Role of Intraoperative Neurophysiological Monitoring in Pediatric Tethered Cord Syndrome Surgeries and Technical Insights

Abstract Spinal cord tethering lesions in pediatric patients may cause neurological deficits through direct or indirect neural impairments, and untethering surgeries must be targeted to prevent further neural impairments. This study aimed to evaluate the role of intraoperative neurophysiological monitoring (IONPM) during spinal dysraphism untethering surgeries, with an emphasis on some technical insights. This retrospective study was conducted on 67 pediatric patients who suffered spinal dysraphismic lesions and underwent spinal cord untethering during the period from January 2017 to January 2023, with a follow-up period of at least 1 year. All surgeries involved the use of IONPM under total intravenous anesthesia. Spinal cord and root untethering were tried by neurolysis, sectioning of the filum terminale, and maximal lesion resection according to the offending pathology. In some cases, intraoperative ultrasound was used for tissue differentiation. There was no significant difference between the preoperative and postoperative clinical conditions of the patients, while after 1 year of follow-up, there were significant clinical improvements regarding motor power, sensation, urinary control, and stool incontinence. Permanent warning changes in IONPM parameters occurred in 10 patients. Motor evoked potential monitoring recorded 100% specificity (true-negative probability rate) and accuracy of 98.51% (overall probability) in relation to the clinical condition of the patients, while electromyographic and bulbocavernosus reflex monitoring recorded 100% sensitivity (true-positive probability rate) with an accuracy of 95.52 and 96%, respectively. Technically, IONPM during pediatric spinal cord and untethering of roots provides safety when dealing with such delicate neural tissues with the aid of intraoperative ultrasound whenever needed, in addition to surgical assurance of maximal neural element untethering.