IONM Assists in Conjoined Twin Separation Surgery
Conjoined twin girls Ballenie and Bellanie Camacho spent almost their entire first year of life facing away from each other. Joined at their lower back and hip, they shared parts of many of their organs and even certain parts of their nervous system. But all that changed on January 17, when the 11-month-old girls underwent surgery to become separated. The team for the 22-hour surgery, which took place in Westchester Medical Center’s Maria Fareri Children’s Hospital in Valhalla, New York, included about 50 clinicians. Among them were pediatric neurosurgeons, general surgeons, pediatric orthopedic surgeons, pediatric urologists, pediatric nursing teams, pediatric anesthesiologists—and five of NeuroAlert’s senior surgical neurophysiologists including Chief Clinical Officer, Dr. Christopher Pace, Christopher Solotaroff, Rose Auerbach, Huma Khan, and Awa Ndiaye.
Intraoperative neuromonitoring was essential during the surgery because of the complexity of separating the twins’ two nervous systems—especially at the sacral sections of their spinal cords, which were fused together. To detect what crossover existed between parts of the spinal cord, several IONM tools were integrated into the protocol for the surgery:
Transcranial electrical motor evoked potential (TcMEP) monitoring evaluated how motor fibers from one twin’s spinal cord were affecting the extremities of the other twin.
Somatosensory evoked potential (SSEP) monitoring was used to evaluate the sensory tracts of each twin.
Both SSEP and motor evoked potential monitoring (MEP) provided real-time feedback on how each twins’ nervous system was working throughout the surgery.
Spontaneous electromyography (EMG) allowed the team to monitor muscle activity.
Triggered EMG was used to stimulate the nerve, allowing the surgeon to map out which of the twins’ nerves were fused.
“[The triggered EMG] changed the way the surgeon dissected the fused portion of the spinal cord and allowed for the successful separation of their nervous systems,” said Rose Auerbach, BS, CNIM, who was a member of the IONM team during the twins’ surgery. After separating the twins’ bony structures, Auerbach explained, the surgeon opened the dura (the outermost sheath that covers the spinal cords), separated the spinal cords, and then closed the dura to ensure a fully independent spinal cord for each twin. In total, the separation of the spinal cord took about 6 hours. “Such an amazing experience to be in that room with so many professionals working toward this goal to give both twins a normal life.”
“With the twins partially sharing the tail end of their spinal cords, it was fascinating the see that the activation of one twin’s nervous system caused a response in the other twins’ limbs and vice versa,” noted Awa Ndiaye, MS, CNIM, a NeuroAlert IONM expert who was part of the team.
A third member of the NeuroAlert IONM team, Huma Khan, BS, CNIM, also reflected on the honor and privilege of being part of the team. “One of the most intense and incredible moments was when the final cut was made to separate the last filum that connected the spinal cords, and we informed the surgeons that our MEPs and SEPs were still intact, in each twin!” Khan stated. “I am so immensely proud of our IONM team and all the teams that contributed their hard efforts toward these two miracles.”
The two girls, who are originally from the Dominican Republic, are recovering well. They are expected to leave the hospital in late March.