title: Spinal cord mapping as an adjunct for resection of intramedullary tumors: surgical technique with case illustrations.
abstract: OBJECTIVE
  Resection of intramedullary spinal cord tumors may result in transient or permanent neurological deficits. Intraoperative somatosensory evoked potentials (SSEPs) and motor evoked potentials are commonly used to limit complications. We used both antidromically elicited SSEPs for planning the myelotomy site and direct mapping of spinal cord tracts during tumor resection to reduce the risk of neurological deficits and increase the extent of tumor resection.
  
  
  METHODS
  In two patients, 3 and 12 years of age, with tumors of the thoracic and cervical spinal cord, respectively, antidromically elicited SSEPs were evoked by stimulation of the dorsal columns and were recorded with subdermal electrodes placed at the medial malleoli bilaterally. Intramedullary spinal cord mapping was performed by stimulating the resection cavity with a handheld Ojemann stimulator (Radionics, Burlington, MA). In addition to visual observation, subdermal needle electrodes inserted into the abductor pollicis brevis-flexor digiti minimi manus, tibialis anterior-gastrocnemius, and abductor halluces-abductor digiti minimi pedis muscles bilaterally recorded responses that identified motor pathways.
  
  
  RESULTS
  The midline of the spinal cord was anatomically identified by visualizing branches of the dorsal medullary vein penetrating the median sulcus. Antidromic responses were obtained by stimulation at 1-mm intervals on either side of the midline, and the region where no response was elicited was selected for the myelotomy. The anatomic and electrical midlines did not precisely overlap. Stimulation of abnormal tissue within the tumor did not elicit electromyographic activity. Approaching the periphery of the tumor, stimulation at 1 mA elicited an electromyographic response before normal spinal cord was visualized. Restimulation at lower currents by use of 0.25-mA increments identified the descending motor tracts adjacent to the tumor. After tumor resection, the tracts were restimulated to confirm functional integrity. Both patients were discharged within 2 weeks of surgery with minimal neurological deficits.
  
  
  CONCLUSIONS
  Antidromically elicited SSEPs were important in determining the midline of a distorted cord for placement of the myelotomy incision. Mapping spinal cord motor tracts with direct spinal cord stimulation and electromyographic recording facilitated the extent of surgical resection.
authors.affiliation: Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, Room M-779, San Francisco, CA 94143-9112, USA. quinones@neurosurg.ucsf.edu
authors.forename: Alfredo
authors.initials: A
authors.lastname: Quinones-Hinojosa
authors.forename: Mittul
authors.initials: M
authors.lastname: Gulati
authors.forename: Russell
authors.initials: R
authors.lastname: Lyon
authors.forename: Nalin
authors.initials: N
authors.lastname: Gupta
authors.forename: Charles
authors.initials: C
authors.lastname: Yingling
mesh_terms: D002648:Child; D002675:Child, Preschool; D004576:Electromyography; D019054:Evoked Potentials, Motor; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D016343:Monitoring, Intraoperative; D013116:Spinal Cord / Q000503:physiopathology* / Q000601:surgery*; D013120:Spinal Cord Neoplasms / Q000175:diagnosis / Q000503:physiopathology* / Q000601:surgery*; D016896:Treatment Outcome