Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response

Vitale, Michael G.; Skaggs, David L.; Pace, Gregory; Wright, Margaret L.; Matsumoto, Hiroko; Anderson, Richard C. E.; Brockmeyer, Douglas L.; Dormans, John P.; Emans, John B.; Erickson, Mark; Flynn, John M.; Glotzbecker, Michael P.; Ibrahim, Kamal; Lewis, Stephen J.; Luhmann, Scott J.; Mendiratta, Anil; Richards, B. Stephens; Sanders, James O.; Shah, Suken A.; Smith, John T.; Song, Kit M.; Sponseller, Paul D.; Sucato, Daniel J.; Roye, David P.; Lenke, Lawrence G.

doi:10.1016/j.jspd.2014.05.003

Cited by 148 publications

(110 citation statements)

References 26 publications

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“…Briefly, this methodology consists of a systematic literature review, a creation of a list of statements or indications, and multiple rounds where these indications are rated anonymously by a group of experts [Linstone and Turoff, ; Adler and Ziglio, ; Fitch et al, ]. This methodology has been widely used in medical research to determine appropriate treatment and best practice guidelines [Vitale et al, , ; Wong et al, ; Stefanidis et al, ].…”

Section: Methodsmentioning

confidence: 99%

Best practices in the evaluation and treatment of foramen magnum stenosis in achondroplasia during infancy

White

Bompadre

Goldberg

et al. 2015

American J of Med Genetics Pt A

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Achondroplasia is the most common inherited disorder of bone growth (skeletal dysplasia). Despite this fact, consistent and evidence-based management approaches to recognized, life-threatening complications, such as foramen magnum stenosis, are lacking. This study aims to outline best practice, based on evidence and expert consensus, regarding the diagnosis, assessment, and management of foramen magnum stenosis in achondroplasia during infancy. A panel of 11 multidisciplinary international experts on skeletal dysplasia was invited to participate in a Delphi process. They were: 1) presented with a list of 26 indications and a thorough literature review, 2) given the opportunity to anonymously rate the indications and discuss in face to face discussion; 3) edit the list and rate it in a second round. Those indications with more than 80% agreement were considered as consensual. After two rounds of rating and a face-to-face meeting, consensus was reached to support 22 recommendations for the evaluation and treatment of foramen magnum stenosis in infants with achondroplasia. These recommendations include indications for surgical decompression, ventriculomegaly, and hydrocephalus, sleep-disordered breathing, physical exams and the use of polysomnography and imaging in this condition. We present a consensus-based best practice guidelines consisting of 22 recommendations. It is hoped that these guidelines will lead to more uniform and structured evaluation, standardizing care pathways, and improving mortality and morbidity outcomes for this cohort.

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Section: Methodsmentioning

confidence: 99%

Best practices in the evaluation and treatment of foramen magnum stenosis in achondroplasia during infancy

White

Bompadre

Goldberg

et al. 2015

American J of Med Genetics Pt A

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“…1) pertaining to loss of IONM signals; the checklist was developed by the neurophysiology team based on the work of Vitale et al 13 The goal of the checklist was to encourage the surgical team to focus on increasing spinal cord perfusion for the patient. The first step consisted of a surgical pause, followed by the anesthesia team increasing the mean arterial pressure above 80-90 mm Hg or 10%-15% above the resting pressure.…”

Section: Interventionmentioning

confidence: 99%

Intraoperative neuromonitoring alerts in a pediatric deformity center

Zuccaro¹,

Zuccaro²,

Samdani

et al. 2017

Neurosurgical Focus

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OBJECTIVEIntraoperative neuromonitoring (IONM) involves the use of somatosensory evoked potentials (SSEPs) and transcranial electric motor evoked potentials (TceMEPs). In this retrospective study the authors examined the sensitivity and specificity of both SSEPs and TceMEPs during pediatric spinal deformity surgeries.METHODSThe authors performed a retrospective quantitative analysis of data obtained in 806 patients (197 males and 609 females) treated from December 2011 until October 2015. All patients were diagnosed with scoliosis that was classified as one of the following: adolescent idiopathic scoliosis (AIS) (38%), congenital scoliosis (22%), or syndromic scoliosis (40%). Also, 53 patients underwent vertebral column resection (VCR). All surgeries were monitored by high-level neuromonitoring specialists and were performed with total intravenous anesthesia. Alerts were described as a decrease in amplitude by 50% or greater (bilateral or unilateral) in SSEPs, TceMEPs, or both.RESULTSTrue-positive alerts for TceMEPs were observed in 60 of the 806 patients (7.4%). True-positive alerts for SSEPs were observed in 7 of the 806 patients (0.9%). In contrast, there were no false-positive or false-negative outcomes. Only 1 case (0.1%) was reported with a permanent postoperative deficit. No reported false negatives or false positives were observed, and thus sensitivity was 100% and specificity was 93%–100% for TceMEPs. The rate of sensitivity was 13.2% and the rate of specificity was 100% for SSEPs. The breakdown of total alert was as follows: 6.6% in AIS cases, 24.5% in congenital scoliosis cases, and 10.2% in syndromic scoliosis cases. Neurological injury rates were significantly lower than in previous studies, as there were 0% for AIS cases (p = 0.12), 0.6% for congenital scoliosis cases (p = 0.17), and 0% for syndromic scoliosis cases (p = 0.07). One injury in a patient with congenital scoliosis occurred during a VCR procedure, which brought the injury rate to 1.9% (p < 0.005). IONM alerts occurred during 34% of rod/correction cases, 25% of thoracic screw placements, 20% of the osteotomies, 17% of the resections, 3% of the cage insertions, and 2% of the sublaminar wiring procedures.CONCLUSIONSThe authors hypothesize that the results of this study will support the necessity, as a standard of care, of multimodality neuromonitoring during high-risk pediatric spinal deformity surgery because of the decrease in postoperative deficits. Their data suggest that the TceMEPs are more sensitive than SSEPs, but when used in combination, they offer the patient a level of safety that would otherwise not exist. Last, these findings support the notion that better outcomes are achieved with high-level IONM professionals.

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“…9,10 For procedures performed in the prone position, obtaining potentials with the neck in a neutral posture (prior to prone positioning) may be beneficial in some cases to provide baseline neurophysiologic data. Potentials can then be repeated in the prone surgical position to help identify cervical positioning related neuromonitoring alterations.…”

Section: Discussionmentioning

confidence: 99%

“…10 The incidence of spinal cord injury has been reported to occur in 0.26% to 1.75% of thoracolumbar deformity operations. 11,18 …”

Section: Discussionmentioning

confidence: 99%

“…The surgeon and surgical team response to neuromonitoring changes in spinal deformity surgery have been thoroughly evaluated in a Delphi Consensus Report by Vitale et al 10 In this investigation, they separated the “mechanically stable spine” from the unstable spine following spinal osteotomy as appropriate response in these 2 situations differs substantially. This delineation may similarly be useful for cervical spine surgery, in which cervical spine trauma or spinal osteotomy may require a specific surgeon response to neuromonitoring changes.…”

Section: Discussionmentioning

confidence: 99%

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Iatrogenic Spinal Cord Injury Resulting From Cervical Spine Surgery

Daniels

Hart

Hilibrand

et al. 2017

Global Spine Journal

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Study Design:Retrospective cohort study of prospectively collected data.Objective:To examine the incidence of iatrogenic spinal cord injury following elective cervical spine surgery.Methods:A retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was conducted. Medical records for 17 625 patients who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were reviewed to identify occurrence of iatrogenic spinal cord injury.Results:In total, 3 cases of iatrogenic spinal cord injury following cervical spine surgery were identified. Institutional incidence rates ranged from 0.0% to 0.24%. Of the 3 patients with quadriplegia, one underwent anterior-only surgery with 2-level cervical corpectomy, one underwent anterior surgery with corpectomy in addition to posterior surgery, and one underwent posterior decompression and fusion surgery alone. One patient had complete neurologic recovery, one partially recovered, and one did not recover motor function.Conclusion:Iatrogenic spinal cord injury following cervical spine surgery is a rare and devastating adverse event. No standard protocol exists that can guarantee prevention of this complication, and there is a lack of consensus regarding evaluation and treatment when it does occur. Emergent imaging with magnetic resonance imaging or computed tomography myelography to evaluate for compressive etiology or malpositioned instrumentation and avoidance of hypotension should be performed in cases of intraoperative and postoperative spinal cord injury.

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Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response

Cited by 148 publications

References 26 publications

Best practices in the evaluation and treatment of foramen magnum stenosis in achondroplasia during infancy

Best practices in the evaluation and treatment of foramen magnum stenosis in achondroplasia during infancy

Intraoperative neuromonitoring alerts in a pediatric deformity center

Iatrogenic Spinal Cord Injury Resulting From Cervical Spine Surgery

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