title: Continuous EMG recordings and intraoperative electrical stimulation for identification and protection of cervical nerve roots during foraminal tumor surgery.
abstract: OBJECTIVE
  Spinal cord function is now routinely monitored with somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) during surgery for intraspinal cervical dumbbell and foraminal tumors. However, upper extremity nerve roots are also at risk during these procedures. Anatomic relations are frequently difficult to interpret because the nerve roots may be displaced by the tumor. We used electrical stimulation with compound muscle action potential (CMAP) recordings at multiple sites to identify the location and course of the involved nerve root and to provide real-time information regarding the functional status of the roots to predict postoperative outcome.
  
  
  METHODS
  Ten patients were monitored during surgery for cervical dumbbell or foraminal tumors. SEPs and MEPs were monitored as a routine procedure. CMAPs were recorded from needle electrodes placed in the deltoid, biceps, triceps, and flexor carpi ulnaris muscles. Spontaneous electromyography (EMG) muscle activity was also continuously monitored. A handheld monopolar stimulation electrode was used to elicit evoked EMG responses to identify and trace the course of nerves in relation to the tumor. In four patients, the stimulation threshold was tested before and after tumor resection to predict postoperative nerve root function.
  
  
  RESULTS
  Electrical stimulation with CMAP recording was successful in localizing nerve roots during tumor resection in all 10 patients. Monitoring predicted postoperative nerve root preservation after tumor removal in each case. It was possible to identify either by using low-level stimulation (<2.0 V) or by observing changes in spontaneous EMG amplitude if activation was present during surgical dissection. The monitoring of spontaneous muscle activity in response to direct or indirect surgical manipulation during tumor resection also provided continuous assessment of nerve root function and identified any physiologic disturbance induced by surgical manipulation.
  
  
  CONCLUSIONS
  Electrical stimulation in the operating field and recording of CMAPs facilitated nerve root identification and predicted postoperative function during dissection and separation from ligamentous or neoplastic tissue in 10 patients. Electrical stimulation might also be useful to predict postoperative preservation of function when nerve root sacrifice is necessary and no motor response is detected intraoperatively.
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143-0112, USA
authors.forename: LanJun
authors.initials: L
authors.lastname: Guo
authors.forename: Alfredo
authors.initials: A
authors.lastname: Quiñones-Hinojosa
authors.forename: Charles D
authors.initials: CD
authors.lastname: Yingling
authors.forename: Philip R
authors.initials: PR
authors.lastname: Weinstein
mesh_terms: D000200:Action Potentials; D000293:Adolescent; D000328:Adult; D002574:Cervical Vertebrae; D004558:Electric Stimulation; D004576:Electromyography; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D013125:Spinal Neoplasms / Q000503:physiopathology / Q000601:surgery*; D013126:Spinal Nerve Roots