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Neurophysiologic intraoperative monitoring during surgery for tethered cord syndrome
Bhojo Khealani1, Aatif M Husain
1Department of Medicine (Neurology), The Aga Khan University, Karachi, Pakistan.
Insights
Neurophysiologic intraoperative monitoring is crucial for tethered cord syndrome (TCS) surgery to prevent nerve damage. This review examines monitoring techniques and supporting evidence to reduce surgical complications.
Area of Science:
- Neurosurgery
- Neurology
- Spinal Cord Medicine
Background:
- Tethered cord syndrome (TCS) involves spinal cord adherence to inelastic tissue, causing progressive sensorimotor deficits and dysfunction.
- Symptoms manifest in lower extremities, bowel/bladder control, and musculoskeletal development, often presenting in childhood but also in adults.
- Surgical correction is essential but risks iatrogenic nerve injury due to proximity or involvement in the tether.
Purpose of the Study:
- To review neurophysiologic intraoperative monitoring (NIOM) paradigms used in TCS surgery.
- To discuss the evidence supporting the efficacy of NIOM in reducing surgical morbidity.
- To highlight the importance of NIOM in identifying neural structures and minimizing injury during TCS operations.
Main Methods:
- Review of various NIOM techniques employed during TCS surgery.
- Analysis of electromyography (EMG) for lower extremity and sphincter muscles.
- Evaluation of somatosensory evoked potentials (SSEPs) and bulbocavernosus reflex testing.
Main Results:
- Multiple NIOM paradigms are utilized in TCS surgery, including EMG, SSEPs, and reflex testing.
- While widely believed to reduce complications, robust data supporting NIOM's efficacy in TCS surgery is limited.
- NIOM aims to identify neural structures and mitigate risks of inadvertent nerve injury.
Conclusions:
- NIOM plays a vital role in TCS surgery by identifying neural structures and potentially reducing iatrogenic injury.
- Further research and data collection are needed to definitively establish the benefits of specific NIOM paradigms in TCS.
- Optimizing NIOM strategies can enhance surgical outcomes and patient safety in tethered cord syndrome treatment.
Abstract:
Tethered cord syndrome (TCS) occurs when the distal spinal cord is adherent to inelastic tissue. This results in sensorimotor deficits in the lower extremities, bowel and bladder dysfunction, and musculoskeletal deformities. Tethered cord syndrome is often found in childhood, but may be first noticed in adults as well. The symptoms are usually progressive unless halted by surgical correction of the spinal cord tethering. Surgery for TCS can be complicated by inadvertent injury to nerves that are either embedded in the tether or in close proximity to it. In an attempt to reduce this iatrogenic injury, neurophysiologic intraoperative monitoring is used to identify neural structures in the surgical field and reduce the risk of injury. Many neurophysiologic intraoperative monitoring paradigms have been used in TCS surgery, including free running and stimulated electromyography of the muscles of the lower extremities, external anal and external urethral sphincter electromyography, tibial, clitoral, and dorsal penile somatosensory evoked potentials, and bulbocavernosus reflex testing. It is widely believed that neurophysiologic intraoperative monitoring helps reduce morbidity of TCS surgery, but data supporting this are limited. This article will review the various neurophysiologic intraoperative monitoring paradigms that can be used in TCS surgery and discuss the data supporting the use of these paradigms.
