Use of multimodal intra-operative monitoring in averting nerve injury during complex hip surgery

Abstract

Peripheral nerve injury is an uncommon but serious complication of hip surgery that can adversely affect the outcome. Several studies have described the use of electromyography and intra-operative sensory evoked potentials for early warning of nerve injury. We assessed the results of multimodal intra-operative monitoring during complex hip surgery. We retrospectively analysed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intra-operative monitoring from a total pool of 7894 patients who underwent hip surgery during this period. In 24 (35%) procedures the surgeon was alerted to a possible lesion to the sciatic and/or femoral nerve. Alerts were observed most frequently during peri-acetabular osteotomy. The surgeon adapted his approach based on interpretation of the neurophysiological changes. From 69 monitored surgical procedures, there was only one true positive case of post-operative nerve injury. There were no false positives or false negatives, and the remaining 68 cases were all true negative. The sensitivity for predicting post-operative nerve injury was 100% and the specificity 100%. We conclude that it is possible and appropriate to use this method during complex hip surgery and it is effective for alerting the surgeon to the possibility of nerve injury.

Risk factors for acute nerve injury after total knee arthroplasty

“…Perhaps there is a role for future studies to determine the utility of preoperative electrodiagnosis as a screening tool and postoperative electrodiagnostic monitoring for patients with neurologic symptoms . Future studies can also include the use of intraoperative electrodiagnostic monitoring during TKA procedures to prevent postoperative nerve deficit, as has been demonstrated in arthroplasty of other joints …”

Anatomical basis for surgical approaches to the hip

“…The nerve must be identified and protected. [19] The superior gluteal nerve has a significant potential for injury particularly in gluteus-splitting approaches. The “safe area” when splitting the abductors (gluteus medius) is 5 cm from the tip of the greater trochanter.…”

Intraoperative Mapping of Roots, Plexuses, and Nerves

“…Monitoring of lumbosacral plexus is not as frequently done as the brachial plexus. A few reports exist, where individual nerves of the lumbosacral plexus were monitored and mapped, examples being the sciatic nerve MEP in hip arthroplasty (Sutter et al, 2012;Satcher et al, 2003) and SSEP in meralgia paresthetica (Seror, 2004). Obstetric brachial plexus injury is common (approximately 1 in 1,000 live births) and up to 20% to 30% kids may need surgical intervention (Pondaag et al, 2004;Thatte and Mehta, 2011) for recovery.…”