Double neurophysiological certification of the filum terminale during sectioning surgery in pediatric population

BACKGROUND: Surgery of thickened-fibrolipoma filum terminale (FT) is performed routinely and without conflict but is not a risk-free surgical procedure. Intraoperative neurophysiological monitoring with mapping techniques can help to certify the FT before sectioning. However, a tailored surgical approach to cauda equina and a low threshold of surrounding nerve roots can confuse the final surgical decision. The aim is to demonstrate the usefulness of this double methodology for FT certification. METHODS: A prospective study collected and reviewed retrospectively, from 2015 to 2018, 40 patients undergoing an FT surgery section were included in the study. After opening the dura mater and under the microscope, the cauda equina mapping is performed and the recording of muscles of the lower limbs and the external anal sphincter. In addition, a high-intensity stimulation of constant current of an isolated FT for a short period of time and in a dry surgical field, obtaining a bilateral-polyradicular-symmetrical response of cauda equina nerve roots. RESULTS: Traditional motor mapping identified FT in 65% (26/40) of patients. Although, 35% (14/40) of the patients still have low-intensity stimuli response (<1 mA) of a muscle, especially anal sphincter. When this happens, the optimization of the dissection around FT is performed. After that, 25% (10/40) of the patients still having a muscle response in spite of seem isolated FT. Increasing the stimulation intensity up to 20 mA evoked a cauda equina response in all cases. No postoperative neurological impairment was observed in this series. CONCLUSION: This proposed methodology accurately confirms the FT so that it can be safely found and cut. The Double Neurophysiological Certification improves the gap of the traditional mapping techniques of cauda equina and can be used in a variety of more complex surgeries in this area.