Neurophysiologie Clinique/Clinical Neurophysiology (2007) 37, 407—414

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REVIEW/MISE AU POINT

Intraoperative neurophysiologic monitoring for

intramedullary spinal-cord tumor surgery
Le monitorage neurophysiologique péropératoire
dans la chirurgie de resection des tumeurs
intramédullaires
K.F. Kothbauer

Division of Neurosurgery, Department of surgery, Kantonsspital Luzern, 6000 Luzern 16, Switzerland

Received 29 September 2007; accepted 15 October 2007

Available online 9 November 2007

KEYWORDS Summary During resection of intramedullary spinal-cord tumors intraoperative neurophysi-

Spinal-cord surgery; ological monitoring has become a true surgical technology. Motor evoked potentials are the
Spinal-cord most important modality for this purpose. Its use requires neurophysiological expertise from
monitoring; the surgeon, and a monitoring team in place able to handle the necessary equipment. Motor
Intramedullary potentials are evoked by transcranial electrical motor cortex stimulation. A ‘‘single stimulus
tumors; technique’’ evokes D-waves recorded from the spinal cord. The ‘‘multipulse (or train) stimula-
Motor evoked tion technique’’ evokes electromyographic responses in peripheral muscles. These are optimally
potentials; recorded from the thenar, hypothenar, tibialis anterior, and flexor hallucis brevis muscles, which
D-wave; are known to have strong pyramidal innervation. D-wave monitoring looks primarily at the peak-
Paraplegia; to-peak amplitude. When monitoring muscle MEPs, the presence or absence of the response
Paraparesis; irrespective of stimulation intensity is the important parameter. Preparations for neurophysi-
Preventive medicine; ological monitoring fit quite well into a neurosurgical operating room environment. Recording
Physical injuries and interpretation of MEPs is fast and straightforward. Pre- and postoperative clinical motor
findings correlate with intraoperative MEP results. Thus correct prediction of the clinical sta-
tus at a given time during surgery is possible with a very high certainty. The sensitivity of
muscle MEPs for postoperative motor deficits is nearly 100%, its specificity is about 90%. Thus
MEP data indeed reflect the clinical ‘‘reality’’. Present and stable recordings document intact
motor pathways and allow the surgeon to confidently proceed with a tumor resection. Loss of
muscle MEPs and/or decrease of the D-wave amplitude constitutes a ‘‘window of warning’’. It
reflects a pattern of MEP change indicating a reversible injury to the essential motor pathways.
Using this information, the surgical strategy can be adapted before irreversible neurological
damage is caused by the surgical manipulation. Such adaptation comprises simply waiting for

E-mail address: Karl.Kothbauer@ksl.ch.

0987-7053/$ — see front matter © 2007 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.neucli.2007.10.003
408 K.F. Kothbauer

the recordings to spontaneously improve again, irrigating with warm saline solution to wash out
blocking potassium. Other measures include the elevation of mean arterial pressure to improve
local perfusion. Even staged resection can be considered if intraoperative measures do not
sufficiently improve the recordings.
© 2007 Elsevier Masson SAS. All rights reserved.

Résumé Le monitorage neurophysiologique intraopératoire, essentiellement basé sur les

MOTS CLÉS potentiels évoqués moteurs (PEM), est réellement devenu une technique neurochirurgicale
Chirurgie médullaire ; à part entière lors des résections de tumeurs intramédullaires. Son utilisation requiert à la
Monitorage spinal ; fois une expertise neurophysiologique de la part du chirurgien et la présence d’une équipe de
Tumeurs monitorage capable de manipuler l’équipement nécessaire. Les PEM sont obtenus par stimula-
intramédullaires ; tion électrique transcrânienne du cortex moteur. Une technique reposant sur des « stimulations
Potentiels évoqués uniques » permet d’enregistrer les ondes-D au départ de la moelle. L’utilisation de « trains de
moteurs ; stimulations » permet l’enregistrement EMG des réponses musculaires. Idéalement, celles-ci
Onde-D ; sont obtenues au niveau des éminences thénar et hypothénar, des jambiers antérieurs et des
Paraplégie ; courts fléchisseurs du gros orteil, muscles dont l’innervation par le système pyramidal est par-
Paraparésie ; ticulièrement importante. Le monitorage de l’onde-D repose principalement sur la mesure de
Médecine son amplitude pic-à-pic. Le monitorage des réponses musculaires repose sur la constatation
préventive ; de leur présence ou absence, indépendamment de l’intensité de stimulation. L’installation du
Dommage corporel monitorage s’adapte aisément à l’environnement des salles d’opérations neurochirurgicales.
Les PEM peuvent être enregistrés et interprétés rapidement et directement. L’état clinique
pré- et postopératoire étant bien corrélés aux PEM intraopératoires, l’état clinique peut être
prédit avec une grande certitude à chaque stade de l’intervention. La sensibilité des PEM par
rapport aux déficits moteurs postopératoires est proche de 100 % et leur spécificité est de l’ordre
de 90 %. Les PEM reflètent donc bien la « réalité clinique ». Des réponses présentes et stables
impliquent l’intégrité des voies motrices et permettent au chirurgien de continuer en toute con-
fiance la résection de la tumeur. La disparition des réponses musculaires et/ou une diminution
d’amplitude de l’onde-D constituent un « feu orange » dans la mesure où ils correspondent à une
altération réversible des voies motrices. Sur la base de cette information, la stratégie chirurgi-
cale peut être adaptée avant que des séquelles neurologiques irréversibles ne surviennent suite
aux manipulations chirurgicales. Cette adaptation peut consister, soit simplement à attendre
que les réponses s’améliorent spontanément, soit à irriguer le champ opératoire au moyen
de sérum physiologique chaud en vue d’éliminer le potassium, facteur de blocage axonal. On
peut également augmenter la tension artérielle pour améliorer la perfusion locale. Une résec-
tion en plusieurs temps pourra être envisagée si ces mesures ne suffisent pas à améliorer les
réponses.
© 2007 Elsevier Masson SAS. All rights reserved.

Introduction SEP loss carries no significance in terms of motor outcome,

Neurosurgeons have due respect for this immensely delicate
structure, which is the spinal cord. It packs an enormous
density of essential fiber tracts and neural circuits into
a very small volume of tissue. Therefore, the removal of
intramedullary tumors carries a significant risk of surgical
damage and neurological dysfunction.
Orthopedic surgeons first implemented evoked poten-
tial monitoring of the spinal cord in an attempt to reduce
neurological morbidity [1,2]. Only somatosensory evoked
potentials (SEPs) were available at that time. The technol-
ogy was slow, often burdened with artifacts, and difficult
to interpret. Last but not least, as SEPs only reflect the
functional integrity of the sensory pathways, SEP monitor-
ing at best allowed indirect inference upon motor tracts.
For external spinal-cord compression as the mechanism
of injury, this was just acceptable, without anything bet-
ter available. Then reports of paralysis with intact SEPs
appeared [3,4]. We now know that SEP changes during
intramedullary surgery frequently occur, because of the
most frequently used midline approach into the cord [5]. But
and SEPs may even be recordable in patients who were non
ambulatory prior to surgery [6].
SEP recording requires signal averaging, which results in a
time delay until data interpretation can generate a response
to the surgeon. Therefore, an injury can be irreversible
before it is even detected.
Many of these problems were solved with MEP monitoring
because of its proven clinical correlation, real-time feed-
back, and reversibility pattern allowing corrective action
before an injury becomes irreversible.
As it is performed today, MEP monitoring is based on a
remarkable accumulation of knowledge about the motor sys-
tem, which has accelerated since the 1950s [7,8]. Already
then, the D-wave was identified as a distinct phenomenon.
The D-wave is a synchronized travelling wave generated in
a rather small fiber population in the corticospinal tract.
After the description of transcranial electrical motor cortex
stimulation in man [9], this knowledge was applied in the
operating room [10—14].
Thereafter, electromyographic recording techniques
were developed with magnetic [15] and electric [16] motor
Intraoperative neurophysiologic monitoring spinal-cord tumor surgery 409

cortex stimulation. However, the anesthesia-induced block-

ade of the ␣-motorneurons raised a significant problem. This
was subsequently solved by the development of the train,
or multipulse, stimulation technique [17,18].
From then on, the investigational and practical appli-
cations of monitoring expanded, thereby improving the
common experience. Several large series provided evidence
that intraoperative MEP monitoring is actually feasible and
useful. But this only holds true for the neurophysiologically
competent neurosurgeon [6,19—22].
More recently, very strong evidence for the advantages
of MEP-monitoring during spinal-cord surgery was reported
[23]. This study compared pre- and postmonitoring spinal-
cord operations performed by a very experienced surgeon,
and showed without question that the neurologic outcome is
improved by monitoring, without compromising the extent
of spinal-cord tumor resection.
It must be acknowledged that more widespread applica-
tion also carries a risk of indiscriminate and less-than-expert
use of this technology. At the same time, more and wider
understanding becomes possible, as new, previously unap-
preciated, risks and limitations become clearer.

Neurophysiology
Figure 1 Single stimulus and multipulse stimulation to evoke
Motor potentials are evoked with transcranial electrical D-waves and motor potentials.
motor cortex stimulation. The stimulus points are C3, C4,
C1, C2, Cz, and a point 6 cm in front of Cz (International
10/20 EEG electrode system [24]). Cork-screw electrodes all four extremities (thenar, hypothenar, anterior tibialis,
are optimal for fixation to the scalp, but straight needle abductor hallucis). Other muscles, such as the quadriceps,
electrodes as well as surface electrodes are also in use. hamstrings, biceps, even the diaphragm, and the external
Electrical stimulation with rectangular constant current anal sphincter can be used. The signals are amplified 10,000
impulses of 0.5 ms duration and intensities between 15 and times, and recorded on epochs of 100 ms with a filter setting
220 mA is used. from 1.5 to 800 Hz. Muscle MEPs also do not require averag-
D-waves [7] are elicited with single stimuli. This is there- ing and can be repeated at a rate of 0.5—2 Hz. With the focal
fore called the ‘‘single stimulus technique’’ (Fig. 1). The anode as stimulating electrode, a montage of C1/2 (anode at
D-waves are recorded as travelling waves directly from the C1, cathode at C2) will first yield responses in the right-sided
spinal cord with an electrode inserted into the spinal epidu- muscles, and higher intensities in muscles of both sides. Usu-
ral space by the surgeon. The signals are amplified 10,000 ally the lower extremities require higher stimulus intensities
times, the filter bandpass is set from 1.5 to 1700 Hz, record- than the upper extremities. C3/4, C4/3 or Cz/6 are used
ing epochs are 20 ms. Baseline recordings are obtained individually as alternative stimulation points. The stimula-
before dura opening. The signal usually does not require tion parameters have recently been further elucidated to
averaging, although recording quality often improves with
a few averages. The stimulations are repeatable at a rate of
0.5—2 Hz. This provides practically real-time feedback.
The relevant D-wave parameter is its peak-to-peak ampli-
tude (Fig. 2). A decrease of more than 50% of the baseline
amplitude is associated with a long-term motor deficit [25].
Latency changes of the D-wave are much less important and
usually not due to surgery but to circumstances such as tem-
perature [26]. Higher stimulation intensities are followed
by shorter D-wave latencies. This is likely due to the corti-
cospinal tract fiber activation occuring deeper in the white
matter of the brain [14].
Muscle MEPs are elicited with transcranial electrical stim-
ulation over the same electrodes as for the D-wave. A short
train of five to seven stimuli with four milliseconds inter-
stimulus intervals [27,28] is used. The technique is called
‘‘multipulse technique’’ [22] or ‘‘train stimulus technique’’
(Fig. 1) [17,18]. Compound muscle action potentials are Figure 2 D-wave recording and interpretation. The peak-to-
recorded with needle electrodes from target muscles in peak amplitude is the relevant parameter.
410
Figure 3 Muscle MEP recording. The presence or absence of
muscle MEPs is the relevant parameter in spinal cord surgery.
substantiate this concept [29]. Muscle MEPs are recorded in
alternance with D-waves.
The principle of evoking muscle responses is understood
in the context of the D-wave concept: each individual elec-
trical stimulus on the motor cortex, either with exposed
cortex or with transcranial stimulation [13], elicits a D-wave
in the corticospinal tract. A fast train of five stimuli at 250 Hz
elicits five consecutive D-waves, which then travel down
the corticospinal tract four milliseconds apart. The spinal
␣-motorneurons are hit by those five D-waves, which ele-
vates their membrane potential to firing threshold [8]. The
monitored parameter is the presence or absence of muscle
MEPs in the target muscles within a stimulus intensity range
of 15 to 220 mA (Fig. 3). This all-or-none concept has been
adopted because of the variability of muscle MEP ampli-
tudes [19,30,31] and because a motor deficit occurred only
when the muscle responses were lost [16,19,31]. To define a
threshold amplitude below which one expects an intraoper-
ative injury is impractical. It must be emphasized that this
principle can only be applied to spinal-cord surgery. This is
not appropriate for posterior-fossa or particularly supraten-
torial brain surgery.
With more and more MEP monitoring performed world-
wide, safety concerns have grown. Fortunately, this wider
use has not resulted in large numbers of reported complica-
tions, resulting from of tissue damage [18,32] or seizures.
Nevertheless, this issue continues to be growing in impor-
tance. It has recently been reviewed in depth [33].
Anesthesia [34]
A constant infusion of propofol (100—150 ␮g kg−1 min−1 )
and fentanyl (1 ␮g kg−1 h−1 ) is used when MEP monitoring
is required. Propofol for anesthesia with MEP monitor-
ing has been reported with various stimulation techniques
[35—39]. Bolus injections of both intravenous agents should
be avoided because this appears to temporarily disrupt mus-
cle MEP recording. This can be particularly problematic
during the critical resection stages of any spinal-cord tumor
surgery.
Short-acting muscle relaxants are given for intubation
only.
K.F. Kothbauer
Halogenated anesthetics should not be used [17,18], even
though low doses may be tolerable [40]. They elevate mus-
cle MEP stimulus thresholds and block muscle MEPs in a
dose-dependent fashion [40]. Using them would add an
uncontrollable variable.
Neurosurgeons may feel unconfortable with some patient
movement during surgery, which results from transcranial
stimulation. ‘‘Partial’’ muscle relaxation [31] to solve this
problem is controversial. One wonders whether it improves
anesthesia management. With the patient fully relaxed,
muscle MEP monitoring is impossible, and only the D-wave
can be recorded. ‘‘Controlled’’ partial relaxation would add
an uncontrolled variable to the interpretation of MEP data.
The specificity of muscle MEP monitoring could deteriorate.
At the same time patient movement from stimulation could
still not be entirely ruled out. This would combine poor
monitoring with poor relaxation.
Operating on the unrelaxed patient is a matter of expe-
rience and comfort with the technique. If the movement
is, indeed, too intense, careful cooperation during surgery
between the surgeon and the monitoring team is required in
order to ensure that stimulation is only performed with the
surgeon warned or at his request between surgical manipu-
lations.
Clinical correlation of D-waves and muscle
MEPs
Primarily in New York, Verona, and Rome, MEP monitor-
ing has been routinely used for intramedullary spinal-cord
tumor surgery beginning in the mid-nineties. Experience was
gained in several hundred surgeries, and other centers have
begun to use the technology more recently.
The interpretation of neurophysiologic data is largely
independent of the nature of the spinal-cord lesion that is
operated on. Only the practical application may differ based
upon the biologic nature of the lesion.
Clinical assessment of pre- and postoperative neurologic
function can be done using the McCormick scale [41] or its
variants [42]. Motor function is classified as normal (no focal
motor deficit), slightly paretic (motor deficit not exceeding
4/5 and not significantly impairing the extremity’s function,
walking not impaired), severely paretic (motor deficit 3/5
or worse, significantly impaired function of extremity, or
inability to walk) and plegic (0/5 or 1/5). The ASIA scale
used for patients victim to spinal-cord injury can be used as
well.
Three questions must be answered by monitoring:
• do the intraoperatively obtained data reflect the ‘‘real’’
clinical status of the patient;
• is there a change indicating a reversible situation, that is
a sufficiently practical window of time and understand-
ing to avoid a permanent motor dysfunction by changing
surgery;
• does the use of monitoring improve the functional out-
come.
The first question — whether or not intraoperative MEP
data reflect the clinical reality — was answered in a series
of 100 consecutive operations of spinal-cord tumors [6].
Intraoperative neurophysiologic monitoring spinal-cord tumor surgery
Ninety-two patients could be reliably monitored. None of
the eight patients in this study who preoperatively had
severe motor deficits had recordable MEPs at the beginning
of surgery. Postoperatively a short-term motor deteriora-
tion was found in roughly one third of the patients (35
out of 92: 38%). Thus, the data obtained with D-wave and
MEP-monitoring during intramedullary surgery do reflect the
clinical ‘‘reality’’. In only two cases a severe permanent
neurological dysfunction occurred as a direct result of the
operation. Therefore the risk of paraplegia following resec-
tion of a spinal-cord tumor is lower than commonly believed.
These changes in clinical status are adquately reflected by
the intraoperative MEP information.
The second question — whether or not there is a time win-
dow of reversible change of MEP recordings — is addressed
by the concept of ‘‘transient motor deficit’’. This concept
comprises correlation of a reversible motor deficit — usu-
ally leg monoparesis or paraparesis — with muscle MEP loss
and D-wave preservation: As long as the D-wave is pre-
served with sufficient amplitude, that is, an amplitude of at
least 50% of the baseline value, loss of muscle MEPs during
intramedullary surgery is only correlating with a paraparesis,
or, at maximal, paraplegia of finite duration. This concept
has been practically observed by numerous surgical groups
and provides a ‘‘window of warning’’, during which the
surgical manipulation can be adapted before a permanent
deficit occurs.
The third question — whether or not the use of MEP
monitoring indeed improves neurological outcome — has
recently been answered by a publication from Verona [23].
A significant number of consecutive intramedullary tumor
surgeries performed before introduction of MEP monitor-
ing were compared to a comparable number of consecutive
operations performed with monitoring. The same highly-
experienced surgeon performed those operations, thereby
virtually excluding the surgical learning curve. The result
was a neurological outcome advantage for the monitored
group. Extent of resection did not differ in both groups,
documenting that the use of monitoring does not make the
surgeon too ‘‘timid’’ to proceed until a tumor resection is,
indeed, complete.
Practical intraoperative neurophysiology for
spinal-cord surgery
Feasibility and practicality of monitoring
The preparation of the electrode setup on the patient is
completed parallel to the surgical and anesthesia prepa-
ration after intubation. After positioning and during the
approach, baseline recordings are obtained. Any additional
time requirement for monitoring preparations is moderate
at most. The epidural recording electrodes are placed by
the surgeon. Occasionally scarring from a prior surgery can
hinder the electrode insertion. Subdural placement can then
be attempted as an alternative.
Practically all patients without severe preoperative
motor deficits can be monitored with either D-wave or mus-
cle MEPs or both.
The recordings are usually robust (between 10 and 70 ␮V
amplitudes of epidural and up to 2 mV in muscle MEPs).
411
Changes due to non-surgical influences (intravenous bolus
of anesthetic, temperature or blood pressure changes) can
be recognized by following these parameters and efficiently
communicating with the anesthesiologist.
During surgery, D-waves and muscle MEPs indicate
some effect of the surgical manipulation on the func-
tional integrity of the motor pathways at some point
during the procedure in almost 50% of the cases. In
about one third of cases, these changes remain until
the end of the operation, and then correlate to a tem-
porary motor deficit. In the remainder of cases the
changes are reversible during surgery and this correlates
to intact motor function when the patient awakes from
anesthesia.
Interpretation of D-wave recordings
The relevant parameter in D-wave interpretation is its peak-
to-peak amplitude.
The monitorability of the D-wave and the intraop-
erative significant decline of its amplitude have been
shown to be of predictive value for the motor outcome
after intramedullary surgery [25]. In about two-thirds of
the patients with non-conus tumors, a D-wave is record-
able [6,25]. Since D-waves are generated by corticospinal
tract axons, conus tumors cannot be monitored with this
modality.
Patients who have no monitorable D-wave at the begin-
ning of surgery have a higher risk of postoperative motor
deficits than those with a recordable D-wave [25]. Whether
this is due to an inherent subclinical damage and vulner-
ability of the motor tract, or to the fact that there was
no monitoring support for the surgery, is not known. The
explanation for the absence of a recordable D-wave in an
individual with intact motor function (and recordable mus-
cle MEPs) is believed to be due to a desynchronization of the
wave [43]. This appears to occur more frequently in patients
with prior surgery, very extensive tumors, and particularly
those with prior radiation therapy to the spinal cord.
The intraoperative amplitude decrease of the D-wave
correlates with postoperative outcome. If the D-wave is
unchanged, there is no permanent postoperative deficit,
although there may be a transient deficit if muscle MEPs are
lost. If the D-wave amplitude declines more than 50% of the
baseline value or even disappears, permanent paraplegia is
likely to occur [11,25].
Interpretation of muscle MEPs
The presence of muscle MEPs always indicates intact func-
tional integrity of the corticospinal tract. Occasionally, in
patients with a moderate motor deficit, it may be difficult
to obtain recordings from both lower extremities. If that
occurs, usually responses in the weaker leg require higher
stimulation intensities. Intraoperative preservation of mus-
cle MEPs means intact motor function postoperatively in all
cases. Intraoperative loss of muscle MEPs indicates some
postoperative impairment of voluntary motor control with
a specificity of about 90%. For instance, muscle MEP loss
in one leg during the resection means that the patient will
postoperatively be unable to move this particular extremity
412
Figure 4 An example for the neurophysiological equivalent
of a temporary motor deficit. Anterior tibialis MEPs are present
at the beginning, but lost at the end of surgery. When the D-
wave is preserved (not shown), this correlates to a transient
paraplegia. Recovery usually takes place within days.
for a limited period of time. This is called a temporary motor
deficit (Fig. 4). Loss of muscle MEPs in both legs is indicat-
ing bilateral motor deficit. Unilateral loss is of less concern
as it has been shown in the past, that unilateral motor dis-
ruption always recovers with a mechanism where the intact
side ‘‘takes over’’ control of the affected side [44].
Combined interpretation of D-wave and muscle
MEPs [6,45]
The D-wave amplitude is a measure of the number of fast
conducting fibers in the corticospinal tract. If 50% of these
fibers are damaged by the procedure, the amplitude will
decrease to 50% of its baseline value.
Experience has shown that a D-wave amplitude decrease
is most frequently gradual. By and large D-wave amplitude
decrease is associated with loss of muscle MEPs. It may
be however, that muscle MEP loss occurs without D-wave
amplitude decrease, or that the D-wave decreases with-
out changes in muscle MEPs. The underlying mechanisms of
these observations are not understood. In any event, preser-
vation of the D-wave above the 50% cutoff value has been
found to be predictive of long-term preservation of vol-
untary motor control in the lower extremities. With loss
of muscle MEPs and preserved D-wave amplitude a tem-
porary motor deficit is expected postoperatively. In this
situation it is still safe to complete a resection, or to pause
and wait for recordings to improve, which they often do.
This situation is the window of warning, the window of
reversible change, which allows for a change in surgical
strategy and manipulation before an irreversible injury has
occurred.
The interpretation of data when the high cervical cord is
affected is more complicated because neural basis for motor
control of the hands and fingers is more complex than that of
the more automated programs controlling lower extremity
function for walking and posture.
K.F. Kothbauer
Patterns of MEP changes during surgical maneuvers
and manipulations
Most frequently MEP changes occur towards the end of the
resection, when the interface to normal tissue comes close.
Since most spinal-cord tumors are resected in an inside-out
and piecemeal fashion (with the exception of some ependy-
momas) direct manipulation or vascular compromise occurs
when the tumor-cord interface is reached. Often muscle
MEPs disappear first. This may be preceded by an increase
in threshold for this particular muscle response. Sometimes
pausing the resection and irrigating the cavity with warm
saline results in reappearance of the response. Similarly
D-wave amplitude deterioration may be reversible by paus-
ing and irrigating. It is believed that removing and diluting
potassium from the field removes a strong axonal blocking
agent. Potassium accumulates as a result from local tissue
damage by surgery.
Sometimes dissection in a particular location results in
MEP changes, and the resection can proceed at a different
spot without further change. Fortunately, sudden decrease
in D-wave amplitude, often coinciding with sudden loss
of muscle MEPs occurs rarely. It is believed to be associ-
ated with vascular injury rather than direct physical tissue
manipulation. Temporary moderate elevation of mean blood
pressure has been successful in improving both D-waves and
muscle MEPs, with a satisfactory clinical result.
Under some circumstances the warning provided by intra-
operative MEP changes remains of but documentary value:
while the removal of an astrocytoma can be terminated
without jeopardizing the patient’s neurologic and oncologic
outcome, the resection of a hemangioblastoma is an all-or-
none enterprise. Once resection is attempted such a lesion
must be entirely removed, no matter what the MEP param-
eters indicate, or serious bleeding and swelling would lead
to a certain damage of the spinal cord.
The use of certain surgical instruments appears to have
a significant impact on changes detected by MEP record-
ings. For instance the use of the ultrasonic aspirator (CUSA)
seems to result rather frequently in an MEP deterioration.
On the contrary, use of the Nd:YAG handheld microsurgical
laser (SLT, Surgical Laser Technologies, Inc.) or the regular,
or the Greenwood bipolars [46] to vaporize tumor and mobi-
lize small fragments seems to be less damaging. This does
not mean the CUSA cannot be used, but its use should be lim-
ited to removing portions of tumor already detached from
the spinal cord itself, rather than to internally debulk in situ
tumor mass.
The use of bipolar coagulation always disrupts electro-
physiological recordings for the time the current is active.
One of the significant advantages of the microsurgical laser
beyond its advantages as a microsurgical instrument with
powerful cutting capability is that its use does not produce
an electrical artifact, therefore monitoring continues undis-
turbed [47].
Influence of MEP monitoring on extent of resection
Sometimes the resection of a spinal-cord tumor must be
terminated before the desired extent of resection is accom-
plished. This is based on the neurophysiological concept
Intraoperative neurophysiologic monitoring spinal-cord tumor surgery
described above and thus an acceptable limit of MEP change
is reached (D-wave decline, loss of muscle MEPs). Although
the actual number of cases is low, about 5% in a previously
cited series [6], this is an important factor in subsequent
decision making. Depending upon the actual extent of resec-
tion on the postoperative MRI scan and the histology of the
lesion a second stage of the resection may be attempted
once the patient has recovered motor control. This is of big
importance for spinal-cord ependymomas where complete
resection is the main predictor for long-term progression
free survival [48]. It has been claimed that MEP monitoring
may be too sensitive, actually stopping resection too early
[49]. There may always be a trade-off between extent of
resection and preservation of motor function in some cases.
But the recent study from Verona [23] clearly shows no dif-
ference in the extent of resection between the monitored
and the non-monitored patient groups. Therefore the con-
clusion can be made that spinal-cord tumors are resected at
least as radical and safer with than without monitoring.
Furthermore, stable MEP recordings are encouraging the
surgeon to proceed with tumor resection even though the
anatomical situation suggested otherwise.
In doubt, it is still wise to err on the safe conserva-
tive side, thus to leave residual tumor behind, which may
be accessible to a second surgical attempt than to risk a
significant and possibly permanent neurological deficit.
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