In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Intraoperative Neuromonitoring During Posterior Spinal Fusion

    Final Number:
    1327

    Authors:
    Nitin Agarwal MD; Alp Ozpinar MD; Phillip Choi MD; Barbara Ochs; Robert Hart MD; D. Kojo Hamilton MD; Ilker Yaylali MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2016 Annual Meeting

    Introduction: Somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP) are frequently used to monitor neurological function during spinal deformity surgery. The sensitivity and specificity of Intraoperative Neuromonitoring (IONM) in patients undergoing Posterior Spinal Fusion Surgery (PSFS) is unknown. Hence, we review our experience.

    Methods: A retrospective review of all patients undergoing PSFS with IONM from October 2008 to December 2012 was performed. Factors including gender, operative time and spinal levels of posterior fusion were analyzed as risk factors for intraoperative alerts.

    Results: A total of 784 consecutive patients who underwent PSFS with IONM with no baseline neurological deficits were analyzed. Patient demographics were: 45% male (n=356), 55% female (n=428) and mean age of 56 years. The mean procedure time was 7 hours. 3.3% (n=26) of patients experienced intraoperative alerts. In this cohort, the average number of levels involved per procedure was approximately 7.1, ranging from 1-16 levels. Of all the spinal levels, the cervico-thoracic region had the highest incidence intraoperative alerts (6 of 97 cervico-thoracic cases p=0.06). Among these patients, age (p= 0.32), gender (p= 0.66) and procedure time (p=0.63) were not predictive factors. 4 out of 26 (15%) patients had neurological deficits despite surgeon intervention following neuromonitoring alerts.

    Conclusions: SSEP and MEP changes occurred in 3.3% of patients undergoing PSFS, with highest incidence at the cervico-thoracic level. 23/26 patients with intraoperative neuromonitoring changes had improvements in IONM signals following interventions during surgery. Neuromonitoring in PSFS enhances surgical safety and in our study prevented post-operative neurological sequelae.

    Patient Care: This research will improve patient care by highlighting the utility of intraoperative monitoring during posterior spinal surgery.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of neuromonitoring during posterior spinal fusion, 2) Discuss, in small groups, regions with the highest incidence for intraoperative alerts.

    References: Bridwell KH, Lenke LG, Baldus C, Blanke K. Major intraoperative neurologic deficits in pediatric and adult spinal deformity patients. Incidence and etiology at one institution. Spine. 1998 Feb 1;23(3):324–31. Calancie B, Donohue ML, Harris CB, Canute GW, Singla A, Wilcoxen KG, et al. Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 1. Methods and alarm criteria. J Neurosurg Spine. 2014a Jun;20(6):675–91. Calancie B, Donohue ML, Moquin RR. Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2. The role of feedback. J Neurosurg Spine. 2014b Jun;20(6):692–704. Chung I, Glow JA, Dimopoulos V, Walid MS, Smisson HF, Johnston KW, et al. Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury. Spine J. 2009 Apr;9(4):287–95. Costa P, Bruno A, Bonzanino M, Massaro F, Caruso L, Vincenzo I, et al. Somatosensory- and motor-evoked potential monitoring during spine and spinal cord surgery. Spinal Cord. 2007 Jan;45(1):86–91. Deletis V, Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol. 2008 Feb;119(2):248–64. Devlin VJ, Schwartz DM. Intraoperative neurophysiologic monitoring during spinal surgery. J Am Acad Orthop Surg. 2007 Sep;15(9):549–60. Eggspuehler A, Sutter MA, Grob D, Jeszenszky D, Dvorak J. Multimodal intraoperative monitoring during surgery of spinal deformities in 217 patients. Eur Spine J. 2007 Nov;16 Suppl 2:S188–96. Fehlings MG, Brodke DS, Norvell DC, Dettori JR. The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference? Spine. 2010 Apr 20;35(9 Suppl):S37–46. Hamilton DK, Smith JS, Sansur CA, Glassman SD, Ames CP, Berven SH, et al. Rates of new neurological deficit associated with spine surgery based on 108,419 procedures: a report of the scoliosis research society morbidity and mortality committee. Spine. 2011 Jul 1;36(15):1218–28. Harel R, Knoller N, Regev G, Anekstein Y, Zaaroor M, Leitner J, et al. The value of neuromonitoring in cervical spine surgery. Surg Neurol Int. 2014;5:120. Husain AM, Emerson RG, Nuwer MN. Emerging subspecialties in neurology: neurophysiologic intraoperative monitoring. Neurology. 2011 Apr 12;76(15):e73–5. Hyun S-J, Rhim S-C. Combined motor and somatosensory evoked potential monitoring for intramedullary spinal cord tumor surgery: correlation of clinical and neurophysiological data in 17 consecutive procedures. Br J Neurosurg. 2009 Aug;23(4):393–400. Hyun SJ, Rhim SC, Kang JK, Hong SH, Park BRG. Combined motor- and somatosensory-evoked potential monitoring for spine and spinal cord surgery: correlation of clinical and neurophysiological data in 85 consecutive procedures. Spinal Cord. 2009 Aug;47(8):616–22. Jones SC, Fernau R, Woeltjen BL. Use of somatosensory evoked potentials to detect peripheral ischemia and potential injury resulting from positioning of the surgical patient: case reports and discussion. Spine J. 2004 Jun;4(3):360–2. Kundnani VK, Zhu L, Tak H, Wong H. Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: Evaluation of 354 consecutive cases. Indian J Orthop. 2010 Jan;44(1):64–72. MacDonald DB, Zayed Z Al, Khoudeir I, Stigsby B. Monitoring scoliosis surgery with combined multiple pulse transcranial electric motor and cortical somatosensory-evoked potentials from the lower and upper extremities. Spine. 2003 Jan 15;28(2):194–203. MacEwen GD, Bunnell WP, Sriram K. Acute neurological complications in the treatment of scoliosis. A report of the Scoliosis Research Society. J Bone Joint Surg Am. 1975 Apr;57(3):404–8. Martirosyan NL, Feuerstein JS, Theodore N, Cavalcanti DD, Spetzler RF, Preul MC. Blood supply and vascular reactivity of the spinal cord under normal and pathological conditions. J Neurosurg Spine. 2011 Sep;15(3):238–51. Nuwer MR. Intraoperative monitoring of the spinal cord. Clin Neurophysiol. 2008 Feb;119(2):247. Nuwer MR. A new multicenter survey of neurologic deficits after spinal deformity surgery: are new models of intraoperative neurophysiologic monitoring less accurate? J Clin Neurophysiol. 2011 Dec;28(6):602–4. O’Brien MF, Lenke LG, Bridwell KH, Padberg A, Stokes M. Evoked potential monitoring of the upper extremities during thoracic and lumbar spinal deformity surgery: a prospective study. J Spinal Disord. 1994 Aug;7(4):277–84. Pajewski TN, Arlet V, Phillips LH. Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. Eur Spine J. 2007 Nov;16 Suppl 2:S115–29. Pelosi L, Lamb J, Grevitt M, Mehdian SMH, Webb JK, Blumhardt LD. Combined monitoring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin Neurophysiol. 2002 Jul;113(7):1082–91. Péréon Y, Nguyen The Tich S, Delécrin J, Pham Dang C, Bodin J, Drouet J-C, et al. Combined spinal cord monitoring using neurogenic mixed evoked potentials and collision techniques. Spine. 2002 Jul 15;27(14):1571–6. Qiu Y, Wang S, Wang B, Yu Y, Zhu F, Zhu Z. Incidence and risk factors of neurological deficits of surgical correction for scoliosis: analysis of 1373 cases at one Chinese institution. Spine. 2008 Mar 1;33(5):519–26. Quraishi NA, Lewis SJ, Kelleher MO, Sarjeant R, Rampersaud YR, Fehlings MG. Intraoperative multimodality monitoring in adult spinal deformity: analysis of a prospective series of one hundred two cases with independent evaluation. Spine. 2009 Jun 15;34(14):1504–12. Sala F, Dvorak J, Faccioli F. Cost effectiveness of multimodal intraoperative monitoring during spine surgery. Eur Spine J. 2007 Nov;16 Suppl 2:S229–31. Sansur CA, Smith JS, Coe JD, Glassman SD, Berven SH, Polly DW, et al. Scoliosis research society morbidity and mortality of adult scoliosis surgery. Spine. 2011 Apr 20;36(9):E593–7. Schwartz DM, Auerbach JD, Dormans JP, Flynn J, Drummond DS, Bowe JA, et al. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am. 2007 Nov;89(11):2440–9. Schwartz DM, Drummond DS, Hahn M, Ecker ML, Dormans JP. Prevention of positional brachial plexopathy during surgical correction of scoliosis. J Spinal Disord. 2000 Apr;13(2):178–82. Sliwa JA, Maclean IC. Ischemic myelopathy: a review of spinal vasculature and related clinical syndromes. Arch Phys Med Rehabil. 1992 Apr;73(4):365–72. Sutter MA, Eggspuehler A, Grob D, Porchet F, Jeszenszky D, Dvorak J. Multimodal intraoperative monitoring (MIOM) during 409 lumbosacral surgical procedures in 409 patients. Eur Spine J. 2007a Nov;16 Suppl 2:S221–8. Sutter M, Deletis V, Dvorak J, Eggspuehler A, Grob D, Macdonald D, et al. Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries. Eur Spine J. 2007b Nov;16 Suppl 2:S232–7. Sutter M, Eggspuehler A, Grob D, Jeszenszky D, Benini A, Porchet F, et al. The diagnostic value of multimodal intraoperative monitoring (MIOM) during spine surgery: a prospective study of 1,017 patients. Eur Spine J. 2007c Nov;16 Suppl 2:S162–70. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993 Feb;17(2):357–68; discussion 368–70. Wang AC, Than KD, Etame AB, La Marca F, Park P. Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature. Neurosurg Focus. 2009 Oct;27(4):E7. Weinzierl MR, Reinacher P, Gilsbach JM, Rohde V. Combined motor and somatosensory evoked potentials for intraoperative monitoring: intra- and postoperative data in a series of 69 operations. Neurosurg Rev. 2007 Apr;30(2):109–16; discussion 116. Wiedemayer H, Sandalcioglu IE, Armbruster W, Regel J, Schaefer H, Stolke D. False negative findings in intraoperative SEP monitoring: analysis of 658 consecutive neurosurgical cases and review of published reports. J Neurol Neurosurg Psychiatr. 2004 Feb;75(2):280–6. Wilber RG, Thompson GH, Shaffer JW, Brown RH, Nash CL. Postoperative neurological deficits in segmental spinal instrumentation. A study using spinal cord monitoring. J Bone Joint Surg Am. 1984 Oct;66(8):1178–87.

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy