BackgroundIntramedullary spinal cord tumours are formidable lesions in spine surgery due to the high risk of postoperative deficits associated with surgical resection. Traditional MRI imaging fails to provide a 3-D rendering of the relationship between the tumour and spinal cord sensory and motor pathways; in contrast, DTI/tractography can show this relationship with the potential to reduce surgery-related morbidity. The use of intraoperative somatosensory evoked potentials (SSEP) and transcranial motor evoked potentials (MEP) have also been considered a standard of care to minimize neurologic complications of surgery. However, in situations where both baseline SSEPs and MEPs are unobtainable, D-wave and direct cord stimulation can become invaluable intra-operative tools. MethodsA 6 year old child presented with new growth from an incompletely resected thoracic intramedullary dermoid tumour. Pre-operative DTI/tractography images were obtained. During tumour resection, SSEP and MEP signals were unable to be obtained, however intraoperative monitoring of the spinal cord was undertaken with D-wave monitoring and direct cord stimulation. ResultsThis multimodal monitoring technique allowed identification of the corticospinal tracts intra-operatively and allowed safe tumour resection. Post-operative MRI revealed gross total resection and the patient returned to her pre-operative neurological baseline without incurring any further deficits. ConclusionsWe have presented a technical description of the clinical utility of DTI/tractography in surgical planning, and D-wave monitoring with direct cord stimulation as adjuncts in the resection of an intramedullary cord tumour. This is particularly useful in the scenario where TcMEP/SSEP signals cannot be obtained and in revision surgery for intramedullary spinal cord tumours.

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