The value of intraoperative neurophysiological monitoring in tethered cord surgery

The value of intraoperative neurophysiological monitoring (IONM) with surgical detethering in dysraphic patients has been questioned. A retrospective analysis of our series of 65 patients is presented with special focus on technical set-up and outcome. All patients were diagnosed with a tethered cord (TC) due to spinal dysraphism. A high-risk group (HRG) was determined consisting of 40 patients with a lipomyelomeningocele and/or a split cord malformation sometimes in combination with a tight filum terminale. The surgical procedure was a detethering operation in all cases performed by a single surgeon during a 9-year period (1999-2008). A standard set-up of IONM was used in all patients consisting of motor-evoked potentials (MEP) evoked by transcranial electrical stimulation (TES) and electrical nerve root stimulation. In young patients, conditioning stimulation was applied in order to improve absent or weak MEPs. IONM responses could be obtained in all patients. Postoperative deterioration of symptoms was found in two patients of whom one patient belonged to the HRG. Mean maximal follow-up of all 65 patients was 4.6 years (median 4.1 years). Long-term deterioration of symptoms was found in 6 of 65 patients with a mean follow-up of 5 years (median 5.3 years). The use of IONM is feasible in all TC patients. The identification of functional nervous structures and continuous guarding of the integrity of sacral motor roots by IONM may contribute to the safety of surgical detethering

A Dutch guideline for the treatment of scoliosis in neuromuscular disorders

<p>Abstract</p> <p>Background</p> <p>Children with neuromuscular disorders with a progressive muscle weakness such as Duchenne Muscular Dystrophy and Spinal Muscular Atrophy frequently develop a progressive scoliosis. A severe scoliosis compromises respiratory function and makes sitting more difficult. Spinal surgery is considered the primary treatment option for correcting severe scoliosis in neuromuscular disorders. Surgery in this population requires a multidisciplinary approach, careful planning, dedicated surgical procedures, and specialized after care.</p> <p>Methods</p> <p>The guideline is based on scientific evidence and expert opinions. A multidisciplinary working group representing experts from all relevant specialties performed the research. A literature search was conducted to collect scientific evidence in answer to specific questions posed by the working group. Literature was classified according to the level of evidence.</p> <p>Results</p> <p>For most aspects of the treatment scientific evidence is scarce and only low level cohort studies were found. Nevertheless, a high degree of consensus was reached about the management of patients with scoliosis in neuromuscular disorders. This was translated into a set of recommendations, which are now officially accepted as a general guideline in the Netherlands.</p> <p>Conclusion</p> <p>In order to optimize the treatment for scoliosis in neuromuscular disorders a Dutch guideline has been composed. This evidence-based, multidisciplinary guideline addresses conservative treatment, the preoperative, perioperative, and postoperative care of scoliosis in neuromuscular disorders.</p

Multimodal intraoperative monitoring during surgery of spinal deformities in 217 patients

A prospective study was performed on 217 patients who received MIOM during corrective surgery of spinal deformities between March 2000 and December 2005. Aim is to determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during corrective spine surgery. MIOM is becoming an increasingly used method of monitoring function during corrective spine surgery. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information regarding any neurological deficits during the operation. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 217 consecutive patients with spinal deformities of different aetiologies were monitored by means of MIOM during the surgical procedure. Out of which 201 patients presented true negative findings while one patient presented false negative and three patients presented false positive findings. Twelve patients presented true positive findings where neurological deficit after the operation was predicted. All neurological deficits in those 12 patients recovered completely. The sensitivity of MIOM applied during surgery of spinal deformities has been calculated of 92.3% and the specificity 98.5%. Based upon the results of this study MIOM is an effective method of monitoring the spinal cord and nerve root function during corrective surgery of spinal deformities and consequently improves postoperative results. The Wake-up test for surgical procedure of spinal deformities became obsolete in our institution

C7 decancellisation closing wedge osteotomy for the correction of fixed cervico-thoracic kyphosis

Our objective is to report on the clinical and radiological outcome following a decancellisation closing wedge osteotomy for the correction of fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis. The only treatment available for severe fixed flexion deformity of the cervical spine in these patients is an extension osteotomy. Traditionally an anterior opening, posterior closing wedge osteotomy is performed with or without internal fixation. We describe a decancellisation closing wedge osteotomy of C7 accompanied by secure segmental internal fixation. Eight patients operated between 1990 and 2003 with mean age of 54 years and minimum follow up of 2 years were retrospectively evaluated. Restoration of normal forward gaze was achieved in all patients. No patient suffered spinal cord injury or permanent nerve root palsy. There was no loss of correction or pseudarthrosis at final follow up. C7 decancellisation closing wedge osteotomy supplemented with secure segmental internal fixation in experienced hands provides a safe and effective treatment for fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis.Devi Prakash Tokala, Khai S. Lam, Brian J. C. Freeman and John K. Web