Table Of ContentSpina/Cord
Monitoring
Edited by J. Schramm and S. J. Jones
With 139 Figures and 63 Tables
Springer- Verlag
Berlin Heidelberg New York Tokyo
Professor Dr. JOHANNES SCHRAMM
Neurochirurgische Klinik der Universitat
Schwabachanlage 6, D-8S20 Erlangen
STEPHEN J .J ONES, Ph.D.
The National Hospital for Nervous Diseases
Queen Square, London WCIN 3BG, Great Britain
ISBN-13: 978-3-642-70689-9 e-ISBN-13: 978-3-642-70687-5
DOl: 10.1007/978-3-642-70687-5
Library of Congress Cataloging in Publication Data. Spinal cord monitoring. Includes bibliographies
and index. J. Spinal cord-Surgery. 2. Evoked potentials (Electrophysiology). 3. Spinal cord
Wounds and injuries. 4. Spinal cord-Abnormalities. 5. Patient monitoring. 1. Schramm. J. (Johan
nes),1946- . II. Jones, S.J. (Stephen J.) [DNLM: 1. Evoked Potentials. 2. Monitoring, Physiologic.
3. Spinal Cord. WL 400 S75778] RD 594.3.S6697 1985 617'.482 85-22096
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List of Contributors
You will find the address of each first mentioned author at the beginning
of the respective contribution
Akin,O.N. 51 Jorg, J. 308
Baba, H. 245,284 Kamikozuru, M. 35
Bajada, S. 316 Kaneda, A. 35,290
Bartels, M. 154 Kanekasu, K. 284
Bennett, M. H. 51 Kawai, S. 274
Berenstein, A. 197 Kepplinger, B. 64,95
Biggs, B.D. 69 Knezevic, W. 316
Bocker, G. 204 Koht, A. 59, 161
Boyd, S.G. 227 Koshino, Y. 284
Breitner, S. 173 Kotani, H. 274
Brown, R.H. 179 Leuteritz, R. 95
Buchner, H. 204 Maie,M. 231
Cantor, D. S. 250 Marsden, C. D. 227
Carter, L. 215 Maruyama, Y. 16
Claus, D. 90 Masuyama, S. 245,284
Conner, A. N. 167 Matzen, K. A. 173
Cowan, J.M.A. 227 McAlaster, R. 250
Demmer, G. 308 McWilliam, R. C. 167
Ducker, T. B. 121,250 Mitzkat, K. 154
Edgar, M.A. 215 Mochizuki, T. 143
Ertekin, C. 43 Morley, T. 215
Fahlbusch, R. 186 Murakami, M. 231
Ferbert, A. 204 Nakagawa, T. 221,231
Frazier, W.T . 69 Nash Jf., C. L. 179
Fujii, S. 143 Netal, R. 261
Fujioka, H. 16 Neundorfer, B. 90
Furuya, K. 290 Noguchi, T. 29
Gerhard, H. 308 Nomura, S. 245',284
G lotzner, F. L. 261 Odom, S.H. 69
Hacke, W. 204 Ogata, M. 143
Hattori, S. 274 Omote, K. 274
Hukuda, S. 143 Pollock, J. C. S. 167
Imai, K. 221,231 Ransford, A. O. 215
Inoue, S. 221 Reisecker, F. 237
Inoue, SA. 231 Riffel, B. 302
Jones, S.J. 215,266 Romstock, J. 82, 186
Jordan, K. H. 308 Ronai, A. 161
VI List of Contributors
Rothwell, J. C. 227 Thomas, D. G. T. 266
Saiki, K. 274 Thurner, F. 82, 186
Sarica, Y. 43 Toleikis, J. R. 59, 161
Sato, H. 35,290 Tomita, K. 245,284
Sawada, Y. 245,284 Tsuji, H. 221
Schmid, H. 95 Tsuji, S. 245,284
Schneider, H. 103 Ugaji, U. 245
Schrader, S. 59 Umeda, S.-1. 245,284
Schramm, J. 82, 186 Valencak, E. 237
Schrottner, O. 95 Wallner, K. 64
Senzoku, F. 274 Webb, P.J. 215,227
Shichikawa, K. 143 Weitbrecht, W. 90
Shima, I. 245,284 Witzmann, A. 237
Shimizu, H. 16 Wurzer, K. 308
Shimoji, K. 16 Yamane, T. 231
Shinoda, K. 245 Yamasaki, H. 274
Shinomiya, K. 35 Yamashita, T. 231
Shinomiya, K.-1. 290 Yamaura, I. 35,290
Sloan, T. 59, 161 Yokoyama, M. 35,290
Stohr, M. 302 Yonezawa, K. 245,284
Taga, K. 16 Y oshimizu, N. 245
Takakuwa, K. 29,221 Young, W. 127, 197
Takano, H. 29,221 Yugami, H. 245,284
Tamaki, T. 29,221 Zeumer, H. 204
Thatcher, R. W. 250 Zimmermann, M. 3
Preface
The two International Symposia on Spinal Cord Monitoring, held in Tokyo
in 1981 [Homma S, Tamaki T (eds) (1984) Fundamentals and clinical appli
cation of spinal cord monitoring. Saikon Publishing, Tokyo] and Erlangen
in 1984, were remarkable in that they stimulated a gathering of electro
encephalographic, neurophysiological, orthopaedic, neurosurgical, anaes
thetic and pathological practitioners, presenting experimental, clinical and
surgical experiences. The factor held in common was an understanding of
the need to reduce the incidence and severity of iatrogenic neurological im
pairment associated with certain surgical and radiographic procedures. In
the past there has been a tendency for the study of human evoked poten
tials (EPs) to be regarded as an end in itself, or at best a discipline which
can be of limited assistance in certain problems of neurological diagnosis.
Symposia such as these serve the valuable function of opening electro
physiological eyes to the problems to which EP techniques might usefully
be devoted in other medical spheres. They also help those who practise
electrophysiology as an adjunct to their speciality to comprehend such of
the more complex properties of EPs as are relevant to their particular
interests.
The title of the Symposia and of this volume arose as a result of an his
torical accident. The pioneers of intraoperative neuronal monitoring were
mostly surgeons specialising in the correction of spinal deformities or the
removal of tumours. Their first meetings, which naturally emphasized the
spinal cord as a structure at risk, were not widely publicised and the pro
ceedings are hard to come by today [Nash CL, Brodkey JS (eds) (1977)
Clinical application of the spinal cord monitoring for operative treatment
of spinal diseases, Cleveland. Nash CL, Brown RH (eds) (1979) Spinal
Cord Monitoring Workshop, Data acquisition and analysis, St. Louis].
Gradually, the field has broadened to include monitoring of spinal and
supraspinal conduction in a number of surgical, radiological and clinical
situations. A similar development has taken place in monitoring the visual
and auditory pathways.
In addition to the short-term assessment of pathways at risk from surgical
or radiological manoeuvres, monitoring should also be understood to in
clude the long-term evaluation of spinal cord function in certain pathologic
conditions, for example myelopathy and spinal trauma. The scope of this
volume additionally covers "once-off" preoperative and perioperative in
vestigations of conduction in pathologic spinal cords. It is of great impor-
VIII Preface
tance that the non-surgical assessment of sensory pathway function be well
represented, giving an indication of the diagnostic and prognostic potential
of EP recordings. Techniques now in routine application range from the
noninvasive recording of cortically and subcortically generated potentials
from the skin, through direct stimulation and recording of activity in the
spinal cord, to the detection of descending motor tract potentials following
transcutaneous cortical stimulation.
As to the course of future development, there have been calls for in
creased standardisation of monitoring techniques and for the establishment
of definite criteria whereby conduction defects may be identified at an
early and, it is hoped, reversible stage. One feels, however, that techniques
have been adapted and modified in different centres with good reason, in
order optimally to address the particular problems associated with the
patients under investigation. Premature standardisation in a rapidly expand
ing field can only lead to stagnation. More effort should certainly be devoted
to establishing, comprehending and if possible reducing the degree of un
certainty inherent in electrophysiological recordings made under the non
ideal conditions of the operating room, but any request to define rigid
"safety" limits should, at this stage, be resisted. Intraoperative monitoring
of the spinal cord is a technique in evolution, and intervention criteria are
still being established empirically. There is no reason why such criteria
should not eventually become well-defined, and the continued application
of different techniques will be helpful in achieving this goal.
J. SCHRAMM
S. J. JONES
Acknowledgments. The publication of this volume has been made possible
due to stubstantial support from Nicolet Biomedical, West Germany. Ad
ditional funding was provided by E. Merck and Pfrimmer.
Contents
Physiology
Fundamentals of Sensory and Motor Functions of the Spinal Cord
M. ZIMMERMANN. With 8 Figures and 1 Table .......... 3
Spinal Cord Monitoring - A Review of Current Techniques and
Knowledge. K.SHIMOJI, Y.MARUYAMA, H.SHIMIZU, H.FuJIOKA, and
K. T AGA. With 11 Figures and 1 Table . . . . . . . . . . . ... . 16
Comparison of Spinal Cord Evoked Potentials Elicited by Spinal Cord
and Peripheral Nerve Stimulation. H.TAKANO, TTAMAKI, TNoGUCHI,
and K. TAKAKuwA. With 3 Figures . .... . .... . ..... 29
An Analysis of Spinal Cord Potentials Evoked by Median Nerve
Stimulation. A. KANEDA, l. Y AMAURA, M. KAMIKOZURU,
K. SHiNOMIYA, H. SATO, and M. YOKOYAMA. With 7 Figures 35
Descending Lumbosacral Cord Potentials (DLCP) Evoked
by Stimulation of the Median Nerve. Y. SARICA and C. ERTEKIN
With 3 Figures and 1 Table . . . . . . . . . . . . . . . . . . 43.
Extraspinal Stimulation and Recording: A Method for Operative
Monitoring. M. H. BENNETT and O. N. AKIN. With 3 Figures . . . 51
Scalp Distribution of Dermatomal Evoked Potentials. J. R. TOLEIKIS,
T SLOAN, S. SCHRADER, and A. KOHT. With 1 Figure and 1 Table 59
Technique of Evoked Potential Recordings from a Radiofrequency
Transmitted Spinal Cord Stimulating System. B. KEPPLINGER and
K. WALLNER. With 1 Figure ........... ... .. . . ... 64
Pharmacological Influences
Anesthetic Technique for Spinal Cord Monitoring. W. T FRAZIER,
S. H. ODOM, and B. D. BIGGS. With 3 Figures and 1 Table .... . 69
x Contents
Effects of Fentanyl and Enflurane on Cortical and Subcortical SEP
During General Anesthesia in Man. F. THURNER, J. SCHRAMM, and
J. ROMSTOCK. With 2 Figures and 5 Tables . . . . . . . . . .. .. 82
Pentobarbital: The Influence on Somatosensory Conduction in the
Rat. D. CLAUS, W. WEITBRECHT, and B. NEUNDORFER. With 3 Figures
and 1 Table . . . . . . . . . . . . . . . . . . . . . . . . 9.0 . .
Pharmacogenic Changes of Cortical Responses to Spinal Cord
Stimulation. B. KEPPLfNGER, H. SCHMID, O. SCHROTTNER, and
R. LEUTERITZ. With 4 Figures . . . . . . . . . . . . . . . . . 9.5
Traumatic Cord Lesions
Acute and Chronic Pathomorphological Reactions to Cord Injury
H. SCHNEIDER. With 9 Figures .................. 103
Evoked Potentials in Experimental Spinal Cord Injury. T. B. DUCKER
With 2 Figures ......................... 121
Somatosensory Evoked Potentials (SEPs) in Spinal Cord Injury
W. YOUNG. With 6 Figures and 2 Tables . . .......... . 127
Therapeutic Trial of Hypertension and Hyperoxia Combined with
Hypercarbia on Experimental Acute Spinal Cord Injury in the Dog
S. HUKUDA, T. MOCHIZUKI, M. OGATA, S. FUJII, and K. SHICHIKAWA
With 2 Figures and 4 Tables ... . ............... . 143
Cortical Evoked Potentials in Experimental Scoliosis. K. MITZKAT
and M. BARTELS. With 3 Figures ................... 154
Monitoring-Cortical Evoked Potentials
Intraoperative Deterioration of Evoked Potentials During Spinal
Surgery. A. KOHT, T. SLOAN, A. RONAl, and J. R. TOLEIKIS
With 1 Figure and 3 Tables : . . . . . . . . . . . . . . ... . .1 61
Cortical Somatosensory Evoked Potentials During Surgery for Scoliosis
and Coarctation of the Aorta. R. C. MCWILLIAM, A. N. CONNER, and
J. C. S. POLLOCK. With 3 Figures ................. 167
Scalp Recorded Somatosensory Evoked Potentials During Spinal
Surgery. S. BREITNER and K. A. MATZEN. With 2 Figures and 1 Table . 173
Contents XI
The "Grey Zone" in Intra-operative S.C.E.P. Monitoring
R. H. BROWN and C. L. NASH JR. With 4 Figures and 4 Tables 179
Variance of Latency and Amplitude in SEPs Monitored During Spinal
Operations with and Without Cord Manipulation. J. SCHRAMM,
J. ROMSTOCK, F. THURNER, and R. FAHLBUSCH. With 4 Figures and
5 Tables ............................ .. 186
Somatosensory Evoked Potential Monitoring of Intraoperative
Procedures. W. YOUNG and A. BERENSTEIN. With 5 Figures 197
Evoked Potential Monitoring During Interventional Neuroradiology:
Experimental Aspects of Special Catheter Techniques. W. HACKE,
H. BUCHNER, A. FERBERT, H. ZEUMER, and G. BOCKER. With 3 Figures
and 1 Table . . . . . . . . . . . . . . . . . . . . . . . . 2. 04 . . . . .
Monitoring-Spinal Evoked Potentials
Experience of Epidural Spinal Cord Monitoring in 410 Cases
S.J.JONES, L.CARTER, M.A.EDGAR, T.MoRLEY, A.O.RANSFORD,
and P.J. WEBB. With 2 Figures . . . . . . . . . . . .. .. . .. 215
An Assessment of the Use of Spinal Cord Evoked Potentials
in Prognosis Estimation of Injured Spinal Cord. T. TAMAKI,
H. TAKANO, K. TAKAKUWA, H. TSUJI, T.NAKAGAWA, K.IMAI, and
S. INOUE. With 3 Figures .................... 221
Monitoring Spinal Motor Tract Function Using Cortical Stimulation:
A Preliminary Report. S. G. BOYD, J. M. A. COWAN, J. C. ROTHWELL,
P.1. WEBB, and C. D. MARSDEN. With 2 Figures ........... 227
Spinal Evoked Potentials in Infants with Myelomeningocele
T. NAKAGAWA, K. IMAI, M. MURAKAMI, S.-I. INOUE, M. MAlE,
T. YAMANE, and T. YAMASHITA. With 4 Figures and 2 Tables ... 231
Intraoperative Spinal Cord Monitoring at Different Levels and
with Varying Surgical Pathology. E. VALENCAK, A. WITZMANN,
and F. REISECKER. With 4 Figures and 2 Tables ........... 237
Clinical Usefulness of Spinal Cord Evoked Potentials. H. BABA,
I. SHIMA, K. TOMITA, S.-I. UMEDA, Y. SAWADA, H. YUGAMI, U. UGAJI,
K.SHINODA, N.YOSHIMIZU, S.MASUYAMA, K.YONEZAWA, S.TsUJI, and
S. NOMURA. With 2 Figures and 1 Table .... . ...... 245
Spinal Cord Monitoring in Neurosurgery in the United States
T. B. DUCKER, R. W. THATCHER, D. S. CANTOR, and R. McALASTER
With 1 Figure . . . . . . . . . . . . . . . . . . . . . . . .2 5. 0. . . .
