Ann Clin Neurophysiol.  2024;26(2):57-62. 10.14253/acn.24003.

Detection of critical intratumoral hemorrhage during spine surgery by intraoperative neurophysiologic monitoring: a case report

• Seo S
• Heo NJ
• Kim S
• Ahn J
• Lee JS
• Seo DW

• KMID: 2560433
• DOI: http://doi.org/10.14253/acn.24003

Abstract

Complete surgical resection is a well-known therapeutic gold standard for spinal ependymoma, but it is associated with high postoperative morbidity. Intraoperative neuromonitoring (INM) is important for detecting and reducing the rate of surgical complications during this operative procedure. We report a case of postoperative paraplegia due to tumor bleeding during the operation. INM of the patient revealed abrupt loss of waveforms during the operation. This finding suggested that INM is helpful for detecting intraoperative hematomyelia and minimizing postoperative neurologic sequelae.

Keyword

Spinal cord neoplasm; Spinal cord neoplasm; Neurophysiological monitoring; Hematomyelia; Neurophysiological monitoring; Hematomyelia

Figure

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  Fig. 1. Preoperative and postoperative spine MRI. (A) Preoperative T2-weighted sagittal MRI revealed the intramedullary tumor at T3 and T4. The mass is well-demarcated and heterogeneous. Note the syrinx in the rostral and caudal regions and intratumoral hemorrhage in the posterior region of the tumor. (B) MRI immediately after the first operation revealed increased low-intensity signals, indicating fresh blood inside the syrinx (arrow). The overall size of the tumor did not change. (C) Preoperative axial T2-weighted sagittal MRI of the right upper panel. The yellow line denotes the level of the axial image. Note that the syrinx in the rostral part of the tumor has heterogeneous signal intensities, indicating hemorrhages that had occurred at different times. (D) Postoperative axial T2-weighted sagittal MRI of the right upper panel. The yellow line denotes the level of the axial image. Postoperative MRI revealed newly developed low-intensity signals inside the syrinx (arrow), indicating rebleeding in that area. MRI, magnetic resonance imaging.

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  Fig. 2. INM results. (A, B) Baseline tcMEPs, SSEPs (C, D), tcMEPs, and SSEPs measured during the surgery. (E, F) tcMEPs and SSEPs measured after the surgery. Note that the initial normal tcMEPs in the bilateral lower extremity (filled triangles) (A) disappeared completely (hollow triangles) (C) and did not recover (E). The PTSEP waveform was unstable at the beginning (filled short arrows) (B) and was lost (hollow short arrows) (D, F) during the surgery. Lt. MEP, left motor evoked potential; Rt. MEP, right motor evoked potential; APB, abductor pollicis brevis; ADQ, abductor digiti quinti; TA, tibialis anterior; AH, abductor hallucis; Lt. MNSEP, left median nerve sensory evoked potential; Rt. MNSEP, right median nerve sensory evoked potential; FPz, frontoparietal; Lt. PTSEP, left posterior tibial somatosensory evoked potential; Rt. PTSEP, right posterior tibial somatosensory evoked potential; INM, intraoperative neuromonitoring; tcMEPs, transcranial electric motor evoked potentials; SSEPs, somatosensory evoked potentials.

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  Fig. 3. Stacked waveforms from INM. (A, B) Sudden and complete loss of left and right MEPs in the lower extremities. (C, D) SSEPs were preserved in the bilateral upper extremities, (E, F) while SSEPs were gradually lost in the bilateral lower extremities. Note that filled and hollow arrows denote intact and lost waveforms, respectively. APB, abductor pollicis brevis; ADQ, abductor digiti quinti; TA, tibialis anterior; AH, abductor hallucis; Cz, center; INM, intraoperative neuromonitoring; MEPs, motor evoked potential; SSEPs, somatosensory evoked potentials.

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