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Acta Neurochirurgica
Published in: Acta Neurochirurgica 2/2021

01-02-2021 | Rhizotomy | Original Article - Neurosurgical Anatomy

Usefulness of external anal sphincter EMG recording for intraoperative neuromonitoring of the sacral roots—a prospective study in dorsal rhizotomy

Authors: Marc Sindou, Anthony Joud, George Georgoulis

Published in: Acta Neurochirurgica | Issue 2/2021

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Abstract

Background

In conus medullaris and cauda equina surgery, identification of the sacral nerve roots may be uncertain in spite of their anatomical/radiological landmarks. Mapping the sacral roots by recording the muscular responses to their stimulation may benefit from EMG recording of the External Anal sphincter (EAS) in addition to the main muscular groups of the lower limbs.

Method

In a consecutive series of 27 lumbosacral dorsal rhizotomy (DRh), authors carried out a prospective study on the reliability of the EMG recording of the EAS for identification of the S1 and S2 sacral roots.

Results

An EAS-response was recorded in all the 27 (bilaterally) explored individuals, testifying good sensitivity and selectivity of the method. EAS-responses were obtained in 96.3% of the 54 stimulated sides of the S2 root versus in only 16.66% for the S1 root, so that an absence of response would indicate S1 rather than S2 level. Furthermore, comparison between myotomal distribution of the S1 and S2 roots showed a significant difference (p < 0.00001), so that myotomal profile may help to identify root level.

Conclusions

EMG recording of the EAS can be recommended for current intraoperative neuromonitoring. This simple method also provides—indirectly by extrapolation—information on the sacral motor pathways of the external urethral sphincter (EUS), as the later has the same somatic innervation via the pudendal nerve and related S2, S3, and S4 roots. Method can be helpful not only for DRh, of all varieties, but also for spine surgery, correction of dysraphisms, lipomas and/or tethered cord, and tumor resection.
Literature
1.
Abbott R (2002) Sensory rhizotomy for the treatment of childhood spasticity. In: Deletis V, Shils JL (eds) Neurophysiology in neurosurgery. Academic Press, Elsevier Science, Amsterdam, pp 219–230
2.
Bors E (1952) Segmental and peripheral innervation of the urinary bladder. J Nerv Ment Dis 116(6):572–578PubMed
3.
Bors E, Commar AE (1971) Neurological urology: physiology of micturition. Karger S, Basel
4.
Deletis V, Vodusek DB, Abbott R, Epstein FJ, Turndorf H (1992) Intraoperative monitoring of the dorsal sacral roots: minimizing the risk of iatrogenic micturition disorders. Neurosurgery 30(1):72–75PubMed
5.
Deletis V, Shils JL, Sala F, Seidel K (2020) Neurophysiology in neurosurgery: a modern approach, 2nd edn. Elsevier, Academic Press, London
6.
Enck P (2004) Functional asymmetry of pelvic floor innervation-myth or fact? Folia Med Cracov 45(1-2):51–61PubMed
7.
Enck P, Hinninghofen H, Merletti R, Azpiroz F (2005) The external anal sphincter and the role of surface electromyography. Neurogastroenterol Motil 17(1):60–67PubMed
8.
Fanciullaci F, Kokodoko A, Garavaglia PF, Galli M, Sandri S, Zanollo A (1987) Comparative study of the motor unit potentials of the external urethral sphincter, anal sphincter, and bulbocavernous muscle in normal men. Neurol Urodyn 6:65–69
9.
Fasano VA, Barolat-Romana G, Ivaldi A, Sguazzi A (1976) La radicotomie postérieure fonctionnelle dans le traitement de la spasticité cérébrale. Premieres observations sur la stimulation électrique peropératoire des racines postérieures, et leur utilisation dans le choix des racines ã sectionner. Neurochirurgie 22:23–34PubMed
10.
Fasano VA, Broggi G, Zeme S, Lo Russo G, Sguazzi A (1980) Long- term results of posterior functional rhizotomy. Acta Neurochir Suppl (Wien) 30:435–439
11.
Georgoulis G, Sindou M (2020) Muscle responses to radicular stimulation during lumbo-sacral dorsal rhizotomy for spastic diplegia: Insights to myotome innervation. Clin Neurophysiol 131(5):1075–1086PubMed
12.
Georgoulis G, Brînzeu A, Sindou M (2018) Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring. J Neurosurg Pediatr 22(1):89–101PubMed
13.
Huang JC, Deletis V, Vodusek DB, Abbott R (1997) Preservation of pudendal afferents in sacral rhizotomies. Neurosurgery. 41(2):411–415PubMed
14.
Jahangiri FR, Asdi RA, Tarasiewicz I, Azzubi M (2019) Intraoperative triggered electromyography recordings from the external urethral sphincter muscles during spine surgeries. Cureus 11(6):e4867PubMedPubMedCentral
15.
James HE, Mulcahy JJ, Walsh JW, Kaplan GW (1979) Use of anal sphincter electromyography during operations on the conus medullaris and sacral nerve roots. Neurosurgery 4(6):521–523PubMed
16.
Jünemann KP, Schmidt RA, Melchior H, Tanagho EA (1987) Neuroanatomy and clinical significance of the external urethral sphincter. Urol Int 42(2):132–136PubMed
17.
Kolhbauer KF, Deletis V (2010) Intraoperative neurophysiology of the conus medullaris and cauda equina. Childs Nerv Syst 26:247–253
18.
Krassioukov AV, Sarjeant R, Arkia H, Fehlings MG (2004) Multimodality intraoperative monitoring during complex lumbosacral procedures: indications, techniques, and long-term follow-up review of 621 consecutive cases. J Neurosurg Spine 1(3):243–253PubMed
19.
Kumar GS, Rajshekhar V, Babu KS (2006) Intraoperative mapping of sacral nervous system (S2-S4). Br J Neurosurg 20:396–402PubMed
20.
Lang FF, Deletis V, Cohen HW, Velasquez L, Abbott R (1994) Inclusion of the S2 dorsal rootlets in functional posterior rhizotomy for spasticity in children with cerebral palsy. Neurosurgery 34(5):847–853PubMed
21.
Marani E, Pijl ME, Kraan MC, Lycklama à Nijeholt GA, Videleer AC (1993) Interconnections of the upper ventral rami of the human sacral plexus: a reappraisal for dorsal rhizotomy in neurostimulation operations. Neurourol Urodyn 12(6):585–598PubMed
22.
Mittal S, Farmer JP, Poulin C, Silver K (2001) Reliability of intraoperative electrophysiological monitoring in selective posterior rhizotomy. J Neurosurg 95(1):67–75PubMed
23.
Morota N (2019) Clinically practical formula for preoperatively estimating the cutting rate of the spinal nerve root in a functional posterior rhizotomy. Childs Nerv Syst 35(4):665–672PubMed
24.
Nishida T, Storrs B (1991) Electrophysiological monitoring in selective posterior rhizotomy for spasticity: principle, techniques and interpretation of responses. In: Sindou M, Abbott R, Keravel Y (eds) Neurosurgery for spasticity. A multidisciplinary approach. Springer-Verlag, New-York, pp 159–163
25.
Ogiwara H, Morota N (2014) Pudendal afferents mapping in posterior sacral rhizotomies. Neurosurgery 74(2):171–175PubMed
26.
Ojemann JG, Park TS, Komanetsky R, Day RA, Kaufman BA (1997) Lack of specificity in electrophysiological identification of lower sacral roots during selective dorsal rhizotomy. J Neurosurg 86(1):28–33PubMed
27.
Park TS, Gaffney PE, Kaufman BA, Molleston MC (1993) Selective lumbosacral dorsal rhizotomy immediately caudal to the conus medullaris for cerebral palsy spasticity. Neurosurgery 33(5):929–933PubMed
28.
Peacock WJ, Arens LJ, Berman B (1987) Cerebral palsy spasticity. Selective posterior rhizotomy. Pediatr Neurosci 13(2):61–66PubMed
29.
Phillips LH II, Park TS (1991) Electrophysiologic mapping of the segmental anatomy of the muscles of the lower extremity. Muscle Nerve 14:1213–1218PubMed
30.
Podnar S, Rodi Z, Lukanovic A, Trsinar B, Vodusek DB (1999) Standardization of anal sphincter EMG: technique of needle examination. Muscle Nerve 22:400–403PubMed
31.
Russell DJ, Rosenbaum PL, Avery LM, Lane Μ (2002) Gross motor function measure (GMFM-66 & GMFM-88). Mac Keith, London
32.
Sala F, Krzan MJ, Deletis V (2002) Intraoperative neurophysiological monitoring in pediatric neurosurgery: why, when, how? Childs Nerv Syst 18(6-7):264–287PubMed
33.
Sala F, Squintani G, Tramontano V, Arcaro C, Faccioli F, Mazza C (2013) Intraoperative neurophysiology in tethered cord surgery: techniques and results. Childs Nerv 29(9):1611–1624
34.
Schirmer CM, Shils JL, Arle JE, Cosgrove GR, Dempsey PK, Tarlov E, Kim S, Martin CJ, Feltz C, Moul M, Magge S (2011) Heuristic map of myotomal innervation in humans using direct intraoperative nerve root stimulation. J Neurosurg Spine 15(1):64–70PubMed
35.
Schröder HD (1985) Anatomical and pathoanatomical studies on the spinal efferent systems innervating pelvic structures. J Auton Nerv Syst 14:23–48PubMed
36.
Sindou M (1995) Microsurgical DREZotomy (MDT) for pain, spasticity and hyperactive bladder: a 20-yeat experience. Acta Neurochir 137:1–5PubMed
37.
Sindou M (2015) Dorsal root entry zone lesions. In: Burchiel KJ (ed) Surgical management of pain, 2nd edn. Thieme, New-York, pp 576–592
38.
Sindou M, Georgoulis G (2015) Keyhole interlaminar dorsal rhizotomy for spastic diplegia in cerebral palsy. Acta Neurochir 157:1187–1196PubMed
39.
Sindou M, jJeanmonod D (1989) Microsurgical DREZotomy for the treatment of spasticity and pain in the lower limbs. Neurosurgery 24:655–670PubMed
40.
Sindou M, Georgoulis G, Mertens P (2014) Neurosurgery for spasticity: a practical guide for treating children and adults. Springer, Wien
41.
Sindou Μ, Brinzeu Α, Georgoulis G (2020) Neurosurgical lesioning-procedures for spasticity and focal dystonia. In: Deletis V, Shils JL, Sala F, Seidel K (eds) Neurophysiology in neurosurgery: a modern approach, 2nd edn. Elsevier, Academic Press, London, pp 499–514
42.
Sindou M, Georgoulis G, Brinzeu A (2020) Neurosurgical lesioning procedures in spinal cord and dorsal root entry zone for pain. In: Deletis V, Shils JL, Sala F, Seidel K (eds) Neurophysiology in neurosurgery: a modern approach, 2nd edn. Elsevier, Academic Press, London, pp 535–550
43.
Steinbok P, Tidemann AJ, Miller S, Mortenson P, Bowen-Roberts T (2009) Electrophysiologically guided versus non-electrophysiologically guided selective dorsal rhizotomy for spastic cerebral palsy: a comparison of outcomes. Childs Nerv Syst 25(9):1091–1096PubMed
44.
Voduzek DB, Deletis V (2020) Intraoperative neurophysiological monitoring of the sacral nervous system. In: Deletis V, Shils JL, Sala F, Seidel K (eds) Neurophysiology in neurosurgery: a modern approach, 2nd edn. Elsevier, Academic Press, London, pp 87–99
45.
Wiesner A, Jost WH (2020) EMG of the external anal sphincter: needle is superior to surface electrode. Dis Colon Rectum 43:116–118
Metadata
Title
Usefulness of external anal sphincter EMG recording for intraoperative neuromonitoring of the sacral roots—a prospective study in dorsal rhizotomy
Authors
Marc Sindou
Anthony Joud
George Georgoulis
Publication date
01-02-2021
Publisher
Springer Vienna
Published in
Acta Neurochirurgica / Issue 2/2021
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI
https://doi.org/10.1007/s00701-020-04610-4

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