Assessment of neuromonitoring use and postoperative readmission rates in pediatric Chiari I malformation with syrinx

Intraoperative neuromonitoring in Chiari I malformation surgery: a systematic review and meta-analysis

Chiari Malformation Type I (CMI) is a prevalent neurosurgical condition characterized by the descent of cerebellar tonsils below the foramen magnum. Surgery, aimed at reducing symptomatology and syrinx size, presents risks, making intraoperative neuromonitoring (IONM) a potentially vital tool. Despite its widespread use in cervical spine surgery, the utility of IONM in CMI surgery remains controversial, with concerns over increased operative time, cost, restricted anesthetic techniques and tongue lacerations. This systematic review and meta-analysis followed the Cochrane Group standards and PRISMA framework. It encompassed an extensive search through PubMed, Embase, and Web of Science up to December 2023, focusing on clinical and surgical outcomes of IONM in CMI surgery. Primary outcomes included the use of various IONM techniques, complication rates, clinical improvement, reoperation, and mortality. The review, registered at PROSPERO (CRD42024498996), included both prospective and retrospective studies, with rigorous selection and data extraction processes. Statistical analysis was conducted using R software. The review included 16 studies, comprising 1358 patients. It revealed that IONM techniques predominantly involved somatosensory evoked potentials (SSEPs), followed by motor evoked potentials (MEPs) and Brainstem auditory evoked potentials (BAEPs). The estimated risk of complications with IONM was 6% (95% CI: 2-11%; I2 = 89%), lower than previously reported rates without IONM. Notably, the clinical improvement rate post-surgery was high at 99% (95% CI: 98-100%; I2 = 56%). The analysis also showed lower reoperation rates in surgeries with IONM compared to those without. Interestingly, no mortality was observed in the included studies. This systematic review and meta-analysis indicate that intraoperative neuromonitoring in Chiari I malformation surgery is associated with favorable clinical outcomes, including lower complication and reoperation rates, and high rates of clinical improvement.

In-House Intraoperative Monitoring in Neurosurgery in England - Benefits and Challenges

BACKGROUND

Intraoperative neurophysiological monitoring (IOM) is a valuable adjunct for neurosurgical operative techniques, and has been shown to improve clinical outcomes in cranial and spinal surgery. It is not necessarily provided by NHS hospitals so may be outsourced to private companies, which are expensive and at cost to the NHS trusts. We discuss the benefits and challenges of developing an in-house service.

METHODS

We surveyed NHS neurosurgical departments across England regarding their expenditure on IOM over the period January 2018 - December 2022 on cranial neurosurgery and spinal surgery. Out of 24 units, all responded to our Freedom of Information requests and 21 provided data. The standard NHS England salary of NHS staff who would normally be involved in IOM, including physiologists and doctors, was also compiled for comparison.

RESULTS

The total spend on outsourced IOM, across the units who responded, was over £8 million in total for the four years. The annual total increased, between 2018 and 2022, from £1.1 to £3.5 million. The highest single unit yearly spend was £568,462. This is in addition to salaries for staff in neurophysiology departments. The mean NHS salaries for staff is also presented.

CONCLUSION

IOM is valuable in surgical decision-making, planning, and technique, having been shown to lead to fewer patient complications and shorter length of stay. Current demand for IOM outstrips the internal NHS provision in many trusts across England, leading to outsourcing to private companies. This is at significant cost to the NHS. Although there is a learning curve, there are many benefits to in-house provision, such as stable working relationships, consistent methods, training of the future IOM workforce, and reduced long-term costs, which planned expansion of NHS services may provide.