Utilization of intraoperative neuromonitoring throughout the United States over a recent decade: an analysis of the nationwide inpatient sample

Laratta, Joseph L.; Shillingford, Jamal N.; Ha, Alex; Lombardi, Joseph M.; Reddy, Hemant; Saifi, Comron; Ludwig, Steven C.; Lehman, Ronald A.; Lenke, Lawrence G.

doi:10.21037/jss.2018.04.05

Cited by 27 publications

(30 citation statements)

References 29 publications

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“…[12,19] IOM was more likely to be used in urban teaching hospitals (72.9%) versus nonteaching hospitals (25.0%) or rural centers (2.2%). [8] Multiple studies had documented the efficacy of somatosensory evoked potentials in decrease the risks of intraoperative neural injury during pediatric/adult scoliosis surgery/ deformity correction. [2,4,16]…”

Section: Discussionmentioning

confidence: 99%

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Barriers of neurophysiology monitoring in spine surgery: Latin America experience

Guiroy

Valacco²,

Gagliardi

et al. 2020

Surgical Neurology International

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Background: Intraoperative neurophysiological monitoring (IOM) has become valuable in spine surgery. Unfortunately, it is not always available in many spine centers, especially in developing countries. Our aim was to evaluate the accessibility and barriers to IOM in spine surgery in Latin America. Methods: We designed a questionnaire to evaluate the characteristics of surgeons and their opinions on the usefulness of IOM for different spine operations. The survey was sent to 9616 members and registered users of AO Spine Latin America (AOSLA) from August 1, 2019, to August 21, 2019. Major variables studied included nationality, years of experience, specialty (orthopedics or neurosurgery), level of complexity of the hospital, number of spine surgeries performed per year by the spine surgeon, the types of spinal pathologies commonly managed, and how important IOM was to the individual surgeon. General questions to evaluate use included accessibility, limitations of IOM usage, management of IOM changes, and the legal value of IOM. The results were analyzed and compared between neurosurgeon and orthopedics, level of surgeon experience, and country of origin. Results: Questionnaires were answered by 200 members of AOSLA from 16 different countries. The most common responses were obtained from orthopedic surgeons (62%), those with more than 10 years of practice (54%); majority of surgeons performed more than 50 spine surgeries per year (69%) and treated mainly spine degenerative diseases (76%). Most surgeons think that IOM has a real importance during surgeries (92%) and not just a legal value. Although surgeons mostly considered IOM essential to scoliosis surgery in adolescents (70%), thoracolumbar kyphosis correction (68%), and intramedullary tumors (68%), access to IOM was limited to 57% for economic reasons. Of interest, in 64% of cases, where IOM was available and significant change occurred, the actual operative procedures were significantly altered. Conclusion: Despite the fact that 68% of spine surgeons believe IOM to be indispensable for complex spine surgery, cost remains the main barrier to its use/availability in Latin America.

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Section: Discussionmentioning

confidence: 99%

“…[13,18] Many spine surgeons agree regarding the usefulness of IOM in deformity cases and spinal cord tumors. [6][7][8] However, appropriate patient selection for IOM and its cost is the main factors limiting its use.…”

Section: Introductionmentioning

confidence: 99%

Barriers of neurophysiology monitoring in spine surgery: Latin America experience

Guiroy

Valacco²,

Gagliardi

et al. 2020

Surgical Neurology International

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“…While the application of neuromonitoring to improve outcomes with the outpatient transforaminal endoscopic decompression procedure is uncommon to current routine clinical practice with surgeries being done under MAC local anesthesia, it is frequently employed in traditional open and other forms of minimally invasive spinal surgery in the United States and the world over. From 2008 to 2014, the number of neuromonitored spine cases increased from 31,762 to 125,835, signifying a 296% increase over one decade [ 56 ]. Its benefit in reducing neurological morbidity has been demonstrated during spinal cord decompression and deformity surgery [ 30 , 33 , 34 , 56 ].…”

Section: Discussionmentioning

confidence: 99%

“…From 2008 to 2014, the number of neuromonitored spine cases increased from 31,762 to 125,835, signifying a 296% increase over one decade [ 56 ]. Its benefit in reducing neurological morbidity has been demonstrated during spinal cord decompression and deformity surgery [ 30 , 33 , 34 , 56 ]. The benefits far outweigh the risk of routine neuromonitoring since complications with it are extremely rare [ 57 ].…”

Section: Discussionmentioning

confidence: 99%

Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine

Carvalho

Ramos

Meireles³

et al. 2020

Brain Sciences

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(1) Background: Postoperative nerve root injury with dysesthesia is the most frequent sequela following lumbar endoscopic transforaminal discectomy. At times, it may be accompanied by transient and rarely by permanent motor weakness. The authors hypothesized that direct compression of the exiting nerve root and its dorsal root ganglion (DRG) by manipulating the working cannula or endoscopic instruments may play a role. (2) Objective: To assess whether intraoperative neurophysiological monitoring can help prevent nerve root injury by identifying neurophysiological events during the initial placement of the endoscopic working cannula and the directly visualized video endoscopic procedure. (3) Methods: The authors performed a retrospective chart review of 65 (35 female and 30 male) patients who underwent transforaminal endoscopic decompression for failed non-operative treatment of lumbar disc herniation from 2012 to 2020. The patients’ age ranged from 22 to 86 years, with an average of 51.75 years. Patients in the experimental group (32 patients) had intraoperative neurophysiological monitoring recordings using sensory evoked (SSEP), and transcranial motor evoked potentials (TCEP), those in the control group (32 patients) did not. The SSEP and TCMEP data were analyzed and correlated to the postoperative course, including dysesthesia and clinical outcomes using modified Macnab criteria, Oswestry disability index (ODI), visual analog scale (VAS) for leg and back pain. (4) Results: The surgical levels were L4/L5 in 44.6%, L5/S1 in 23.1%, and L3/L4 in 9.2%. Of the 65 patients, 56.9% (37/65) had surgery on the left, 36.9% (24/65) on the right, and the remaining 6.2% (4/65) underwent bilateral decompression. Postoperative dysesthesia occurred in 2 patients in the experimental and six patients in the control group. In the experimental neuromonitoring group, there was electrodiagnostic evidence of compression of the exiting nerve root’s DRG in 24 (72.7%) of the 32 patients after initial transforaminal placement of the working cannula. A 5% or more decrease and a 50% or more decrease in amplitude of SSEPs and TCEPs recordings of the exiting nerve root were resolved by repositioning the working cannula or by pausing the root manipulation until recovery to baseline, which typically occurred within an average of 1.15 min. In 15 of the 24 patients with such latency and amplitude changes, a foraminoplasty was performed before advancing the endoscopic working cannula via the transforaminal approach into the neuroforamen to avoid an impeding nerve root injury and postoperative dysesthesia. (5) Conclusion: Neuromonitoring enabled the intraoperative diagnosis of DRG compression during the initial transforaminal placement of the endoscopic working cannula. Future studies with more statistical power will have to investigate whether employing neuromonitoring to avoid intraoperative compression of the exiting nerve root is predictive of lower postoperative dysesthesia rates in patients undergoing videoendoscopic transforaminal discectomy.

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“… 50 , 56 , 57 Despite a lack of quality supporting evidence, there has been a nearly 300% increase in use over the last 10 years. 54 , 58 However, a parallel decrease in the rate of neurological injury has NOT been observed, and there is evidence to suggest IONM lacks clinical benefit for certain procedure types. 59 , 60 …”

Section: Introductionmentioning

confidence: 99%

Achieving Value in Spine Surgery: 10 Major Cost Contributors

Philipp

Leibold

Mahtabfar

et al. 2021

Global Spine Journal

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Study Design: Narrative Review. Objectives: The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused—often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement. Methods: We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal—if any—clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive. Results: We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing. Conclusions: In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.

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Utilization of intraoperative neuromonitoring throughout the United States over a recent decade: an analysis of the nationwide inpatient sample

Cited by 27 publications

References 29 publications

Barriers of neurophysiology monitoring in spine surgery: Latin America experience

Barriers of neurophysiology monitoring in spine surgery: Latin America experience

Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine

Achieving Value in Spine Surgery: 10 Major Cost Contributors

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