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Brain and Spine, clinical Case Reviews

Case Review Updates:
Its been a long time since I posted Case Reviews, wish to keep up whenever possible!. Keep checking this column for Case Reviews!!.
August 23 2021: 

Case report

Delayed neuromonitoring alarm after scoliosis correction in  Lenke type 4 adolescent idiopathic scoliosis

Scoliosis Case: 13 Year Old girl with "Lenke Type 4 Adolescent Idiopathic Scoliosis
Patient 13 Year Old girl
Condition or diagnosis: Idiopathic Scoliosis, Lenke Type4
Surgery: Corrective scoliosis surgical procedure
IONM: TcMEPs, not sure if EMGs or SSEPs!? tested.
The case review is published in BMJ Case Reports, only abstract is available, full article is a paid service, I have not read the full article. My comments are totally based on the abstract for which a Link is provided at the bottom.
Lenke Type 4 Scoliosis is a classification of the different type of scoliosis, type4 is bit complicated with multiple curves, in this case 3 or triple curves, considered complex and high risk neurologically!. The authors claimed in the abstract there was IONM alarm after the Correction procedure.  But in the same sentence they say decrease in Amplitude ~ 10 minutes after the surgery?... Is that not after the surgery?...
It looks like during the surgical procedure for correction when all the traction, forces and corrective steps being carried out there was no significant changes in TcMEP signals.  During the corrective procedure due to the complex nature of the case, possible transient ischemia occurred, and no IONM signal reported, but ~10 minutes after the surgery was completed, a decrease in TcMEP reported, authors find this a Delayed response may be due to Indirect Spinal Cord transient Ischemia?, both blood pressure, Temperature was normal, no IONM technical errors found!. A weak final correction was conducted, where a recovery in TcMEP amplitude recorded. Authors conclude that Scoliosis corrective surgery with triple curve may cause delayed TcMEP response and the Neurophysiologists or IONM team should check signals carefully!.
Case: Link
Other Links Lenke type classification:
Journal cover 
June7 2020 Today's Case Review!:
Foot Drop!:- a Rare case of Foot Drop.....!!
Presented and discussed by Ervina Bilic etal, published in Acta Neurol. Belg. Online Edition before Print Edition:  2019 Nov 30. doi: 10.1007/s13760-019-01255-8. Online ahead of print.
In the general practice or emergency, the foot drop cases will be examined by the respective practitioner and possibly get treated. However "Foot drop" is a different challenge in Operating room if it happens during surgical procedure or after!, though this foot drop case review is not about a particular Surgery related procedural after effect or results, it is about what broader perspective of what are the causes other than Peroneal nerve injury. In the surgery or consultation, a Neurophysiologist or Neurologist got to know all the possible factors to find out the actual cause of why a foot drop happened in a patient. For the IONM technicians who are doing the neuromonitoring, basic knowledge is neccessary, this will provide background knowledge information to know what is foot drop and how it happens, what are the causes etc!.. Obviously, Sciatic nerve branch "peroneal neuropathy or peroneal palsy is not the only cause a foot drop can happen?.

Today's interesting case review is about spinal cord glial cell cancer known as "Spinal Glioblastoma", glial cells are supporting cells that is not as specialized as neurons but they are an important part of the neuronal integerity as glia plays the scaffolding and scavenging role that keeps the neuronal cells healthy and functioning well. However, abnormal morphology or behavior of glial cells can make life miserable, case in point is the glioblastoma or astrocytoma etc, the following case report is an interesting review about a rare condition, surgical intervention is important regardless of the risks, as the growth of glioblastoma can produce severe lower extremity weakness and debilitating condition unattended can lead to death.         A Must read...published in Oncology Letters, March issue of 2013.

Primary spinal glioblastoma: A case report and review of the literature

NUNO MORAIS,1 et al.,
Oncol Lett. Mar 2013; 5(3): 992–996.
Published online Dec 14, 2012. doi:  10.3892/ol.2012.1076
Abstract:- Primary spinal glioblastoma (GBM) is a rare disease, with an aggressive course and a poor prognosis. We report a case of a 19-year-old male with a 4-week history of progressive weakness in both lower limbs, which progressed to paraparesis with a left predominance and difficulty in initiating urination over a week. Spine magnetic resonance imaging (MRI) showed an intramedullary expansile mass localised between T6 and T11. We performed a laminotomy and laminoplasty between T6 and T11 and the tumour was partially removed. Histopathological study was compatible with GBM. The patient was administered focal spine radiotherapy with chemotherapy with temozolamide. Serial MRI performed after the initial surgery demonstrated enlargement of the enhancing mass from T3 to T12 and subarachnoid metastatic deposits in C2 and C4, the pituitary stalk, inter-peduncular cistern, left superior cerebellar peduncle and hydrocephalus. We review the literature with regard to the disease and treatment options, and report the unique features of this case. Primary spinal GBM is an extremely rare entity with a poor prognosis and a short survival time. An aggressive management of the different complications as they arise and improvement of current modes of treatment and new treatment options are required to improve survival and ensure better quality of life.

Sept 2012
Case Review: Todays Case Review post
Case Report

Evolving Compartment Syndrome Detected by Loss of Somatosensory- and Motor-evoked Potential Signals During Cervical Spine Surgery

Wesley H. Bronson, BA; David Forsh, MD; Sheeraz A. Qureshi, MD; Stacie G. Deiner, MD; Donald J. Weisz, PhD; Andrew C. Hecht, MD
 Orthopedics, September 2012 - Volume 35 · Issue 9: e1453-e1456  DOI: 10.3928/01477447-20120822-40

Neurologic injury is a rare but devastating complication of spinal surgery that can result in mild sensory to severe motor deficits. With improved surgical techniques, the incidence of postoperative sensory and motor deficits has been reported to range from .01% to .05% during complex spinal procedures, such as spinal deformity corrective surgery.1
Surgeons increasingly use electro-physiological monitoring of spinal cord function, including somatosensory- and motor-evoked potentials signals, during spinal surgery to provide intraoperative information about spinal cord function, aid in surgical decision making, improve outcomes, and reduce complication rates. By providing real-time information about the dorsal and anterior motor column function, somatosensory- and motor-evoked potentials signals allow surgeons to reverse noticeable changes and avoid devastating neurologic injuries.
In combination, transcranial motor- and somatosensory-evoked potentials signals have been effective in improving the accuracy of monitoring spinal cord function. Many types of insults can result in intraoperative reductions of greater than 50% or complete loss of somatosensory- and motor-evoked potentials signals during spinal surgery.2–5 Surgeon-related influences, such as compression, stretching, vascular insufficiency, direct trauma, anesthesia, and temperature, can cause changes in signal intensity and cord damage.
Recognizing changes in baseline signals in the setting of known risk factors enables surgeons to correct these risks. Somatosensory-evoked potentials changes that are the result of hypotension, hypothermia, or high levels of anesthetic agents can be reversed by inducing hypertension or hyperthermia, reducing the inhalation of the anesthetic agent, or increasing the levels of inspired oxygen, thereby decreasing the incidence of lasting neurological injury.4 When surgical manipulation or graft placement is the cause, actions can be immediately stopped and corrected to avoid further injury. However, spinal cord monitoring has also been useful in identifying peripheral nerve issues related to malpositioned extremities.
This article describes a case in which the loss of somatosensory- and motor-evoked potentials signals occurred secondary to intravenous infiltration and near compartment syndrome during a 2-level anterior cervical diskectomy and fusion. The corrective steps taken intraoperatively prevented a devastating neurologic complication. To the authors’ knowledge, this is the first reported case of spinal cord monitoring detecting an evolving compartment syndrome during cervical spine surgery.

Case Report

A 45-year-old man presented with a history of a previous C6–C7 anterior cervical diskectomy and fusion for disk herniation and radiculopathy many years before. He subsequently developed a large C4–C5 disk herniation causing cervical myeloradiculopathy. He presented with continued bilateral upper-extremity weakness and pain refractory to nonoperative care. He underwent C4–C5 and C5–C6 anterior cervical diskectomy and fusion with instrumentation. The patient was positioned on a Jackson table (OSI Medical, Union City, California) with the arms tucked at the side wrapped in egg crate with the ulnar nerves well padded and the wrists in a neutral orientation. Gentle taping was applied to the shoulders to improve visualization on intraoperative fluoroscopy.
For full report:  http://www.healio.com/orthopedics/journals/ORTHO/%7BFEEFEA04-DF0F-45AA-BE99-601896C7622C%7D/Evolving-Compartment-Syndrome-Detected-by-Loss-of-Somatosensory--and-Motor-evoked-Potential-Signals-During-Cervical-Spine-Surgery
doi: 10.3928/01477447-20120822-40

May, 2 2012
Case Review: Todays case review of Interest.

The Electroencephalogram in Neonatal Maple Syrup Urine Disease
A Case Report, Satish Agadi, James J. Riviello Jr1 et al.,
1Section of Neurology and Developmental Neuroscience, Department of Pediatrics, and Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, TX, USA 2Department of Molecular and Human Genetics, Baylor College of Medicine. Satish Agadi, Section of Neurology and Developmental Neuroscience, Texas Children’s Hospital, 6621 Fannin, CC# 1250, Houston, TX 77030, USA Email: agadi@bcm.tmc.edu 
Untreated maple syrup urine disease (MSUD) leads to encephalopathy in neonates and causes abnormalities on the electroencephalogram (EEG). A case is presented of MSUD with unique features consisting of a comb-like rhythm before the therapy and its disappearance with therapy is presented. This case illustrates the potential use of the EEG in the identification of this specific cause of a neonatal encephalopathy.

Sept 10, 2010,
Todays Case Review Article: Paralyzed and Comatose Patients, usage of Neuromonitoring?.
MS:I had a request to look at the patient who had 65% burn, paralyzed and comatose due to airline accident. The Ortho was looking into different aspects if he really wanted to do surgery on this patient to stabilize, so he wanted to make sure if there are any signals at all on SSEP's and MEP's. However, they changed the mind not to do a elaborate surgical procedure considering the condition of patient, so they did not need IONM, and I finally did not get to see the patient or do this case. Despite, my quest and interest regarding what would be the neurophysiological signals, what is the neurological status of this patient?. 
In my search on the internet, I did not get much references, may be a better and combination of search might yield some results, however, I found the following 100 Case Study. This is an interesting analysis.
Here, 100 comatose patients been evaluated using multi modality Motor evoked potentials, I am hoping they mean here in addition to Motor other tests done?. Whatever it may be the full study, I do not have the material with me, but taking the results of Motor evoked potentials alone is very promising in terms of prognosis of the Recovery or neurological recovery of 100 patients by testing MEP over few days in the intensive care unit. Using graded MEP test results, they could predict recovery in these patients, the accuracy of their test results and recovery was about 80%, that is very significant. For those surgeons who are unsure whether or not to conduct a surgical procedure in these terminally disabled patient due to accident or some other means, just call a neurophysiologist/neurologist and run those multi modality test.....

Here is the Report:
Journal of Neurosurgery
Prognostic implications of early multimodality evoked potentials in severely head-injured patients
A prospective study
Richard P. Greenberg, M.D.et al.,
Division of Neurological Surgery, Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia
Address for Ms. Hyatt: Department of Physiology, University of Virginia, Charlottesville, Virginia 22908.
Address reprint requests to: Richard P. Greenberg, M.D., Division of Neurosurgery, Medical College of Virginia, Box 631, MCV Station, Richmond, Virginia 23298.
DOI: 10.3171/jns.1981.55.2.0227
 Results of multimodality evoked potential (MEP) studies recorded from 100 comatose patients soon after severe head injury were analyzed prospectively, using a previously established grading system, to assess the prognostic value of MEP's with respect to patient outcome, to evaluate the effect of clinically relevant sequelae of head injury on the prediction of outcome by MEP's, and to describe time to clinical recovery as a function of initial MEP grade. Graded MEP's, when recorded in the first few days after head injury, could predict patient outcome at 1 year with approximately 80% accuracy. Exclusion from the analysis of patients who died from causes unrelated to the brain and those with severe systemic complications that occurred after the evoked potentials were recorded improved the accuracy of outcome prediction to nearly 100%. The presence of a mass lesion requiring surgery reduces the probability of good to moderate outcome for a given MEP grade group by approximately 25% to 40% from that seen in patients without mass lesions. The clinical outcome predicted shortly after head injury by MEP grades may not be realized for many months. Patients with mild MEP abnormality (Grade I or II) generally reach their outcome by 3 to 6 months, whereas those with more severe deficits (Grade III) may not show improvement for at least 1 year.
July 18: Today's Case Review article:
MS:Thoracic surgical procedure and the importance of Neuromonitoring, could save the patient and help both anesthesiologist and surgeon in troubleshooting the problems during surgery.
Somatosensory evoked potential monitoring during spine surgery can detect uncommon generalized nerve conduction block, and further alert surgical teams to a systemic impairment. This was discovered to result from a compromised endotracheal tube. This can apply in various monitoring situations, as the changes affecting the SSEPs were not related to surgical manipulation.
Results and Morbidity in a Consecutive Series of Patients Undergoing Spinal Fusion With Iliac Screws for Neuromuscular Scoliosis
by Alex Gitelman, MD; Samuel A. Joseph Jr., MD; Wesley Carrion, MD; Mark Stephen, MD

Abstract : We performed a retrospective review study to evaluate the safety and efficacy of iliac screws as a method of pelvic fixation in neuromuscular spinal deformity. All patients with the diagnosis of neuromuscular scoliosis operatively managed with iliac screws undergoing posterior spinal fusion were retrospectively identified over a 32-month period, from December 2002 to August 2005. Evaluation was done for correction of deformity, progression, instrumentation failure, and complications.

Debilitating  Back Pain with Neurogenic Claudication
Dr.Neel Anand, an Orthopaedic and Scoliosis Surgeon discusses this very complicated case and the type of surgical approach they carried out on this patient. This is a very interesting case.
SpineUniverse Case Study Library  For Professionals › Case Study Library ›

Debilitating Back

Pain with Neurogenic Claudication

Patient History

The patient is a 76-year-old female who presents with debilitating back pain, sagittal imbalance, and neurogenic claudication. Symptoms have progressively worsened the past 2 years.


Neurologically, the patient is intact. She is takes no medication, except narcotics for pain.

Prior Treatment

She tried, without success, physical therapy, epidural steroid injections, facet blocks, acupuncture, and yoga.


The AP radiograph (Fig. 1A) shows degenerative scoliosis in the coronal plane. Sagittal imbalance is demonstrated in the lateral radiograph (Fig. 1B)

American Journal of Radiology:
49 Y old patient has no history of trauma or surgery but develops a progressive and debilitating left leg pain, what it could be and what do the surgeon plan to do?. It is an idiopathic spinal cord herniation at Thoracic level. Prof.Dr.Dillon's Page:

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