Editorial. Intraoperative neuromonitoring: gold standard or fool’s gold?

Jea, Andrew

doi:10.3171/2017.7.focus17457

Cited by 7 publications

(4 citation statements)

References 7 publications

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“…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%

“…Therefore, the authors decided to retrospectively study the result obtained by using neuromonitoring during transforaminal videoendoscopy in patients who were treated for herniated discs. While the three senior key opinion leader (KOL) surgeons (JFRL, ATY, and KUL) of this article have performed over 18,000 endoscopic spine surgeries between them [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ] under monitored local anesthesia care (MAC) and sedation [ 12 , 18 , 19 ] with minimal complications [ 1 , 20 ] and utilizing the patients’ direct intraoperative feedback to treat validated pain generators [ 11 , 15 , 19 , 21 , 22 ], they recognize that neuromonitoring in some countries and in some clinical settings is the standard of care [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ] in spite of added cost [ 33 ]. In some instances, it may even be a matter of necessity if MAC protocols for spine surgery are not supported by the local anesthesia teams.…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

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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“…Widespread adoption of IONM has occurred in the developed world, yet distinct limitations have, to date, prevented its incorporation in resource-limited settings. While no prospective, randomized clinical trials exist, and will likely never exist given the current medicolegal environment, available data both supports and discourages its use ( 64 ). However, these same authors state that the preponderance of the evidence supports the routine use of IONM for a diverse array of surgical procedures and additionally support increasing technological and supervisory capacity to implement this technology in locations where it does not currently exist ( 11 , 12 ).…”

Section: Barriers To Ionm Utilization In Resource-limited Areasmentioning

confidence: 99%

New frontiers in intraoperative neurophysiologic monitoring: a narrative review

Oliva,

Montejano,

Simmons

et al. 2023

Ann Transl Med

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Background and Objective Neurological insults during surgery arise from anatomic and/or physiologic perturbations. Intraoperative neurophysiologic monitoring (IONM) fills a critical role of ensuring that any neurological insults during certain surgical procedures are caught in real-time to prevent patient harm. IONM provides immediate feedback to the surgeon and anesthesiologist about the need for an intervention to prevent a neurologic deficit postoperatively. As important as it seems to have IONM available to any patient having surgery where a neurological injury is possible, the truth is that IONM is unavailable to large swaths of people around the world. This review is intended to bring attention to all of the ways IONM is critically important for a variety of surgeries and highlight the barriers preventing most patients around the world from benefiting from the technology. Expansion of IONM to benefit patients from all over the world is the new frontier. Methods We searched all English language original papers and reviews using Embase and MEDLINE/PubMed databases published from 1995 to 2022. Different combinations of the following search terms were used: intraoperative neuromonitoring, neurosurgery, low-income countries, cost, safety, and efficacy. Key Content and Findings We describe common IONM modalities used during surgery as well as explore barriers to implementation of IONM in resource-limited regions. Additionally, we describe ongoing efforts to establish IONM capabilities in new locations around the world. Conclusions In this paper, we performed a review of the literature on IONM with an emphasis on the basic understanding of clinical applications and the barriers for expansion into resource-limited settings. Finally, we provide our interpretation of “new frontiers” in IONM quite literally facilitating access to the tools and education so a hospital in Sub-Saharan Africa can incorporate IONM for their high-risk surgeries.

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“…At that time skepticism about the reliability of ION was still quite diffuse, but Dr. Albright pointed out something which became more and more relevant in the following two decades, namely the debate on the medico-legal implications of neuromonitoring. In 2017, more than 20 years later, A. Jea in an Editorial in Neurosurgical Focus entitled: “Intraoperative Neuromonitoring: gold standard or fool’s gold” critically reviewed a paper by Zuccaro et al [ 72 ] addressing the value of ION during surgery for spine deformity in children [ 73 ]. In his editorial, he mentioned that “the authors are too aggressive in suggesting that IONM is “standard of care”; it implies that spine surgeons who do not use IONM are committing malpractice.” Almost 30 years have gone by since that respectful debate on the value of ION, which took place in a pediatric neurosurgical journal and, to some extent, that discussion is not completely over.…”

Section: Spinal Cord Surgery (Fig 3 )mentioning

confidence: 99%

Intraoperative neurophysiology in pediatric neurosurgery: a historical perspective

Sala

2023

Childs Nerv Syst

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Introduction Intraoperative neurophysiology (ION) has been established over the past three decades as a valuable discipline to improve the safety of neurosurgical procedures with the main goal of reducing neurological morbidity. Neurosurgeons have substantially contributed to the development of this field not only by implementing the use and refinement of ION in the operating room but also by introducing novel techniques for both mapping and monitoring of neural pathways. Methods This review provides a personal perspective on the evolution of ION in a variety of pediatric neurosurgical procedures: from brain tumor to brainstem surgery, from spinal cord tumor to tethered cord surgery. Results and discussion The contribution of pediatric neurosurgeons is highlighted showing how our discipline has played a crucial role in promoting ION at the turn of the century. Finally, a view on novel ION techniques and their potential implications for pediatric neurosurgery will provide insights into the future of ION, further supporting the view of a functional, rather than merely anatomical, approach to pediatric neurosurgery.

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Editorial. Intraoperative neuromonitoring: gold standard or fool’s gold?

Cited by 7 publications

References 7 publications

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

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

New frontiers in intraoperative neurophysiologic monitoring: a narrative review

Intraoperative neurophysiology in pediatric neurosurgery: a historical perspective

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