Should evoked potential monitoring be used in degenerative cervical spine surgery? A systematic review

Abstract

Background Intraoperative somatosensory evoked potential (SSEP) and transcranial motor evoked potential (tcMEP) monitoring are frequently used in spinal as well as spinal cord surgery for so-called intraoperative neuromonitoring (IONM), while the combination of these techniques is known as concomitant multimodal intraoperative monitoring (MIOM). The aim of this review is to collect available evidence concerning use of IONM and MIOM in cervical decompression surgery in the degenerative setting and attempt to identify the best practice to be advocated. Materials and methods A review of the PubMed and MEDLINE databases and Cochrane Central Registry of Controlled Trials was performed. Studies were included if they involved patients who underwent cervical spine decompression surgery for degenerative stenosis with use of IONM or MIOM and where sensitivity/specificity was reported. Results In the identified studies, the sensitivity of SSEP was estimated to be between 22 and 100% with constant specificity of 100%. In the included studies, the sensitivity of MEP was estimated to be between 78 and 100% with specificity ranging from 83.2 to 100%. Conclusions On the basis of available evidence, MIOM could be a helpful tool in decompression cervical spine surgery in patients affected by degenerative spinal stenosis, since it is associated with high specificity and sensitivity for detection of intraoperative neural damage. However, evidence is still lacking regarding patient selection to identify individuals in whom monitoring is indicated. Level of evidence IV (systematic review of studies with LOE II to IV).

Degenerative Cervical Myelopathy: Clinical Presentation, Assessment, and Natural History

“…A recent systematic review reported that intraoperative monitoring may be a helpful tool in these surgical procedures given its high sensitivity and specificity for intraoperative neural damage detection. However, at this time evidence is limited, with no criteria for indications for its use [60]. An earlier systematic review made similar conclusions, noting that MEP/SEP monitoring may provide a sensitive tool for detecting neurologic injury during anterior approaches, intraoperative changes are not specific, and its recognition has not been found to prevent neurologic injury or result in improved outcome [61].…”

Power-Tool Use in Orthopaedic Surgery

“…Numerous papers investigated novel technology to detect damage during orthopaedic surgery. This includes spectroscopy 15 , electrical conductivity devices 61,62 , electromyography 63 , stimulus-evoked potential 64 , bioimpedance drills 65 , and acoustic emission-signal analysis 66 .…”

“…Two of these were systematic reviews that investigated proximal femoral fractures 6 and total hip arthroplasty 12 , with the majority being retrospective studies and 1 questionnaire sent to vascular surgeons 22 . In addition, there were multiple case reports of arterial, nervous, and ureteric injury due to screw placement and drill bit use [24][25][26][27][28][29] 15 , electrical conductivity devices 61,62 , electromyography 63 , stimulus-evoked potential 64 , bioimpedance drills 65 , and acoustic emission-signal analysis 66 .…”

Combined Motor and Sensory Intraoperative Neuromonitoring for Cervical Spondylotic Myelopathy Surgery Causes Confusion

“…Although IONM was developed partly in hope of reducing intraoperative neurological events during spinal surgery, its utility and value continue to be debated in the literature due to its associated cost, set-up time, and reported sensitivity and specificity. 14,20,21,23 Part of the issue with IONM is that intraoperative neurological events are relatively rare, thus the number needed to treat to potentially save a single event may be quite high. Moreover, among those rare neurological events that do occur, the utility of IONM requires that an event be reversible.…”