IntroductionIntraoperative neuromonitoring (IONM) has become a standard of care in spinal deformity surgeries to minimize the incidence of new onset neurological deficit. Stagnara wake up test and ankle clonus test are the oldest techniques described for spinal cord monitoring, but they cannot be solely relied upon as a neuromonitoring modality. Somatosensory evoked potentials monitor only dorsal tracts and give high false positive and negative alerts. Transcranial motor evoked potentials (TcMEPs) monitor the more useful motor pathways. The purpose of our study was to report the safety, efficacy, limitations of TcMEPs in spine deformity surgeries, and the role of a checklist.Study designRetrospective review of all spinal deformity surgeries performed with TcMEPs from 2011 to 2015.Materials and methodsAll patients were subjected to IONM by TcMEPs during the spinal deformity surgery. Patients were included in the study only if complete operative reports and neuromonitoring data and postoperative neurological data were available for review. An alert was defined as 80% or more decrement in the motor evoked potential amplitude, or increase in threshold of 100 V or more from baseline. The systemic and surgical causes of IONM alerts and the postoperative neurological status were recorded.ResultsIn total, 61 patients underwent surgery for spinal deformities with TcMEPs. The average age was 12.6 years (6–36 years) and male:female ratio was 1:1.3. Diagnoses included idiopathic scoliosis (n = 35), congenital scoliosis (n = 13), congenital kyphosis (n = 7), congenital kyphoscoliosis (n = 4), post-infectious kyphosis (n = 1), and post-traumatic kyphosis (n = 1). The average kyphosis was 72° (45°–101°) and the average scoliosis was 84° (62°–128°). There were in total 33 alerts in 22 patients (36%). The most common causes were hypotension (n = 7), drug induced (n = 5), deformity correction (n = 5), osteotomies (n = 3), tachycardia (n = 1), screw placement (n = 2), and electrodes disconnection (n = 1). Reversal of the inciting event cause resulted in complete reversal of the alert in 90% of the times. Three patients showed persistent alerts, out of whom one had a positive wake up test and woke up with neurodeficit, which recovered over few weeks, while the other patients showed persistent alerts but woke up without any deficit. Sensitivity and specificity of TcMEP in deformity correction surgery were 100 and 96.6%, respectively, in our study.ConclusionIONM alerts are frequent during spinal deformity surgery. In our study, more than 50% of the alerts were associated with anesthetic management. IONM with TcMEPs is a safe and effective monitoring technique and wake up test still remains a valuable tool in cases of a persistent alert.
IntroductionCervical spondylotic myelopathy affects the middle to elderly population, causing significant morbidity. Keegan 1 first described the C5 nerve palsy that developed following posterior decompression surgeries as a "dissociated motor loss." C5 palsy causes significant morbidity to patients, making them unable to perform their daily activities. 2,3 Both anterior and posterior decompression surgeries can cause this complication. 4,5 Controversy still exists regarding the incidence, cause, risk factors, and measures to prevent C5 palsy. Incidence varied between 0 to 26.4% in anterior surgeries and 0 to 50% in posterior surgeries. 6 Here, we tried to study the incidence in both anterior and posterior surgeries as well as identify various risk factors that lead to development of C5 nerve palsy. AbstractIntroduction C5 palsy following cervical decompression is a known complication. The exact incidence is unclear, due to varying definitions in literature. C5 palsy is associated with significant morbidity due to weakness of deltoid/biceps. Aim To report incidence of postoperative C5 palsy in cervical decompression surgeries for myelopathy and its correlation with demographic factors, etiology, radiological factors, and to assess recovery of palsy. Materials and Methods All patients who underwent cervical decompression surgeries from 2006 to 2015 in a single institute were reviewed. A postoperative decrease by ! 1 manual muscle testing grade in only C5 myotome (deltoid/biceps/ both) is taken as positive. Demographic, radiological, surgical factors resulting in C5 palsy and time of onset, duration of symptoms, and degree of recovery were noted. Results A total of 390 patients were included in the study. Out of which, 232 patients underwent anterior while 158 had posterior surgeries. In all, 72 patients had ossification of the posterior longitudinal ligament (OPLL) and rest had spondylotic myelopathy. Incidence of palsy was 6.3% and mean onset of palsy was 2.8 days. Mean duration for recovery was 6.3 months with near complete recovery seen in majority of the patients (9/10). No significant relation was noted with age, preoperative Japanese Orthopedic Association score, change in cervical lordosis, and C45 intervertebral angle. Posterior surgeries, laminectomy, C45 foraminal stenosis, and OPLL were seen as risk factors for C5 palsy. Conclusion Cervical decompression surgeries are relatively safe, with a small risk of C5 palsy. Though majority of patients recover with conservative treatment, preoperative counseling of this complication has to be explained.
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