Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials

Abstract

Objective:To evaluate whether spinal cord intraoperative monitoring (IOM) with somatosensory and transcranial electrical motor evoked potentials (EPs) predicts adverse surgical outcomes. Methods:A panel of experts reviewed the results of a comprehensive literature search and identified published studies relevant to the clinical question. These studies were classified according to the evidence-based methodology of the American Academy of Neurology. Objective outcomes of postoperative onset of paraparesis, paraplegia, and quadriplegia were used because no randomized or masked studies were available. Results and Recommendations:Four Class I and 8 Class II studies met inclusion criteria for analysis. The 4 Class I studies and 7 of the 8 Class II studies reached significance in showing that paraparesis, paraplegia, and quadriplegia occurred in the IOM patients with EP changes compared with the IOM group without EP changes. All studies were consistent in showing all occurrences of paraparesis, paraplegia, and quadriplegia in the IOM patients with EP changes, with no occurrences of paraparesis, paraplegia, and quadriplegia in patients without EP changes. In the Class I studies, 16%-40% of the IOM patients with EP changes developed postoperative-onset paraparesis, paraplegia, or quadriplegia. IOM is established as effective to predict an increased risk of the adverse outcomes of paraparesis, paraplegia, and quadriplegia in spinal surgery (4 Class I and 7 Class II studies). Surgeons and other members of the operating team should be alerted to the increased risk of severe adverse neurologic outcomes in patients with important IOM changes (Level A). Neurology

Interpretation of surgical neuromonitoring data in Canada: a survey of practising surgeons

“…The practice guidelines require the realtime interpretation by a medical professional with training in IOM. 1 There has been a relatively rapid expansion of IOM across Canada, but it is still largely concentrated in academic centres. However, the practice remains unregulated and inconsistent in terms of implementation and quality.…”

Intraoperative Evoked Potentials: A Review of Clinical Impact and Limitations

“…Further, rate of gross total resection was higher when used IONM. In fact, electromyography may complement anatomical location of nerve roots as well as recognize irritation or traction features [17].…”

“…Exceptionally, IONM may be rather useless during certain surgical procedures (i.e. pituitary adenoma resection without cavernous sinus invasion) [2,12,[15][16][17][18].…”

“…In fact, IONM potentiates procedures' strategic alterations aiming to prevent perpetual neurological deficit, such as degree of distraction adjustment, retractors or grafts correction, reimplanting or unclamping arteries, placing vascular bypass grafts and minimizing the remaining portion of the surgery of others [17,23,24].…”

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“…NIOM has been used clinically in the last thirty years, to identify the risk of deficits in time to intervene and prevent permanent deficits, although, there are still controversial opinions 1,2 about its effectiveness in preventing a postoperative neurological deficit. Recently an evidence-based guideline update 2 demonstrates that NIOM can detect an impending neurological deficit with reasonable sensitivity and specificity. On the other hand, the main argument against the NIOM is the heterogeneity in NIOM services, with techniques and criteria remaining unstandardized, and the thresholds at which a signal change constitutes a significant change may vary considerably from one neuromonitoring group to another.…”