Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist

Abstract

<jats:p>Spine surgery carries an inherent risk of damage to critical neural structures. Intraoperative neurophysiological monitoring (IONM) is frequently used to improve the safety of spine surgery by providing real-time assessment of neural structures at risk. Evidence-based guidelines for safe and efficacious use of IONM are lacking and its use is largely driven by surgeon preference and medicolegal issues. Due to this lack of standardization, the preoperative sign-in serves as a critical opportunity for 3-way discussion between the neurosurgeon, anesthesiologist, and neuromonitoring team regarding the necessity for and goals of IONM in the ensuing case. This analysis contains a review of commonly used IONM modalities including somatosensory evoked potentials, motor evoked potentials, spontaneous or free-running electromyography, triggered electromyography, and combined multimodal IONM. For each modality the methodology, interpretation, and reported sensitivity and specificity for neurological injury are addressed. This is followed by a discussion of important IONM-related issues to include in the preoperative checklist, including anesthetic protocol, warning criteria for possible neurological injury, and consideration of what steps to take in response to a positive alarm. The authors conclude with a cost-effectiveness analysis of IONM, and offer recommendations for IONM use during various forms of spine surgery, including both complex spine and minimally invasive procedures, as well as lower-risk spinal operations.</jats:p>

A socioeconomic analysis of intraoperative neurophysiological monitoring during spine surgery: national use, regional variation, and patient outcomes

“…4 Some evidence suggests that IONM prevents postoperative neurological deficits in patients undergoing more complex spinal procedures, particularly deformity correction. 13,14 Indeed, use of IONM with somatosensory evoked potentials and transcranial motor evoked potentials represents the minimum standard of care for patients undergoing scoliosis surgery. 13 Additionally, one would expect use of IONM to prevent neurological deficits in patients undergoing spine surgery in which the spinal cord or its nerve roots are intimately involved with the pathology (e.g., spinal cord tumor and spinal dysraphism).…”

“…13,14 Indeed, use of IONM with somatosensory evoked potentials and transcranial motor evoked potentials represents the minimum standard of care for patients undergoing scoliosis surgery. 13 Additionally, one would expect use of IONM to prevent neurological deficits in patients undergoing spine surgery in which the spinal cord or its nerve roots are intimately involved with the pathology (e.g., spinal cord tumor and spinal dysraphism). 8,10 There is evidence to support use of IONM during revision spine surgeries, which inherently pose higher risk for neurological injury.…”

Surgical nuances on the treatment of giant dumbbell cervical spine schwannomas: description of a challenging case and review of the literature

“…15 The aim of the monitoring in cervical spine surgery is a direct control of the functional status of the spinal cord and the verification of the integrity of the spinal roots. Indeed, the neuromonitoring not only improves the safety of the dissection of the extradural component of the tumor ensuring the integrity of the neural structures, but also it provides information about the possible occurrence of vascular or mechanical damages to the spinal cord.…”

Impact of a Bundled Payment System on Resource Utilization During Spine Surgery

“…However, our data also demonstrate that bundling may prompt surgeons to riskadjust the need for neuromonitoring based on case complexity. 18 For example, in case 5, which presented a complex surgery involving the cervical spinal cord, 68% of respondents would utilize neuromonitoring in the bundled scenario as compared to 73% who employ neuromonitoring in current practice.…”