What is the Optimal Surgical Method for Achieving Correction and Avoiding Neurological Complications in Pediatric High-grade Spondylolisthesis?

BACKGROUND: Controversy persists in the treatment of high-grade spondylolisthesis (HGS). Surgery is recommended in patients with intrusive symptoms and evidence debates the competing strategies. This study compares the radiologic outcomes and postoperative complications at a minimum of 2 years follow-up for patients with HGS treated with instrumented fusion with partial reduction (IFIS) with those treated with reduction, decompression, and instrumented fusion (RIF). We hypothesize that IFIS leads to a lower rate of complication and revision surgery than RIF. METHODS: A retrospective comparative methodology was used to analyze consecutive HGS treated surgically between 2006 and 2017. Patients diagnosed with ≥grade 3 spondylolisthesis treated with arthrodesis before the age of 18 years with a minimum of 2 years follow-up were included. Patients were excluded if surgery did not aim to achieve arthrodesis or was a revision procedure. Cases were identified through departmental and neurophysiological records. RESULTS: Thirty patients met the inclusion criteria. Mean follow-up was 4 years. Ten patients underwent IFIS and the remaining 20 underwent RIF. The 2 groups showed no difference in demographics, grade of slip, deformity or presenting symptoms. Of 10 treated with IFIS, the SA reduced by a mean of 10 degrees and C7 sagittal vertical line changed by 31 mm. In the RIF cohort, SA reduced by 16 degrees and C7 sagittal vertical line reduced by 26 mm. PT was unchanged in both groups. In IFIS cohort, 2 patients showed postoperative weakness, resolved by 2 years. None required revision surgery. In the RIF group, 4 sustained dural tears and 1 a laminar fracture, 7 showed postoperative weakness or dysaesthesia, 3 of which had not resolved by 2 years. Eight patients underwent unplanned further surgery, 3 for pseudarthrosis. CONCLUSIONS: RIF and IFIS show similar radiologic outcomes. RIF shows a higher rate of unplanned return to surgery, pseudarthrosis and persisting neurological changes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

The effect of dexmedetomidine on motor-evoked potentials during pediatric posterior spinal fusion surgery: a retrospective case-control study.

PURPOSE: Motor-evoked potentials (MEPs) are frequently used in pediatric posterior spinal fusion surgery (PSFS) to detect spinal cord ischemia. Dexmedetomidine is increasingly being used as an adjunct to total intravenous anesthesia, but its effect on MEP amplitude has been variably reported. The purpose of this study was to evaluate the effect of an infusion of dexmedetomidine on the amplitude of MEPs. METHODS: We performed a retrospective case-control study of 30 pediatric patients who received a 0.5 µg·kg-1·hr-1 infusion of dexmedetomidine, ten patients who received 0.3 µg·kg-1·hr-1 dexmedetomidine, and 30 control patients who did not receive dexmedetomidine during PSFS. Two neurophysiologists reviewed the MEP amplitudes in six muscle groups at three time points: when the patient was turned prone (baseline; T1), one hour after incision (T2), and after exposure of the spine but before insertion of the first screw (T3). RESULTS: In all muscles tested, the mean MEP amplitude was reduced by T3 when dexmedetomidine was infused at 0.5 µg·kg-1·hr-1. The greatest reduction from baseline MEP amplitude was 829 µV (95% confidence interval, 352 to 1230; P < 0.001) seen in first right dorsus interosseous. When dexmedetomidine was infused at 0.3 µg·kg-1·hr-1, there was a significant reduction in MEP amplitude in four of the six muscles tested at T3 compared with the control group. CONCLUSIONS: Dexmedetomidine at commonly used infusion rates of 0.3 µg·kg-1·hr-1 or 0.5 µg·kg-1·hr-1 causes a significant decrease in MEP amplitude during pediatric PSFS. We suggest that dexmedetomidine should be avoided in children undergoing PSFS so as not to confuse the interpretation of this important neurophysiological monitor.

RéSUMé: OBJECTIF: Les potentiels évoqués moteurs (PEM) sont fréquemment utilisés lors de chirurgies de fusion spinale postérieure chez l'enfant afin de détecter une ischémie de la moelle épinière. La dexmédétomidine est de plus en plus utilisée comme adjuvant à l'anesthésie intraveineuse totale, mais son effet sur l'amplitude des PEM n'a été rapporté que de façon variable. L'objectif de cette étude était d'évaluer l'effet d'une perfusion de dexmédétomidine sur l'amplitude des PEM. MéTHODE: Pendant une chirurgie de fusion spinale postérieure, nous avons réalisé une étude cas témoins rétrospective auprès de 30 patients pédiatriques ayant reçu une perfusion 0,5 µg·kg−1·h−1 de dexmédétomidine, 10 patients ayant reçu 0,3 µg·kg−1·h−1 de dexmédétomidine, et 30 patients témoins n'ayant pas reçu de dexmédétomidine. Deux neurophysiologistes ont passé en revue les amplitudes des PEM dans six groupes musculaires à trois moments de la chirurgie : lorsque le patient a été tourné sur le ventre (valeur de base; T1), une heure après l'incision (T2), et après l'exposition de la colonne mais avant l'insertion de la première vis (T3). RéSULTATS: Dans tous les muscles testés, l'amplitude moyenne des PEM était réduite à T3 lorsque la dexmédétomidine était perfusée à 0,5 µg·kg−1·h−1. La plus grande réduction par rapport à l'amplitude de base des PEM était de 829 µV (intervalle de confiance 95 %, 352 à 1230; P < 0,001) et a été observée au niveau du premier interosseux dorsal. Lorsque la dexmédétomidine était perfusée à 0,3 µg·kg−1·h−1, une réduction significative de l'amplitude des PEM a été observée dans quatre des six muscles testés à T3 par rapport au groupe témoin. CONCLUSION: La dexmédétomidine, administrée à des taux de perfusion fréquemment utilisés de 0,3 µg·kg−1·h−1 ou 0,5 µg·kg−1·h−1, a entraîné une réduction significative de l'amplitude des PEM pendant une chirurgie de fusion spinale postérieure chez l'enfant. Nous proposons d'éviter l'administration de dexmédétomidine chez les enfants devant subir une chirurgie de fusion spinale postérieure afin de ne pas brouiller l'interprétation de ce moniteur neurophysiologique important.

Feasibility of awake craniotomy in the pediatric population.

BACKGROUND: Awake craniotomy with direct cortical stimulation and mapping is the gold standard for resection of lesions near eloquent brain areas, as it can maximize the extent of resection while minimizing the risk of neurological damage. In contrast to the adult population, only small series of awake craniotomies have been reported in children. AIMS: The aim of our study is to establish the feasibility of awake craniotomy in the pediatric population. METHODS: We performed a retrospective observational study of children undergoing a supratentorial awake craniotomy between January 2009 and April 2019 in a pediatric tertiary care center. Our primary outcome was feasibility of awake craniotomy, defined as the ability to complete the procedure without conversion to general anesthesia. Our secondary outcomes were the incidence of serious intraoperative complications and the mapping completion rate. RESULTS: Thirty procedures were performed in 28 children: 12 females and 16 males. The median age was 14 years (range 7-17). The primary diagnosis was tumor (83.3%), epilepsy (13.3%), and arterio-venous malformation (3.3%). The anesthetic techniques were asleep-awake-asleep (96.7%) and conscious sedation (3.3%), all cases supplemented with scalp block and pin-site infiltration. Awake craniotomy was feasible in 29 cases (96.7%), one patient converted to general anesthesia due to agitation. Serious complications occurred in six patients: agitation (6.7%), seizures (3.3%), increased intracranial pressure (3.3%), respiratory depression (3.3%), and bradycardia (3.3%). All complications were quickly resolved and without major consequences. Cortical mapping was completed in 96.6% cases. New neurological deficits occurred in six patients (20%)-moderate in one case and mild in 5-being all absent at 6 months of follow-up. CONCLUSION: Awake craniotomy with intraoperative mapping can be successfully performed in children. Adequate patient selection and close cooperation between neurosurgeons, anesthesiologists, neuropsychologists, and neurophysiologists is paramount. Further studies are needed to determine the best anesthetic technique in this population group.

Transcutaneous electrical nerve stimulation as a novel method of remote preconditioning: in vitro validation in an animal model and first human observations.

Remote ischemic preconditioning (rIPC) induced by transient limb ischemia (li-rIPC) leads to neurally dependent release of blood-borne factors that provide potent cardioprotection. We hypothesized that transcutaneous electrical nerve stimulation (TENS) is a clinically relevant stimulus of rIPC. Study 1: seven rabbits were subjected to lower limb TENS; six to li-rIPC, and six to sham intervention. Blood was drawn and used to prepare a dialysate for subsequent analysis of cardioprotection in rabbit Langendorff preparation. Study 2: 14 healthy adults underwent upper limb TENS stimulation on one study day, 10 of whom also underwent li-rIPC on another study day. Blood was drawn before and after each stimulus, dialysate prepared, and cardioprotective activity assessed in mouse Langendorff preparation. The infarct size and myocardial recovery were measured after 30 min of global ischemia and 60 or 120 min of reperfusion. Animal validation: compared to control, TENS induced marked cardioprotection with significantly reduced infarct size (TENS vs. sham p < 0.01, rIPC vs. sham p < 0.01, TENS vs. rIPC p = ns) and improved functional recovery during reperfusion. Human study: compared to baseline, dialysate after rIPC (pre-rIPC vs. post-rIPC, p < 0.001) and TENS provided potent cardioprotection (pre-TENS vs. post-TENS p < 0.001) and improved myocardial recovery during reperfusion. The cardioprotective effects of TENS dialysates were blocked by pretreatment of the receptor heart with the opioid antagonist naloxone. TENS is a novel method for inducing cardioprotection and may provide an alternative to the limb ischemia stimulus for induction of rIPC clinically.

The Effect of Anaemia on Intra-operative Neuromonitoring Following Correction of Large Scoliosis Curves: Two Case Reports.

The correction of anemia is important in reversing significant intraoperative bilateral motor-evoked potential (MEP) loss following rod placement for correction of large scoliosis curves. This article presents a retrospective review of intraoperative neuromonitoring (IONM) data, anesthesia records, and medical charts of two patients with significant bilateral MEP changes associated with posterior spinal surgery for deformity correction. A 70 kg 12-year-old and a 44 kg 16-year-old female with main thoracic curves underwent a posterior scoliosis correction with multilevel posterior column osteotomies. Following rod insertion, significant reduction in the bilateral lower extremity MEP occurred in both cases despite mean arterial pressure exceeding 70 mmHg, which was presumed to be due to the scale of the correction attempted in the setting of haemorrhage which rendered the patient acutely anaemic, thus compromising cord vasculature and oxygen delivery. The rods were removed and packed red blood cell transfusions were administered in response to acute anaemia as a result of haemorrhage in both cases. Neither was noted to be anaemic preoperatively. Once the MEP signals improved, the rods were reinserted and correction was attempted, limited by neuromonitoring signals and resistance of the bony anchors to pullout. At closure, the MEPs were near baseline in the first case and >50% of baseline in the second. There were no changes in the somatosensory evoked potential signals in either case. Post-operative neurological function was normal in both patients. Correcting the circulating haemoglobin concentration through blood product resuscitation allowed for safe correction of spinal deformity in two cases with significant bilateral MEP loss following the initial placement of rods.

The Management of Intraoperative Spinal Cord Injury - A Scoping Review.

STUDY DESIGN: Scoping Review. OBJECTIVE: To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS: MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS: Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION: There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.

A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery.

STUDY DESIGN: Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. OBJECTIVE: The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. METHODS: All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. RESULTS: Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. CONCLUSION: We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.

Phasic genioglossus and palatoglossus muscle activity during recovery from sevoflurane anesthesia: a prospective observational study in children.

BACKGROUND: Inhalational anesthetic effects on upper airway muscle activity in children are largely unknown. The authors tested the hypothesis that phasic inspiratory genioglossus and palatoglossus activity increases during recovery from sevoflurane anesthesia in a dose-dependent manner in children. METHODS: Sixteen children, aged 2.0 to 6.9 yr, scheduled for elective urological surgery were studied. Electromyogram recordings were acquired using intramuscular needle electrodes during spontaneous ventilation. After a 15-min period of equilibration, electromyogram activity was recorded over 30 s at each of three end-tidal concentrations, 1.5, 1.0, and 0.5 minimum alveolar concentration (MAC), administered in sequence. RESULTS: Phasic genioglossus activity was noted in four children at 1.5 MAC, five at 1.0 MAC, and six children at 0.5 MAC sevoflurane. Phasic palatoglossus activity was noted in 4 children at 1.5 MAC, 6 at 1.0 MAC, and 10 children at 0.5 MAC sevoflurane. Both the proportion of children exhibiting phasic activity, and the magnitude of phasic activity increased during recovery from anesthesia. For the genioglossus, decreasing the depth of sevoflurane anesthesia from 1.5 to 1.0 MAC increased phasic activity by approximately 35% and a further decrease to 0.5 MAC more than doubled activity (median [range] at 1.5 and 0.5 MAC: 2.7 µV [0 to 4.0 µV] and 8.6 µV [3.2 to 17.6], respectively; P = 0.029). A similar dose-related increase was recorded at the palatoglossus (P = 0.0002). CONCLUSIONS: Genioglossus and palatoglossus activity increases during recovery from sevoflurane anesthesia in a dose-dependent manner over the clinical range of sevoflurane concentrations in children.

Utility of intraoperative neurophysiological monitoring in detecting motor and sensory nerve injuries in pediatric high-grade spondylolisthesis.

BACKGROUND CONTEXT: Intraoperative neuromonitoring (IONM) during surgical correction of spinal deformity has been shown to reduce iatrogenic injury in pediatric and adult populations. Although motor-evoked potentials (MEP), somatosensory-evoked potentials (SSEP), and electromyography (EMG) have been shown to be highly sensitive and specific in detecting spinal cord and nerve root injuries, their utility in detecting motor and sensory nerve root injury in pediatric high-grade spondylolisthesis (HGS) remains unknown. PURPOSE: We aim to assess the diagnostic accuracy and therapeutic impact of unimodal and multimodal IONM in the surgical management of HGS. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Pediatric patients undergoing posterior spinal fusion (PSF) for treatment of HGS. OUTCOME MEASURES: Data on patient demographics, spinopelvic and spondylolisthesis parameters, and the presence of pre-and postoperative neurological deficits were collected. METHODS: Intraoperative MEP, SSEP, and EMG alerts were recorded. Alert criteria were defined as a change in amplitude of more than 50% for MEP and/or SSEP, with or without change in latency, and more than 10 seconds of sustained EMG activity. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each modality and the combination of MEP and SSEP. The 95% confidence intervals (CIs) were calculated using the exact (Clopper-Pearson) method. RESULTS: Fifty-four pediatric patients with HGS undergoing PSF between 2003 and 2021 in a single tertiary center were included. Seventy-two percent (39/54) of patients were female; the average age of patients was 13.7±2.3 years. The sensitivity of MEP in detecting new postoperative neurologic deficit was 92.3% (95% CI [64.0-99.8]), SSEP 77.8% (95% CI [40.0-97.2]), EMG 69.2% (95% CI [38.6-90.9]), and combination MEP and SSEP 100% (95% CI [73.5-100]). The specificity of MEP was 80.0% (95% CI [64.4-91.0]), SSEP 95.1% (95% CI [83.5-99.4]), EMG 65.9% (95% CI [49.4-79.9]), and combination MEP and SSEP 82.9% (95% CI [67.9-92.9]). The accuracy of SSEP was 92.0% (95% CI [80.8%-97.8%]), and the combination of MEP and SSEP was 86.8% (95% CI [74.7%-94.5%]). Twelve (22.2%) patients had a new motor or sensory deficit diagnosed immediately postoperatively. Nine patients made a full recovery, and 3 had some neurologic deficit on final follow-up. CONCLUSION: Unimodal IONM using SSEP and MEP alone were accurate in diagnosing sensory and motor nerve root injuries, respectively. The diagnostic accuracy in predicting motor and sensory nerve injuries in pediatric HGS improved further with the use of multimodal IONM (combining MEP and SEP). We recommend the utilization of multimodal IONM in all HGS PSF surgeries.

Remote cardioprotection by direct peripheral nerve stimulation and topical capsaicin is mediated by circulating humoral factors.

We have previously shown that remote ischemic preconditioning by limb ischemia (rIPC) or intra-arterial adenosine releases a dialyzable cardioprotective circulating factor(s), the release of which requires an intact neural connection to the limb and is blocked by pretreatment with S-nitroso-N-acetylpenicillamine (SNAP). Remote cardioprotection can be induced by other forms of peripheral stimulation including topical capsaicin, but the mechanisms of their signal transduction are incompletely understood. Rabbits were anesthetized by intravenous pentobarbital, intubated and ventilated, then randomized (4-7 animals in each group) to receive sham procedure, rIPC (4 cycles of 5 min lower limb ischemia, 5 min reperfusion), direct femoral nerve stimulation, topical capsaicin, pretreatment with intra-arterial SNAP + capsaicin, pretreatment with topical DMSO (a sensory nerve blocker) + topical capsaicin, or pretreatment with intra-arterial SNAP + femoral nerve stimulation, topical DMSO alone, or intra-arterial SNAP alone. Blood was then rapidly drawn from the carotid artery to produce the plasma dialysate which was used to perfuse a naïve heart from an untreated donor rabbit. The infarct size and recovery of LV-developed pressure and end-diastolic pressure were measured after 30 min of global ischemia and 120 min of reperfusion. Compared to sham, dialysate from rIPC, femoral nerve stimulation, and topical capsaicin groups all produced significant cardioprotection with significantly reduced infarct size, and improved the post-ischemic cardiac performance. Cardioprotection was not seen in the topical DMSO-capsaicin, SNAP + capsaicin, and SNAP + FNS groups. These results confirm the central role of peripheral nerves in the local signal transduction of remote cardioprotection. Direct electrical or peripheral neural stimulation evokes the release of cardioprotective substances into the bloodstream, with comparable effects to that of rIPC induced by limb ischemia.

Supplementing Extraoperative Electrocorticography With Real-Time Intraoperative Recordings Using the Same Chronically Implanted Electrodes.

BACKGROUND: The practice of intraoperative electrocorticography (iECoG) to guide resective epilepsy surgery is variable. Limitations of iECoG include variability in recordings from previously unsampled cortex, increased operative time and cost, and a lack of clear benefit to surgical decision-making. OBJECTIVE: To describe a simple technique to supplement extraoperative intracranial recordings with real-time iECoG using the same chronically implanted electrodes that overcome some of these limitations. METHODS: We describe the technical procedure, intraoperative findings, and outcomes of 7 consecutive children undergoing 2-stage resective epilepsy surgery with invasive subdural grid monitoring between January 2017 and December 2019. All children underwent placement of subdural grids, strips, and depth electrodes. Planned neocortical resection was based on extraoperative mapping of ictal and interictal recordings. During resection in the second stage, the same electrodes were used to perform real-time iECoG. RESULTS: Real-time iECoG using this technique leads to modification of resection for 2 of the 7 children. The first was extended due to an electroencephalographic seizure from a distant electrode not part of the original resection plan. The second was restricted due to attenuation of epileptiform activity following a partial resection, thereby limiting the extent of a Rolandic resection. No infections or other adverse events were encountered. CONCLUSION: We report a simple technique to leverage chronically implanted electrodes for real-time iECoG during 2-stage resective surgery. This technique presents fewer limitations than traditional approaches and may alter intraoperative decision-making.

Brainstem Associated Somatosensory Evoked Potentials and Response to Vagus Nerve Stimulation: An Investigation of the Vagus Afferent Network.

Despite decades of clinical usage, selection of patients with drug resistant epilepsy who are most likely to benefit from vagus nerve stimulation (VNS) remains a challenge. The mechanism of action of VNS is dependent upon afferent brainstem circuitry, which comprises a critical component of the Vagus Afferent Network (VagAN). To evaluate the association between brainstem afferent circuitry and seizure response, we retrospectively collected intraoperative data from sub-cortical recordings of somatosensory evoked potentials (SSEP) in 7 children with focal drug resistant epilepsy who had failed epilepsy surgery and subsequently underwent VNS. Using multivariate linear regression, we demonstrate a robust negative association between SSEP amplitude (p < 0.01), and seizure reduction. There was no association between SSEP latency and seizure outcomes. Our findings provide novel insights into the mechanism of VNS and inform our understanding of the importance of brainstem afferent circuitry within the VagAN for seizure responsiveness following VNS.

Stimulation threshold potentials of intraoperative cortical motor mapping using monopolar trains of five in pediatric epilepsy surgery.

OBJECTIVE: Direct cortical stimulation in commonly used for the accurate localization of the motor cortex but the electrical threshold stimulation parameters with this technique had not been fully established. PATIENTS AND METHODS: A retrospective review of 15 cases of pediatric surgical cases were performed. The patients consisted of nine male patients and six female patients with age range from 2 to 18 years (mean: 10.8 years; median: 14 years). The most common pathology was cortical dysplasia (nine cases). Stimulation was performed with a train of five stimulations (range five-seven stimulations; <5% of stimulations required more than five stimulations) applied, each train of 50 micros pulse duration, with an interstimulus interval of 1.1 msec. Stimulation intensity commenced at 25 V and this was increased at 5-10 V increments until motor evoked potentials waveforms of sufficient duration and morphology were consistently generated. RESULTS: Monopolar electrical stimulation threshold for intraoperative motor cortical mapping were found to be more consistent in the upper limb compared to lower limb and facial muscles. Evoked responses from the extensor digitorium communis had the highest recorded rate (83.7%) and required the lowest stimulation voltage (36.0 V). The stimulation voltage was found to be statistically significant compared to threshold values for abductor hallucis, tibialis anterior, deltoid, and orbicularis oris with respective p values of 0.006, 0.021, 0,027, and 0.015. There was also a distinct trend that patients with cortical dysplasia/tuberous sclerosis have higher stimulation thresholds when compared to other pathology (p = 0.067). CONCLUSION: Monopolar electrical stimulation threshold for intraoperative motor cortical mapping were more consistent in the upper limb compared to lower limb and facial muscles. Evoked responses from the extensor digitorium communis had the highest recorded rate and required the lowest stimulation voltage. There was also a distinct trend that patients with cortical dysplasia/tuberous sclerosis have higher stimulation thresholds.

Intraoperative neurophysiological monitoring during complex spinal deformity cases in pediatric patients: methodology, utility, prognostication, and outcome.

INTRODUCTION: Complex spinal deformity (CSD) problems in pediatric patients result from a wide variety of congenital, acquired, neoplastic, or traumatic abnormalities that result in a combination of spinal deformity and spinal cord impingement. While these problems are rare, decompression, correction, instrumentation, and fusion are quite hazardous. Intraoperative neurophysiological monitoring (IONM) seems particularly beneficial in these patients. METHODOLOGY: Somatosensory evoked potentials, transcranial electrical motor evoked potentials (MEPs), direct waves, and electromyography were used in a variety of CSD cases over a period when IONM was routine for most spinal cases. Examples of cases in which IONM provided important intraoperative information and significantly affected the course of the operation are illustrated. RESULTS: IONM is a useful tool particularly in CSD cases in pediatric patients but requires special expertise and anesthetic considerations. Loss of MEP appears to have particularly important adverse prognostic information. Conversely, maintenance of IONM provides significant reassurance that the spinal cord function is being maintained. Preserved but persistently diminished MEPs usually predict a neurological injury that will significantly improve and possibly completely recover. Issues concerning training, certification, oversight, standardization of equipment, and technique are partially but incompletely resolved. DISCUSSION: IONM is an extremely valuable tool for management of CSD pediatric patients. The utility of IONM is such and the detection of unexpected or unanticipated neurological injury frequent enough that a strong argument that it be used in every spinal surgery case can be made.

Selective dorsal rhizotomy: an illustrated review of operative techniques.

OBJECTIVE: Selective dorsal rhizotomy (SDR) is a procedure primarily performed to improve function in a subset of children with limitations related to spasticity. There is substantial variability in operative techniques among centers and surgeons. Here, the authors provide a technical review of operative approaches for SDR. METHODS: Ovid MEDLINE, Embase, and PubMed databases were queried in accordance with PRISMA guidelines. All studies included described a novel surgical technique. The technical nuances of each approach were extracted, including extent of exposure, bone removal, and selection of appropriate nerve roots. The operative approach preferred at the authors' institution (the "2 × 3 exposure") is also detailed. RESULTS: Five full-text papers were identified from a total of 380 articles. Operative approaches to SDR varied significantly with regard to level of exposure, extent of laminectomy, and identification of nerve roots. The largest exposure involved a multilevel laminectomy, while the smallest exposure involved a keyhole interlaminar approach. At the Hospital for Sick Children, the authors utilize a two-level laminoplasty at the level of the conus medullaris. The benefits and disadvantages of the spectrum of techniques are discussed, and illustrative figures are provided. CONCLUSIONS: Surgical approaches to SDR vary considerably and are detailed and illustrated in this review as a guide for neurosurgeons. Future studies should address the long-term impact of these techniques on functional outcomes and complications such as spinal deformity.

Patient with postcentral gyrectomy demonstrates reliable localization of hand motor area using magnetoencephalography.

Magnetoencephalography (MEG) data analyzed with novel spatial filtering methods, namely event-related beamforming (ERB), have shown success in localizing hand motor areas in healthy adults and in a group of pediatric patients with peri-Rolandic tumors. The validity of this method to localize the primary motor field in a pediatric tumor case was confirmed by intraoperative direct cortical stimulation. Currently, the reliability of this method has not been demonstrated. We report on a 16-year-old boy with localization-related epilepsy originating from his right hemisphere sensory cortex. Hand motor and sensory areas were identified preoperatively by ERB analysis of MEG data. The patient underwent invasive monitoring which localized the epileptic focus to right postcentral gyrus, immediately posterior to the MEG motor area and adjacent to the MEG sensory area. The patient received a gyrectomy of sensory cortex guided by intraoperative direct cortical stimulation to ensure sparing of hand motor cortex. Replication of the MEG motor mapping protocol postoperatively demonstrated reliable localization of the motor and sensory areas. We also discuss caveats for future applications of this protocol.

Responding to Intraoperative Neuromonitoring Changes During Pediatric Coronal Spinal Deformity Surgery.

STUDY DESIGN: Retrospective case study on prospectively collected data. OBJECTIVES: The purpose of this explorative study was: 1) to determine if patterns of spinal cord injury could be detected through intra-operative neuromonitoring (IONM) changes in pediatric patients undergoing spinal deformity corrections, 2) to identify if perfusion based or direct trauma causes of IONM changes could be distinguished, 3) to observe the effects of the interventions performed in response to these events, and 4) to attempt to identify different treatment algorithms for the different causes of IONM alerts. METHODS: Prospectively collected neuromonitoring data in pre-established forms on consecutive pediatric patients undergoing coronal spinal deformity surgery at a single center was reviewed. Real-time data was collected on IONM alerts with >50% loss in signal. Patients with alerts were divided into 2 groups: unilateral changes (direct cord trauma), and bilateral MEP changes (cord perfusion deficits). RESULTS: A total of 97 pediatric patients involving 71 females and 26 males with a mean age of 14.9 (11-18) years were included in this study. There were 39 alerts in 27 patients (27.8% overall incidence). All bilateral changes responded to a combination of transfusion, increasing blood pressure, and rod removal. Unilateral changes as a result of direct trauma, mainly during laminotomies for osteotomies, improved with removal of the causative agent. Following corrective actions in response to the alerts, all cases were completed as planned. Signal returned to near baseline in 20/27 patients at closure, with no new neurological deficits in this series. CONCLUSION: A high incidence of alerts occurred in this series of cases. Dividing IONM changes into perfusion-based vs direct trauma directed treatment to the offending cause, allowing for safe corrections of the deformities. Patients did not need to recover IONM signal to baseline to have a normal neurological examination.

Intraoperative confirmation of hand motor area identified preoperatively by magnetoencephalography.

BACKGROUND: Presurgical functional mapping using magnetoencephalography (MEG) has been performed for somatosensory, auditory and visual functions; however, the traditional analysis method utilizing dipole source analysis has some inherent limitations when applied to the mapping of cortical motor areas. Recently, a novel source reconstruction algorithm [event-related synthetic aperture magnetometry (erSAM)] has demonstrated success for the localization of motor function in healthy adults. We applied this technique to preoperatively map motor function in a young patient. We then confirmed our mapping with direct cortical stimulation intraoperatively. METHODS: This is a case report of an 8-year-old girl with right hand and arm weakness and poor right hand motor control secondary to a left peri-rolandic tumor. Preoperatively, whole-head MEG was recorded while the patient performed a self-paced button pressing task. Cortical activity associated with the onset of movement was localized to the right hand precentral gyrus superior and medial to the tumor using erSAM, while sensory function was localized posterior to the tumor on the postcentral gyrus. RESULTS: Intraoperative direct cortical stimulation of the motor area identified by MEG resulted in electromyographic activation of intrinsic muscles of the contralateral hand exclusively. CONCLUSIONS: This is the first report of a case where direct cortical stimulation has confirmed a motor cortical location identified by the erSAM method.

Intra-operative cortical motor mapping using subdural grid electrodes in children undergoing epilepsy surgery evaluation and comparison with the conventional extra-operative motor mapping.

OBJECTIVES: The objective of this study was to review our experience with intra-operative "train of five" stimulation using subdural grid for motor mapping in children undergoing epilepsy surgery evaluation. METHODS: Twenty consecutive children below 18-years of age with drug-refractory epilepsy who underwent invasive-EEG monitoring using subdural-grid placement and intra-operative motor mapping using direct cortical stimulation by sub-dural grid electrodes (IODCS-SDG) at our institution between January-2016 and June-2017 were reviewed. Stimulation was delivered through the subdural-grid electrodes using a train-of-five pulses and muscle responses were recorded by motor-evoked-potentials (MEPs). Intra-operative direct cortical stimulation delivered through a ball-tipped probe (IODCS-probe) and extra-operative motor-mapping (EODCS-SDG) were also performed. RESULTS: IODCS-SDG was completed in 20 patients and subsequent EODCS-SDG was done in 17/20 patients. MEP responses were more commonly obtained in the deltoid (19/20), extensor-digitorum-communis (20/20) and first-dorsal-interosseus (19/20). The median thresholds varied between 40 V and 60 V for the six muscle groups. The respective IODCS-probe thresholds tended to be similar. No stimulation-provoked seizures or anaesthesia-related complications were noted during IODCS-SDG. EODCS-SDG could not be completed in 4/17 children and mapping data obtained was frequently inadequate. Nine patients demonstrated 100% concordance between IODCS-SDG and EODCS-SDG for the common mapped body regions. Stimulation-provoked seizures during EODCS-SDG were seen in 6/17 (35.3%) and after-discharges in 7/17 (41.2%) children. CONCLUSIONS: IODCS-SDG could be performed safely in children with drug refractory epilepsy undergoing invasive EEG monitoring. SIGNIFICANCE: IODCS-SDG may be a useful adjunct to EODCS-SDG in motor mapping for children.