedullary spinal cord lesions (ISCLs) can be complicated by neurological deficits. Neuromonitoring has been used to reduce intraoperative risk. We have used somatosensory evoked potentials (SEPs) and muscle-derived transcranial electrical motor evoked potentials (myogenic TCE-MEPs) to monitor ISCL removal. We report our retrospective experience with the addition of free-running electromyography (EMG). METHODS: Thirteen patients underwent 14 monitored ISCL excisions. Anesthesia was maintained with minimal inhalant to reduce motoneuron suppression and enhance the myogenic TCE-MEPs. Free-running EMG was examined in the four limbs for evidence of abnormal bursts, prolonged tonic discharge, or sudden electrical silence. Warning of an electromyographic abnormality or myogenic TCE-MEP loss prompted interventions, including blood pressure elevation, a pause in surgery, a wake-up test, or termination of surgery. Pre- and postoperative neurological examinations determined the incidence of new deficits. RESULTS: The combined use of free-running EMG and myogenic TCE-MEPs detected all eight patients with a new motor deficit after surgery; there was one false-positive report. In three of the eight true-positive cases, an electromyographic abnormality immediately anticipated loss of the myogenic TCE-MEPs. Two patients with abnormal EMGs but unchanged myogenic TCE-MEPs experienced mild postoperative worsening of motor deficits; myogenic TCE-MEPs alone would have generated false-negative reports in these cases. CONCLUSION: During resection of ISCLs, free-running EMG can supplement motor tract monitoring by TCE-MEPs. Segmental and suprasegmental elicitation of neurotonic discharges can be observed in four-limb EMG. Abnormal electromyographic bursts, tonic discharge, or abrupt electromyographic silence may anticipate myogenic TCE-MEP loss and predict a postoperative motor deficit.

Spinal Cord Mapping as an Adjunct for Resection of Intramedullary Tumors: Surgical Technique with Case Illustrations

Neurosurgery ◽  
2002 ◽  
Vol 51 (5) ◽  
pp. 1199-1207 ◽  
Author(s):  
Alfredo Quinones-Hinojosa ◽  
Mittul Gulati ◽  
Russell Lyon ◽  
Nalin Gupta ◽  
Charles Yingling
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Cervical Spinal Cord ◽  
Tumor Resection ◽  
Neurological Deficits ◽  
Electromyographic Activity ◽  
Intramedullary Spinal Cord ◽  
Motor Tracts ◽  
Stimulation Of

Abstract OBJECTIVE Resection of intramedullary spinal cord tumors may result in transient or permanent neurological deficits. Intraoperative somatosensory evoked potentials (SSEPs) and motor evoked potentials are commonly used to limit complications. We used both antidromically elicited SSEPs for planning the myelotomy site and direct mapping of spinal cord tracts during tumor resection to reduce the risk of neurological deficits and increase the extent of tumor resection. METHODS In two patients, 3 and 12 years of age, with tumors of the thoracic and cervical spinal cord, respectively, antidromically elicited SSEPs were evoked by stimulation of the dorsal columns and were recorded with subdermal electrodes placed at the medial malleoli bilaterally. Intramedullary spinal cord mapping was performed by stimulating the resection cavity with a handheld Ojemann stimulator (Radionics, Burlington, MA). In addition to visual observation, subdermal needle electrodes inserted into the abductor pollicis brevis-flexor digiti minimi manus, tibialis anterior-gastrocnemius, and abductor halluces-abductor digiti minimi pedis muscles bilaterally recorded responses that identified motor pathways. RESULTS The midline of the spinal cord was anatomically identified by visualizing branches of the dorsal medullary vein penetrating the median sulcus. Antidromic responses were obtained by stimulation at 1-mm intervals on either side of the midline, and the region where no response was elicited was selected for the myelotomy. The anatomic and electrical midlines did not precisely overlap. Stimulation of abnormal tissue within the tumor did not elicit electromyographic activity. Approaching the periphery of the tumor, stimulation at 1 mA elicited an electromyographic response before normal spinal cord was visualized. Restimulation at lower currents by use of 0.25-mA increments identified the descending motor tracts adjacent to the tumor. After tumor resection, the tracts were restimulated to confirm functional integrity. Both patients were discharged within 2 weeks of surgery with minimal neurological deficits. CONCLUSION Antidromically elicited SSEPs were important in determining the midline of a distorted cord for placement of the myelotomy incision. Mapping spinal cord motor tracts with direct spinal cord stimulation and electromyographic recording facilitated the extent of surgical resection.

scholarly journals Intraoperative changes in transcranial motor evoked potentials and somatosensory evoked potentials predicting outcome in children with intramedullary spinal cord tumors

2014 ◽  
Vol 13 (6) ◽  
pp. 591-599 ◽  
Author(s):  
Jason S. Cheng ◽  
Michael E. Ivan ◽  
Christopher J. Stapleton ◽  
Alfredo Quinones-Hinojosa ◽  
Nalin Gupta ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Somatosensory Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Dorsal Column ◽  
Motor Deficits ◽  
Intramedullary Spinal Cord ◽  
Sensory Deficits ◽  
Motor Strength ◽  
Transcranial Motor Evoked Potentials

Object Intraoperative dorsal column mapping, transcranial motor evoked potentials (TcMEPs), and somatosensory evoked potentials (SSEPs) have been used in adults to assist with the resection of intramedullary spinal cord tumors (IMSCTs) and to predict postoperative motor deficits. The authors sought to determine whether changes in MEP and SSEP waveforms would similarly predict postoperative motor deficits in children. Methods The authors reviewed charts and intraoperative records for children who had undergone resection for IMSCTs as well as dorsal column mapping and TcMEP and SSEP monitoring. Motor evoked potential data were supplemented with electromyography data obtained using a Kartush microstimulator (Medtronic Inc.). Motor strength was graded using the Medical Research Council (MRC) scale during the preoperative, immediate postoperative, and follow-up periods. Reductions in SSEPs were documented after mechanical traction, in response to maneuvers with the cavitational ultrasonic surgical aspirator (CUSA), or both. Results Data from 12 patients were analyzed. Three lesions were encountered in the cervical and 7 in the thoracic spinal cord. Two patients had lesions of the cervicomedullary junction and upper spinal cord. Intraoperative MEP changes were noted in half of the patients. In these cases, normal polyphasic signals converted to biphasic signals, and these changes correlated with a loss of 1–2 grades in motor strength. One patient lost MEP signals completely and recovered strength to MRC Grade 4/5. The 2 patients with high cervical lesions showed neither intraoperative MEP changes nor motor deficits postoperatively. Dorsal columns were mapped in 7 patients, and the midline was determined accurately in all 7. Somatosensory evoked potentials were decreased in 7 patients. Two patients each had 2 SSEP decreases in response to traction intraoperatively but had no new sensory findings postoperatively. Another 2 patients had 3 traction-related SSEP decreases intraoperatively, and both had new postoperative sensory deficits that resolved. One additional patient had a CUSA-related SSEP decrease intraoperatively, which resolved postoperatively, and the last patient had 3 traction-related sensory deficits and a CUSA-related sensory deficit postoperatively, none of which resolved. Conclusions Intraoperative TcMEPs and SSEPs can predict the degree of postoperative motor deficit in pediatric patients undergoing IMSCT resection. This technique, combined with dorsal column mapping, is particularly useful in resecting lesions of the upper cervical cord, which are generally considered to be high risk in this population. Furthermore, the spinal cord appears to be less tolerant of repeated intraoperative SSEP decreases, with 3 successive insults most likely to yield postoperative sensory deficits. Changes in TcMEPs and SSEP waveforms can signal the need to guard against excessive manipulation thereby increasing the safety of tumor resection.

Use of Intraoperative Transcranial Motor Evoked Potentials to Predict Outcome after Resection of Pediatric Intramedullary Spinal Cord Tumors

Neurosurgery ◽  
2005 ◽  
Vol 57 (2) ◽  
pp. 436-436
Author(s):  
Kurtis Auguste ◽  
Alfredo Quiñones-Hinojosa ◽  
Russ Lyon ◽  
Peter P. Sun ◽  
Victor L. Perry ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Spinal Cord Tumors ◽  
Intramedullary Spinal Cord ◽  
Transcranial Motor Evoked Potentials
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