Barriers of neurophysiology monitoring in spine surgery: Latin America experience

Abstract

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.

New frontiers in intraoperative neurophysiologic monitoring: a narrative review

“…Despite the known benefits of IONM for neurosurgical procedures in preventing iatrogenic injuries resulting in permanent and debilitating harm, cost continues to be prohibitive for its widespread adoption ( 12 , 67 ). In a survey performed in higher-middle resource countries in Latin America it was found that although 68% of the spine surgeons surveyed believed IONM was vital for complex spine surgeries, the cost barrier limited its use to only 57% of cases ( 68 ). Such data is not readily available for LIMC but one can imagine that cost is an issue as well and potentially even more limiting.…”

“…In a survey of Latin American spine surgeons, greater than 95% of respondents said IONM was indispensable or important for pediatric and adult scoliosis correction, thoracolumbar kyphosis correction, and intradural tumors ( 68 ). Despite the overwhelming endorsement, a majority of the same surgeons readily admitted that access to IONM is limited because of lack of service availability and cost.…”

“…After training at our institution for six months, he returned to Colombia and was met with numerous obstacles to broaden the use of IONM. While IONM is not new in Colombia, its use is very limited largely because of the unfamiliarity with the technology and its clinical application among surgeons and anesthesiologists ( 68 ). Few surgeons use IONM and most interpreters of IONM are physiatrists.…”

“…Few surgeons use IONM and most interpreters of IONM are physiatrists. Anesthesiologists often struggle with adapting anesthetic plans to accommodate for neuromonitoring needs because of an incomplete understanding of how various anesthetic agents impact the different IONM modalities ( 68 ).…”

Anaesthesia workstation monitor: why surgeons should monitor?

“…5 In developing countries, the universal availability of the IONM is a significant limitation, especially in the emergency theatre. [6][7][8] But, the anaesthesia monitoring is routine in all cases. A visible documented change can be satisfying to the whole surgical team when there are no other ways to confirm intraoperatively.…”