Optimization of direct cortical stimulation using tibial versus median nerve sensory mapping during midline brain tumor resection: illustrative case.

BACKGROUND: During brain tumor resection, neurophysiological mapping and monitoring help surgeons locate, characterize, and functionally assess eloquent brain areas in real time. The selection of mapping and monitoring targets has implications for successful surgery. Here, the authors compare direct cortical stimulation (DCS) as suggested by median nerve (MN) with posterior tibial nerve (PTN) cortical sensory mapping (SM) during mesial lesion resection. OBSERVATIONS: Recordings from a 6-contact cortical strip served to generate an MN and a PTN sensory map, which indicated the strip was anterior to the central sulcus. Responses exhibited an amplitude gradient with no phase reversal (PR). DCS, elicited through a stimulus probe or contact(s) of the strip, yielded larger responses from the corresponding sensory mapped limb; that is, PTN SM resulted in larger lower limb muscle responses than those suggested by MN SM. LESSONS: SM of the MN and PTN is effective for localizing eloquent cortical areas wherein the PTN is favored in surgery for mesial cortical tumors. The recorded amplitude of the cortical somatosensory evoked potential is a valuable criterion for defining the optimal location for DCS, despite an absent PR. The pathway at risk dictates the specifics of SM, which subsequently defines the optimal location for DCS.

Safety analysis and complications of condylar screws in a single-surgeon series of 250 occipitocervical fusions.

OBJECTIVE: Condylar screw fixation is a rescue technique and an alternative to the conventional configuration of occipitocervical fusion. Condylar screws are utilized when previous surgical bone removal along the supraocciput has occurred which makes anchoring of a traditional barplate technically difficult or impossible. However, the challenging dissection of C0-1 necessary for condylar screw fixation and the concerns about possible complications have, thus far, prevented the acquisition of large surgical series utilizing occipital condylar screws. In the largest case series to date, this paper aims to evaluate the safety profile and complications of condylar screw fixation for occipitocervical fusion. METHODS: A retrospective safety and complication-based analysis of occipitocervical fusion via condylar screws fixation was performed. RESULTS: A total of 250 patients underwent occipitocervical fusions using 500 condylar screws between September 2012 and September 2018. No condylar screw pullouts, or vertebral artery impingements were observed in this series. The sacrifice of condylar veins during the dissection at C0-1 did not cause any venous stroke. Hypotrophic condyles were found in 36.4% (91 of the 250) cases and did not prevent the insertion of condylar screws. Two transient hypoglossal deficits occurred at the beginning of this surgical series and were followed by recovery a few months later. Corrective strategies were effective in preventing further hypoglossal injuries. CONCLUSIONS: This surgical series suggests that the use of condylar screws fixation is a relatively safe and reliable option for OC fusion in both adult and pediatric patients. Methodical dissection of anatomical landmarks, intraoperative imaging, and neurophysiologic monitoring allowed the safe execution of the largest series of condylar screws reported to date. Separate contributions will follow in the future to provide details about the long-term clinical outcome of this series.

Electromyographic assessment of condylar screw placement during occipitocervical fusion.

OBJECTIVE: This is a retrospective study of a series of occipitocervical fusion procedures with condylar screw fixation in which the authors investigated the utility of electromyography (EMG, free-running and triggered) as a reliable tool in assessing the positioning of condylar screws. This series consisted of 197 patients between 15 and 60 years of age who presented with craniocervical instability, and who were treated between October 2014 and December 2017. METHODS: Intraoperative free-running EMG was observed at the placement of condylar screws, as well as at realigning of the spine. After placement the condylar screws were stimulated electrically, and the thresholds were recorded. CT scans were obtained intraoperatively soon after screw stimulation, and the results were analyzed by the surgeon in real time. Free-running EMG results and triggered EMG thresholds were tabulated, and the minimum acceptable threshold was established. RESULTS: Intraoperative free-running EMG and triggered EMG were able to correlate alerts with condylar screw placement accurately. A triggered EMG threshold of 2.7 mA was found to be a minimum acceptable threshold. A combination criterion of free-running EMG and triggered EMG alerts was found to enable accurate assessment of condylar screw positioning and placement. CONCLUSIONS: Intraoperative free-running EMG and triggered EMG were both found to be invaluable utilities in assessing the placement and positioning of condylar screws. Stimulation thresholds below 2.7 mA correlated with a superior or anterior condylar breach. Thresholds in the 2.7-mA to 9.0-mA range were generally acceptable but warranted additional inspection by the surgeon. Threshold values above 9.0 mA corresponded with solid condylar screw placement.