Quantitative Estimation of the Recurrent Laryngeal Nerve Irritation by Employing Spontaneous Intraoperative Electromyographic Monitoring During Anterior Cervical Discectomy and Fusion

Dimopoulos, Vasilios; Chung, In Kwon; Lee, Gregory P.; Johnston, Kim W.; Kapsalakis, Ioannis Z.; Smisson, Hugh F.; Grigorian, Arthur A.; Robinson, Joe Sam; Fountas, Kostas N.

doi:10.1097/bsd.0b013e31815ea8b6

Cited by 26 publications

(14 citation statements)

References 47 publications

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“…The sensitivity of monitoring was calculated at 100%, the specificity at 87%, the positive predictive value at 16%, and the negative predictive value at 97%. Thus, the authors concluded that “laryngeal intraoperative electromyography is a high-sensitivity modality that can provide real-time information and can potentially minimize the risk of operative RLN injury.” 15 …”

Section: Discussionmentioning

confidence: 99%

Recurrent Laryngeal Nerve Palsy After Cervical Spine Surgery: A Multicenter AOSpine Clinical Research Network Study

Gokaslan

Bydon

Ramos

et al. 2017

Global Spine Journal

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Study Design:Multicenter retrospective study.Objectives:To investigate the risk of symptomatic recurrent laryngeal nerve palsy (RLNP) following cervical spine surgery, to examine risk factors for its development, and to report its treatment and outcomes.Methods:A multicenter study from 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was performed. Each center screened for rare complications following cervical spine surgery, including RLNP. Patients were included if they underwent cervical spine surgery (levels from C2 to C7) between January 1, 2005 and December 31, 2011. Data were analyzed with regard to complication treatment and outcome. Cases were compared to a control group from the AOSpine CSM and CSM-I studies.Results:Three centers reported 19 cases of RLNP from a cohort of 1345 patients. The reported incidence of RLNP ranged from 0.6% to 2.9% between these 3 centers. Fifteen patients (79%) in the RLNP group were approached from the left side. Ten patients (52.6%) required treatment for RLNP—6 required medical therapy (steroids), 1 interventional treatment (injection laryngoplasty), and 3 conservative therapy (speech therapy). When examining outcomes, 73.7% (14/19) of cases resolved completely, 15.8% (3/19) resolved with residual effects, and in 10.5% (2/19) of cases this could not be determined.Conclusions:In this multicenter study examining rare complications following cervical spine surgery, the risk of RLNP after cervical spine surgery ranged from 0.6% to 2.9% between centers. Though rare, it was found that 16% of patients may experience partial resolution with residual effects, and 74% resolve completely.

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Section: Discussionmentioning

confidence: 99%

Recurrent Laryngeal Nerve Palsy After Cervical Spine Surgery: A Multicenter AOSpine Clinical Research Network Study

Gokaslan

Bydon

Ramos

et al. 2017

Global Spine Journal

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“…[41114] Thus, within the past two decades, increased emphasis has been placed on developing intraoperative neurophysiologic methods to accurately monitor the integrity of the spinal cord during spinal surgery. [58–9] Currently, one such widely used technique is SSEP.…”

Section: Discussionmentioning

confidence: 99%

A role for motor and somatosensory evoked potentials during anterior cervical discectomy and fusion for patients without myelopathy: Analysis of 57 consecutive cases

Xu¹,

Ritzl²,

Sait³

et al. 2011

Surg Neurol Int

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Background:Although the usage of combined motor and sensory intraoperative monitoring has been shown to improve the surgical outcome of patients with cervical myelopathy, the role of transcranial electric motor evoked potentials (tceMEP) used in conjunction with somatosensory evoked potentials (SSEP) in patients presenting with radiculopathy but without myelopathy has been less clear.Methods:We retrospectively reviewed all patients (n = 57) with radiculopathy but without myelopathy, undergoing anterior cervical decompression and fusion at a single institution over the past 3 years, who had intraoperative monitoring with both tceMEPs and SSEPs.Results:Fifty-seven (100%) patients presented with radiculopathy, 53 (93.0%) with mechanical neck pain, 35 (61.4%) with motor dysfunction, and 29 (50.9%) with sensory deficits. Intraoperatively, 3 (5.3%) patients experienced decreases in SSEP signal amplitudes and 4 (6.9%) had tceMEP signal changes. There were three instances where a change in neuromonitoring signal required intraoperative alteration of the surgical procedure: these were deemed clinically significant events/true positives. SSEP monitoring showed two false positives and two false negatives, whereas tceMEP monitoring only had one false positive and no false negatives. Thus, tceMEP monitoring exhibited higher sensitivity (33.3% vs. 100%), specificity (95.6% vs. 98.1%), positive predictive value (33.3% vs. 75.0%), negative predictive value (97.7% vs. 100%), and efficiency (91.7% vs. 98.2%) compared to SSEP monitoring alone.Conclusions:Here, we present a retrospective series of 57 patients where tceMEP/SSEP monitoring likely prevented irreversible neurologic damage. Though further prospective studies are needed, there may be a role for combined tceMEP/SSEP monitoring for patients undergoing anterior cervical decompression without myelopathy.

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“…2 A recently published study found increased levels of recurrent laryngeal irritation (on intraoperative electromyography studies) with self-retained retractors compared with hand-held retractors with periodic soft-tissue release. 7 Dysphonia may also be caused by laryngeal damage due to its compression onto the unyielding shaft of the endotracheal tube, which is fixed distally by the balloon cuff and proximally by tape at the mouth. 13 This happens with the laryngeal displacement that occurs with retraction.…”

Section: Retraction-related Complicationsmentioning

confidence: 99%

Comparison of retraction pressure between novel and conventional retractor systems—a cadaver study

Pattavilakom¹,

Seex²

2010

SPI

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Object Sore throat, dysphagia, and dysphonia are very common after anterior cervical surgery; clinical studies show an incidence of up to 60% or more. Neural, mucosal, or muscular injuries during dissection or retraction are regularly discussed, but investigations are few. Retraction pressure causing ischemia might explain these complications. A new anterior cervical retractor system (Seex retractor) using novel principles has been introduced to surgical practice. There are isolated reported investigations comparing different anterior cervical retractors. Therefore, the purpose of this study was to measure retraction pressure on the aerodigestive tract in cadavers during the anterior surgical approach for cervical spine operations performed using either the conventional (Cloward) retractor system or the Seex retractor system. The goal was to find the significance of the shape of the retraction blades (flat vs curved) in retraction pressures. Methods In cadavers, the anterior cervical spine was approached surgically at the C3/4, C4/5, C5/6, and C6/7 levels. A simulated anterior discectomy procedure was performed using a Cloward retractor with curved blade, a Seex retractor with curved blade, and a Seex retractor with flat blade at each level. For each retractor application, an online pressure transducer (Tekscan pressure measurement system) is applied between the rear side of the medial retractor blade and medial soft-tissue complex. Retraction pressures are recorded twice for both retractors at each level. Average retraction pressure (ARP), average peak retraction pressure (APRP), pressure distribution along the area of retraction, pressure difference at the edge and surface of the retractor blades, pressure variation with flat and curved blades, and so on were determined and compared. One-way ANOVA and Tukey honestly significant difference tests were used for statistical evaluation. Results Forty sets of pressure recordings were made in 5 cadavers. The Cloward retractor system showed higher average contact pressure than the Seex retractor system in 36 sets. In 32 sets, the Cloward retractor system showed higher peak retraction pressure than the Seex retractor system. None of the recordings showed uniform pressure distribution over the retracted area. With the Seex retractor itself, the flat blade generated more peak retraction pressure than the curved blades in 28 sets of measurements; it was the reverse in 3 sets; and in 9 sets the peak pressure was almost the same. Higher retraction pressure was noted along the edges of retractor blades in general, and along the convexity of a curved blade. Those parallel bands corresponded to the edges of the retractor blades. The Seex retractor with a curved blade generated the lowest average retraction pressure and average peak retraction pressure (p < 0.01, ANOVA). Conclusions Retraction pressure was found not to be uniform all over the retracted surface. Higher retraction pressure was noted along the edges of retractor blades in general, and along the convexity of a curved blade. The conventional retractor system with a curved blade generated significantly higher retraction pressures than the novel Seex retractor with a curved blade.

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Quantitative Estimation of the Recurrent Laryngeal Nerve Irritation by Employing Spontaneous Intraoperative Electromyographic Monitoring During Anterior Cervical Discectomy and Fusion

Abstract: Our study indicates that laryngeal IEMG is a high-sensitivity modality that can provide real-time information and can potentially minimize the risk of operative RLN injury.

Cited by 26 publications

References 47 publications

Recurrent Laryngeal Nerve Palsy After Cervical Spine Surgery: A Multicenter AOSpine Clinical Research Network Study

Recurrent Laryngeal Nerve Palsy After Cervical Spine Surgery: A Multicenter AOSpine Clinical Research Network Study

A role for motor and somatosensory evoked potentials during anterior cervical discectomy and fusion for patients without myelopathy: Analysis of 57 consecutive cases

Comparison of retraction pressure between novel and conventional retractor systems—a cadaver study

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