Download PDF
J Neurol Surg A Cent Eur Neurosurg 2021; 82(04): 325-332
DOI: 10.1055/s-0040-1710504
Original Article

Predictive Value of Transcranial Evoked Potential Monitoring for Intramedullary Spinal Cord Tumors

Sebastian Ille
1   Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
,
Arthur Wagner
1   Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
,
Ann Kathrin Joerger
1   Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
,
Maria Wostrack
1   Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
,
Bernhard Meyer
1   Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
,
Ehab Shiban
1   Department of Neurosurgery, Technical University Munich Faculty of Medicine, München, Bayern, Germany
2   Department of Neurosurgery, University of Augsburg, Augsburg, Bayern, Germany
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Intraoperative neurophysiologic monitoring (IONM) has increased patient safety and extent of resection in patients with eloquent brain tumors. Despite its comprehensive capability for the resection of intramedullary spinal cord tumors (ISCTs), the application during the resection of these tumors is controversial.

Methods We retrospectively analyzed the resection of ISCTs in 83 consecutive cases. IONM was performed in all cases. Each patient's motor status and the McCormick scale was determined preoperatively, directly after surgery, at the day of discharge, and at long-term follow-up.

Results IONM was feasible in 71 cases (85.5%). Gross total resection was performed in 75 cases (90.4%). Postoperatively, patients showed new transient deficits in 12 cases (14.5%) and new permanent deficits in 12 cases (14.5%). The mean McCormick variance between baseline and long-term follow-up was − 0.08 ± 0.54. IONM's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the patient's motor status at the day of discharge was 75.0%, 64.7%, 45.5%, and 86.8%. It was 88.9%, 59.7%, 24.2%, and 97.4% for the motor outcome at long-term follow-up. Patients experienced postoperative complications in 15 cases (18.1%).

Conclusion IONM, as performed in the present study, shows a high sensitivity and NPV but low specificity and PPV, particularly for the patient's motor status at the long-term follow-up. As far as practicable by a retrospective study on IONM, our results confirm IONM's usefulness for its application during the resection of ISCTs. However, these results must be approved by a prospective study.

Keywords

intramedullary spinal cord tumor - intraoperative neuromonitoring - transcranial evoked potential monitoring

Financial Disclosures

Ehab Shiban received research grants and is a consultant for Nevro and Icotec. Bernhard Meyer received research grants and is a consultant for Brainlab AG. He received honoraria, consulting fees, and research grants from Medtronic, Icotec, and Relievant Medsystems; honoraria and research grants from Ulrich Medical; honoraria and consulting fees from Spineart Deutschland and DePuy Synthes; and royalties from Spineart Deutschland. The study was completely financed by institutional grants from the Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München.




Publication History

Received: 25 March 2019

Accepted: 22 October 2019

Article published online:
21 January 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Sala F, Bricolo A, Faccioli F, Lanteri P, Gerosa M. Surgery for intramedullary spinal cord tumors: the role of intraoperative (neurophysiological) monitoring. Eur Spine J 2007; 16 (02, Suppl 2): S130-S139
    CrossrefPubMedGoogle Scholar
  • 2 Matsuyama Y, Sakai Y, Katayama Y. et al. Surgical results of intramedullary spinal cord tumor with spinal cord monitoring to guide extent of resection. J Neurosurg Spine 2009; 10 (05) 404-413
    CrossrefPubMedGoogle Scholar
  • 3 Boström A, Kanther NC, Grote A, Boström J. Management and outcome in adult intramedullary spinal cord tumours: a 20-year single institution experience. BMC Res Notes 2014; 7: 908
    CrossrefPubMedGoogle Scholar
  • 4 Constantini S, Miller DC, Allen JC, Rorke LB, Freed D, Epstein FJ. Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults. J Neurosurg 2000; 93 (02) 183-193
    CrossrefPubMedGoogle Scholar
  • 5 Epstein FJ, Farmer JP, Freed D. Adult intramedullary spinal cord ependymomas: the result of surgery in 38 patients. J Neurosurg 1993; 79 (02) 204-209
    CrossrefPubMedGoogle Scholar
  • 6 Raco A, Esposito V, Lenzi J, Piccirilli M, Delfini R, Cantore G. Long-term follow-up of intramedullary spinal cord tumors: a series of 202 cases. Neurosurgery 2005; 56 (05) 972-981 ; discussion 972–981
    PubMedGoogle Scholar
  • 7 Karikari IO, Nimjee SM, Hodges TR. et al. Impact of tumor histology on resectability and neurological outcome in primary intramedullary spinal cord tumors: a single-center experience with 102 patients. Neurosurgery 2015; 76 (Suppl. 01) S4-S13 ; discussion S13
    CrossrefPubMedGoogle Scholar
  • 8 Minehan KJ, Brown PD, Scheithauer BW, Krauss WE, Wright MP. Prognosis and treatment of spinal cord astrocytoma. Int J Radiat Oncol Biol Phys 2009; 73 (03) 727-733
    CrossrefPubMedGoogle Scholar
  • 9 Manzano G, Green BA, Vanni S, Levi AD. Contemporary management of adult intramedullary spinal tumors—pathology and neurological outcomes related to surgical resection. Spinal Cord 2008; 46 (08) 540-546
    CrossrefPubMedGoogle Scholar
  • 10 Sandalcioglu IE, Gasser T, Asgari S. et al. Functional outcome after surgical treatment of intramedullary spinal cord tumors: experience with 78 patients. Spinal Cord 2005; 43 (01) 34-41
    CrossrefPubMedGoogle Scholar
  • 11 Sanai N, Polley MY, McDermott MW, Parsa AT, Berger MS. An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg 2011; 115 (01) 3-8
    CrossrefPubMedGoogle Scholar
  • 12 Sanai N, Berger MS. Glioma extent of resection and its impact on patient outcome. Neurosurgery 2008; 62 (04) 753-764 ; discussion 264–266
    CrossrefPubMedGoogle Scholar
  • 13 Duffau H. Long-term outcomes after supratotal resection of diffuse low-grade gliomas: a consecutive series with 11-year follow-up. Acta Neurochir (Wien) 2016; 158 (01) 51-58
    CrossrefPubMedGoogle Scholar
  • 14 Capelle L, Fontaine D, Mandonnet E. , et al; French Réseau d'Étude des Gliomes. Spontaneous and therapeutic prognostic factors in adult hemispheric World Health Organization grade II gliomas: a series of 1097 cases: clinical article. J Neurosurg 2013; 118 (06) 1157-1168
    CrossrefPubMedGoogle Scholar
  • 15 Wijnenga MMJ, French PJ, Dubbink HJ. et al. The impact of surgery in molecularly defined low-grade glioma: an integrated clinical, radiological, and molecular analysis. Neuro Oncol 2018; 20 (01) 103-112
    CrossrefPubMedGoogle Scholar
  • 16 Chang EF, Clark A, Smith JS. et al. Functional mapping-guided resection of low-grade gliomas in eloquent areas of the brain: improvement of long-term survival. Clinical article. J Neurosurg 2011; 114 (03) 566-573
    CrossrefPubMedGoogle Scholar
  • 17 De Witt Hamer PC, Robles SG, Zwinderman AH, Duffau H, Berger MS. Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol 2012; 30 (20) 2559-2565
    CrossrefPubMedGoogle Scholar
  • 18 Sanai N, Mirzadeh Z, Berger MS. Functional outcome after language mapping for glioma resection. N Engl J Med 2008; 358 (01) 18-27
    CrossrefPubMedGoogle Scholar
  • 19 Ojemann G, Ojemann J, Lettich E, Berger M. Cortical language localization in left, dominant hemisphere. An electrical stimulation mapping investigation in 117 patients. J Neurosurg 1989; 71 (03) 316-326
    CrossrefPubMedGoogle Scholar
  • 20 Haglund MM, Berger MS, Shamseldin M, Lettich E, Ojemann GA. Cortical localization of temporal lobe language sites in patients with gliomas. Neurosurgery 1994; 34 (04) 567-576 ; discussion 576
    PubMedGoogle Scholar
  • 21 Deletis V, Seidel K, Sala F. et al. Intraoperative identification of the corticospinal tract and dorsal column of the spinal cord by electrical stimulation. J Neurol Neurosurg Psychiatry 2018; 89 (07) 754-761
    CrossrefPubMedGoogle Scholar
  • 22 Deletis V, Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol 2008; 119 (02) 248-264
    CrossrefPubMedGoogle Scholar
  • 23 Sala F, Palandri G, Basso E. et al. Motor evoked potential monitoring improves outcome after surgery for intramedullary spinal cord tumors: a historical control study. Neurosurgery 2006; 58 (06) 1129-1143 ; discussion 1129–1143
    CrossrefPubMedGoogle Scholar
  • 24 Costa P, Peretta P, Faccani G. Relevance of intraoperative D wave in spine and spinal cord surgeries. Eur Spine J 2013; 22 (04) 840-848
    CrossrefPubMedGoogle Scholar
  • 25 Forster MT, Marquardt G, Seifert V, Szelényi A. Spinal cord tumor surgery—importance of continuous intraoperative neurophysiological monitoring after tumor resection. Spine 2012; 37 (16) E1001-E1008
    CrossrefPubMedGoogle Scholar
  • 26 Kothbauer KF. Intraoperative neurophysiologic monitoring for intramedullary spinal-cord tumor surgery. Neurophysiol Clin 2007; 37 (06) 407-414
    CrossrefPubMedGoogle Scholar
  • 27 Skinner SA, Nagib M, Bergman TA, Maxwell RE, Msangi G. The initial use of free-running electromyography to detect early motor tract injury during resection of intramedullary spinal cord lesions. Neurosurgery 2005; 56 (02) 299-314 ; discussion 299–314
    PubMedGoogle Scholar
  • 28 Yanni DS, Ulkatan S, Deletis V, Barrenechea IJ, Sen C, Perin NI. Utility of neurophysiological monitoring using dorsal column mapping in intramedullary spinal cord surgery. J Neurosurg Spine 2010; 12 (06) 623-628
    CrossrefPubMedGoogle Scholar
  • 29 Scheufler KM, Zentner J. Total intravenous anesthesia for intraoperative monitoring of the motor pathways: an integral view combining clinical and experimental data. J Neurosurg 2002; 96 (03) 571-579
    CrossrefPubMedGoogle Scholar
  • 30 Shiban E, Wunderlich S, Kreiser K. et al. Predictive value of transcranial evoked potentials during mechanical endovascular therapy for acute ischaemic stroke: a feasibility study. J Neurol Neurosurg Psychiatry 2016; 87 (06) 598-603
    CrossrefPubMedGoogle Scholar
  • 31 Obermueller T, Schaeffner M, Shiban E. et al. Intraoperative neuromonitoring for function-guided resection differs for supratentorial motor eloquent gliomas and metastases. BMC Neurol 2015; 15: 211
    CrossrefPubMedGoogle Scholar
  • 32 Shiban E, Krieg SM, Haller B. et al. Intraoperative subcortical motor evoked potential stimulation: how close is the corticospinal tract?. J Neurosurg 2015; 123 (03) 711-720
    CrossrefPubMedGoogle Scholar
  • 33 Krieg SM, Schäffner M, Shiban E. et al. Reliability of intraoperative neurophysiological monitoring using motor evoked potentials during resection of metastases in motor-eloquent brain regions: clinical article. J Neurosurg 2013; 118 (06) 1269-1278
    CrossrefPubMedGoogle Scholar
  • 34 Krieg SM, Shiban E, Droese D. et al. Predictive value and safety of intraoperative neurophysiological monitoring with motor evoked potentials in glioma surgery. Neurosurgery 2012; 70 (05) 1060-1070 ; discussion 1070–1071
    CrossrefPubMedGoogle Scholar
  • 35 Bellut D, Burkhardt JK, Mannion AF, Porchet F. Assessment of outcome in patients undergoing surgery for intradural spinal tumor using the multidimensional patient-rated Core Outcome Measures Index and the modified McCormick Scale. Neurosurg Focus 2015; 39 (02) E2
    CrossrefPubMedGoogle Scholar
  • 36 Kothbauer KF, Deletis V, Epstein FJ. Motor-evoked potential monitoring for intramedullary spinal cord tumor surgery: correlation of clinical and neurophysiological data in a series of 100 consecutive procedures. Neurosurg Focus 1998; 4 (05) e1
    CrossrefPubMedGoogle Scholar
  • 37 Quiñones-Hinojosa A, Lyon R, Zada G. et al. Changes in transcranial motor evoked potentials during intramedullary spinal cord tumor resection correlate with postoperative motor function. Neurosurgery 2005; 56 (05) 982-993 ; discussion 982–993
    PubMedGoogle Scholar
  • 38 Zentner J. Noninvasive motor evoked potential monitoring during neurosurgical operations on the spinal cord. Neurosurgery 1989; 24 (05) 709-712
    CrossrefPubMedGoogle Scholar
  • 39 Kurokawa R, Kim P, Itoki K. et al. False-positive and false-negative results of motor evoked potential monitoring during surgery for intramedullary spinal cord tumors. Oper Neurosurg (Hagerstown) 2018; 14 (03) 279-287
    CrossrefPubMedGoogle Scholar
  • 40 Jin SH, Chung CK, Kim CH, Choi YD, Kwak G, Kim BE. Multimodal intraoperative monitoring during intramedullary spinal cord tumor surgery. Acta Neurochir (Wien) 2015; 157 (12) 2149-2155
    CrossrefPubMedGoogle Scholar
  • 41 Kim DG, Son YR, Park YS. et al. Differences in multimodality intraoperative neurophysiological monitoring changes between spinal intramedullary ependymoma and hemangioblastoma. J Clin Neurophysiol 2016; 33 (02) 120-126
    CrossrefPubMedGoogle Scholar
  • 42 Morota N, Deletis V, Constantini S, Kofler M, Cohen H, Epstein FJ. The role of motor evoked potentials during surgery for intramedullary spinal cord tumors. Neurosurgery 1997; 41 (06) 1327-1336
    CrossrefPubMedGoogle Scholar
  • 43 Velayutham P, Rajshekhar V, Chacko AG, Krothapalli Babu S. Influence of tumor location and other variables on predictive value of intraoperative myogenic motor-evoked potentials in spinal cord tumor surgery. World Neurosurg 2016; 92: 264-272
    CrossrefPubMedGoogle Scholar
  • 44 Accadbled F, Henry P, de Gauzy JS, Cahuzac JP. Spinal cord monitoring in scoliosis surgery using an epidural electrode. Results of a prospective, consecutive series of 191 cases. Spine 2006; 31 (22) 2614-2623
    CrossrefPubMedGoogle Scholar
  • 45 Quraishi NA, Lewis SJ, Kelleher MO, Sarjeant R, Rampersaud YR, Fehlings MG. Intraoperative multimodality monitoring in adult spinal deformity: analysis of a prospective series of one hundred two cases with independent evaluation. Spine 2009; 34 (14) 1504-1512
    CrossrefPubMedGoogle Scholar
  • 46 Nuwer MR, Dawson EG, Carlson LG, Kanim LE, Sherman JE. Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 1995; 96 (01) 6-11
    CrossrefPubMedGoogle Scholar
  • 47 Hadley MN, Shank CD, Rozzelle CJ, Walters BC. Guidelines for the use of electrophysiological monitoring for surgery of the human spinal column and spinal cord. Neurosurgery 2017; 81 (05) 713-732
    CrossrefPubMedGoogle Scholar