title: The value of multimodality intraoperative neurophysiological monitoring in treating pediatric Chiari malformation type I.
abstract: BACKGROUND
  Chiari malformation type I is defined as a descent of cerebellar tonsils below the level of the foramen magnum. The traditional treatment for symptomatic patients is foramen magnum decompression (FMD) surgery. Intraoperative neurophysiological monitoring (INM) is an established surgical adjunct, which is proposed to reduce the potential risk of various surgical procedures. Though INM has been suggested as being helpful in patient positioning and in determining the optimal surgical extent of FMD (i.e., duroplasty, laminectomy, tonsillectomy), its shortcomings include prolongation of anesthesia and surgery as well as monetary costs. Multimodality INM including transcranial-electric motor evoked potential (TcMEP) is not routinely employed in most practices. This study evaluates efficacy of multimodality INM during FMD.
  
  
  METHODS
  This work is a retrospective analysis of prospectively collected data. Twenty-two FMD surgeries in 21 pediatric patients (aged 1-18 years) were performed at our center utilizing multimodality INM. All patients presented Chiari malformation type I, 18 of which had presented with syringomyelia, underwent posterior fossa decompression (FMD + C1 laminectomy), accompanied in some with additional cervical laminectomies, duroplasty, and partial tonsillectomies. TcMEP and somatosensory evoked potentials (SSEP) were monitored throughout the procedure including before and after positioning. INM alarms were correlated with perioperative and long-term patient outcomes.
  
  
  RESULTS
  INM data remained stable during 19 operations. Three cases displayed significant attenuation in the monitoring signals, all concomitant with patient positioning on the surgical table. One case showed attenuation in SSEP data only, which remained attenuated following repositioning. Another displayed altered TcMEP concomitant with positioning which partially stabilized following repositioning and resolved following bony decompression. The third case showed unilateral attenuation of both TcMEP and SSEP data, which did not rectify until closure. In each of these three cases, no new neurological deficits were observed post operatively.
  
  
  CONCLUSIONS
  Multimodality INM can be useful in FMD surgery, particularly during patient positioning. TcMEP attenuations may occur independent of SSEPs. The clinical implications of these monitoring alerts have yet to be defined. There is a need to establish an optimal, cost-effective monitoring protocol for FMD.
authors.affiliation: Department of Pediatric Neurosurgery, "Dana" Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Weizman 6, Tel Aviv, 64239, Israel.|Department of Neurosurgery, Tel Aviv, "Sourasky" Medical Center, Tel Aviv, Israel.
authors.forename: Ori
authors.initials: O
authors.lastname: Barzilai
authors.affiliation: Department of Pediatric Neurosurgery, "Dana" Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Weizman 6, Tel Aviv, 64239, Israel.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Roth
authors.affiliation: Department of Pediatric Neurosurgery, "Dana" Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Weizman 6, Tel Aviv, 64239, Israel.
authors.forename: Akiva
authors.initials: A
authors.lastname: Korn
authors.affiliation: Department of Pediatric Neurosurgery, "Dana" Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Weizman 6, Tel Aviv, 64239, Israel. sconsts@netvision.net.il.
authors.forename: Shlomi
authors.initials: S
authors.lastname: Constantini
mesh_terms: D000293:Adolescent; D001139:Arnold-Chiari Malformation / Q000601:surgery*; D002648:Child; D019299:Decompression, Surgical / Q000379:methods*; D019054:Evoked Potentials, Motor; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D008297:Male
keywords: Chiari 1 malformation; Foramen magnum decompression (FMD); Intraoperative neurophysiological monitoring; Motor evoked potentials (TcMEP); Somatosensory evoked potentials (SSEP)