Routine Use of Intraoperative Neuromonitoring During ACDFs for the Treatment of Spondylotic Myelopathy and Radiculopathy Is Questionable

Abstract

Study Design A retrospective database study. Objective The goal of this study was to (1) evaluate the trends in the use of intraoperative neuromonitoring (ION) for anterior cervical discectomy and fusion (ACDF) surgery in the United States and (2) assess the incidence of neurological injuries after ACDFs with and without ION. Summary of Background Data Somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) are the commonly used ION modalities for ACDFs. Controversy exists on the routine use of ION for ACDFs and there is limited literature on national practice patterns of its use. Methods A retrospective review was performed using the PearlDiver Patient Record Database to identify cases of spondylotic myelopathy and radiculopathy that underwent ACDF from 2007 to 2014. The type of ION modality used and the rates of neurological injury after surgery were assessed. Results During the study period, 15,395 patients underwent an ACDF. Overall, ION was used in 2627 (17.1%) of these cases. There was a decrease in the use of ION for ACDFs from 22.8% in 2007 to 4.3% use in 2014 (P < 0.0001). The ION modalities used for these ACDFs were quite variable: SSEPs only (48.7%), MMEPs only (5.3%), and combined SSEPs and MMEPs (46.1%). Neurological injuries occurred in 0.23% and 0.27% of patients with and without ION, respectively (P = 0.84). Younger age was associated with a higher utility of ION (<45: 20.3%, 45–54: 19.3%, 55–64: 16.6%, 65–74: 14.3%, and >75: 13.6%, P < 0.0001). Significant regional variability was observed in the utility of ION for ACDFs across the country (West; 21.9%, Midwest; 12.9% (P < 0.0001). Conclusion There has been a significant decrease in the use of ION for ACDFs. Furthermore, there was significant age and regional variability in the use of ION for ACDFs. Use of ION does not further prevent the rate of postoperative neurological complications for ACDFs as compared with the cases without ION. The utility of routine ION for ACDFs is questionable.

The Use of Intraoperative Neurophysiological Monitoring in Spine Surgery

“…In a retrospective analysis of 720 patients, Traynelis et al 3 concluded that surgical decompression and reconstruction for symptomatic cervical spine disease may be safely performed without utilizing IONM. In line with this study, Ajiboye et al 4 also found no benefit of IONM in the prevention of new postoperative neurological complications after anterior cervical surgery.…”

Utilization of intraoperative neuromonitoring throughout the United States over a recent decade: an analysis of the nationwide inpatient sample

“…However, multiple studies have suggested that neuromonitoring effects may have limited benefits in relatively simple spine surgeries. Neuromonitoring use in single-level spinal procedures showed decreased neurologic complications only among lumbar laminectomies without any significant improvement in anterior cervical discectomy and fusions (ACDF), lumbar fusions, or lumbar discectomies (23,25,26). Furthermore, neuromonitoring use in minimally invasive 1-and 2-level transforaminal lumbar interbody fusions did not decrease the incidence of malpositioned pedicle screws (27).…”

Barriers of neurophysiology monitoring in spine surgery: Latin America experience

“…IOM was used in 2627 patients (17.1%), and there was a significant decrease in the use of ACDF from 22.8% in 2007 to 4.3% use in 2014. [1] In addition, another group of authors has performed a systematic search to identify studies on IOM use for anterior cervical spine surgery, and they limited usefulness for IOM for ACDF as there was no difference in the risk of neurological injury with or without IOM. [2] Cost-benefit relation A point of permanent debate is the cost-benefit relation of IOM.…”