Use of an anal sphincter pressure monitor during operations on the sacral spinal cord and nerve roots.

The distinction of sacral roots and conus medullaris from lipoma, fibrous adhesions, and an abnormally thickened filum terminale can be difficult during operations on certain complicated dysraphic lesions. We describe a simple, noninvasive method of monitoring external anal sphincter "squeeze pressure" by means of an elongated, fluid-filled, polyethylene anal balloon connected to a pressure transducer. Cutaneous electrocardiographic (ECG) leads on both hips register the stimulus artifact from a monopolar nerve stimulator. The simultaneous display on the oscilloscope screen of the stimulus artifact and the resultant pressure response form an electromechanical coupling that allows the operator to identify a faulty stimulator probe and to distinguish true stimulus-induced external anal sphincter activity from spontaneous rhythmic contractions of the internal anal sphincter. Unilateral stimulation of the S-2, S-3, and S-4 roots generates tall pressure spikes between 40 and 75 torr in peak amplitudes, whereas S-1 and L-5 stimulation produces a stimulus artifact on the ECG but either no pressure response or a mere "ripple wave" of less than 7 torr. During operations on 11 patients with various dysraphic lesions, the S-2, S-3, and S-4 roots were identified easily and preserved, and the caudal extent of functioning neurons was localized within coni grossly distorted by intramedullary lipoma or chronic tethering. We prefer the anal sphincter pressure monitor to anal sphincter electromyography because of its simplicity, the inexpensive equipment, and its noise-free display that is virtually unaffected by other electronic systems in the operating room.