Spinal cord mapping as an adjunct for resection of intramedullary tumors: Surgical technique with case illustrations

Alfredo Quinones-Hinojosa, Mittul Gulati, Russell Lyon, Nalin Gupta, Charles Yingling, Paul R. Cooper, Edward C. Benzel, Volker K H Sonntag, Paul C. McCormick

Research output: Contribution to journalArticle

Abstract

OBJECTIVE: Resection of intramedullary spinal cord tumors may result in transient or permanent neurological deficits. Intraoperative somatosensory evoked potentials (SSEPs) and motor evoked potentials are commonly used to limit complications. We used both antidromically elicited SSEPs for planning the myelotomy site and direct mapping of spinal cord tracts during tumor resection to reduce the risk of neurological deficits and increase the extent of tumor resection. METHODS: In two patients, 3 and 12 years of age, with tumors of the thoracic and cervical spinal cord, respectively, antidromically elicited SSEPs were evoked by stimulation of the dorsal columns and were recorded with subdermal electrodes placed at the medial malleoli bilaterally. Intramedullary spinal cord mapping was performed by stimulating the resection cavity with a handheld Ojemann stimulator (Radionics, Burlington, MA). In addition to visual observation, subdermal needle electrodes inserted into the abductor pollicis brevis-flexor digiti minimi manus, tibialis anteriorgastrocnemius, and abductor halluces-abductor digiti minimi pedis muscles bilaterally recorded responses that identified motor pathways. RESULTS: The midline of the spinal cord was anatomically identified by visualizing branches of the dorsal medullary vein penetrating the median sulcus. Antidromic responses were obtained by stimulation at 1-mm intervals on either side of the midline, and the region where no response was elicited was selected for the myelotomy. The anatomic and electrical midlines did not precisely overlap. Stimulation of abnormal tissue within the tumor did not elicit electromyographic activity. Approaching the periphery of the tumor, stimulation at 1 mA elicited an electromyographic response before normal spinal cord was visualized. Restimulation at lower currents by use of 0.25-mA increments identified the descending motor tracts adjacent to the tumor. After tumor resection, the tracts were restimulated to confirm functional integrity. Both patients were discharged within 2 weeks of surgery with minimal neurological deficits. CONCLUSION: Antidromically elicited SSEPs were important in determining the midline of a distorted cord for placement of the myelotomy incision. Mapping spinal cord motor tracts with direct spinal cord stimulation and electromyographic recording facilitated the extent of surgical resection.

Original languageEnglish (US)
Pages (from-to)1199-1207
Number of pages9
JournalNeurosurgery
Volume51
Issue number5
DOIs
StatePublished - Nov 1 2002
Externally publishedYes

Fingerprint

Spinal Cord
Somatosensory Evoked Potentials
Neoplasms
Electrodes
Hallux
Spinal Cord Neoplasms
Spinal Cord Stimulation
Efferent Pathways
Motor Evoked Potentials
Needles
Veins
Thorax
Observation
Muscles

Keywords

  • Direct stimulation spinal cord
  • Electrophysiological monitoring
  • Intramedullary spinal cord tumor
  • Intraoperative mapping
  • Motor evoked potentials
  • Somatosensory evoked potentials

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Quinones-Hinojosa, A., Gulati, M., Lyon, R., Gupta, N., Yingling, C., Cooper, P. R., ... McCormick, P. C. (2002). Spinal cord mapping as an adjunct for resection of intramedullary tumors: Surgical technique with case illustrations. Neurosurgery, 51(5), 1199-1207. https://doi.org/10.1097/00006123-200211000-00015

Spinal cord mapping as an adjunct for resection of intramedullary tumors : Surgical technique with case illustrations. / Quinones-Hinojosa, Alfredo; Gulati, Mittul; Lyon, Russell; Gupta, Nalin; Yingling, Charles; Cooper, Paul R.; Benzel, Edward C.; Sonntag, Volker K H; McCormick, Paul C.

In: Neurosurgery, Vol. 51, No. 5, 01.11.2002, p. 1199-1207.

Research output: Contribution to journalArticle

Quinones-Hinojosa, A, Gulati, M, Lyon, R, Gupta, N, Yingling, C, Cooper, PR, Benzel, EC, Sonntag, VKH & McCormick, PC 2002, 'Spinal cord mapping as an adjunct for resection of intramedullary tumors: Surgical technique with case illustrations', Neurosurgery, vol. 51, no. 5, pp. 1199-1207. https://doi.org/10.1097/00006123-200211000-00015
Quinones-Hinojosa, Alfredo ; Gulati, Mittul ; Lyon, Russell ; Gupta, Nalin ; Yingling, Charles ; Cooper, Paul R. ; Benzel, Edward C. ; Sonntag, Volker K H ; McCormick, Paul C. / Spinal cord mapping as an adjunct for resection of intramedullary tumors : Surgical technique with case illustrations. In: Neurosurgery. 2002 ; Vol. 51, No. 5. pp. 1199-1207.
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AU - Gupta, Nalin

AU - Yingling, Charles

AU - Cooper, Paul R.

AU - Benzel, Edward C.

AU - Sonntag, Volker K H

AU - McCormick, Paul C.

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N2 - OBJECTIVE: Resection of intramedullary spinal cord tumors may result in transient or permanent neurological deficits. Intraoperative somatosensory evoked potentials (SSEPs) and motor evoked potentials are commonly used to limit complications. We used both antidromically elicited SSEPs for planning the myelotomy site and direct mapping of spinal cord tracts during tumor resection to reduce the risk of neurological deficits and increase the extent of tumor resection. METHODS: In two patients, 3 and 12 years of age, with tumors of the thoracic and cervical spinal cord, respectively, antidromically elicited SSEPs were evoked by stimulation of the dorsal columns and were recorded with subdermal electrodes placed at the medial malleoli bilaterally. Intramedullary spinal cord mapping was performed by stimulating the resection cavity with a handheld Ojemann stimulator (Radionics, Burlington, MA). In addition to visual observation, subdermal needle electrodes inserted into the abductor pollicis brevis-flexor digiti minimi manus, tibialis anteriorgastrocnemius, and abductor halluces-abductor digiti minimi pedis muscles bilaterally recorded responses that identified motor pathways. RESULTS: The midline of the spinal cord was anatomically identified by visualizing branches of the dorsal medullary vein penetrating the median sulcus. Antidromic responses were obtained by stimulation at 1-mm intervals on either side of the midline, and the region where no response was elicited was selected for the myelotomy. The anatomic and electrical midlines did not precisely overlap. Stimulation of abnormal tissue within the tumor did not elicit electromyographic activity. Approaching the periphery of the tumor, stimulation at 1 mA elicited an electromyographic response before normal spinal cord was visualized. Restimulation at lower currents by use of 0.25-mA increments identified the descending motor tracts adjacent to the tumor. After tumor resection, the tracts were restimulated to confirm functional integrity. Both patients were discharged within 2 weeks of surgery with minimal neurological deficits. CONCLUSION: Antidromically elicited SSEPs were important in determining the midline of a distorted cord for placement of the myelotomy incision. Mapping spinal cord motor tracts with direct spinal cord stimulation and electromyographic recording facilitated the extent of surgical resection.

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