| 제목 |
Neurophysiological Effect of Intravenous Corticosteroid during Spinal Cord Tumor Removal |
| 소속 |
Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea, Department of Rehabilitation Medicine1, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea, Department of Rehabilitation Medicine2, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea, Department of Neurosurgery3 |
| 저자 |
Jinyoung Park1*, Dawoon Kim2, Junseok Oh2, Jihyun Park2, Yong-Eun Cho1, Yoon Ghil Park1† |
1. Objective
There have been controversies over the effects of the high dose IV corticosteroid for acute spinal cord injury. A few studies tried to reveal the effect of IV prednisolone on electrophysiological outcomes, and there is no report on direct (D) waves, somatosensory evoked potentials (SEPs) or motor evoked potentials (MEPs). Thus we report a case of which revealed the intraoperative neurophysiological effect of IV corticosteroid during surgery.
2. Methods
1) Patient
A 72kg, 58-year-old man visited the Department of Neurosurgery complaining numbness and weakness in 2004. By the magnetic resonance imaging (MRI), cavernous malformation was revealed at T3/4 level. Despite the progressing weakness and sensory deterioration of bilateral lower extremities, he has been refused surgery until the additional urinary and fecal incontinences developed. After confirming hemorrhage in tumor by MRI (Figure 1A and 1B), and he finally agreed for surgery in 2018. The motor score of bilateral 10 key muscles was 94.
2) Anesthesia
Total intravenous anesthesia was continued with remifentanil and propofol.
3) Intraoperative Neurophysiological Monitoring
The MEPs were obtained by delivering the short trains of 6 square-wave stimuli (duration 0.5 ms, inter-stimulus interval 3 ms) with supra maximal intensity (250V~400V) at C1 and C2 scalp sites, and recording in bilateral deltoids, abductor pollicis brevis, tibialis anterior (TA), and abductor halluces (AH). The SEPs were elicited by stimulating bilateral posterior tibial nerves at the ankles (duration 0.2 ms, repetition rate of 5 Hz), and recording at C3, C4 and Cz referenced to FPz. D waves was obtained stimulating the same sites as MEPs with single pulse (duration 0.5 ms, intensity 150~200 mA), and recording on epidural space of T2 and T5 levels.
3. Results
During tumor removal, the sequential P37 latencies of bilateral posterior tibial nerves showed no significant changes. However, the MEPs dropped to 11.3% of the baseline amplitude in right TA and AH (Figure 2). After promptly alarmed to neurosurgeon, and the IV SOLU-MEDROL® (methylprednisolone sodium succinate) was administered with 30 mg/kg during 15 min and again with a rate of 5.4 mg/kg/hr during next 23 hours. While the final MEPs stayed 11.2% and 15.3% of the baseline amplitude in right TA and AH, the amplitude of the D wave in T2 and T5 abruptly amplified to 597% and 563% within 3 minutes after administration compared to the amplitude just before corticosteroid administration (Figure 3A), and ended with 657% and 504% of the baseline before dura closing (Figure 3B). A day after surgery, the MRI revealed small amount of hemorrhagic residue (Figure 1C and 1D), and the motor score improved to 95 from 94.
4. Conclusion
Prompt administration IV corticosteroid would prevent motor deterioration even with compromised MEPs over alarm criteria, and the amplification of the D wave right after steroid administration may be a signal to good prognosis. |
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Fig 1. Preoperative and postoperative magnetic resonance images of the intramedullary cavernous malformation.
Fig 2. Significant reduction in amplitudes of motor evoked potentials during tumor removal.
Fig 3. Direct waves amplified after administration of intravenous methylprednisolone.
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