Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery

Lenke, Lawrence G.; Fano, Adam N; Iyer, Rajiv R.; Matsumoto, Hiroko; Sucato, Daniel J.; Samdani, Amer F.; Smith, Justin S.; Gupta, Munish C.; Kelly, Michael P.; Kim, Hee Jin; Sciubba, Daniel M.; Cho, Samuel K.; Polly, David W.; Boachie-Adjei, Oheneba; Lewis, Stephen J.; Angevine, Peter D.; Vitale, Michael G.

doi:10.1007/s43390-022-00485-w

Cited by 27 publications

(47 citation statements)

References 18 publications

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“…Finally, providers should be aware of recently developed checklists to optimize response to intraoperative neuromonitoring events, which can be expertly reviewed elsewhere. 11 12…”

Section: Discussionmentioning

confidence: 99%

Failure of Sequential Compression Device Detected by Neuromonitoring during Minimally Invasive Posterior Scoliosis Surgery

Raue

Shils

Fessler

2023

J Neuroanaesth Crit Care

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Intraoperative neuromonitoring is recommended as standard practice for corrective scoliosis surgery. Common methods include somatosensory-evoked potentials (SSEPs) and transcranial motor-evoked potentials (TcMEPs), which have been shown to have a high diagnostic accuracy in detecting new neurological deficits postoperatively. Sequential compression devices (SCDs) are a common method for thromboprophylaxis in spine surgery and are not known to have many device-related complications. To date, there have been no reports of lower extremity ischemia secondary to SCD deflation failure detected by multimodality neuromonitoring during minimally invasive posterior spine surgery. We, therefore, present a case report of an 18-year-old male with adolescent idiopathic scoliosis who underwent minimally invasive posterior spinal fusion with instrumentation. Intraoperative decrease in SSEPs and TcMEPs were noted in the left leg shortly after incision before any instrumentation or reduction occurred. Further examination revealed that the left leg was hypoperfused compared with the right leg and that the left SCD was not properly deflating. Bilateral SCDs were removed, and perfusion and neuromonitoring returned to baseline immediately. Bilateral SCDs and the machine were replaced, and neuromonitoring remained within normal limits for the rest of the surgery. The patient had no postoperative neurologic or vascular deficits. Early detection of lower extremity ischemia by neuromonitoring resulted in the prompt identification and addressing of SCD malfunction, sparing devastating neurological and vascular injury to the patient's leg. This case reinforces the importance of neuromonitoring within spine surgery.

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“…Finally, providers should be aware of recently developed checklists to optimize response to intraoperative neuromonitoring events, which can be expertly reviewed elsewhere. 11 12…”

Section: Discussionmentioning

confidence: 99%

Failure of Sequential Compression Device Detected by Neuromonitoring during Minimally Invasive Posterior Scoliosis Surgery

Raue

Shils

Fessler

2023

J Neuroanaesth Crit Care

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“…The DAR, a measure of curve magnitude per level of deformity, was calculated before traction being applied and at each subsequent week until definitive fusion by dividing the angle of coronal deformity by the number of levels involved in the curve. 11,12 The improvement in DAR each week was expressed as a percentage of the improvement achieved by the traction treatment immediately before fusion. The change in T1-L5 height was calculated as the difference between the T1-L5 before traction and the T1-L5 height during each 7-day period expressed as a percentage of the T1-L5 height seen immediately before fusion.…”

Section: Methodsmentioning

confidence: 99%

The Use of Halo Gravity Traction in Severe, Stiff Scoliosis

Rocos

Reda

Lebel

et al. 2021

Journal of Pediatric Orthopaedics

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Purpose: The correction of severe, stiff scoliosis in children is challenging. One method used to reduce the risk is preoperative halo gravity traction (HGT). In this study, the authors sought to define the efficiency and safety of HGT and characterize the chronology of the correction seen. Method: A consecutive group of pediatric patients with severe spinal deformities was treated with HGT before definitive correction. A standard protocol with the daily addition of weight to 50% of body weight at 3 weeks was used. Traction remained in place until signs of impending neurological complication or 6 weeks, whichever was sooner. Results: Twenty-four patients were included with a mean age of 11.8 years. The mean coronal deformity was 123 degrees, with a T1-L5 height of 234 mm. The mean duration of traction was 42 days with a mean improvement in height of 72 mm with 82% occurring over the first 3 weeks. Hundred percent of the angular and 98% of T1-L5 height correction was reached by 6 weeks. One patient showed early signs of a cranial nerve palsy prompting early surgery and 8 patients showed pin loosening, 1 of which required revision of their halo. One patient underwent a slower progression of traction because of transitory urinary disturbance. Following fusion, angular correction of the major curve was 49%. Conclusion: HGT is a safe treatment for severe, stiff scoliosis because it can respond to early signs of impending neurological impairment. The first 3 weeks of treatment, reaching 50% of body weight as a traction force accounts for 80% of correction, with the remaining 20% in the following 2 weeks. At least 4 weeks of traction is recommended when following this protocol.

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“…Prior Delphi studies have established checklists to help surgeons respond to changes in intraoperative neuromonitoring during pediatric and adult spinal deformity surgery. [38][39][40] These studies, however, did not consider pediatric cervical spine stabilization surgery. In this study, 100% of surgeons agreed that intraoperative neuromonitoring including MEPs and SSEPs is recommended, including pre-positioning baseline signals when there is concern for significant instability.…”

Section: Consensus Surrounding Intraoperative and Perioperative Manag...mentioning

confidence: 99%

Developing consensus for the management of pediatric cervical spine disorders and stabilization: a modified Delphi study

Dastagirzada

Alexiades

Kurland

et al. 2023

Journal of Neurosurgery: Pediatrics

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OBJECTIVE Cervical spine disorders in children are relatively uncommon; therefore, paradigms for surgical and nonsurgical clinical management are not well established. The purpose of this study was to bring together an international, multidisciplinary group of pediatric cervical spine experts to build consensus via a modified Delphi approach regarding the clinical management of children with cervical spine disorders and those undergoing cervical spine stabilization surgery. METHODS A modified Delphi method was used to identify consensus statements for the management of children with cervical spine disorders requiring stabilization. A survey of current practices, supplemented by a literature review, was electronically distributed to 17 neurosurgeons and orthopedic surgeons experienced with the clinical management of pediatric cervical spine disorders. Subsequently, 52 summary statements were formulated and distributed to the group. Statements that reached near consensus or that were of particular interest were then discussed during an in-person meeting to attain further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS Forty-five consensus-driven statements were identified, with all participants willing to incorporate them into their practice. For children with cervical spine disorders and/or stabilization, consensus statements were divided into the following categories: A) preoperative planning (12 statements); B) radiographic thresholds of instability (4); C) intraoperative/perioperative management (15); D) postoperative care (11); and E) nonoperative management (3). Several important statements reaching consensus included the following recommendations: 1) to obtain pre-positioning baseline signals with intraoperative neuromonitoring; 2) to use rigid instrumentation when technically feasible; 3) to provide postoperative external immobilization for 6–12 weeks with a rigid cervical collar rather than halo vest immobilization; and 4) to continue clinical postoperative follow-up at least until anatomical cervical spine maturity was reached. In addition, preoperative radiographic thresholds for instability that reached consensus included the following: 1) translational motion ≥ 5 mm at C1–2 (excluding patients with Down syndrome) or ≥ 4 mm in the subaxial spine; 2) dynamic angulation in the subaxial spine ≥ 10°; and 3) abnormal motion and T2 signal change on MRI seen at the same level. CONCLUSIONS In this study, the authors have demonstrated that a multidisciplinary, international group of pediatric cervical spine experts was able to reach consensus on 45 statements regarding the management of pediatric cervical spine disorders and stabilization. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

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Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery

Cited by 27 publications

References 18 publications

Failure of Sequential Compression Device Detected by Neuromonitoring during Minimally Invasive Posterior Scoliosis Surgery

Failure of Sequential Compression Device Detected by Neuromonitoring during Minimally Invasive Posterior Scoliosis Surgery

The Use of Halo Gravity Traction in Severe, Stiff Scoliosis

Developing consensus for the management of pediatric cervical spine disorders and stabilization: a modified Delphi study

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