{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T02:37:55Z","timestamp":1792809475635,"version":"4.5.0"},"reference-count":33,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,8,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Resections of the supplementary motor area (SMA) in the dorsomedial frontal cortex (DMFC) have traditionally been thought to result in predictable postoperative motor deficits termed the \"SMA syndrome.\" However, the true incidence, etiology, and duration of these deficits seem overstated in the modern era. Herein, the authors aimed to critically evaluate and reassess the SMA syndrome in the context of surgical navigation, retractorless surgery, and contemporary motor mapping and monitoring techniques.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>The authors retrospectively reviewed the electronic medical records of all patients who underwent DMFC resections for tumors or epilepsy between 2004 and 2025 at a single institution. Patients with insufficient data were excluded from the study. Compiled data included demographics, presenting symptoms, surgical characteristics, intraoperative mapping, postoperative motor function, postoperative complications, and follow-up visits up to 12 weeks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>Eighty patients were eligible for study inclusion. New postoperative motor deficits occurred in 33.8% of patients (27\/80); however, when cases with concomitant involvement of the primary motor cortex or cingulate gyrus were excluded, the incidence of SMA-specific deficits was only 10.0% (8\/80). Moreover, 81.5% of new deficits (22\/27) resolved by a median of 13 days, and 51.9% (14\/27) recovered very rapidly. Patients with new deficits were more likely to have right hemisphere resections (p = 0.033). Motor strip involvement (p = 0.019) and postoperative complications (p = 0.042) were also associated with new deficits. No association was found with the use of intraoperative mapping, percentage of resected SMA, or other clinical characteristics. As expected, patients with new deficits experienced a longer postoperative hospital course (p = 0.023) and were more often discharged to inpatient rehabilitation (p = 0.012). Permanent deficits occurred in 6.3% of patients (5\/80) and were more often associated with preoperative weakness (p = 0.047) and a major postoperative complication (p = 0.013).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>These findings challenge the classic perspectives on SMA syndrome. When resections are confined to the SMA, postoperative deficits are uncommon, mild, and resolved rapidly. Persistent deficits reflect injury to adjacent eloquent regions rather than injury from the SMA resection itself. With gravity-based retraction, modern navigation, and functional mapping, DMFC lesions can be resected more safely than in the past. Study findings support redefining SMA syndrome and expanding the role of mapping-guided resections in this region.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2026.3.jns252548","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T00:01:15Z","timestamp":1787097675000},"page":"1-9","source":"Crossref","is-referenced-by-count":0,"title":["The myth of the supplementary motor area syndrome: the etiology of motor deficits after dorsomedial frontal resections"],"prefix":"10.3171","author":[{"given":"Antonio","family":"Dono","sequence":"first","affiliation":[{"name":"Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shalin","family":"Shah","sequence":"additional","affiliation":[{"name":"Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Morkas","sequence":"additional","affiliation":[{"name":"Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston;"},{"name":"Texas Institute for Restorative Neurotechnologies, University of Texas Health Science Center at Houston; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathryn","family":"Snyder","sequence":"additional","affiliation":[{"name":"Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston;"},{"name":"Texas Institute for Restorative Neurotechnologies, University of Texas Health Science Center at Houston; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ellery","family":"Wheeler","sequence":"additional","affiliation":[{"name":"Texas Institute for Restorative Neurotechnologies, University of Texas Health Science Center at Houston; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoshua","family":"Esquenazi","sequence":"additional","affiliation":[{"name":"Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston;"},{"name":"Memorial Hermann Hospital, Texas Medical Center, Houston, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nitin","family":"Tandon","sequence":"additional","affiliation":[{"name":"Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston;"},{"name":"Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston;"},{"name":"Memorial Hermann Hospital, Texas Medical Center, Houston, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"1","key":"b1","series-title":"J Neurosurg","first-page":"62","article-title":"Postoperative deficits and functional recovery following removal of tumors involving the dominant hemisphere supplementary motor area","volume":"75","author":"Rostomily RC","year":"1991","unstructured":"Rostomily RC, Berger MS, Ojemann GA, Lettich E. Postoperative deficits and functional recovery following removal of tumors involving the dominant hemisphere supplementary motor area. J Neurosurg. 1991;75(1):62\u201368. doi:10.3171\/jns.1991.75.1.0062"},{"issue":"6","key":"b2","series-title":"J Neurosurg","first-page":"1152","article-title":"Prediction of neurological deficits and recovery after surgery in the supplementary motor area: a prospective study in 26 patients","volume":"113","author":"Rosenberg K","year":"2010","unstructured":"Rosenberg K, Nossek E, Liebling R,  Prediction of neurological deficits and recovery after surgery in the supplementary motor area: a prospective study in 26 patients. J Neurosurg. 2010;113(6):1152\u20131163. doi:10.3171\/2010.6.JNS1090"},{"issue":"1","key":"b3","series-title":"iScience","first-page":"111531","article-title":"Supplementary motor area in speech initiation: a large-scale intracranial EEG evaluation of stereotyped word articulation","volume":"28","author":"Bullock L","year":"2025","unstructured":"Bullock L, Forseth KJ, Woolnough O, Rollo PS, Tandon N. Supplementary motor area in speech initiation: a large-scale intracranial EEG evaluation of stereotyped word articulation. iScience. 2025;28(1):111531. doi:10.1016\/j.isci.2024.111531"},{"issue":"1","key":"b4","series-title":"J Neurosurg","first-page":"7","article-title":"Risk factor analysis of the development of new neurological deficits following supplementary motor area resection","volume":"119","author":"Kim YH","year":"2013","unstructured":"Kim YH, Kim CH, Kim JS,  Risk factor analysis of the development of new neurological deficits following supplementary motor area resection. J Neurosurg. 2013;119(1):7\u201314. doi:10.3171\/2013.3.JNS121492"},{"issue":"1","key":"b5","series-title":"Neuroimage","first-page":"250","article-title":"Electrophysiological and functional connectivity of the human supplementary motor area","volume":"62","author":"Narayana S","year":"2012","unstructured":"Narayana S, Laird AR, Tandon N, Franklin C, Lancaster JL, Fox PT. Electrophysiological and functional connectivity of the human supplementary motor area. Neuroimage. 2012;62(1):250\u2013265. doi:10.1016\/j.neuroimage.2012.04.060"},{"issue":"11","key":"b6","series-title":"Nat Rev Neurosci","first-page":"856","article-title":"Functional role of the supplementary and pre-supplementary motor areas","volume":"9","author":"Nachev P","year":"2008","unstructured":"Nachev P, Kennard C, Husain M. Functional role of the supplementary and pre-supplementary motor areas. Nat Rev Neurosci. 2008;9(11):856\u2013869. doi:10.1038\/nrn2478"},{"issue":"5","key":"b7","series-title":"Neurosurgery","first-page":"966","article-title":"Surgical resection of grade II astrocytomas in the superior frontal gyrus","volume":"50","author":"Peraud A","year":"2002","unstructured":"Peraud A, Meschede M, Eisner W, Ilmberger J, Reulen HJ. Surgical resection of grade II astrocytomas in the superior frontal gyrus. Neurosurgery. 2002;50(5):966\u2013977. doi:10.1097\/00006123-200205000-00009"},{"issue":"3","key":"b8","series-title":"J Neurol Sci","first-page":"301","article-title":"Clinical consequences of corticectomies involving the supplementary motor area in man","volume":"34","author":"Laplane D","year":"1977","unstructured":"Laplane D, Talairach J, Meininger V, Bancaud J, Orgogozo J. Clinical consequences of corticectomies involving the supplementary motor area in man. J Neurol Sci. 1977;34(3):301\u2013314. doi:10.1016\/0022-510x(77)90148-4"},{"issue":"4","key":"b9","series-title":"J Neurosurg","first-page":"542","article-title":"Functional results after resective procedures involving the supplementary motor area","volume":"85","author":"Zentner J","year":"1996","unstructured":"Zentner J, Hufnagel A, Pechstein U, Wolf H, Schramm J. Functional results after resective procedures involving the supplementary motor area. J Neurosurg. 1996;85(4):542\u2013549. doi:10.3171\/jns.1996.85.4.0542"},{"issue":"3","key":"b10","series-title":"Neurosurgery","first-page":"506","article-title":"Incidence and clinical evolution of postoperative deficits after volumetric stereotactic resection of glial neoplasms involving the supplementary motor area","volume":"52","author":"Russell SM","year":"2003","unstructured":"Russell SM, Kelly PJ. Incidence and clinical evolution of postoperative deficits after volumetric stereotactic resection of glial neoplasms involving the supplementary motor area. Neurosurgery. 2003;52(3):506\u2013516. doi:10.1227\/01.neu.0000047670.56996.53"},{"issue":"5","key":"b11","series-title":"Neurosurgery","first-page":"1152","article-title":"Characterization of the supplementary motor area syndrome and seizure outcome after medial frontal lobe resections in pediatric epilepsy surgery","volume":"70","author":"Kasasbeh AS","year":"2012","unstructured":"Kasasbeh AS, Yarbrough CK, Limbrick DD,  Characterization of the supplementary motor area syndrome and seizure outcome after medial frontal lobe resections in pediatric epilepsy surgery. Neurosurgery. 2012;70(5):1152\u20131168. doi:10.1227\/NEU.0b013e31823f6001"},{"issue":"1","key":"b12","series-title":"Neurosurg Rev","first-page":"81","article-title":"The supplementary motor area syndrome: a neurosurgical review","volume":"45","author":"Pinson H","year":"2022","unstructured":"Pinson H, Van Lerbeirghe J, Vanhauwaert D, Van Damme O, Hallaert G, Kalala JP. The supplementary motor area syndrome: a neurosurgical review. Neurosurg Rev. 2022;45(1):81\u201390. doi:10.1007\/s10143-021-01566-6"},{"issue":"5","key":"b13","series-title":"Neurology","first-page":"871","article-title":"Role of the supplementary motor area in motor deficit following medial frontal lobe surgery","volume":"57","author":"Krainik A","year":"2001","unstructured":"Krainik A, Leh\u00e9ricy S, Duffau H,  Role of the supplementary motor area in motor deficit following medial frontal lobe surgery. Neurology. 2001;57(5):871\u2013878. doi:10.1212\/wnl.57.5.871"},{"issue":"4","key":"b14","series-title":"J Neurosurg","first-page":"1181","article-title":"Recovery of functional connectivity of the sensorimotor network after surgery for diffuse low-grade gliomas involving the supplementary motor area","volume":"126","author":"Vassal M","year":"2017","unstructured":"Vassal M, Charroud C, Deverdun J,  Recovery of functional connectivity of the sensorimotor network after surgery for diffuse low-grade gliomas involving the supplementary motor area. J Neurosurg. 2017;126(4):1181\u20131190. doi:10.3171\/2016.4.JNS152484"},{"issue":"3","key":"b15","series-title":"J Neurosurg","first-page":"865","article-title":"Recovery time from supplementary motor area syndrome: relationship to postoperative day 7 paralysis and damage of the cingulum","volume":"132","author":"Nakajima R","year":"2020","unstructured":"Nakajima R, Kinoshita M, Yahata T, Nakada M. Recovery time from supplementary motor area syndrome: relationship to postoperative day 7 paralysis and damage of the cingulum. J Neurosurg. 2020;132(3):865\u2013874. doi:10.3171\/2018.10.JNS182391"},{"issue":"3","key":"b16","series-title":"Brain Behav","first-page":"e00926","article-title":"The crossed frontal aslant tract: a possible pathway involved in the recovery of supplementary motor area syndrome","volume":"8","author":"Baker CM","year":"2018","unstructured":"Baker CM, Burks JD, Briggs RG,  The crossed frontal aslant tract: a possible pathway involved in the recovery of supplementary motor area syndrome. Brain Behav. 2018;8(3):e00926. doi:10.1002\/brb3.926"},{"issue":"Pt 4","key":"b17","series-title":"Brain","first-page":"1017","article-title":"Motor deficits correlate with resting state motor network connectivity in patients with brain tumours","volume":"135","author":"Otten ML","year":"2012","unstructured":"Otten ML, Mikell CB, Youngerman BE,  Motor deficits correlate with resting state motor network connectivity in patients with brain tumours. Brain. 2012;135(Pt 4):1017-1026. doi:10.1093\/brain\/aws041"},{"issue":"4","key":"b18","series-title":"Neurosurgery","first-page":"900","article-title":"Epilepsy surgery of the cingulate gyrus and the frontomesial cortex","volume":"70","author":"Von Lehe M","year":"2012","unstructured":"Von Lehe M, Wagner J, Wellmer J, Clusmann H, Kral T. Epilepsy surgery of the cingulate gyrus and the frontomesial cortex. Neurosurgery. 2012;70(4):900\u2013910. doi:10.1227\/NEU.0b013e318237aaa3"},{"issue":"5","key":"b19","series-title":"J Neurosurg","first-page":"1278","article-title":"Resection of supplementary motor area gliomas: revisiting supplementary motor syndrome and the role of the frontal aslant tract","volume":"136","author":"Young JS","year":"2022","unstructured":"Young JS, Gogos AJ, Aabedi AA,  Resection of supplementary motor area gliomas: revisiting supplementary motor syndrome and the role of the frontal aslant tract. J Neurosurg. 2022;136(5):1278\u20131284. doi:10.3171\/2021.4.JNS21187"},{"issue":"3","key":"b20","series-title":"J Neurosurg","first-page":"640","article-title":"Assessment of morbidity following resection of cingulate gyrus gliomas","volume":"114","author":"Tate MC","year":"2011","unstructured":"Tate MC, Kim CY, Chang EF, Polley MY, Berger MS. Assessment of morbidity following resection of cingulate gyrus gliomas. J Neurosurg. 2011;114(3):640\u2013647. doi:10.3171\/2010.9.JNS10709"},{"issue":"0 3","key":"b21","series-title":"Operative Neurosurgery","first-page":"447-456","article-title":"Recurrent supplementary motor area syndrome following repeat brain tumor resection involving supplementary motor cortex","volume":"11 Suppl 3","author":"Abel TJ","year":"2015","unstructured":"Abel TJ, Buckley RT, Morton RP, Gabikian P, Silbergeld DL. Recurrent supplementary motor area syndrome following repeat brain tumor resection involving supplementary motor cortex. Operative Neurosurgery. 2015;11 Suppl 3(0 3):447-456 doi:10.1227\/NEU.0000000000000847"},{"issue":"2","key":"b22","first-page":"297","article-title":"Somatotopy of the supplementary motor area: evidence from correlation of the extent of surgical resection with the clinical patterns of deficit","volume":"50","author":"Fontaine D","year":"2002","unstructured":"Fontaine D, Capelle L, Duffau H. Somatotopy of the supplementary motor area: evidence from correlation of the extent of surgical resection with the clinical patterns of deficit. 2002;50(2):297\u2013305. doi:10.1097\/00006123-200202000-00011"},{"issue":"3","key":"b23","series-title":"Br J Neurosurg","first-page":"323","article-title":"Resection extent of the supplementary motor area and post-operative neurological deficits in glioma surgery","volume":"30","author":"Ibe Y","year":"2016","unstructured":"Ibe Y, Tosaka M, Horiguchi K,  Resection extent of the supplementary motor area and post-operative neurological deficits in glioma surgery. Br J Neurosurg. 2016;30(3):323\u2013329. doi:10.3109\/02688697.2015.1133803"},{"issue":"5","key":"b24","series-title":"J Neurosurg","first-page":"1153","article-title":"Long-term surgical results of supplementary motor area epilepsy surgery","volume":"127","author":"Alonso-Vanegas MA","year":"2017","unstructured":"Alonso-Vanegas MA, San-Juan D, Buentello Garc\u00eda RM,  Long-term surgical results of supplementary motor area epilepsy surgery. J Neurosurg. 2017;127(5):1153\u20131159. doi:10.3171\/2016.8.JNS16333"},{"issue":"6","key":"b25","series-title":"Neurosurg Focus","first-page":"E3","article-title":"Prediction of recovery from supplementary motor area syndrome after brain tumor surgery: preoperative diffusion tensor tractography analysis and postoperative neurological clinical course","volume":"44","author":"Oda K","year":"2018","unstructured":"Oda K, Yamaguchi F, Enomoto H, Higuchi T, Morita A. Prediction of recovery from supplementary motor area syndrome after brain tumor surgery: preoperative diffusion tensor tractography analysis and postoperative neurological clinical course. Neurosurg Focus. 2018;44(6):E3. doi:10.3171\/2017.12.FOCUS17564"},{"issue":"8","key":"b26","series-title":"Neuro Oncol","first-page":"1231","article-title":"The 2021 WHO Classification of Tumors of the Central Nervous System: a summary","volume":"23","author":"Louis DN","year":"2021","unstructured":"Louis DN, Perry A, Wesseling P,  The 2021 WHO Classification of Tumors of the Central Nervous System: a summary. Neuro Oncol. 2021;23(8):1231\u20131251. doi:10.1093\/neuonc\/noab106"},{"issue":"2","key":"b27","series-title":"Neurosurgery","first-page":"275","article-title":"The survival advantage of \"supratotal\" resection of glioblastoma using selective cortical mapping and the subpial technique","volume":"81","author":"Esquenazi Y","year":"2017","unstructured":"Esquenazi Y, Friedman E, Liu Z, Zhu JJ, Hsu S, Tandon N. The survival advantage of \"supratotal\" resection of glioblastoma using selective cortical mapping and the subpial technique. Neurosurgery. 2017;81(2):275\u2013288. doi:10.1093\/neuros\/nyw174"},{"issue":"3","key":"b28","series-title":"Bone Marrow Transplant","first-page":"452","article-title":"Investigation of the freely available easy-to-use software \u2018EZR\u2019 for medical statistics","volume":"48","author":"Kanda Y","year":"2013","unstructured":"Kanda Y. Investigation of the freely available easy-to-use software \u2018EZR\u2019 for medical statistics. Bone Marrow Transplant. 2013;48(3):452\u2013458. doi:10.1038\/bmt.2012.244"},{"issue":"5","key":"b29","series-title":"Neurosurgery","first-page":"515","article-title":"Molecular, histological, and clinical characteristics of oligodendrogliomas: a multi-institutional retrospective study","volume":"90","author":"Dono A","year":"2022","unstructured":"Dono A, Alfaro-Munoz K, Yan Y,  Molecular, histological, and clinical characteristics of oligodendrogliomas: a multi-institutional retrospective study. Neurosurgery. 2022;90(5):515\u2013522. doi:10.1227\/neu.0000000000001875"},{"issue":"3","key":"b30","series-title":"J Neurooncol","first-page":"537","article-title":"Early rehabilitation after surgery improves functional outcome in inpatients with brain tumours","volume":"107","author":"Bartolo M","year":"2012","unstructured":"Bartolo M, Zucchella C, Pace A,  Early rehabilitation after surgery improves functional outcome in inpatients with brain tumours. J Neurooncol. 2012;107(3):537\u2013544. doi:10.1007\/s11060-011-0772-5"},{"issue":"3","key":"b31","series-title":"Neurosurgery","first-page":"457","article-title":"Clinical pearls and methods for intraoperative motor mapping","volume":"88","author":"Rossi M","year":"2021","unstructured":"Rossi M, Sciortino T, Conti Nibali M,  Clinical pearls and methods for intraoperative motor mapping. Neurosurgery. 2021;88(3):457\u2013467. doi:10.1093\/neuros\/nyaa359"},{"issue":"3","key":"b32","series-title":"J Clin Neurol","first-page":"393","article-title":"Postoperative transient neurologic dysfunction: a proposal for pathophysiology","volume":"14","author":"Phi JH","year":"2018","unstructured":"Phi JH, Lee SJ, Kang HS,  Postoperative transient neurologic dysfunction: a proposal for pathophysiology. J Clin Neurol. 2018;14(3):393\u2013400. doi:10.3988\/jcn.2018.14.3.393"},{"key":"b33","series-title":"Aids to the Examination of Peripheral Nerve Injuries (Memorandum No. 45)","year":"1976","unstructured":"Medical Research Council, Nerve Injuries Committee. Aids to the Examination of Peripheral Nerve Injuries (Memorandum No. 45). Her Majesty\u2019s Stationery Office;1976."}],"container-title":["Journal of Neurosurgery"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/aop\/article-10.3171-2026.3.JNS252548\/article-10.3171-2026.3.JNS252548.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/aop\/article-10.3171-2026.3.JNS252548\/article-10.3171-2026.3.JNS252548.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T01:43:26Z","timestamp":1792806206000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/aop\/article-10.3171-2026.3.JNS252548\/article-10.3171-2026.3.JNS252548.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,1]]},"references-count":33,"URL":"https:\/\/doi.org\/10.3171\/2026.3.jns252548","relation":{},"ISSN":["0022-3085","1933-0693"],"issn-type":[{"value":"0022-3085","type":"print"},{"value":"1933-0693","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,1]]}}}