Neuromonitoring changes in pediatric spinal deformity surgery: a single-institution experience

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Intraoperative monitoring of the spinal cord has become the standard of care during surgery for pediatric spinal deformity correction. The use of both somatosensory and motor evoked potentials has dramatically increased the sensitivity and specificity of detecting intraoperative neurophysiological changes to the spinal cord, which assists in the intraoperative decision-making process. The authors report on a large, single-center experience with neuromonitoring changes and outline the surgical management of patients who experience significant neuromonitoring changes during spinal deformity correction surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors conducted a retrospective review of all cases involving pediatric patients who underwent spinal deformity correction surgery at Shriners Hospital for Children, Philadelphia, between January 2007 and March 2010. Five hundred nineteen consecutive cases were reviewed in which neuromonitoring was used, with 47 cases being identified as having significant changes in somatosensory evoked potentials, motor evoked potentials, or both. These cases were reviewed for patient demographic data and surgical characteristics.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The incidence of significant neuromonitoring changes was 9.1% (47 of 519 cases), including 6 cases of abnormal Stagnara wake-up tests, of which 4 had corroborated postoperative neurological deficits (8.5% of 47 cases, 0.8% of 519). In response to neuromonitoring changes, wake-up tests were performed in 37 (79%) of 47 cases, hardware was adjusted in 15 (32%), anesthesiology interventions were reported in 5 (11%), hardware was removed in 5 (11%), the patient was successfully repositioned in 3 (6%), and the procedure was aborted in 13 (28%). In 1 of the 4 patients with new postoperative deficits, the deficit had fully resolved by the last follow-up; the other 3 patients had persistent neurological impairment as of the most recent follow-up examination. The authors observed a sensitivity of 100% for intraoperative neuromonitoring.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Due to the profound risks associated with spinal deformity surgery, intraoperative neurophysiological monitoring is an integral tool to warn of impending spinal cord injury. Intraoperative neuromonitoring appears to provide a safe and useful warning mechanism to minimize spinal cord injury that may arise during scoliosis correction surgery in pediatric patients.</jats:p></jats:sec>

Intraoperative neuromonitoring alerts in a pediatric deformity center

“…5 Multimodality neuromonitoring of SSEPs and TceMEPs allows for a greater level of specificity regarding patient outcome after spinal deformity surgery. 2 Nuwer et al observed a sensitivity level of 92% and a specificity level of 98% for SSEP monitoring, in terms of new postoperative motor deficits.…”

“…1 Last, neurological disorders, such as seizures, were once thought to be a contraindication to TceMEPs. [1][2][3]8 According to MacDonald and colleagues, the incidence of seizures was 0.03% and the incidence of bite injuries was 0.2%. 6 Therefore, a risk/benefit analysis should be performed prior to utilizing TceMEPs.…”

“…First, the small computerized averaged response lacks immediate feedback through data collection. 2 Second, SSEPs do not reveal the integrity of motor tracts. 2 Third, there may be a delay in response time.…”

“…2 The dorsal columns are located in the posterior two-thirds of the spinal cord, and blood is supplied by 2 posterior spinal arteries. 4 Three limitations of SSEP monitoring exist.…”

Feasibility and Predictability of Intraoperative Monitoring in Patients with Intradural Extramedullary and Epidural Metastatic Spinal Tumors

“…Studies of IOM in spinal deformity surgery reported an end result occurrence (postoperative deficit) of less than 1%. Hence, it was natural that specificity of IOM was around 99% and sensitivity varied according to wake-up test result [2,14]. Meanwhile, in the surgery for intramedullary tumour, at which postoperative neurologic deficit occur at higher rate and wake-up test is rarely applicable, the sensitivity is still high but specificity comes out less accurately.…”