[Practical localization of the central sulcus using a video display during surgery by cortical somatosensory evoked...

In patients with lesions around the central sulcus, cortical surface somatosensory evoked potentials (SEPs) have been applied for the purpose of localization of the central sulcus based on the polarity inversion of postcentral N20 to precentral P20 across the central sulcus. We have intraoperatively monitored SEPs to infer the location of the central sulcus in 16 cases since December 1988. Intraoperative localization of the central sulcus has been most useful in patients with frontal lobe gliomas in which the localization of the central sulcus enables the surgeon to extensively resect tumor without postoperative motor weakness. The localization of the central sulcus, however, might be misjudged by using the polarity inversion criterion alone, because central P25 following N20 and P20 complicates SEP waveforms. It is significant that P25, which is recorded also posterior to the central sulcus, is discerned from the precentral P20. In order to solve this matter, we regarded only the positivity in SEP waveforms having the identical peak latency to that of N20 as the precentral P20. Positive potentials having a later peak latency than that of N20 are the superposition of P20 and P25, and might also be recorded posterior to the central sulcus. For the observation of the polarity inversion of N20 to P20 across the central sulcus, a multi-channel SEP should be recorded using a sheet of silicone rubber embedded in a 16-electrode array consisting of a 4 by 4 grid. We projected the exposed cortical surface on the video display through the microscope apparatus and marked the locations of the recording electrodes on the video display. This enabled the location of the recording electrodes to correspond easily and precisely to the cortical surface. Our reliable and simple method of intraoperative localization of the central sulcus by cortical SEPs monitoring is presented in a practical case.