Intraoperative neuromonitoring for one-level lumbar discectomies is low yield and cost-ineffective

Krause, Katie; Cheaney, Barry; Obayashi, James T.; Kawamoto, Aaron; Than, Khoi D.

doi:10.1016/j.jocn.2019.08.116

Cited by 12 publications

(12 citation statements)

References 24 publications

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“…Using multimodal IONM at all lumbar levels as a standard practice may result in increased intraoperative time, unnecessary changes to anesthesia technique, and ultimately increased cost which will be passed on to the patient and payer. 36,37 The results of this study demonstrate some significant findings, but they must be interpreted within the limitations of the study design. First, the study utilized 2 private IONM databases in which patients undergoing LLIF were identified but no control group of patients without IONM were available for comparison.…”

Section: Discussionmentioning

confidence: 61%

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Multimodality Intraoperative Neuromonitoring in Lateral Lumbar Interbody Fusion: A Review of Alerts in 628 Patients

Alluri

Vaishnav

Sivaganesan

et al. 2021

Global Spine Journal

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Study Design: Retrospective review of private neuromonitoring databases. Objectives: To review neuromonitoring alerts in a large series of patients undergoing lateral lumbar interbody fusion (LLIF) and determine whether alerts occurred more frequently when more lumbar levels were accessed or more frequently at particular lumbar levels. Methods: Intraoperative neuromonitoring (IONM) databases were reviewed and patients were identified undergoing LLIF between L1 and L5. All cases in which at least one IONM modality was used (motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), evoked electromyography (EMG)) were included in this study. The type of IONM used and incidence of alerts were collected from each IONM report and analyzed. The incidence of alerts for each IONM modality based on number of levels at which at LLIF was performed and the specific level an LLIF was performed were compared. Results: A total of 628 patients undergoing LLIF across 934 levels were reviewed. EMG was used in 611 (97%) cases, SSEP in 561 (89%), MEP in 144 (23%). The frequency of IONM alerts for EMG, SSEP and MEPs did not significantly increase as the number of LLIF levels accessed increased. No EMG, SSEP, or MEP alerts occurred at L1-L2. EMG alerts occurred in 2-5% of patients at L2-L3, L3-L4, and L4-L5 and did not significantly vary by level ( P = .34). SSEP and MEP alerts occurred more frequently at L4-L5 versus L2-L3 and L3-L4 ( P < .03). Conclusions: IONM may provide the greatest utility at L4-L5, particularly MEPs, and may not be necessary for more cephalad LLIF procedures such as at L1-L2.

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Section: Discussionmentioning

confidence: 61%

Section: Discussionmentioning

confidence: 99%

Multimodality Intraoperative Neuromonitoring in Lateral Lumbar Interbody Fusion: A Review of Alerts in 628 Patients

Alluri

Vaishnav

Sivaganesan

et al. 2021

Global Spine Journal

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“…The benefits far outweigh the risk of routine neuromonitoring since complications with it are extremely rare [ 57 ]. Nonetheless, the added cost has been recognized [ 58 , 59 ], questioning its routine use during low-risk lumbar decompressions [ 58 ]. However, the authors stipulated that its use would lower surgical risk and improve clinical outcomes with the transforaminal endoscopic discectomy when the procedure is performed under general anesthesia.…”

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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“…There are multiple studies questioning the utility of ION in single-level cervical and lumbar surgeries, and it is up to the expert witnesses in the case to show the standard of care. 3,26,27 Although a plaintiff still must prove that the lack of monitoring led to an injury, it is likely that expert witness could be introduced, maintaining use of ION as the standard of care in many, if not all, of these instances. It behooves the operating surgeon to ensure that, if ION is regarded as the standard of care for a particular surgery, it is used.…”

Section: Failure To Monitormentioning

confidence: 99%

Damned if you monitor, damned if you don’t: medical malpractice and intraoperative neuromonitoring for spinal surgery

Hatef

Katzir

Toop

et al. 2020

Neurosurgical Focus

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OBJECTIVEThe aim of this study was to identify trends in medical malpractice litigation related to intraoperative neuromonitoring.METHODSThe Westlaw Edge legal research service was queried for malpractice litigation related to neuromonitoring in spine surgery. Cases were reviewed to determine if the plaintiff’s assertion of negligence was due to either failure to use neuromonitoring or negligent monitoring. Comparative statistics and a detailed qualitative analysis of the resulting cases were performed.RESULTSTwenty-six cases related to neuromonitoring were identified. Spinal fusion was the procedure in question in all cases, and defendants were nearly evenly divided between orthopedic surgeons and neurosurgeons. Defense verdicts were most common (54%), followed by settlements (27%) and plaintiff verdicts (19%). Settlements resulted in a mean $7,575,000 damage award, while plaintiff verdicts resulted in a mean $4,180,213 damage award. The basis for litigation was failure to monitor in 54% of the cases and negligent monitoring in 46%. There were no significant differences in case outcomes between the two allegations of negligence.CONCLUSIONSThe use and interpretation of intraoperative neuromonitoring findings can be the basis for a medical malpractice litigation. Spine surgeons can face malpractice risks by not monitoring when required by the standard of care and by interpreting or reacting to neuromonitoring findings inappropriately.

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Intraoperative neuromonitoring for one-level lumbar discectomies is low yield and cost-ineffective

Cited by 12 publications

References 24 publications

Multimodality Intraoperative Neuromonitoring in Lateral Lumbar Interbody Fusion: A Review of Alerts in 628 Patients

Multimodality Intraoperative Neuromonitoring in Lateral Lumbar Interbody Fusion: A Review of Alerts in 628 Patients

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

Damned if you monitor, damned if you don’t: medical malpractice and intraoperative neuromonitoring for spinal surgery

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