Neurophysiologic Intraoperative Monitoring for Spine Surgery: A Practical Guide From Past to Present

Abstract

Intraoperative neuromonitoring was introduced in the second half of the 20th century with the goal of preventing patient morbidity for patients undergoing complex operations of the central and peripheral nervous system. Since its early use for scoliosis surgery, the growth and utilization of IOM techniques expanded dramatically over the past 50 years to include spinal tumor resection and evaluation of cerebral ischemia. The importance of IOM has been broadly acknowledged, and in 1989, the American Academy of Neurology (AAN) released a statement that the use of SSEPs should be standard-of-care during spine surgery. In 2012, both the AAN and the American Clinical Neurophysiology Society (ACNS) recommended that: “Intraoperative monitoring (IOM) using SSEPs and transcranial MEPs be established as an effective means of predicting an increased risk of adverse outcomes, such as paraparesis, paraplegia, and quadriplegia, in spinal surgery.” With a multimodal approach that combines SSEPs, MEPs, and sEMG with tEMG and D waves, as appropriate, sensitivity and specificity can be maximized for the diagnosis of reversible insults to the spinal cord, nerve roots, and peripheral nerves. As with most patient safety efforts in the operating room, IOM requires contributions from and communication between a number of different teams. This comprehensive review of neuromonitoring techniques for surgery on the central and peripheral nervous system will highlight the technical, surgical and anesthesia factors required to optimize outcomes. In addition, this review will discuss important trouble shooting measures to be considered when managing ION changes concerning for potential injury.

Lumbar Sympathetic Trunk Injury: An Underestimated Complication of Oblique Lateral Interbody Fusion

“…OLIF surgery has good clinical efficacy and safety in the treatment of lumbar degenerative disorders, but the surgical complications of OLIF, such as LST injury, should not be ignored. The exact cause of sympathetic nerve injury during OLIF is not fully clear, and there is a lack of effective neurophysiological detection techniques for this complication 11 …”

“…In our study, eigth patients (14.8%) had different self-perceived bilateral lower limb temperatures after OLIF, and 16 patients (29.6%) had different lower limb skin temperature as measured by electronic thermometer, while in most studies on OLIF complications, no other objective physical examination modalities were mentioned in the assessment of lumbar sympathetic trunk injury. 11,13,16,17 Hrabalek et al reported that only 32% of patients with lumbar sympathetic trunk injury show distinguishable difference in skin temperature of lower limbs by palpation, and the diagnostic accuracy of lumbar sympathetic trunk injury using lower limb surface thermography was significantly higher than the subjective examination. 6 Li et al suggested that the use of digital infrared thermography and physical testing could help increase the diagnostic accuracy of lumbar sympathetic trunk injury.…”

“…The exact cause of sympathetic nerve injury during OLIF is not fully clear, and there is a lack of effective neurophysiological detection techniques for this complication. 11 In 2017, Abe et al reported a multicenter retrospective study that included 11 affiliated hospitals to analyze the incidence of postoperative complications after OLIF. 12 Among 155 patients with OLIF, a total of 75 (48.3%) had various degrees of intraoperative and postoperative complications.…”

Multimodal Neuroelectrophysiological Monitoring Combined with Robot-Assisted Placement of a Transiliac–Transsacral Screw for the Treatment of Transforaminal Sacral Fractures

“…Intraoperative multimodal neuroelectrophysiological monitoring technology has been well developed in neurosurgery and spine surgery, which can provide real-time monitoring of nerve function for surgeons and timely detection of nerve injury, ensuring surgical safety. Thus, monitoring is currently favored by an increasing number of orthopedic surgeons [17,[35][36][37][38]. Nevertheless, few studies have reported neuroelectrophysiological monitoring during pelvic surgery [18,39].…”

“…MNM has been fully developed during spinal surgery because it provides real-time monitoring information of nerve function and timely detection of nerve injury for surgeons. Therefore, MNM ensures the safety of surgery, which has been favored by an increasing number of orthopedic surgeons [ 17 , 18 ]. The goal of intraoperative neuroelectrophysiological monitoring is to identify early changes in neural activity to guide procedural actions and adjustments that ultimately may prevent definitive injury to nerves.…”