Intraoperative Neurophysiological Monitoring During Spinal Cord Stimulation Surgery: A Systematic Review.

OBJECTIVES This study aims to describe the state of literature regarding the use of intraoperative neurophysiological monitoring (IONM) during spinal cord stimulator surgery. MATERIALS AND METHODS A systematic review of the use of IONM during spinal cord stimulation (SCS) surgery was performed using the following three data bases: PubMed, Ovid MEDLINE, and Embase. Research techniques included systematic research following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol by Cochrane, and backward searching. Qualitative analysis of included articles was performed using the methodologic index for nonrandomized studies assessment tool. Direction of effect, consistency across studies, and cost-effectiveness were narratively synthesized. RESULTS A total of 15 records were identified through data base searching. All records used IONM methods under general anesthesia for guidance of epidural lead placement. IONM techniques used for determining lateralization in the found articles were compound muscle action potentials (CMAPs) (n = 8), somatosensory evoked potentials (SSEPs) (n = 3) or both (n = 4). Motor evoked potentials were used in three trials for neuroprotection purposes. Two studies were comparative, and 12 were noncomparative. CONCLUSIONS We found a good body of level II evidence that using IONM during SCS surgery is a valid alternative to awake surgery and may even be superior regarding pain management, cost-effectiveness, and postoperative neurologic deficits. In direct comparison, the found evidence suggested using CMAP provided more consistently favorable results than using SSEP for midline placement of epidural leads under general anesthesia. Selection of IONM modality should be made on the basis of pathophysiology of disease, individual IONM experience, and the individual patient

Stereotactic posterior midline approach under direct microscopic view for biopsy of medulla oblongata tumors: technical considerations.

BACKGROUND Open and stereotactic transfrontal or transcerebellar approaches have been used to biopsy brainstem lesions. METHOD In this report, a stereotactic posterior and midline approach to the distal medulla oblongata under microscopic view is described. The potential advantages and limitations are discussed, especially bilateral damage of the X nerve nuclei. CONCLUSION This approach should be considered for biopsy of distal and posterior lesions. We strongly recommend the use of direct microscopic view to identify the medullary vessels, confirm the midline entry point, and avoid potential shift of the medulla. Further experience is needed to confirm safety and success rate of this approach

Mood effects after deep brain stimulation for Parkinson’s disease: an update

Depression in Parkinson's Disease (PD) is a prevalent and invalidating symptom. Deep brain stimulation (DBS) allows for an improvement of PD motor features, but its effects on mood are difficult to predict. Here, we review the evidence regarding mood effects after DBS of either subthalamic nucleus (STN) or globus pallidus pars interna (GPi). Different influences of multiple factors contribute to impact the neuropsychiatric outcome after surgery. Psychosocial presurgical situation, postsurgical coping mechanisms, dopaminergic treatment modifications, and direct effects of the stimulation of either target are all playing a distinct role on the psychological well- being of patients undergoing DBS. No clear advantage of either target (STN vs. GPi) has been consistently found, both being effective and with a favorable profile on depression symptoms. However, specific patients' characteristics or anatomical considerations can guide the neurosurgeon in the target choice. Further research together with technological advances are expected to confine the stimulation area within dysfunctional circuits causing motor symptoms of PD

Validation of Experts versus Atlas-based and Automatic Registration Methods for Subthalamic Nucleus Targeting on MRI

Objects In functional stereotactic neurosurgery, one of the cornerstones upon which the success and the operating time depends is an accurate targeting. The subthalamic nucleus (STN) is the usual target involved when applying deep brain stimulation for Parkinson's disease (PD). Unfortunately, STN is usually not clearly visible in common medical imaging modalities, which justifies the use of atlas-based segmentation techniques to infer the STN location. Materials and methods Eight bilaterally implanted PD patients were included in this study. A three-dimensional T1-weighted sequence and inversion recovery T2-weighted coronal slices were acquired pre-operatively. We propose a methodology for the construction of a ground truth of the STN location and a scheme that allows both, to perform a comparison between different non-rigid registration algorithms and to evaluate their usability to locate the STN automatically. Results The intra-expert variability in identifying the STN location is 1.06±0.61mm while the best non-rigid registration method gives an error of 1.80±0.62mm. On the other hand, statistical tests show that an affine registration with only 12 degrees of freedom is not enough for this application. Conclusions Using our validation-evaluation scheme, we demonstrate that automatic STN localization is possible and accurate with non-rigid registration algorithm

Validation of Experts versus Atlas-based and Automatic Registration Methods for Subthalamic Nucleus Targeting on MRI

Objects In functional stereotactic neurosurgery, one of the cornerstones upon which the success and the operating time depends is an accurate targeting. The subthalamic nucleus (STN) is the usual target involved when applying deep brain stimulation for Parkinson's disease (PD). Unfortunately, STN is usually not clearly visible in common medical imaging modalities, which justifies the use of atlas-based segmentation techniques to infer the STN location. Materials and methods Eight bilaterally implanted PD patients were included in this study. A three-dimensional T1-weighted sequence and inversion recovery T2-weighted coronal slices were acquired pre-operatively. We propose a methodology for the construction of a ground truth of the STN location and a scheme that allows both, to perform a comparison between different non-rigid registration algorithms and to evaluate their usability to locate the STN automatically. Results The intra-expert variability in identifying the STN location is 1.06±0.61mm while the best non-rigid registration method gives an error of 1.80±0.62mm. On the other hand, statistical tests show that an affine registration with only 12 degrees of freedom is not enough for this application. Conclusions Using our validation-evaluation scheme, we demonstrate that automatic STN localization is possible and accurate with non-rigid registration algorithm

Neuropsychological outcome after extra-temporal epilepsy surgery

Background: The neuropsychological results of temporal lobe epilepsy surgery are well reported in the literature. The aim of this study was to analyse the neuropsychological outcome in a consecutive series of patients with extra-temporal epilepsy. Methods: We retrospectively analysed the data of patients operated between 1996 and 2008 for extra-temporal epilepsy. Standard neuropsychological tests were applied. We assessed the neuropsychological outcome after surgery and the correlation of the neuropsychological outcome with (1) side and localisation of surgery, (2) Engel scale for seizure outcome and (3) timing of surgery. Findings: Patients had a better neuropsychological outcome when undergoing non-frontal resection [χ2 (2) =6.66, p = 0.036]. Subjects who had undergone left or right resection showed no difference in outcome [χ2 (2) =0.533, p = 0.766]. The correlation between the Engel scale for seizure re-occurence and the neuropsychological scores showed only a tendency for better outcome (Spearman ρ = −0.437; p = 0.069). The global measure of change did not correlate significantly with delay of surgery (Spearman ρ = −0.163; p = 0.518). Conclusions: Resective epilepsy surgery improves neuropsychological status outcome in patients with extra-temporal epilepsy even if the patient did not become seizure free. The outcome is better for non-frontal localisatio

Proactive inhibition is not modified by deep brain stimulation for Parkinson's disease: An electrical neuroimaging study.

In predictable contexts, motor inhibitory control can be deployed before the actual need for response suppression. The brain functional underpinnings of proactive inhibition, and notably the role of basal ganglia, are not entirely identified. We investigated the effects of deep brain stimulation of the subthalamic nucleus or internal globus pallidus on proactive inhibition in patients with Parkinson's disease. They completed a cued go/no-go proactive inhibition task ON and (unilateral) OFF stimulation while EEG was recorded. We found no behavioural effect of either subthalamic nucleus or internal globus pallidus deep brain stimulation on proactive inhibition, despite a general improvement of motor performance with subthalamic nucleus stimulation. In the non-operated and subthalamic nucleus group, we identified periods of topographic EEG modulation by the level of proactive inhibition. In the subthalamic nucleus group, source estimation analysis suggested the initial involvement of bilateral frontal and occipital areas, followed by a right lateralized fronto-basal network, and finally of right premotor and left parietal regions. Our results confirm the overall preservation of proactive inhibition capacities in both subthalamic nucleus and internal globus pallidus deep brain stimulation, and suggest a partly segregated network for proactive inhibition, with a preferential recruitment of the indirect pathway

Programming of subthalamic nucleus deep brain stimulation for Parkinson’s disease with sweet spot-guided parameter suggestions

Deep Brain Stimulation (DBS) is an effective treatment for advanced Parkinson’s disease. However, identifying stimulation parameters, such as contact and current amplitudes, is time-consuming based on trial and error. Directional leads add more stimulation options and render this process more challenging with a higher workload for neurologists and more discomfort for patients. In this study, a sweet spot-guided algorithm was developed that automatically suggested stimulation parameters. These suggestions were retrospectively compared to clinical monopolar reviews. A cohort of 24 Parkinson’s disease patients underwent bilateral DBS implantation in the subthalamic nucleus at our center. First, the DBS’ leads were reconstructed with the open-source toolbox Lead-DBS. Second, a sweet spot for rigidity reduction was set as the desired stimulation target for programming. This sweet spot and estimations of the volume of tissue activated were used to suggest (i) the best lead level, (ii) the best contact, and (iii) the effect thresholds for full therapeutic effect for each contact. To assess these sweet spot-guided suggestions, the clinical monopolar reviews were considered as ground truth. In addition, the sweet spot-guided suggestions for best lead level and best contact were compared against reconstruction-guided suggestions, which considered the lead location with respect to the subthalamic nucleus. Finally, a graphical user interface was developed as an add-on to Lead-DBS and is publicly available. With the interface, suggestions for all contacts of a lead can be generated in a few seconds. The accuracy for suggesting the best out of four lead levels was 56%. These sweet spot-guided suggestions were not significantly better than reconstruction-guided suggestions (p = 0.3). The accuracy for suggesting the best out of eight contacts was 41%. These sweet spot-guided suggestions were significantly better than reconstruction-guided suggestions (p < 0.001). The sweet spot-guided suggestions of each contact’s effect threshold had a mean error of 1.2 mA. On an individual lead level, the suggestions can vary more with mean errors ranging from 0.3 to 4.8 mA. Further analysis is warranted to improve the sweet spot-guided suggestions and to account for more symptoms and stimulation-induced side effects