[Intraoperative neuromonitoring in surgery of cervical neurogenic tumors].

Objective: To investigate the application value of intraoperative motor nerve monitoring in cervical neurogenic tumor surgery. Methods: The efficacy of intraoperative neuromonitoring (IONM) was analyzed retrospectively in 18 patients, including 6 males and 12 females, aged from 15 to 74 years, treated in Affiliated Drum Tower Hospital, Medical School of Nanjing University from June 2019 to September 2022 who underwent total cystectomy of cervical neurogenic tumors under intraoperative nerve monitoring. Results: All 18 patients had complete tumor removal, including 8 patients with tumors from the vagus nerve and 10 patients with tumors from the brachial plexus nerve. Postoperative nerve functions were normal in patients with tumors from brachial plexus nerve, and incomplete vocal cord paralysis occurred in 2 patients with tumors from vagus vagus nerve. The total incidence of motor nerve injury was 11.1% (2/18). All patients were followed up for 6 to 45 months, with no tumor recurrence. Conclusion: Intraoperative neuromonitoring has significant values in surgery of cervical neurogenic tumors, which is helpful to remove completely the tumors on the basis of protecting the nerve functions to the maximum extent.

Prevention of esophageal lesions during atrial fibrillation catheter ablation using esophageal temperature monitoring: A systematic review and meta-analysis.

INTRODUCTION: The use of esophageal temperature monitoring (ETM) for the prevention of esophageal injury during atrial fibrillation (AF) ablation is often advocated. However, evidence supporting its use is scarce and controversial. We therefore aimed to review the evidence assessing the efficacy of ETM for the prevention of esophageal injury. METHODS: We performed a meta-analysis and systematic review of the available literature from inception to December 31, 2022. All studies comparing the use of ETM, versus no ETM, during radiofrequency (RF) AF ablation and which reported the incidence of endoscopically detected esophageal lesions (EDELs) were included. RESULTS: Eleven studies with a total of 1112 patients undergoing RF AF ablation were identified. Of those patients, 627 were assigned to ETM (56%). The overall incidence of EDELs was 9.8%. The use of ETM during AF ablation was associated with a non significant increase in the incidence of EDELs (12.3% with ETM, vs. 6.6 % without ETM, odds ratio, 1.44, 95%CI, 0.49, 4.22, p = .51, I2 = 72%). The use of ETM was associated with a significant increase in the energy delivered specifically on the posterior wall compared to patients without ETM (mean power difference: 5.13 Watts, 95% CI, 1.52, 8.74, p = .005). CONCLUSIONS: The use of ETM does not reduce the incidence of EDELs during RF AF ablation. The higher energy delivered on the posterior wall is likely attributable to a false sense of safety that may explain the lack of benefit of ETM. Further randomized controlled trials are needed to provide conclusive results.

A novel method of neurophysiological brainstem mapping in neurosurgery.

BACKGROUND: Brainstem mapping with electrical stimulation allows functional identification of neural structures during resection of deep lesions. Single pulses or train of pulses are delivered to map cranial nerves and corticospinal tracts, respectively. NEW METHOD: We introduce a hybrid stimulation technique for mapping the brainstem. The stimulus consists of an electrical single pulse followed by a short train of 3-5 pulses at 500 Hz, at an interval of 60-75 ms. The responses to this stimulation pattern are recorded from appropriate cranial and limb muscles. RESULTS: Both the single pulse and the short train elicit electromyographic responses when motor fibers or motor nuclei of the cranial nerves are stimulated. Responses to the train but not to the preceding single pulse indicate activation of the descending motor tracts, in the mesencephalon and the pons. Conversely, in the medulla, limb responses to stimulation of the corticospinal tracts are elicited by a single pulse. Identification of the extra and intra-axial courses of the trigeminal motor and sensory fibers is possible by recording responses from the masseter and the tongue muscles. COMPARISON WITH EXISTING METHOD(S): To date, either a pulse or a train is delivered during brainstem mapping, switching from one to the other modality according to the expected target structure. This procedure can be time-consuming and may even lead to false negative responses to the stimulation, eventually leading to inaccurate neurosurgical procedures. CONCLUSIONS: The novel hybrid pulse-train technique enhances the advantage of brainstem mapping procedure, minimizing pitfalls and improving patient safety.

Key points for protecting the external branch of the superior laryngeal nerve in open thyroidectomy: A possible exploration technique.

OBJECTIVE: Injury of the external branch of the superior laryngeal nerve (EBSLN) is easily overlooked in thyroidectomy, and voice changes caused by the injury have a negative effect on an increasing number of patients. This study aimed to reduce the injury rate of EBSLN by expanding the sternothyroid-laryngeal triangle and standardizing the exploration procedure. METHODS: A total of 520 patients who had undergone thyroidectomy at the First Affiliated Hospital of Nanchang University between September 2021 and April 2022 were analyzed. During the operation, the exposure rate of the EBSLN before and after sternothyroid-laryngeal triangle expansion was compared, and all EBSLNs were anatomically classified. RESULTS: The exposure rate of EBSLN after sternothyroid-laryngeal triangle expansion reached 82.7%, which is much higher than that before sternothyroid-laryngeal triangle expansion (33.7%), and voice change caused by injury of the EBSLN was reported in one case (the injury rate was 0.2%). The classification and proportion of the EBSLN were as follows: Type 1 (55.3%), the nerve ran within 1 cm above the STP, but no coincidence or crossover with blood vessels was observed in this region; Type 2 (14.7%), the nerve travelled within 1 cm above the STP and overlapped or intersected with blood vessels in this region; Type 3 (12.7%), the EBSLN ran below the level of the STP; and Type 4 (17.3%), no EBSLN was observed within 1 cm above the STP. CONCLUSION: In thyroidectomy, injury to the EBSLN can be effectively reduced by expanding the sternothyroid-laryngeal triangle and exploring the upper pole area of the thyroid as far as possible, which has great clinical significance in reducing postoperative voice box injury.

Effect of hyperbilirubinemia on the accuracy of continuous non-invasive hemoglobin measurements in liver transplantation recipients.

This study evaluated the effect of hyperbilirubinemia on the accuracy of continuous non-invasive hemoglobin (SpHb) measurements in liver transplantation recipients. Overall, 1465 SpHb and laboratory hemoglobin (Hb) measurement pairs (n = 296 patients) were analyzed. Patients were grouped into normal (< 1.2 mg/dL), mild-to-moderate (1.2-3.0 mg/dL), and severe (> 3.0 mg/dL) hyperbilirubinemia groups based on the preoperative serum total bilirubin levels. Bland-Altman analysis showed a bias of 0.20 (95% limit of agreement, LoA: - 2.59 to 3.00) g/dL, 0.98 (95% LoA: - 1.38 to 3.35) g/dL, and 1.23 (95% LoA: - 1.16 to 3.63) g/dL for the normal, mild-to-moderate, and severe groups, respectively. The four-quadrant plot showed reliable trending ability in all groups (concordance rate > 92%). The rates of possible missed transfusion (SpHb > 7.0 g/dL for Hb < 7.0 g/dL) were higher in the hyperbilirubinemia groups (2%, 7%, and 12% for the normal, mild-to-moderate, and severe group, respectively. all P < 0.001). The possible over-transfusion rate was less than 1% in all groups. In conclusion, the use of SpHb in liver transplantation recipients with preoperative hyperbilirubinemia requires caution due to the positive bias and high risk of missed transfusion. However, the reliable trending ability indicated its potential use in clinical settings.

The weepy cry - short neural signal bursts in intraoperative neuromonitoring.

PURPOSE: This study aimed to establish an in-vitro alternative to existing in-vivo systems to analyze nerve dysfunction using continuous neuromonitoring (C-IONM). METHODS: Three hundred sixty-three recurrent laryngeal nerves (RLN) (N(pigs) = 304, N(cattle) = 59) from food industry cadavers were exposed by microsurgical dissection following euthanasia. After rinsing with Ringer's lactate, they were tempered at 22 °C. Signal evaluation using C-IONM was performed for 10 min at 2 min intervals, and traction forces of up to 2N were applied for a median time of 60 s. Based on their post-traumatic electrophysiological response, RLNs were classified into four groups: Group A: Amplitude ≥ 100%, Group B: loss of function (LOS) 0-25%, Group C: ≥ 25-50%, and Group D: > 50%. RESULTS: A viable in-vitro neuromonitoring system was established. The median post-traumatic amplitudes were 112%, 88%, 59%, and 9% in groups A, B, C, and D, respectively. A time-dependent further dynamic LOS was observed during the 10 min after cessation of strain. Surprisingly, following initial post-traumatic hyperconductivity, complete LOS occurred in up to 20% of the nerves in group A. The critical threshold for triggering LOS was 2N in all four groups, resulting in immediate paralysis of up to 51.4% of the nerves studied. CONCLUSION: Consistent with in-vivo studies, RLN exhibit significant intrinsic electrophysiological variability in response to tensile forces. Moreover, nerve damage progresses even after the complete cessation of strain. Up to 20% of nerves with transiently increased post-traumatic amplitudes above 100% developed complete LOS, which we termed the "weepy cry." This time-delayed response must be considered during the interpretation of C-IONM signals.

Extravascular injection of neuromuscular blocking drugs: A systematic review of current evidence and management.

Extravascular injection of neuromuscular blocking drugs (NMBDs) can cause a neuromuscular block because of systemic absorption. Currently, there are no guidelines available on managing extravasation of NMBDs. This article reviews the available literature on extravasation of NMBDs. Medline and Embase databases were searched for studies concerning the paravenous or subcutaneous injection of NMBDs. Nine articles were included consisting of seven case reports, one case series and one clinical trial. Rocuronium was used as primary NMBD in nine cases, vecuronium in two cases and pancuronium in one case. Although there exists significant heterogeneity between the reported information in the included studies, the majority of the case reports describe a slower onset, with a median delay of 20 min and prolonged duration of the neuromuscular block. Nine patients had a residual neuromuscular block at the end of the surgery. Postoperative monitoring in the recovery room was prolonged (median time 4 h). Most studies suggest that the delay in NMBD onset and recovery is caused by the formation of a subcutaneous depot, from which the NMBD is slowly absorbed into the systemic circulation. According to the current literature, extravasation of NMBDs results in an unpredictable neuromuscular block. Strategies to prevent potentially harmful side effects, such as frequent train-of-four (TOF) monitoring, the use of NMBD reversal agents and prolonged length of stay in the postanaesthesia care unit (PACU), should be considered. This article suggests a clinical pathway that can be used after extravascular injection of NMBDs.

[Surgical treatment of brain tumors adjacent to corticospinal tract in children]. / Aktual'nye voprosy khirurgicheskogo lecheniya opukholei golovnogo mozga, prilegayushchikh k kortikospinal'nomu traktu u detei.

An urgent problem in modern neurosurgery is resection of brain tumors adjacent to corticospinal tract (CST) due to high risk of its damage and subsequent disability. The main methods for prevention of intraoperative damage to CST are preoperative MR tractography and intraoperative electrophysiological monitoring. Both methods are used in pediatric neurosurgery. We reviewed the PubMed database since 2000 using the following keywords: «tumors of the hemispheres in children¼, «corticospinal tract¼, «MR tractography¼, «intraoperative electrophysiological monitoring¼. We present available literature data on preoperative MR tractography and intraoperative electrophysiological monitoring in children with supratentorial tumors near CST. Algorithm of intraoperative electrophysiological monitoring is often missing or insufficiently described. MR tractography is usually presented in case reports. Researchers do not compare the effectiveness of MR tractography and intraoperative electrophysiological monitoring. In case of MR tractography, a limitation is impossible CST reconstruction in children 2-3 years old. This may be due to unformed pyramidal system in these children. CONCLUSION: Preoperative MR tractography and intraoperative electrophysiological monitoring are valid methods for assessment of CST. Optimal research parameters in children require careful study that will allow objective planning of each stage of preoperative management and increase resection quality for gliomas near CST in children without neurological deterioration.

The Edwards Acumen IQ system using peripheral arterial catheter-based waveforms to estimate cardiac output is not accurate as compared to thermodilution in dogs.

OBJECTIVE: To assess the agreement between cardiac output (CO) estimated via evaluation of the arterial pressure waveform by a novel monitoring system (Edwards Acumen IQ sensor and HemoSphere Advanced Monitor Platform [HS-IQ]; Edwards LifeSciences) and measured by thermodilution (TD) in anesthetized, normovolemic, and hypovolemic dogs. To assess the agreement between the HS-IQ CO measurements in the radial artery and dorsal metatarsal artery. ANIMALS: 8 purpose-bred Beagles. METHODS: Dogs were placed under general anesthesia. CO was measured via TD and via the HS-IQ at radial and dorsal metatarsal arterial catheters. CO measurements were obtained at 4 time points including normovolemic and multiple hypovolemic states. Paired measurements of CO were evaluated via the method of Bland and Altman with acceptable limits of agreement (LOA) defined as < 30%. RESULTS: A total of 24 (dorsal metatarsal) and 21 (radial) paired measurements were collected in 8 dogs. The overall bias (CI) for comparison of TD to radial arterial HS-IQ CO measurements was -0.09 L/min. LOA and proportional LOA were -2.66 to 2.49 L/min and -140.72% to 104.94%. The overall bias (CI) for comparison of TD to dorsal metatarsal arterial HS-IQ CO measurements was -0.26 L/min. LOA and proportional LOA were -2.76 to 2.24 L/min and -135.96% to 93.25%. The overall proportional error for radial arterial was -17.9% and for dorsal metatarsal was -21.4%. CLINICAL RELEVANCE: CO measurements with the HS-IQ were easy to obtain but did not produce results within a clinically acceptable range for either measurement site, with a very wide LOA. The CO estimations from the HS-IQ are not appropriate for clinical use at this time.

[A sampling survey of intraoperative facial nerve monitoring in China].

Objective: This study aims to investigate the current application and the level of knowledge of intraoperative facial nerve monitoring among medical staff in China. Methods: A comprehensive online questionnaire was conducted among medical professionals across different regions in China from October 2022 to February 2023. The survey exclusively targeted departments specializing in otolaryngology, head and neck surgery, neurosurgery, and oral and maxillofacial surgery. The questionnaire covered various aspects including general information, intraoperative facial nerve monitoring practices, training history, indications for monitoring, parameters used during monitoring procedures, as well as factors influencing its implementation. Results: A total of 417 participants from 31 provincial, municipal, and autonomous regions were included. Intraoperative facial nerve monitoring was found to be implemented in 227 (54.4%,227/417) repondents of 53 institutions (24.9%, 53/213). The top three indications for implementing this technique were acoustic neuroma, parotid gland surgery, and modified middle ear surgery (mastoidectomy). Herein 81.1%(184/227) medical staff involved in intraoperative facial nerve monitoring had received relevant training, 57.3%(130/227)-92.1%(209/227) reported a lack of clear description regarding recording thresholds, stimulation currents/frequencies/wave widths. Conclusion: The majority of the institutions surveyed have not yet adopted intraoperative facial nerve monitoring. Furthermore, significant gaps concerning the procedure exist. It is imperative to establish standards or guidelines to promote its better development and application.

Consistency analysis of consciousness index and bispectral index in monitoring the depth of sevoflurane anesthesia in laparoscopic surgery.

Background: The Index of Consciousness (IoC) is a new monitoring index of anesthesia depth reflecting the state of consciousness of the brain independently developed by China. The research on monitoring the depth of anesthesia mainly focuses on propofol, and bispectral index (BIS) is a sensitive and accurate objective index to evaluate the state of consciousness at home and abroad. This study mainly analyzed the effect of IoC on monitoring the depth of sevoflurane anesthesia and the consistency and accuracy with BIS when monitoring sevoflurane maintenance anesthesia. Objective: To investigate the monitoring value of the Index of Consciousness (IoC) for the depth of sevoflurane anesthesia in laparoscopic surgery. Methods: The study population consisted of 108 patients who experienced elective whole-body anesthesia procedures within the timeframe of April 2020 to June 2023 at our hospital. Throughout the anesthesia process, which encompassed induction and maintenance using inhaled sevoflurane, all patients were diligently monitored for both the Bispectral Index (BIS) and the Index of Consciousness (IoC). We conducted an analysis to assess the correlation between IoC and BIS throughout the anesthesia induction process and from the maintenance phase to the regaining of consciousness. To evaluate the predictive accuracy of IoC and BIS for the onset of unconsciousness during induction and the return of consciousness during emergence, we employed receiver operating characteristic (ROC) curve analysis. Results: The mean difference between BIS and IoC, spanning from the pre-anesthesia induction phase to the completion of propofol induction, was 1.3 (95% Limits of Agreement [-53.4 to 56.0]). Similarly, during the interval from the initiation of sevoflurane inhalation to the point of consciousness restoration, the average difference between BIS and IoC was 0.3 (95% LOA [-10.8 to 11.4]). No statistically significant disparities were observed in the data acquired from the two measurement methodologies during both the anesthesia induction process and the journey from maintenance to the regaining of consciousness (P > 0.05). The outcomes of the ROC curve analysis disclosed that the areas under the curve (AUC) for prognosticating the occurrence of loss of consciousness were 0.967 (95% CI [0.935-0.999]) for BIS and 0.959 (95% CI [0.924-0.993]) for IoC, with optimal threshold values set at 81 (sensitivity: 88.10%, specificity: 92.16%) and 77 (sensitivity: 79.55%, specificity: 95.45%) correspondingly. For the prediction of recovery of consciousness, the AUCs were 0.995 (95% CI [0.987-1.000]) for BIS and 0.963 (95% CI [0.916-1.000]) for IoC, each associated with optimal cutoff values of 76 (sensitivity: 92.86%, specificity: 100.00%) and 72 (sensitivity: 86.36%, specificity: 100.00%) respectively. Conclusion: The monitoring of sevoflurane anesthesia maintenance using IoC demonstrates a level of comparability to BIS, and its alignment with BIS during the maintenance phase of sevoflurane anesthesia is robust. IoC displays promising potential for effectively monitoring the depth of anesthesia.

In-House Intraoperative Monitoring in Neurosurgery in England - Benefits and Challenges.

BACKGROUND: Intraoperative neurophysiological monitoring (IOM) is a valuable adjunct for neurosurgical operative techniques, and has been shown to improve clinical outcomes in cranial and spinal surgery. It is not necessarily provided by NHS hospitals so may be outsourced to private companies, which are expensive and at cost to the NHS trusts. We discuss the benefits and challenges of developing an in-house service. METHODS: We surveyed NHS neurosurgical departments across England regarding their expenditure on IOM over the period January 2018 - December 2022 on cranial neurosurgery and spinal surgery. Out of 24 units, all responded to our Freedom of Information requests and 21 provided data. The standard NHS England salary of NHS staff who would normally be involved in IOM, including physiologists and doctors, was also compiled for comparison. RESULTS: The total spend on outsourced IOM, across the units who responded, was over £8 million in total for the four years. The annual total increased, between 2018 and 2022, from £1.1 to £3.5 million. The highest single unit yearly spend was £568,462. This is in addition to salaries for staff in neurophysiology departments. The mean NHS salaries for staff is also presented. CONCLUSION: IOM is valuable in surgical decision-making, planning, and technique, having been shown to lead to fewer patient complications and shorter length of stay. Current demand for IOM outstrips the internal NHS provision in many trusts across England, leading to outsourcing to private companies. This is at significant cost to the NHS. Although there is a learning curve, there are many benefits to in-house provision, such as stable working relationships, consistent methods, training of the future IOM workforce, and reduced long-term costs, which planned expansion of NHS services may provide.

Intraoperative EEG-based monitors: are we looking under the lamppost?

PURPOSE OF REVIEW: While electroencephalogram (EEG)-based depth of anesthesia monitors have been in use clinically for decades, there is still a major debate concerning their efficacy for detecting awareness under anesthesia (AUA). Further utilization of these monitors has also been discussed vividly, for example, reduction of postoperative delirium (POD).It seems that with regard to reducing AUA and POD, these monitors might be applicable, under specific anesthetic protocols. But in other settings, such monitoring might be less contributive and may have a 'built-it glass ceiling'.Recent advances in other venues of electrophysiological monitoring might have a strong theoretical rationale, and early supporting results, to offer a breakthrough out of this metaphorical glass ceiling. The purpose of this review is to present this possibility. RECENT FINDINGS: Following previous findings, it might be concluded that for some anesthesia protocols, the prevailing depth of anesthesia monitors may prevent incidences of AUA and POD. However, in other settings, which may involve other anesthesia protocols, or specifically for POD - other perioperative causes, they may not. Attention-related processes measured by easy-to-use real-time electrophysiological markers are becoming feasible, also under anesthesia, and might be applicable for more comprehensive prevention of AUA, POD and possibly other perioperative complications. SUMMARY: Attention-related monitoring might have a strong theoretical basis for the prevention of AUA, POD, and potentially other distressing postoperative outcomes, such as stroke and postoperative neurocognitive disorder. There seems to be already some initial supporting evidence in this regard.

"Non-Eloquent" brain regions predict neuropsychological outcome in tumor patients undergoing awake craniotomy.

Supratotal resection of primary brain tumors is being advocated especially when involving "non-eloquent" tissue. However, there is extensive neuropsychological data implicating functions critical to higher cognition in areas considered "non-eloquent" by most surgeons. The goal of the study was to determine pre-surgical brain regions that would be predictive of cognitive outcome at 4-6 months post-surgery. Cortical reconstruction and volumetric segmentation were performed with the FreeSurfer-v6.0 image analysis suite. Linear regression models were used to regress cortical volumes from both hemispheres, against the total cognitive z-score to determine the relationship between brain structure and broad cognitive functioning while controlling for age, sex, and total segmented brain volume. We identified 62 consecutive patients who underwent planned awake resections of primary (n = 55, 88%) and metastatic at the University of New Mexico Hospital between 2015 and 2019. Of those, 42 (23 males, 25 left hemispheric lesions) had complete pre and post-op neuropsychological data available and were included in this study. Overall, total neuropsychological functioning was somewhat worse (p = 0.09) at post-operative neuropsychological outcome (Mean = -.20) than at baseline (Mean = .00). Patients with radiation following resection (n = 32) performed marginally worse (p = .036). We found that several discrete brain volumes obtained pre-surgery predicted neuropsychological outcome post-resection. For the total sample, these volumes included: left fusiform, right lateral orbital frontal, right post central, and right paracentral regions. Regardless of lesion lateralization, volumes within the right frontal lobe, and specifically right orbitofrontal cortex, predicted neuropsychological difference scores. The current study highlights the gaps in our current understanding of brain eloquence. We hypothesize that the volume of tissue within the right lateral orbital frontal lobe represents important cognitive reserve capacity in patients undergoing tumor surgery. Our data also cautions the neurosurgeon when considering supratotal resections of tumors that do not extend into areas considered "non-eloquent" by current standards.

Depth of Anesthesia and Nociception Monitoring: Current State and Vision For 2050.

Anesthesia objectives have evolved into combining hypnosis, amnesia, analgesia, paralysis, and suppression of the sympathetic autonomic nervous system. Technological improvements have led to new monitoring strategies, aimed at translating a qualitative physiological state into quantitative metrics, but the optimal strategies for depth of anesthesia (DoA) and analgesia monitoring continue to stimulate debate. Historically, DoA monitoring used patient's movement as a surrogate of awareness. Pharmacokinetic models and metrics, including minimum alveolar concentration for inhaled anesthetics and target-controlled infusion models for intravenous anesthesia, provided further insights to clinicians, but electroencephalography and its derivatives (processed EEG; pEEG) offer the potential for personalization of anesthesia care. Current studies appear to affirm that pEEG monitoring decreases the quantity of anesthetics administered, diminishes postanesthesia care unit duration, and may reduce the occurrence of postoperative delirium (notwithstanding the difficulties of defining this condition). Major trials are underway to further elucidate the impact on postoperative cognitive dysfunction. In this manuscript, we discuss the Bispectral (BIS) index, Narcotrend monitor, Patient State Index, entropy-based monitoring, and Neurosense monitor, as well as middle latency evoked auditory potential, before exploring how these technologies could evolve in the upcoming years. In contrast to developments in pEEG monitors, nociception monitors remain by comparison underdeveloped and underutilized. Just as with anesthetic agents, excessive analgesia can lead to harmful side effects, whereas inadequate analgesia is associated with increased stress response, poorer hemodynamic conditions and coagulation, metabolic, and immune system dysregulation. Broadly, 3 distinct monitoring strategies have emerged: motor reflex, central nervous system, and autonomic nervous system monitoring. Generally, nociceptive monitors outperform basic clinical vital sign monitoring in reducing perioperative opioid use. This manuscript describes pupillometry, surgical pleth index, analgesia nociception index, and nociception level index, and suggest how future developments could impact their use. The final section of this review explores the profound implications of future monitoring technologies on anesthesiology practice and envisages 3 transformative scenarios: helping in creation of an optimal analgesic drug, the advent of bidirectional neuron-microelectronic interfaces, and the synergistic combination of hypnosis and virtual reality.

Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery.

PURPOSE: To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). METHODS: Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated. RESULTS: Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively. CONCLUSION: Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery. LEVEL OF EVIDENCE: Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of high-field iMRI guided resection in cerebral glioma surgery: A randomized clinical trial.

BACKGROUND: Extent of resection (EOR) in glioma contributes to longer survival. The purpose of NCT01479686 was to prove whether intraoperative magnetic resonance imaging (iMRI) increases EOR in glioma surgery and benefit survival. METHODS: Patients were randomized (1:1) to receive the iMRI (n = 161) or the conventional neuronavigation (n = 160). The primary endpoint was gross total resection (GTR); secondary outcomes reported were progression-free survival (PFS), overall survival (OS), and safety. RESULTS: 188 high-grade gliomas (HGGs) and 133 low-grade gliomas (LGGs) were enrolled. GTR was 83.85% in the iMRI group vs. 50.00% in the control group (P < 0.0001). In 321 patients, the median PFS (mPFS) was 65.12 months in the iMRI group and 61.01 months in the control group (P = 0.0202). For HGGs, mPFS was improved in the iMRI group (19.32 vs. 13.34 months, P = 0.0015), and a trend of superior OS compared with control was observed (29.73 vs. 25.33 months, P = 0.1233). In the predefined eloquent area HGG subgroup, mPFS, and mOS were 20.47 months and 33.58 months in the iMRI vs. 12.21 months and 21.16 months in the control group (P = 0.0098; P = 0.0375, respectively). From the exploratory analyses of HGGs, residual tumor volume (TV) < 1.0 cm3 decreased the risk of survival (mPFS: 18.99 vs. 9.43 months, P = 0.0055; mOS: 29.77 vs. 18.10 months, P = 0.0042). LGGs with preoperative (pre-OP) TV > 43.1 cm3 and postoperative (post-OP) TV > 4.6 cm3 showed worse OS (P= 0.0117) CONCLUSIONS: It showed that iMRI significantly increased EOR and indicated survival benefits for HGGs, particularly eloquent HGGs. Residual TV in either HGGs or LGGs is a prognostic factor for survival.