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Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
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Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
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Daroszewski P, Huber J, Kaczmarek K, Janusz P, Główka P, Tomaszewski M, Domagalska M, Kotwicki T. Comparison of Motor Evoked Potentials Neuromonitoring Following Pre- and Postoperative Transcranial Magnetic Stimulation and Intraoperative Electrical Stimulation in Patients Undergoing Surgical Correction of Idiopathic Scoliosis. J Clin Med 2023; 12:6312. [PMID: 37834956 PMCID: PMC10573895 DOI: 10.3390/jcm12196312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
The relationships between the results of pre- and intraoperative motor evoked potential recordings during neuromonitoring and whether idiopathic scoliosis (IS) surgical correction improves the spinal efferent transmission have not been specified in detail. This study aims to compare the results of surface-recorded electromyography (EMG), electroneurography (ENG, M, and F-waves), and especially motor evoked potential (MEP) recordings from tibialis anterior muscle (TA) bilaterally in 353 girls with right idiopathic scoliosis (types 1-3 according to Lenke classification). It has not yet been documented whether the results of MEP recordings induced by transcranial single magnetic stimulus (TMS, pre- and postoperatively) and trains of electrical stimuli (TES; intraoperatively in T0-before surgery, T1-after pedicle screws implantation, and T2-after scoliosis curvature distraction and derotation following two-rod implantation) can be compared for diagnostic verification of the improvement of spinal cord neural transmission. We attempted to determine whether the constant level of optimal anesthesia during certain surgical steps of scoliosis treatment affects the parameters of MEPs recorded during neuromonitoring procedures. No neurological deficits have been observed postoperatively. The values of amplitudes but not latencies in MEP recordings evoked with TMS in IS patients compared before and after surgery indicated a slight improvement in efferent neural transmission. The results of all neurophysiological studies in IS patients were significantly asymmetrical and recorded worse on the concave side, suggesting greater neurological motor deficits at p = 0.04. The surgeries brought significant improvement (p = 0.04) in the parameters of amplitudes of sEMG recordings; however, the consequences of abnormalities in the activity of TA motor units were still reflected. ENG study results showed the symptoms of the axonal-type injury in peroneal motor fibers improving only on the concave side at p = 0.04, in parallel with F-wave parameters, which suggests that derotation and distraction might result in restoring the proper relations of the lumbar ventral roots in the spinal central canal, resembling their decompression. There were no significant differences detected in the amplitudes or latencies of MEPs induced with TMS or TES when comparing the parameters recorded preoperatively and intraoperatively in T0. The amplitudes of TES-evoked MEPs increased gradually at p = 0.04 in the subsequent periods (T1 and T2) of observation. A reduction in MEP latency at p = 0.05 was observed only at the end of the IS surgery. Studies on the possible connections between the level of anesthesia fluctuations and the required TMS stimulus strength, as well as the MEP amplitude changes measured in T0-T2, revealed a lack of relationships. These might not be the factors influencing the efferent transmission in spinal pathways beside the surgical procedures. Pre- (TMS-evoked) and intraoperative (TES-evoked) recordings are reliable for evaluating the patient's neurological status before and during surgical scoliosis correction procedures. An increase in MEP amplitude parameters recorded on both sides after scoliosis surgery proves the immediate improvement of the total efferent spinal cord transmission. Considering comparative pre- and postoperative sEMG and ENG recordings, it can be concluded that surgeries might directly result in additional lumbar ventral root decompression. We can conclude that MEP parameter changes are determined by the surgery procedures during neuromonitoring, not the anesthesia conditions if they are kept stable, which influences a decrease in the number of false-positive neuromonitoring warnings.
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Affiliation(s)
- Przemysław Daroszewski
- Department of Organization and Management in Health Care, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Str., no. 135/147, 61-545 Poznań, Poland;
| | - Juliusz Huber
- Department Pathophysiology of Locomotor Organs, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Str., no. 135/147, 61-545 Poznań, Poland;
| | - Katarzyna Kaczmarek
- Department Pathophysiology of Locomotor Organs, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Str., no. 135/147, 61-545 Poznań, Poland;
| | - Piotr Janusz
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Str., no. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
| | - Paweł Główka
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Str., no. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
| | - Marek Tomaszewski
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Str., no. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
| | - Małgorzata Domagalska
- Department of Palliative Medicine, Poznań University of Medical Sciences, Rusa 55, 61-245 Poznań, Poland;
| | - Tomasz Kotwicki
- Department of Spine Disorders and Pediatric Orthopaedics, Poznań University of Medical Sciences, 28 Czerwca 1956 r. Str., no. 135/147, 61-545 Poznań, Poland; (P.J.); (P.G.); (M.T.); (T.K.)
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Angelliaume A, Alhada TL, Parent HF, Royer J, Harper L. Intraoperative neurophysiological monitoring in scoliosis surgery: literature review of the last 10 years. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3072-3076. [PMID: 37434021 DOI: 10.1007/s00586-023-07837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Patients with spinal deformities undergoing corrective surgery are at risk for iatrogenic spinal cord injury (SCI) and subsequent neurological deficit. Intraoperative neurophysiological monitoring (IONM) allows early detection of SCI which enables early intervention resulting in a better prognosis. The primary aim of this literature review was to search if there are threshold values of TcMEP and SSEP in the literature that are widely accepted as alert during IONM. The secondary aim was to update knowledge concerning IONM during scoliosis surgery. METHOD PubMed/MEDLINE and Cochrane library electronic databases were used to search publication from 2012 to 2022. The following keywords were used: evoked potential, scoliosis, surgery, intraoperative monitoring and neurophysiological. We included all studies dealing with SSEP and TcMEP monitoring during scoliosis surgery. Two authors reviewed all titles and abstracts to identify studies that met the inclusion criteria. RESULTS We included 43 papers. Rates of IONM alert and neurological deficit varied from 0.56 to 64% and from 0.15 to 8.3%, respectively. Threshold values varied from a loss of 50 to 90% for TcMEP amplitude, whereas it seems that a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted for SSEP. Causes of IONM changes most frequently reported were surgical maneuver. CONCLUSION Concerning SSEP, a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted as an alert. For TcMEP, it seems that the use of highest threshold values can avoid unnecessary surgical procedure for the patient without increasing risk of neurological deficit.
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Affiliation(s)
| | - Toul-la Alhada
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | | | - Julia Royer
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Luke Harper
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
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Morito S, Yamada K, Nakae I, Sato K, Yokosuka K, Yoshida T, Shimazaki T, Hazemoto Y, Saruwatari R, Nishida K, Okazaki S, Hiraoka K. Intradural extramedullary tumor location in the axial view affects the alert timing of intraoperative neurophysiologic monitoring. J Clin Monit Comput 2023; 37:775-782. [PMID: 36635568 DOI: 10.1007/s10877-022-00971-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/28/2022] [Accepted: 12/31/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Intraoperative neurophysiologic monitoring (IONM) reportedly helps prevent postoperative neurological complications following high-risk spinal cord surgeries. There are negative and positive reports about using IONM for intradural extramedullary (IDEM) tumors. We investigated factors affecting alerts of IONM in IDEM tumor surgery. METHODS We analyzed 39 patients with IDEM tumors who underwent surgery using IONM at our hospital between January 2014 and March 2021. Neurological symptoms were evaluated pre- and postoperatively using the manual muscle test (MMT). All patients were evaluated to ascertain the tumor level and location in the axial view, the operative time, intraoperative bleeding volume, and histological type. Additionally, the intraoperative procedure associated with significant IONM changes in transcranial electrical stimulation muscle-evoked potential was investigated. RESULTS There were 11 false-positive and 16 true-negative cases. There was one true-positive case and one false-negative case; the monitoring accuracy achieved a sensitivity of 50%, a specificity of 59%, a positive predictive value of 8%, and a negative predictive value of 94%. In the 22 alert cases, if the tumor was located anterolateral in the axial view, alerts were triggered with a significant difference (p = 0.02) during tumor resection. Alerts were generated for fifteen patients during tumor resection; nine (60%) showed waveform improvement by intervention and were classified as rescue cases. CONCLUSION Alert is probably triggered during tumor resection for anterolaterally located tumors. Alerts during tumor resection procedures were more likely to be rescued than other procedures in IDEM tumor surgery.
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Affiliation(s)
- Shinji Morito
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kei Yamada
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan.
| | - Ichirou Nakae
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kimiaki Sato
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kimiaki Yokosuka
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Tatsuhiro Yoshida
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Takahiro Shimazaki
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Yutaro Hazemoto
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Rikiya Saruwatari
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kota Nishida
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Shingo Okazaki
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Koji Hiraoka
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
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Besse M, Gaume M, Eisermann M, Kaminska A, Glorion C, Miladi L, Gitiaux C, Ferrero E. Intraoperative neuromonitoring in non-idiopathic pediatric scoliosis operated with minimally fusionless procedure: A series of 290 patients. Arch Pediatr 2022; 29:588-593. [PMID: 36167615 DOI: 10.1016/j.arcped.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 06/08/2022] [Accepted: 08/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND One of the worst complications of surgery for spinal deformity is postoperative neurological deficit. Multimodal intraoperative neuromonitoring (IONM) can be used to detect impending neurological injuries. This study aimed to analyze IONM in non-idiopathic scoliosis using a minimally invasive fusionless surgical technique. METHODS This retrospective, single-center study was performed from 2014 to 2018. Patients with non-idiopathic scoliosis who underwent a minimally invasive fusionless procedure and had at least 2 years of follow-up were included. IONM was performed using a neurophysiological monitoring work station with somatosensory evoked potentials (SSEP) and neurogenic mixed evoked potentials (NMEP). RESULTS A total of 290 patients were enrolled. The mean age at surgery was 12.9±3 years. The main etiology was central nervous system (CNS) disorders (n=139, 48%). Overall, 35 alerts (11%) in the SSEP and 10 (7%) in the NMEP occurred. There were two neurological deficits with total recovery after 6 months. There were no false negatives in either SSEP or NMEP, although there was one false positive in SSEP and two false positives for NMEP in the group without signal recovery. There was no significant relationship between the incidence of SSEP or NMEP loss and age, body mass index (BMI), number of rods used, upper instrumented vertebrae (p=0.36), lower instrumented vertebrae, or type of surgery. A preoperative greater Cobb angle was associated with a significantly higher risk of NMEP loss (p=0.02). In CNS patients, a higher BMI was associated with a statistically significant risk of NMEP loss (p=0.004). The use of a traction table was associated with a higher risk of signal loss (p=0.0005). CONCLUSION A preoperative higher Cobb angle and degree of correction were associated with a significant risk of NMEP loss. In CNS scoliosis, a higher BMI was associated with a significant risk of NMEP loss. The use of a traction table was associated with a higher risk of signal loss.
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Affiliation(s)
- M Besse
- Service de chirurgie orthopédique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris, France.
| | - M Gaume
- Service de chirurgie orthopédique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris, France
| | - M Eisermann
- Service de neurophysiologie clinique, centre de référence des pathologies neuromusculaires, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris cité, France
| | - A Kaminska
- Service de neurophysiologie clinique, centre de référence des pathologies neuromusculaires, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris cité, France
| | - C Glorion
- Service de chirurgie orthopédique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris, France
| | - L Miladi
- Service de chirurgie orthopédique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris, France
| | - C Gitiaux
- Service de neurophysiologie clinique, centre de référence des pathologies neuromusculaires, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris cité, France
| | - E Ferrero
- Service de chirurgie orthopédique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris, France; Service de chirurgie orthopédique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris cité, Paris, France
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Zhang HQ, Du YX, Liu JY, Deng A, Wu JH, Wang YX, Guo CF. Strategy and Efficacy of Surgery for Congenital Cervicothoracic Scoliosis with or without Hemivertebra Osteotomy. Orthop Surg 2022; 14:2050-2058. [PMID: 36040110 PMCID: PMC9483056 DOI: 10.1111/os.13480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Cervicothoracic scoliosis will cause severe deformities in the early stage, and its structure is complex and the surgical methods are varied. The purpose of this research is to explore the indication and analyze the corrective effect of the two different posterior approach surgical strategies, including correction with fusion and hemivertebra osteotomy, for congenital cervicothoracic scoliosis deformities in children and adolescents. METHODS This was a retrospective study of 21 patients with cervicothoracic scoliosis who received surgical treatment from January 2010 to June 2020, including nine cases of posterior hemivertebra osteotomy and fusion surgery and 12 cases of posterior correction and fusion alone. The Cobb angle, T1 tilt angle, clavicular angle, neck tilt angle, radiographic shoulder height, sagittal vertical axis, coronal balance distance, and local kyphosis angle were measured preoperatively, postoperatively, and at the last follow-up. Posterior approach hemivertebra resection or correction with fusion surgery was adopted based on the different individual characteristics of deformity such as main curve Cobb angle, growth potential, and flexibility. Patients were divided into two groups (osteotomy group and nonosteotomy group) according to whether a hemivertebra osteotomy was performed, and the corrective results in the two groups were compared. Paired-sample t tests or independent-sample t tests were used. RESULTS The median follow-up after surgery of the 21 patients was 36 months (range, 18-72 months). The Cobb angle was corrected from 45.81° ± 14.23° preoperatively to 10.48° ± 5.56° postoperatively (correction rate, 77.78% ± 8.93%). The T1 tilt angle decreased from 15.26° ± 7.08° preoperatively to 3.33° ± 2.14° postoperatively (correction rate,73.42% ± 21.86%). The radiographic shoulder height was corrected from 1.13 ± 0.74 cm preoperatively to 0.52 ± 0.42 cm postoperatively (correction rate, 39.51% ± 35.65%). The clavicular angle improved from 2.52° ± 1.55° preoperatively to 1.16° ± 0.96° postoperatively (correction rate, 47.18% ± 35.84%). No significant differences were found at the last follow-up (p > 0.05). The Cobb angle of the main curve, T1 tilt angle, clavicular angle, cervical tilt angle, and shoulder height difference were similar in the two groups (p > 0.05). CONCLUSIONS Posterior approach hemivertebra resection or correction with fusion surgery can be used in the treatment of congenital cervicothoracic scoliosis with satisfactory results, and the surgeon can make an individualized surgical plan according to individual characteristics of deformity.
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Affiliation(s)
- Hong-Qi Zhang
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital of Central-South University, Changsha, China
| | - Yu-Xuan Du
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital of Central-South University, Changsha, China
| | - Jin-Yang Liu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital of Central-South University, Changsha, China
| | - Ang Deng
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital of Central-South University, Changsha, China
| | - Jian-Huang Wu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital of Central-South University, Changsha, China
| | - Yu-Xiang Wang
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital of Central-South University, Changsha, China
| | - Chao-Feng Guo
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital of Central-South University, Changsha, China
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Smals LDEDM, Hulsbosch MHHM, de Faber SIPJ, Arts JJ, van Rhijn LW, Willems PC. Post-marketing surveillance on safety and efficacy of posterior spinal correction and fusion with the CD Horizon Solera instrumentation for adolescent idiopathic scoliosis. A retrospective cohort study. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 8:100085. [PMID: 35141650 PMCID: PMC8819889 DOI: 10.1016/j.xnsj.2021.100085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 10/24/2022]
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Complete paraplegia 36 h after attempted posterior spinal fusion for severe adolescent idiopathic scoliosis: a case report. Spinal Cord Ser Cases 2021; 7:33. [PMID: 33879781 DOI: 10.1038/s41394-021-00386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/20/2021] [Accepted: 02/12/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The incidence of neurologic complications with spinal surgery for adolescent idiopathic scoliosis (AIS) has been reported to be 0.69%. This rare complication typically occurs during surgery or immediately postoperatively. We report the occurrence of a delayed neurologic deficit that presented 36 h after the initial surgery of a staged posterior spinal fusion for severe AIS. CASE PRESENTATION A 12-year-old girl with severe thoracolumbar AIS of 125° underwent attempted posterior spinal fusion from T2-L4. The case was complicated by a transient loss of transcutaneous motor evoked potentials (TcMEP) that resolved with an increase in the mean arterial pressure (MAP) and relaxation of curve correction with rod removal. The patient awoke with normal neurologic function. She had a transient decrease in MAP 36 h post-op and awoke on postoperative day #2 with nearly complete lower extremity paraplegia (American Spinal Injury Association [ASIA] Impairment Scale B). Emergent exploration and removal of the concave apical pedicles resulted in improvement of TcMEPs and return of function. DISCUSSION Delayed postoperative neurologic deficit is a very rare phenomenon, with only a few case reports in the literature to date. The delayed neurologic decline of our patient was likely secondary to a transient episode of postoperative hypotension combined with spinal cord compression by the apical concave pedicles. Close monitoring and support of spinal cord perfusion as well as emergent decompression are imperative in the setting of a delayed neurologic deficit. Further multicenter study on this rare occurrence is underway to identify potential causes and improve treatment.
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Kaur V, Agrawal A, Dhawale T, Passi G. Case report of congenital kyphoscoliosis with myotonic dystrophy type 1: Perioperative and anesthetic considerations. J Pediatr Neurosci 2021; 16:281-284. [DOI: 10.4103/jpn.jpn_119_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/29/2020] [Accepted: 08/02/2020] [Indexed: 11/04/2022] Open
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Dlamini M. Neuromonitoring. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Neuromonitoring is used during surgery to assess the functional integrity of the brain, brain stem, spinal cord, or peripheral nerves. The aim of monitoring is to prevent permanent damage by early intervention when changes are detected in the monitor. Neuromonitoring is also used to map areas of the nervous system in order to guide management in some cases.
The best neuromonitor remains the awake patient. In the conscious state, the function of individual parts of the nervous system and the complex interactions of its different parts can be assessed more accurately. However, most surgical procedures involving the nervous system require general anaesthesia.
Procedures that require neuromonitoring can have changes in their monitored parameters corrected by modifying the surgical approach or by having the anaesthesiologist manipulate the parameters under their control. An ideal neuromonitor would be one that is specific for the parameter of interest, and gives reliable, reproducible, or continuous results.
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Welling SE, Bauer JM. Delayed Postoperative Spinal Cord Ischemia After Posterior Spinal Fusion in a Pediatric Patient with Syrinx and Decompressed Chiari: A Case Report. JBJS Case Connect 2020; 10:e1900610. [PMID: 32910606 DOI: 10.2106/jbjs.cc.19.00610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present a case of delayed postoperative neurologic deficits 1 day after posterior spinal fusion in a pediatric patient with syrinx and previous Chiari decompression, which reversed with urgent rod removal. CONCLUSION There is limited literature on delayed cord injury occurring after surgery in a patient with scoliosis of neuromuscular origin. Patients with syrinx and a history of Chiari decompression may have spinal cords more sensitive to injury including delayed ischemia after deformity treatment and should be paid extra perioperative attention including considering prolonged mean arterial pressure goals or more conservative deformity correction.
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Affiliation(s)
- Sebastian E Welling
- 1University of Washington Medical School, Seattle, Washington 2Department of Orthopaedic Surgery, Seattle Children's Hospital, Seattle, Washington 3Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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Preoperative pregabalin has no effect on intraoperative neurophysiological monitoring in adolescents undergoing posterior spinal fusion for spinal deformities: a double-blind, randomized, placebo-controlled clinical trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:298-304. [PMID: 29147795 DOI: 10.1007/s00586-017-5396-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 09/19/2017] [Accepted: 11/12/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE This study was designed to evaluate the effect of preoperative pregabalin on intraoperative neurophysiological monitoring in adolescents undergoing surgery for spinal deformities. METHODS Thirty-one adolescents undergoing posterior spinal fusion were randomized to receive preoperatively either pregabalin 2 mg/kg twice daily or placebo. The ability to make reliable intraoperative neurophysiological measurements, transcranial motor (MEPs) and sensory evoked potentials (SSEP) was evaluated. RESULTS Two patients (pregabalin group) did not fulfil the inclusion criteria and one patient's (placebo group) spinal monitoring was technically incomplete and these were excluded from the final data. In the rest, spinal cord monitoring was successful. Anaesthesia prolonged the latency of MEPs and increased the threshold current of MEP. The current required to elicit MEPs did not differ between the study groups. There were no statistically significant differences between the study groups regarding the latency of bilateral SSEP (N32 and P37) and MEP latencies at any time point. CONCLUSIONS Preoperative pregabalin does not interfere spinal cord monitoring in adolescents undergoing posterior spinal fusion. LEVEL OF EVIDENCE I.
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Multimodal Neuromonitoring During Safe Surgical Dislocation of the Hip for Joint Preservation: Feasibility, Safety, and Intraoperative Observations. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2017; 1:e038. [PMID: 30211362 PMCID: PMC6132301 DOI: 10.5435/jaaosglobal-d-17-00038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Introduction: Nerve injuries can occur from major hip surgeries, and some may be significant. Our goal was to assess the feasibility and safety of neuromonitoring during hip preservation surgery and the incidence of alerting events during such monitoring. Methods: Twenty-five adult patients underwent surgical hip dislocation for femoroacetabular impingement. Upper and lower extremity somatosensory evoked potentials, lower extremity transcranial motor evoked potentials, and lower extremity electromyography were recorded. Results: We observed a temporary reduction of the monitored parameters in twelve patients (48%) during surgery. There were no clinically significant neurological deficits postoperatively in any cases. Discussion: Neuromonitoring did demonstrate events during hip surgery in our case series. Although it may not be practical to use neuromonitoring in all major hip surgeries, it may be prudent from the perspective of patient safety to use it in high-risk cases, including those requiring prolonged surgical time; in patients with high body mass index, excessive deformity correction, and preexisting neuropathy; and in revision cases, among others.
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Harel R, Schleifer D, Appel S, Attia M, Cohen ZR, Knoller N. Spinal intradural extramedullary tumors: the value of intraoperative neurophysiologic monitoring on surgical outcome. Neurosurg Rev 2017; 40:613-619. [DOI: 10.1007/s10143-017-0815-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/06/2017] [Accepted: 01/16/2017] [Indexed: 10/20/2022]
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Diagnostic Accuracy of Neuromonitoring for Identification of New Neurologic Deficits in Pediatric Spinal Fusion Surgery. Anesth Analg 2016; 123:1556-1566. [DOI: 10.1213/ane.0000000000001503] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Errando CL, Blanco T, Díaz-Cambronero Ó. Repeated sugammadex reversal of muscle relaxation during lumbar spine surgery with intraoperative neurophysiological multimodal monitoring. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:533-538. [PMID: 27216713 DOI: 10.1016/j.redar.2016.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/11/2016] [Accepted: 03/16/2016] [Indexed: 06/05/2023]
Abstract
Intraoperative neurophysiological monitoring during spine surgery is usually acomplished avoiding muscle relaxants. A case of intraoperative sugammadex partial reversal of the neuromuscular blockade allowing adequate monitoring during spine surgery is presented. A 38 year-old man was scheduled for discectomy and vertebral arthrodesis throughout anterior and posterior approaches. Anesthesia consisted of total intravenous anesthesia plus rocuronium. Intraoperatively monitoring was needed, and the muscle relaxant reverted twice with low dose sugammadex in order to obtain adequate responses. The doses of sugammadex used were conservatively selected (0.1mg/kg boluses increases, total dose needed 0.4mg/kg). Both motor evoqued potentials, and electromyographic responses were deemed adequate by the neurophysiologist. If muscle relaxation was needed in the context described, this approach could be useful to prevent neurological sequelae. This is the first study using very low dose sugammadex to reverse rocuronium intraoperatively and to re-establish the neuromuscular blockade.
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Affiliation(s)
- C L Errando
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
| | - T Blanco
- Servicio de Neurofisiología Clínica, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Ó Díaz-Cambronero
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Politécnico La Fe, Valencia, Spain
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Fan B, Li HX, Hu Y. An Intelligent Decision System for Intraoperative Somatosensory Evoked Potential Monitoring. IEEE Trans Neural Syst Rehabil Eng 2016; 24:300-7. [DOI: 10.1109/tnsre.2015.2477557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Jain A, Khanna AJ, Hassanzadeh H. Management of intraoperative neuromonitoring signal loss. ACTA ACUST UNITED AC 2015. [DOI: 10.1053/j.semss.2015.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Rabai F, Sessions R, Seubert CN. Neurophysiological monitoring and spinal cord integrity. Best Pract Res Clin Anaesthesiol 2015; 30:53-68. [PMID: 27036603 DOI: 10.1016/j.bpa.2015.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/10/2015] [Accepted: 11/17/2015] [Indexed: 12/15/2022]
Abstract
An integral part of a major spine surgery is the intraoperative neurophysiological monitoring (IONM). By providing continuous functional assessment of specific anatomic structures, IONM allows the rapid detection of neuronal compromise and the opportunity for corrective action before an insult causes permanent neurological damage. Thus, IONM functions not just as a diagnostic tool but may also improve surgical outcomes. Effective clinical application requires a thorough understanding of the scope and limitations of IONM modalities not only by the monitoring team but also by the surgeon and anesthesiologist. Intraoperatively, collaboration and communication between monitorist, surgeon, and anesthesiologist are critical to the effectiveness of IONM. In this study, we review specific monitoring modalities, focusing on the relevant anatomy, physiology, and mechanisms of neuronal injury during major spine surgery. We discuss how these factors interact with anesthetic and surgical management. This review concludes with the current controversies surrounding the evidence in support of IONM and directions of future research.
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Affiliation(s)
- Ferenc Rabai
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254 JHMHSC, 1600 SW Archer Rd., Room M-509, Gainesville, FL 32610-0254, USA.
| | - Renard Sessions
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254 JHMHSC, 1600 SW Archer Rd., Room M-509, Gainesville, FL 32610-0254, USA.
| | - Christoph N Seubert
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254 JHMHSC, 1600 SW Archer Rd., Room M-509, Gainesville, FL 32610-0254, USA.
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Charrow J, Alden TD, Breathnach CAR, Frawley GP, Hendriksz CJ, Link B, Mackenzie WG, Manara R, Offiah AC, Solano ML, Theroux M. Diagnostic evaluation, monitoring, and perioperative management of spinal cord compression in patients with Morquio syndrome. Mol Genet Metab 2015; 114:11-8. [PMID: 25496828 DOI: 10.1016/j.ymgme.2014.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 10/22/2014] [Indexed: 12/13/2022]
Abstract
Mucopolysaccharidosis IVA is an autosomal recessive condition caused by mutations in the GALNS gene, which encodes N-acetylgalactosamine-6-sulfatase, also called galactosamine-6-sulfatase (GALNS). A reduction in or absence of effective GALNS leads to faulty catabolism of keratan sulfate and chondroitin-6-sulfate within the lysosome; their accumulation causes cell, tissue, and organ dysfunction. The connective tissue, cartilage, ligaments, and bone of patients with Morquio A syndrome are particularly affected. Patients with Morquio A syndrome are at high risk of neurological complications because of their skeletal abnormalities; many patients are in danger of cervical myelopathy due to odontoid hypoplasia and ligamentous laxity leading to atlantoaxial subluxation. The multisystemic involvement of patients with Morquio A syndrome requires treatment by multidisciplinary teams; not all members of these teams may be aware of the potential for subluxation and quadriparesis. A multinational, multidisciplinary panel of 10 skeletal dysplasia or Morquio A syndrome specialists convened in Miami, FL on December 7 and 8, 2012 to develop consensus recommendations for early identification and effective management of spinal cord compression, for anesthesia and surgical best practices, and for effectual cardiac and respiratory management in patients with Morquio A syndrome. The target audience for these recommendations includes any physician who may encounter a patient with Morquio A syndrome, however doctors who do not have access to the full spectrum of specialists and resources needed to support patients with Morquio A syndrome should attempt to refer patients to a center that does. Physicians who manage Morquio A syndrome or comorbid conditions within specialty centers should review these expert panel recommendations and fully understand the implications of spinal cord instability for their own practices.
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Affiliation(s)
- Joel Charrow
- Division of Genetics, Birth Defects and Metabolism, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Tord D Alden
- Division of Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | | | - Geoffrey P Frawley
- Department of Paediatric Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Australia.
| | - Christian J Hendriksz
- Department of Adult Inherited Metabolic Disorders, University of Manchester, Salford Royal NHS Foundation Trust, Clinical Science Building B105, Stott lane, Salford M6 8HD, England, UK.
| | - Bianca Link
- Division of Metabolism, Connective Tissue Unit, University Children's Hospital Zurich, Steinwiessstrasse 75, CH-8032 Zurich, Switzerland.
| | - William G Mackenzie
- Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803-3607, USA; Jefferson Medical College, 1600 Rockland Road, Wilmington, DE 19803-3607, USA.
| | - Renzo Manara
- Neuroradiology, University of Salerno, Via S. Allende 1, 84081, Salerno, Italy.
| | - Amaka C Offiah
- Academic Unit of Child Health, Room C4, Stephenson Wing, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, England, UK.
| | - Martha L Solano
- Department of Neuropediatrics, Fundación Cardioinfantil, Universidad del Rosario, 163rd Street A No. 13B-60, Bogotá, Colombia.
| | - Mary Theroux
- Department of Anesthesiology & Critical Care, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803-3607, USA.
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Lu HL, Ying PH, Li WJ. Effects of propofol with midazolam verus lidocaine during gastroscopy in elderly patients. Shijie Huaren Xiaohua Zazhi 2014; 22:1201-1206. [DOI: 10.11569/wcjd.v22.i9.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effects of propofol with midazolam versus lidocaine during endoscopy in elderly patients.
METHODS: Ninety-seven ASA-Ⅱ class patients were used as an experimental group. They were treated with propofol with midazolam for painless gastroscopy between July 2008 and July 2013 at our hospital. Eighty-two ASA-Ⅱ level patients who used traditional lidocaine gel pulp in painless gastroscopy were used as a control group. Age, weight, baseline blood pressure between two groups had no significant differences (P > 0.05 for all). Professional medical personnel recorded the changes in blood pressure, heart rate, oxygen saturation and adverse reactions in the examination process.
RESULTS: After the painless gastroscopy procedure, blood pressure and heart rate in the experimental group were significantly lower than those in the control group (blood pressure: 90.2 mmHg ± 2.5 mmHg vs 131.2 mmHg ± 3.4 mmHg; heart rate: 70.2 ± 1.5 vs 85.0 ± 6.4, P < 0.05). During the examination process, blood pressure and heart rate dropped initially and then rose to a stable level in the experimental group, while in the control group, blood pressure and heart rate initially increased and then decreased to a stable level. The differences were statistically significant (P < 0.05) within the two groups. Oxygen saturation between groups and within groups showed no significant differences (P > 0.05). Compared with the control group, adverse reactions in the experimental group were significantly reduced (χ2 = 12.991, 142.482, 55.838, 179.000, P < 0.05). Times to wake up from anesthesia and drug elimination were relatively short in the experimental group (1.51 s ± 0.17 s, 8.21 s ± 2.32 s).
CONCLUSION: Propofol combined with midazolam in painless gastroscopy can effectively reduce the risk of cardiovascular diseases in patients and is associated with shorter times to wake up and drug elimination.
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