The value of intraoperative motor evoked potential monitoring during surgical intervention for thoracic idiopathic spinal cord herniation

Clinical article

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Object

Thoracic idiopathic spinal cord herniation (TISCH) is a rare neurological disorder characterized by an incarceration of the spinal cord at the site of a ventral dural defect. The disorder is associated with clinical signs of progressive thoracic myelopathy. Surgery can withhold the natural clinical course, but surgical repair of the dural defect bears a significant risk of additional postoperative motor deficits, including permanent paraplegia. Intraoperative online information about the functional integrity of the spinal cord and warning signs about acute functional impairment of motor pathways could contribute to a lower risk of permanent postoperative motor deficit. Motor evoked potential (MEP) monitoring can instantly and reliably detect dysfunction of motor pathways in the spinal cord. The authors have applied MEPs during intraoperative neurophysiological monitoring (IOM) for surgical repair of TISCH and have correlated the results of IOM with its influence on the surgical procedure and with the functional postoperative outcome.

Methods

The authors retrospectively reviewed the intraoperative neurophysiological data and clinical records of 4 patients who underwent surgical treatment for TISCH in 3 institutions where IOM, including somatosensory evoked potentials and MEPs, is routinely used for spinal cord surgery. In all 4 patients the spinal cord was reduced from a posterior approach and the dural defect was repaired using a dural graft.

Results

Motor evoked potential monitoring was feasible in all patients. Significant intraoperative changes of MEPs were observed in 2 patients. The changes were detected within seconds after manipulation of the spinal cord. Monitoring of MEPs led to immediate revision of the placement of the dural graft in one case and to temporary cessation of the release of the incarcerated spinal cord in the other. Changes occurred selectively in MEPs and were reversible. In both patients, transient changes in intraoperative MEPs correlated with a reversible postoperative motor deficit. Patients without significant changes in somatosensory evoked potentials and MEPs demonstrated no additional neurological deficit postoperatively and showed improvement of motor function during follow-up.

Conclusions

Surgical repair of the dural defect is effected by release and reduction of the spinal cord and insertion of dural substitute over the dural defect. Careful monitoring of the functional integrity of spinal cord long tracts during surgical manipulation of the cord can detect surgically induced impairment. The authors' documentation of acute loss of MEPs that correlated with reversible postoperative motor deficit substantiates the necessity of IOM including continuous monitoring of MEPs for the surgical treatment of TISCH.

Abbreviations used in this paper: eMEP = epidural motor evoked potential; EP = evoked potentials; IOM = intraoperative neurophysiological monitoring; MEP = motor evoked potential; mMEP = muscle MEP; MRC = Medical Research Council; SEP = somatosensory evoked potential; TISCH = thoracic idiopathic spinal cord herniation.

Article Information

Address correspondence to: Klaus Novak, M.D., Medical University of Vienna, Department of Neurosurgery, Währinger Gürtel 18-20, A-1090, Wien, Austria, European Union. email: klaus.novak@meduniwien.ac.at.

Please include this information when citing this paper: published online November 25, 2011; DOI: 10.3171/2011.10.SPINE11109.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graphic depiction of TISCH and its surgical treatment. A: Case 2. Illustration showing an intradural arachnoid cyst located dorsally to the ventral deviation of the spinal cord associated with TISCH. B: Case 2. Placement of a circular dural graft to prevent recurrent herniation of the spinal cord. C: Case 4. Modification of graft fixation using laterally arrayed tacking sutures. Th 4 = T-4.

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    Case 1. Left: Intraoperative photograph showing the ventrally herniated spinal cord (arrow). Right: Muscle MEPs before (marked open) and after surgical repair for TISCH (marked clos). The traces show loss of right lower-extremity mMEPs recorded from the anterior tibial (Rt Tib) and abductor hallucis (Rt AHB) muscles. Recordings from left lower-extremity muscles show preservation of mMEPs from the anterior tibial (Lt Tib) and abductor hallucis (Lt AHB) muscles. ms = msec.

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    Case 2. A: Axial and sagittal T2-weighted MR images demonstrating TISCH. The axial image shows the characteristic dumb-bell shaped configuration of the transdurally herniated spinal cord. B: Intraoperative photograph of the arachnoid cyst dorsal to the herniated cord. The arrows indicate an arachnoid cyst beneath arachnoid adhesions. C: Endoscopic view of the arachnoid cyst. D: Intraoperative presentation of the herniated spinal cord after mobilization on the right side. The thin black arrows indicate the dural edge; the wide arrow indicates the herniated cord. E: Photograph showing careful mobilization of the spinal cord through the dural defect. The arrows indicate the left lateral ridge of the dural defect. F: Photograph showing focal pial sclerosis that was revealed after release of the spinal cord. The arrow indicates sclerosis on the surface of the exposed herniated spinal cord.

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    Case 2. Left: Postoperative T2-weighted MR image showing intradural alignment of the spinal cord 2 weeks after reduction and dural repair. Right: Follow-up T2-weighted MR image obtained 4 months after surgery showing pathological intramedullary signal indicating postoperative myelopathy caudal to the dural graft.

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    Case 4. Left: Sagittal T2-weighted MR image demonstrating TISCH at the T4–5 level. Right: Axial T2-weighted MR image demonstrating severe atrophy of the spinal cord at the level of the TISCH.

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    Case 4. Intraoperative changes in eMEP monitoring. Significant eMEP changes occurred during release and mobilization of the incarcerated spinal cord on the right side. A: Traces of eMEPs from stimuli predominantly activating the left corticospinal tract (CST) before surgical manipulation of the spinal cord (open), during mobilization of the spinal cord, after loss of mMEPs, and at the end of surgery (closing), showing a significant decrease after mobilization of the spinal cord. B: Traces showing decrease of eMEPs from stimuli predominantly activating the right CST after mobilization of the spinal cord.

  • View in gallery

    Case 4. Postoperative MR images. Upper: Sagittal T2-weighted (left) and contrast-enhanced T1-weighted (right) images obtained 2 weeks after surgery showing regular alignment of the spinal cord with no intramedullary signal alteration. Lower: Sagittal T2-weighted (left) and T1-weighted (right) images obtained 30 months after surgery showing focal spinal cord atrophy at the level of TISCH.

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