The patient came to the hospital 18-October-2017 bedridden. She suffered fracture of the right ankle 1 year ago, for what P.O.P was applied. The last 7 months she started to suffer of difficulty of walking with loss of urination and defecation control. The patient performed elsewhere MRI and reported as having glioma of the spinal cord at D7 level. She is a known diabetic for 15 years under treatment.  

On examination, the patient is in bed with inability to walk, nor set down. Examination of the cranial nerves and neck was unremarkable. There is para-aneasthesia below the nipples. There is severe spastic both lower limbs with difficulty to move the limbs more spastic the right one. Dorsiflexion right foot was 0/5 and left foot -3/5, the same with planterflexion. Abduction left knee was -3/5, but abduction of the left knee and movements of the right knee was 0/5. Quadriceps were difficult to evaluate. SLRS was 0 degree in the right and 3 degrees in the left. KJ was exaggerated in both sides and absent in the left side, Babinski positive both side with clonus right foot and very spastic both lower limbs. There is ulceration in the right side of the lower back. 

The patient was sent for investigations and MRI dorsal spine showed meningioma 3.3 x1.3 cm in diameter pushing the spinal cord to the left, extending from the D6 down to D7. CT-scan of the dorsal area was performed for the surgical planning.

Laminectomy of lower half of D6, D7 and upper half of D8 under guidance of the C-arm. The upper border was full of epidural fat, for what it was believed that we were at right level. The dura was opened and inspection of the spinal cord from all corners was normal. The patient was sent for MRI and the tumor was locating 3-4 mm above the upper border of the exposed dura. Laminectomy of the above vertebra, where the epidural fat was hypertrophied with arterialized veins. The dural incision was extended up, until the upper border of the meningioma was seen. About 1/3 of the tumor came out off the dura from the right side and the matrix of the tumor was coagulated. Step-wise resection of the tumor with resection of the right D7 bridging root to avoid traction injury to the spinal cord. The tumor was totally resected without touching the spinal cord, which by time started to have normal appearance.  Using MultiGen, bipolar motor stimulation of the right side of the spinal cord below the resected tumor was achieved with 0.7 V. Bipolar motor stimulation of the right side of the spinal cord above the lesion did not gave response even with 6V. Stimulation of the left side of the spinal cord was achieved with 1.7 V below the resected tumor and 2V above the resected tumor. Routine closure of the wound. Before extubation another MRI demonstrated radical resection of the tumor.

Smooth postoperative recovery.  The patient got some movement of the right foot and the power of the left foot became slightly better. She was sent to the ward.

The patient came to the clinic 16-December-2018 walking with walker with full recovery of the sensory deficit and full power of both lower extremities except for slight weak dorsiflexion right foot +4/5 with full control of urination and defecation and was sent for control MRI dorsal spine. See Fig-1 below.

The patient has huge meningioma with pending complete paraplegia. Surgical removal is the only solution.

This is the 138th case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

It could be that the spinal cord and nerve is recovering minute by minute after decompression and this can explain why the motor conductivity is improving. In this case the left side was confirming that the left side of the spinal cord was in good condition, but why the right side of the spinal cord did not responded even to 6V above the lesion was unclear. It could be a technical error.

Using the absence of the epidural fat as guidance for severe compression, led us to the wrong direction. The meningioma was causing hypertrophy of the epidural fat with arterialized veins.

Intraoperative MRI is an integral requirement for most cranial and spinal tumors surgery. Without MRI, mistakes could happen even with long term experience of the surgeon.

The slight improvement of the right lower limb function is contradicted the stimulation parameters, for what the surgeon must not trust the technology. In this case it was misleading.