Neurological Outcomes Following Spinal Tumour Procedures and Intraoperative Neurophysiological Monitoring: A Single Institution Experience

Jafar Lie^*
*Correspondence: Jafar Lie, Department of Medicine and Surger, University of Bari, Bari Taranto, Brindisi, Italy, Email:

Keywords

Intradural spinal tumor • Intraoperative neurophysiological monitoring • Neurological outcomes

Introduction

Approximately 15% of neurogenic tumors are intraspinal. Primary intraspinal tumors are those that originate in intraspinal tissues; secondary intraspinal tumors are those that originate in tissues that extend beyond the intraspinal origin or that have metastasized long distances to spinal tissues. Surgical decompression, with or without instrumentation, is the treatment of choice for patients who present with symptoms or notice that there is evidence of tumor growth. The "gold standard" for most intraspinal tumors is total resection. On the other hand, total resection is not safe whenever tumors are adjacent to significant structural elements [1,2]

Description

The removal of a spinal cord lesion always carries the possibility of neurological damage after surgery. Nerve root deficits have a postoperative complication rate of 6–8%, and myelopathy has a rate of 3–12%.Today, technological advancements have significantly improved intraoperative neurophysiological monitoring (IONM) during spinal surgery. The benefit of IONM has been reported in deformity spinal surgery. IONM shows high sensitivity and specificity in deformity correction spinal surgery, preventing postoperative neurological complications. The goal of the IONM is to prevent irreversible neural injury by using the appropriate IONM modalities that alert, rather than predict, a neurological complication. In this, IONM is using electrophysiological recordings such as motor evoked potential (MEP), somatosensory [3,4].

In this study, the neurological outcomes of intradural spinal tumor surgeries with and without IONM were compared. In order to demonstrate the ability of IONM to predict postoperative neurological outcome and neurological recovery in intradural spinal tumors, we conduct a retrospective study. The study's retrospective design only provides original information from a setting with limited resources, making it worthy of consideration. During the first few years of this study, our academic hospital performed surgical removal of the tumor prior to the IONM era. We used IONM for every operation during the IONM era. Multimodal IONM included transcranial MEP, SSEP, and continuous EMG in all patients. Transcranial stimulation of the right and left primary motor cortex produced MEP. Two pairs of electrodes are positioned on each hand to monitor the muscles of the upper extremities (deltoid, biceps brachii, brachioradialis abductor digiti minimi, abductor pollicis brevis). Eight electrode pairs are positioned on four bilateral muscle groups for the lower extremities (right and left: biceps femoris, vastus medialis, anterior tibialis, and medial gastrocnemius). The peroneal nerve at the tibial nerve in the popliteal fossa in the lower extremities and the posterior tibial nerve at the foot served as alternate stimulation sites for SSEP. After positioning, baseline signals were recorded as part of the monitoring procedure. SSEP and EMG baseline signals were continuously monitored, while MEP signals were obtained prior to and following tumor decompression, prior to closure, and whenever the surgeon requested it [5].

MEP was developed to better characterize the integrity of the corticospinal tracts. In the 1970s, SSEP were developed as an indirect method of monitoring the ventral corticospinal tracts through dorsal column integrity. However, several studies reported its limitation regarding postoperative neurological deficit in normal SSEP. EMG is a real-time monitoring of nerve root function, particularly during instrumentation and manipulation during surgery. Due to the effectiveness of replacing the limitations of individual monitoring, multimodality neurophysiological monitoring has become a standard procedure for a variety of spinal procedures. In addition, it was useful for predicting postoperative neurological deficit and recovery. Spinal deformity surgery has utilized a combination of MEP and SSEP monitoring. In particular, the addition of free running EMG and triggered EMG can improve the efficiency with which nerve root injuries can be detected. Correlations between IONM changes and postoperative neurological outcomes indicate that alarm IONM contributed to postoperative neurological poor outcome or neurological deficit. It may assist in detecting early neural injury at a reversible stage, preventing poor postoperative outcomes. On the other hand, intraoperative recovery of the IONM modality can indicate a favorable postoperative outcome. In addition, it aids in improving the assessment of neural function, thereby guiding intraoperative decision-making regarding what should be done at that time for the management of alarm IONM in that position. In order to determine the relationship between IONM use and neurological outcomes after surgery, we used a variety of measurements, including the KPS Scale, the Frenkel Grade, the JOA Score, the ASIA Score, and McCormick Score [6-9].

Conclusion

All measurements improved over the 24 months following surgery in both groups, but only the IONM group saw a statistically significant improvement. Additionally, there was a statistically significant distinction in the improvement of the neurological postoperative outcome between the IONM and non-IONM groups. In addition, all measurements decreased in the non-IONM group one month after surgery; however, neurological outcomes improved following treatment, but not by a statistically significant amount. Minor surgical injuries to the neural integrity, such as intraoperative manipulation or neural tissue contusion during tumor dissection, are probably to blame for this. In intradural spinal tumor surgery, we presume that the routine use of multimodality IONM resulted in a decrease in neurological deficit and improved postoperative neurological outcome.

Acknowledgement

None.

Conflict of Interest

None.

References

1. Yanagisawa, N., and A. Goto. "Dystonia musculorum deformans: analysis with electromyography." J Neurol Sci 13 (1971): 39-65.

Google Scholar, Crossref, Indexed at

2. Hanin, Cyril, Isabelle Arnulf, Jean‐Baptiste Maranci and Michel Lecendreux, et al.Narcolepsy and psychosis: A systematic review. Acta Psychiatr Scand 144 (2021): 28-41.

Google Scholar, Crossref, Indexed at

3. Bassetti, Claudio LA, Antoine Adamantidis, Denis Burdakov and Fang Han, et al.Narcolepsy—clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol 15 (2019): 519-539.

Google Scholar, Crossref, Indexed at

4. Dauvilliers, Yves, Lucie Barateau, Benita Middleton and Daan R. van der Veen et al,Metabolomics signature of patients with narcolepsy. Neurol 98 (2022): e493-e505.

Google Scholar, Crossref, Indexed at

5. Sun, Hong-Qiang, Su-Xia Li, Fang-Bin Chen and Yan Zhang, et al. Diurnal neurobiological alterations after exposure to clozapine in first-episode schizophrenia patients. Psychoneuroendocrinology 64 (2016): 108-116.

Google Scholar, Crossref, Indexed at

6. Ohayon, Maurice M. Narcolepsy is complicated by high medical and psychiatric comorbidities: A comparison with the general population. Sleep Med 14 (2013): 488-492.

Google Scholar, Crossref, Indexed at

7. Brown, Steven, Michael J. Martinez and Lawrence M. Parsons. "Music and language side by side in the brain: A PET study of the generation of melodies and sentences." Eur J Neurosci 23 (2006): 2791-2803.

Google Scholar, Crossref, Indexed at

8. Bush, George, Phan Luu and Michael I. Posner. "Cognitive and emotional influences in anterior cingulate cortex." Trends Cogn Sci 4 (2000): 215-222.

Google Scholar, Crossref, Indexed at

9. Chan, Agnes S., Yim-Chi Ho and Mei-Chun Cheung. "Music training improves verbal memory." Nature 396 (1998): 128.

Google Scholar, Crossref, Indexed at