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Utility of Intraoperative Electromyography in Microvascular Decompression for Hemifacial Spasm: a Meta-Analysis

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Neurosurg Focus 27 (4):E10, 2009 Utility of intraoperative electromyography in microvascular decompression for hemifacial spasm: a meta-analysis RAYMOND F. SEKULA JR., M.D., SAN J AY BHATIA , M.D., AND R EW M. FR EDE R ICK S ON , B.S., PETE R J. JANNETTA , M.D., MATTHEW R. QUIGLEY , M.D., GEO R GE A. SMALL , M.D., AND RYAN BR EI S INGE R , B.S. Center for Cranial Nerve Disorders, Department of Neurosurgery, Allegheny General Hospital, Allegheny Neuroscience Institute/Drexel University College of Medicine, Pittsburgh, Pennsylvania Object. In this paper, the authors’ goal was to determine the utility of monitoring the abnormal muscle response (AMR) or “lateral spread” during microvascular decompression surgery for hemifacial spasm. Methods. The authors’ experience with AMR as well as the data available in the English-language literature regarding resolution or persistence of AMR and the resolution or persistence of hemifacial spasm at follow-up was pooled and subjected to a meta-analysis. Results. The pooled OR revealed by the meta-analysis was 4.2 (95% CI 2.7–6.7). The chance of a cure if the AMR was abolished during surgery was 4.2 times greater than if the lateral spread persisted. Conclusions. The AMR should be monitored routinely in the operating room, and surgical decision-making in the operating room should be augmented by the AMR. (DOI: 10.3171/2009.8.FOCUS09142) KEY WO R D S • hemifacial spasm • intraoperative electromyography • lateral spread • abnormal motor response EMIFACIAL spasm, a syndrome of unilateral facial intraoperative EMG, it is unlikely that a large prospec- nerve hyperactive dysfunction, is a severe and tive, randomized multicenter trial will be undertaken. In disabling condition that causes impairments in the addition, because of the high cure rate of HFS a large Hquality of life of patients.4 Typical and atypical variations number of patients will be required to uncover a differ- of the disorder exist. In typical HFS, the spasms begin in- ence in outcome. sidiously in the orbicularis oculi muscle and spread over In this report, we will review the salient features time to muscles of the face with variable involvement of of EMG in HFS and our own results with intraopera- the frontalis and platysma muscles. Conversely, in atypi- tive EMG. We also performed a meta-analysis of com- cal HFS, spasms begin insidiously in the muscles of the bined data regarding the utility of intraoperative EMG lower face and spread to the orbicularis oculi muscle over for MVD in HFS. time. Typical HFS occurs much more frequently than atypical HFS.8 Intraoperative EMG has been used increasingly in Methods the surgical management of HFS.17 While several retro- This retrospective review of existing study materials spective and prospective studies have strongly supported was performed under a protocol approved by our institu- its use,6,21,27,31 several other studies have failed to show tional review board and in accordance with patient priva- that intraoperative EMG improves outcome (that is, a cy rights protection as enforced by the Health Insurance cure of HFS).1,3,9,11,28 To date, there are no reported ran- Portability and Accountability Act. domized controlled trials of intraoperative EMG that were designed or powered to study cure of HFS as the Preoperative Demographics primary end point. Because the majority of surgeons per- Between January 1, 2007, and May 31, 2009, we pro- forming MVD for HFS believe strongly about the use of spectively collected information on all patients with HFS who presented to our center. The diagnosis of HFS was Abbreviations used in this paper: AMR = abnormal muscle based on the clinical history and physical examination response; EMG = electromyography; HFS = hemifacial spasm; and then confirmed with EMG. A Gd-enhanced MR im- MVD = microvascular decompression. aging examination of the brain confirmed the absence of Neurosurg Focus / Volume 27 / October 2009 1 Unauthenticated | Downloaded 09/23/21 01:19 PM UTC R. F. Sekula Jr. et al. structural lesions including tumors, AVM, Chiari mal- ally, the AMR disappears as CSF is drained or retractors formation Type I, and other confounding diagnoses (for are placed, ostensibly causing a relaxation of vascular example, multiple sclerosis) in each patient. All patients compression of the facial nerve. An attempt is made to underwent preoperative EMG confirming the AMR. restore the AMR by increasing the current intensity (up No patient who met these criteria was denied operation. to 15 mA), stimulation frequency (5.1 Hz), and finally Eighty-six patients underwent MVD by the senior au- by increasing pulse widths in increments of 50 µsec. A thors (R.F.S. and P.J.J.). Thirteen of these patients were Cadwell Cascade (Cadwell Laboratories, Inc.) machine is excluded because they had undergone a previous MVD used at our institution. for HFS at another institution. Additionally, intraopera- During decompression of suspected arteries and tive AMR data were unavailable in 4 patients because the veins from the facial nerve, the intensity of the stimula- AMR was lost after the operation was begun but before tion is increased to make sure that the AMR has resolved. the facial nerve had been exposed. Thus, data for both the A further attempt is made to “drive” or stimulate the intraoperative resolution of the AMR and the postopera- AMR by increasing the current to 20 mA or frequency tive outcome were available in 69 patients and were used to 30 Hz. If the AMR cannot be driven, we consider the in this analysis. In the operating room, AMR was noted AMR to have completely resolved. as present (even if reduced by as much as 95%) or absent In addition to AMR monitoring, all patients under- (elimination of AMR). going MVD surgery are monitored for changes in the Following MVD, data were collected at routine post- brainstem auditory evoked potentials. Occasionally direct operative office visits and by formal telephone interviews stimulation of cranial nerve VII is used. of all patients in June 2009, which were conducted by a disinterested observer (A.M.F.). Each patient was evalu- Operative Procedure ated in our clinic on postoperative Day 5, and all patients Microvascular decompression is performed under were queried by telephone at the last follow-up. The me- general anesthesia with the patient in the contralateral dian follow-up was 10.7 months (range 1–28.6 months). decubitus position, utilizing auditory brainstem evoked Patients were queried regarding status of spasms immedi- 15 ately postoperatively and since MVD. The cases in which potentials in a previously described manner. A retro- patients reported that their facial spasms were eliminated mastoid incision is made behind the hairline, and a small or were reduced by ≥ 90% (for example, occasional “flut- craniectomy below the asterion is performed. The edge tering about eye”) were considered cured. of the sigmoid sinuses is identified, and the dura mater is opened. After appropriate brain relaxation is achieved Intraoperative EMG with CSF drainage, the cerebellum is gently elevated, and the root entry zone of the facial nerve is exposed and The AMR can be elicited in every patient with HFS. examined for vascular contact. In concert with our neu- The term “lateral spread” is often used interchangeably romonitoring team, arteries are decompressed from the with the term abnormal motor response. The term, how- facial nerve using shredded Teflon pledgets while some ever, should be reserved for describing the AMR in re- veins are coagulated using bipolar cautery or are pur- lationship to the theory of ephaptic transmission as the posely avulsed. term “lateral spread” neglects the theory of motor nucleus hyperexcitability. To monitor the AMR intraoperatively, Statistical Analysis we use a technique similar to that originally described by Nielsen.25 Depolarizing muscle relaxants are not used. Statistical analysis was performed with MedCalc Bipolar subdermal needle electrodes are placed 0.5–1 cm 9.001 for a personal computer. Specific tests used in each apart in the orbicularis oculi and mentalis muscles. The instance are documented below. orbicularis oculi muscle is activated by setting the stimu- lating electrode to 10 mA and by finding the zygomatic Results branches of the facial nerve supplying the ocular muscle. This is done by gently passing the stimulating electrode Our experience over the past 2 years is presented. over the face, with slight pressure over the superior mar- The AMR was monitored in every patient. Seventy-three gin of the zygomatic arch. Final positioning of the stimu- patients without previous decompressions underwent lating electrode is based on the location that maximizes surgery performed by 2 surgeons (R.F.S. and P.J.J.). Of the activation of the orbicularis oculi muscle. The needle these, 69 patients are free of spasm at last follow-up. electrodes are affixed to the skin in their optimal posi- Two patients required reoperation for persistent spasms tion with tape. The AMR is recorded from the mentalis despite abolishment of the AMR during the first MVD. muscle. Spontaneous activity from the mentalis muscle is Both patients were subsequently cured of HFS with a sec- not usually seen with general anesthesia. ond MVD. Both cases have been counted as failures in Once the AMR is obtained, the stimulating electrode the meta-analysis because the patients had abolishment is secured and a low limit threshold is obtained. The of the AMR at the conclusion of the first surgery, but they AMR is then recorded at that current intensity at 2.79 Hz returned with recurrent spasms. In 4 patients, the AMR with a 100-µsec pulse width. The stimulation frequency disappeared on dural opening. These 4 patients were ex- is 2–4 Hz.
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