A 77-year-old male presented with a history of severe lower back pain for 10 years with radiculopathy, positive claudication type symptoms in his calf with walking, and severe "burning" in his legs bilaterally with walking. Magnetic resonance imaging (MRI) revealed lumbar stenosis at the L3-L4 and L4-L5 levels. During the direct or extreme lateral interbody fusion (DLIF/XLIF) procedure, bilateral posterior tibial, femoral, and ulnar nerve somatosensory evoked potentials (SSEPs) were recorded with good morphology of waveforms observed. Spontaneous electromyography (S-EMG) and triggered electromyography (T-EMG) were recorded from cremaster and ipsilateral leg muscles. A left lateral retroperitoneal transpsoas approach was used to access the anterior disc space for complete discectomy, distraction, and interbody fusion. T-EMG ranging from 0.05 to 55.0 mA with duration of 200 microsec was used for identification of the genitofemoral nerve using a monopolar stimulator during the approach. The genitofemoral nerve (L1-L2) was identified, and the guidewire was redirected away from the nerve. Post-operatively, the patient reported complete pain relief and displayed no complications from the procedure. Intraoperative SSEPs, S-EMG, and T-EMG were utilized effectively to guide the surgeon's approach in this DLIF thereby preventing any post-operative neurological deficits such as damage to the genitofemoral nerve that could lead to groin pain.
Children undergoing corrective spine surgery are at risk of serious neurologic injury. Monitoring transcranial electric motor evoked potentials (TCeMEPs) during these procedures may identify and help prevent injury to motor pathways. The difficulty in obtaining consistent motor evoked potential (MEP) responses during pediatric spine surgery can result in part to the suppression of evoked responses caused by volatile inhalational anesthetics, elevated levels of propofol, and/or physiologic variables. Data obtained from 140 pediatric patients who underwent spine surgery with MEP monitoring were retrospectively analyzed and evaluated for age and anesthetic effects on stimulation variables. MEPs acquired under inhalational anesthetic agents required greater stimulation compared to intravenous propofol anesthesia. Additionally, the responses were more variable when inhalational agents were used. These effects were more prominent in younger age patients. The number of alerts of MEP loss or reduction related to anesthetic levels or blood pressure changes was higher under inhalational agents.
The titanium rib procedure is a safe and effective way of surgically treating pediatric patients with thoracic insufficiency syndrome and scoliosis. As with any invasive surgical procedure, it is not without risks. This article explains the potential risks to neurological structures while outlining the surgical approach and the neurological anatomy in the vicinity of the implanted instrumentation. The types of potential nerve injury involve ischemia, trauma, compression, and stretch. Furthermore, a suitable compilation of modalities of intraoperative neurophysiologic monitoring is recommended to detect and avoid long-term nerve or spinal cord insult. Monitoring modalities that would be appropriate for this procedure are discussed.
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