[D-wave-guided navigation in spinal cord surgery: From monitoring to decision-making]

The primary goal of spinal cord surgery is to achieve maximal safe resection of lesions while preserving neurological function. Direct wave (D-wave) monitoring, regarded as the gold standard for assessing the functional integrity of the corticospinal tract (CST), has evolved from a passive monitoring tool into an active intraoperative functional navigation system. To systematically review the evolution and clinical application of D-wave-guided navigation, this article discusses 3 key aspects. First, technological advancements, such as subdural recording techniques, have improved signal stability and enabled quantitative assessment. Second, multimodal integration, particularly in combination with motor evoked potentials, facilitates the differential diagnosis between presynaptic and postsynaptic injuries. Third, the scope of application has been successfully expanded to include very young children and a wide range of complex spinal cord surgeries, overcoming traditional limitations related to age and disease type. Furthermore, emerging directions such as artificial intelligence-based warning systems and image-guided fusion navigation are explored, highlighting the transition of D-wave monitoring from experience-based practice to data-driven intelligence. These developments may provide both theoretical support and practical guidance for improving the precision and safety of spinal cord surgery.