NEUROPHYSIOLOGICAL INTRAOPERATIVE MONITORING IN CAUDA EQUINA TUMOR SURGERY – TWO CASE

REPORTS
FILIP Dan¹˒², MATEI Claudiu ¹˒², PEREANU Marcel ¹, FLORE Paul ², TALĂU Mariana ²
¹Universitatea Lucian Blaga Sibiu, ²Clinica Polisano Sibiu - România

Background Results
Case 2
Cauda equina's tumors surgery pose the risk to damage the spinal roots, We present here two case reports, one of a patient with a filum terminale
sometimes with dramatic consequences not only for motor or sensitive tumor located at L2-L3 vertebral level(fig.4) and another with a L5 spinal
functions in lower limbs, but also for sphincters activity. In order to avoid canal tumor(fig.9), which underwent surgery for excision of these tumors.
these injuries it is important to use the neurophysiological intraoperative They were monitored intraoperative by spontaneous electromyography and
monitoring (NIOM) of cauda equina’s spinal roots. The purpose of NIOM by direct root stimulation, and also by MEP.(fig.6,7,11,12,13)
in lumbosacral surgical procedures is to detect the radicular irritation in an In the first case, the stimulation of cauda equina’s roots produced a
early and potentially reversible stage, when it is possible to alert the response at an intensity below 5 mA. The stimulation of peritumoral Fig.11. Spontaneous electromyography -
neurosurgeon, preventing in this way a significant lesion, and structures with more than 20 mA didn’t produce any response, suggesting Fig.9 . Sagital T2 MRI - spinal canal tumor neurotonic discharges on sphincters, especially
at L5 vertebral level on the left side
consecutively a postoperative deficit.(1,2,3) that it was filum terminale (4); the tumor was resected together with filum
terminale.(fig.5,8)
Methods
The second patient, while monitoring, presented spontaneous electrical
NIOM was performed with the aid of spontaneous electromyography and discharges as spikes, bursts or trains on S1, S2 and S3 roots, especially on
by direct root stimulation, as well as by motor evoked potentials through the left side, sometimes even neurotonic discharges on sphincters.(fig.11) Fig.12. Cauda equina mapping by direct root
transcranial electrical stimulation. The stimulation of the roots was made stimulation
The occurrence of spontaneous discharges was followed by timing and
by a monopolar stimulator with the intensities between 0,5 – 5 mA and a reconsideration of surgical protocol, irrigation, until the electromyographic
duration of 0,2 ms.(fig.1) records were remediated. MEP remained unmodified during surgical
The motor evoked potentials were obtained by transcranial electrical interventions in both cases.(fig.13) The postoperative evolution was good,
stimulation with corkscrew-electrodes in C1-C2 positions on the scalp with no motor/sensitive or sphincter deficits. Fig.10. Intraoperative aspect with the cauda
equina tumor
(according with International 10/20 EEG System). (fig.2,6,13) Case 1
For the recording of motor responses needle-electrodes were inserted in the Fig.13. Motor evoked potentials remained
unchanged on the end of the surgery
muscles of lower limbs – vastus lateralis, tibialis anterior, gastrocnemius,
anal sfincters.(fig.3) Conclusions
• Neurophysiological intraoperative monitoring in lumbosacral surgery is
useful in early, real time detection, of a root irritation or lesion, as well as
Fig.6. Motor evoked potentials of lower
limbs in identification of nerve roots which belong to cauda equina.
• We used spontaneous electromyography and electromyography
assocciated with direct nerve stimulation, respectively radicular mapping.
• By thorough mapping of cauda equina roots it is avoided their damage
and it is identified filum terminale in case of tumors originating in these
Fig. 1. Stimulation of the roots of cauda Fig. 2. Montage of the corkscrew-
equina electrodes for transcranial stimulation (C1
nonneural structure.
and C2 for these cases) Fig.4. a) Coronar T2 MRI ; b)Sagital T2
MRI – filum terminale tumor located at
Fig. 7 . Motor responses to direct root References
stimulation of cauda equina
L2-L3 vertebral level
1. Tessitore E, et al. Cauda equina tumor surgery: how I do it. Acta Neurochirurgica. 2012. Vol. 154 Issue
10, p. 1815-1820.
2. Lang NJ, Doan AT, Harrop JS. Cauda equine monitoring. In: Loftus CM, et al, eds. Intraoperative
neuromonitoring. McGraw-Hill Education; 2014: p.439-448.
3. Husain AM, Watkins LR, Muh CR. Tethered cord surgery. In: Husain AM, ed. A practical approach to
neurophysiologic intraoperative monitoring. New York, Demos Medical; 2015: p. 142-155.
4. Quinones-Hinojosa A, et al. Neurophysiological monitoring for safe surgical tethered cord syndrome
Fig. 3. The muscles of lower limbs used for recording of motor Fig. 5. Direct elecrtical stimulation and Fig.8. Sagital T2 MRI after tumor release in adults. Surg Neurol. 2004; 62: 127-133.
responses resection of filum terminale resection

RESEARCH POSTER PRESENTATION DESIGN © 2015

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