The mapping and continuous monitoring of the intrinsic motor nuclei during brain stem surgery.

A comprehensive technique was developed for continuous electrophysiological monitoring of intrinsic brain stem motor function during surgery to remove space-occupying lesions in the fourth ventricle and brain stem. The technique is analogous to that used during surgery in the cerebellopontine angle; motor nuclei and peripheral pontine fiber tracts of Cranial Nerves III-XII are identified by the electrical stimulation of structures in the operative field and the evaluation of the compound muscle action potentials recorded from the corresponding muscles of the head. Nerve function is monitored continuously by recording the ongoing electromyographic activity in these same muscles. Broadcasting electromyographic responses through a loudspeaker gives the surgeon immediate feedback on the status of the motor nuclei being monitored. Advantages of this technique include 1) the positive, objective identification of the nuclei and fiber tracts; 2) the continuous feedback on the status of these structures; 3) a safe approach through the fourth ventricle to the lesions in the brain stem; 4) the positive identification of the boundaries between the neoplasm and the motor structures of the rhomboid fossa; and 5) a warning to the surgeon of potentially harmful nerve manipulations (contact, dissection, transection) during surgery. After this technique was used in 16 consecutive operations to remove cavernomas (n = 9), gliomas (n = 4), and other types of tumors (n = 3), surgical and neurological results showed the method to be reliable and simple to perform.