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Reddy RP, Singh-Varma A, Chang R, Vedire A, Anetakis KM, Balzer JR, Crammond DJ, Shandal V, Lee JY, Shaw JD, Thirumala PD. Transcranial Motor Evoked Potentials as a Predictive Modality for Postoperative Deficit in Cervical Spine Decompression Surgery - A Systematic Review and Meta-Analysis. Global Spine J 2024; 14:1609-1628. [PMID: 38047537 DOI: 10.1177/21925682231219224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVE The purpose of this study was to evaluate whether transcranial motor evoked potential (TcMEP) alarms can predict postoperative neurologic complications in patients undergoing cervical spine decompression surgery. METHODS A meta-analysis of the literature was performed using PubMed, Web of Science, and Embase to retrieve published reports on intraoperative TcMEP monitoring for patients undergoing cervical spine decompression surgery. The sensitivity, specificity, and diagnostic odds ratio (DOR), of overall, reversible, and irreversible TcMEP changes for predicting postoperative neurological deficit were calculated. A subgroup analysis was performed to compare anterior vs posterior approaches. RESULTS Nineteen studies consisting of 4608 patients were analyzed. The overall incidence of postoperative neurological deficits was 2.58% (119/4608). Overall TcMEP changes had a sensitivity of 56%, specificity of 94%, and DOR of 19.26 for predicting deficit. Reversible and irreversible changes had sensitivities of 16% and 49%, specificities of 95% and 98%, and DORs of 3.54 and 71.74, respectively. In anterior procedures, TcMEP changes had a DOR of 17.57, sensitivity of 49%, and specificity of 94%. In posterior procedures, TcMEP changes had a DOR of 21.01, sensitivity of 55%, and specificity of 94%. CONCLUSION TcMEP monitoring has high specificity but low sensitivity for predicting postoperative neurological deficit in cervical spine decompression surgery. Patients with new postoperative neurological deficits were 19 times more likely to have experienced intraoperative TcMEP changes than those without new deficits, with irreversible TcMEP changes indicating a much higher risk of deficit than reversible TcMEP changes.
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Affiliation(s)
- Rajiv P Reddy
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anya Singh-Varma
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Chang
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Abhinav Vedire
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Varun Shandal
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joon Y Lee
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Wilson JP, Vallejo JB, Kumbhare D, Guthikonda B, Hoang S. The Use of Intraoperative Neuromonitoring for Cervical Spine Surgery: Indications, Challenges, and Advances. J Clin Med 2023; 12:4652. [PMID: 37510767 PMCID: PMC10380862 DOI: 10.3390/jcm12144652] [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: 04/11/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Intraoperative neuromonitoring (IONM) has become an indispensable surgical adjunct in cervical spine procedures to minimize surgical complications. Understanding the historical development of IONM, indications for use, associated pitfalls, and recent developments will allow the surgeon to better utilize this important technology. While IONM has shown great promise in procedures for cervical deformity, intradural tumors, or myelopathy, routine use in all cervical spine cases with moderate pathology remains controversial. Pitfalls that need to be addressed include human error, a lack of efficient communication, variable alarm warning criteria, and a non-standardized checklist protocol. As the techniques associated with IONM technology become more robust moving forward, IONM emerges as a crucial solution to updating patient safety protocols.
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Affiliation(s)
- John Preston Wilson
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Javier Brunet Vallejo
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Deepak Kumbhare
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Stanley Hoang
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
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Michaeli A, Appel S, Danto J, Korn A, Schroeder JE. Intraoperative Deterioration of Neurophysiological Potentials of the Spinal Tracts in Cervical Spine Surgery: Correlation With Patient-Related and Procedure-Related Variables. J Clin Neurophysiol 2023; 40:325-330. [PMID: 35089908 DOI: 10.1097/wnp.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To identify characteristics associated with higher incidence of intraoperative deterioration of neurophysiological potentials related to spinal tracts in cervical spine surgeries. METHODS Electrophysiological raw data and neurophysiological case reports of 1,611 patients from multiple medical centers, who underwent cervical spine surgery for decompression and/or fusion, were retrospectively reviewed. Patient-related and procedure-related variables were identified and analyzed for correlation with intraoperative neurophysiological event of the spinal tracts. The neurophysiological events were analyzed for identification of collective characteristics. RESULTS The study cohort presented consistent dominancy of male over female patients (67% vs. 33%). Intraoperative deterioration of spinal tract-derived potentials was noted in 10.5% of the total cases, which was not correlated with gender, age, or indication of the surgery. Higher incidence of neurophysiological events was noted in patients with impaired baseline of motor evoked potentials from the thenar muscle ( P = 0.01) or somatosensory evoked potentials of the posterior tibial nerve ( P = 0.0002). Procedures of circumferential approach or procedures that involved ≥3 spinal levels demonstrated higher incidence of neurophysiological events as well ( P = 0.0003 and 0.001, respectively). CONCLUSIONS Patients with deteriorated neurophysiological baseline and procedures of extensive intervention are at higher risk of intraoperative neurophysiological event in cervical spine surgery. Inclusion of intraoperative neurophysiological monitoring should be encouraged in complicated cases of cervical spine surgeries.
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Affiliation(s)
| | - Shmuel Appel
- Surgical Monitoring Services LTD, Beit Shemesh, Israel
- Department of Neurology, Barzilai Medical Center, Ashkelon, Israel, affiliated with the Joyce and Irving Goldman School of Medicine, Ben Gurion University of the Negev
| | - Joseph Danto
- Surgical Monitoring Services LTD, Beit Shemesh, Israel
| | - Akiva Korn
- Surgical Monitoring Services LTD, Beit Shemesh, Israel
- Departmet of Pediatric Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Josh E Schroeder
- Department of Orthopedics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Intraoperative Monitoring During Neurosurgical Procedures and Patient Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Delgado-López PD, Montalvo-Afonso A, Araus-Galdós E, Isidro-Mesa F, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A. Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:209-218. [PMID: 36084957 DOI: 10.1016/j.neucie.2021.03.002] [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: 01/05/2021] [Accepted: 03/14/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.
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Affiliation(s)
| | | | - Elena Araus-Galdós
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
| | - Francisco Isidro-Mesa
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
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Luc F, Mainard N, Payen M, Bernardini I, El-Ayoubi M, Friberg A, Piccoli ND, Simon AL. Study of the latency of transcranial motor evoked potentials in spinal cord monitoring during surgery for adolescent idiopathic scoliosis. Neurophysiol Clin 2022; 52:299-311. [PMID: 35777989 DOI: 10.1016/j.neucli.2022.06.001] [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: 11/22/2021] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE An increase in the latency of a motor evoked potential might be as significant as a decrease in amplitude to predict a significant and clinically symptomatic neurological injury in spinal surgery for adolescent idiopathic scoliosis. The aim of the study was to investigate the impact of monitoring of latency of motor evoked potentials during spinal surgery for adolescent idiopathic scoliosis by describing intraoperative data. METHODS Preoperative recordings of 50 patients undergoing posterior spinal fusion for idiopathic scoliosis were studied. Latencies of appearance of the motor evoked potential curves on the right and left side were recorded for each group of muscles at several key moments during the procedure (basal, before the first implant, before and after corrective maneuvers). RESULTS Mean latencies were approximately the same in each muscle group on the right and the left side, before and after correction. There was no significant increase in latency during surgery. Overall results showed that the measured latency did not differ significantly between the two age groups (p=0.07). Negative correlation between height and the means of latencies was recorded in the abductor pollicis brevis and abductor digiti minimi (r=0.4; p=0.009), rectus femoris (r=0.4; p=0.01), tibialis anterior (r=0.4; p=0.007), and abductor hallucis (r=0.5; p=0.0004). No significant correlation was found between age and intraoperative parameters. CONCLUSION Intraoperative latency could be a reliable intraoperative monitoring criteria with low variability, that might be used to predict postoperative motor deficits in surgery for adolescent idiopathic scoliosis.
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Affiliation(s)
- François Luc
- Department of Pediatric Surgery, Rouen University Hospital, France.
| | - Nicolas Mainard
- Department of Pediatric Surgery, Lille University Hospital, France
| | - Mathilde Payen
- Department of Pediatric Surgery, Rouen University Hospital, France
| | | | | | - Andreas Friberg
- Department of Pediatric Surgery, Rouen University Hospital, France
| | | | - Anne-Laure Simon
- Department of Pediatric Surgery, Paris Diderot University, France
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Agarwal N, Shabani S, Huang J, Ben-Natan AR, Mummaneni PV. Intraoperative Monitoring for Spinal Surgery. Neurol Clin 2022; 40:269-281. [DOI: 10.1016/j.ncl.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Effect of reversal of residual neuromuscular blockade on the amplitude of motor evoked potentials: a randomized controlled crossover study comparing sugammadex and placebo. Neurol Sci 2021; 43:615-623. [PMID: 34041634 DOI: 10.1007/s10072-021-05318-8] [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: 02/03/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To compare the amplitude changes in motor evoked potentials (MEP) with reversal of residual neuromuscular blockade using sugammadex or placebo in patients with cervical myelopathy. METHODS In this prospective randomized double-blind, placebo-controlled crossover trial, 38 patients with cervical myelopathy undergoing posterior cervical decompression and fusion were randomized to either sugammadex (2mg/kg) or placebo. The primary outcome measure was the increase in amplitude of the MEP in the first dorsal interossei (FDI) muscle at 3 min. Mann-Whitney U test was used to analyze the primary outcome measure. RESULTS There was a significant increase in the amplitude of MEP at 3 min with sugammadex when compared to placebo group. The median (IQR) increase in MEP amplitude (μV) at 3 min from the left FDI in sugammadex and placebo group was 652.9 (142:1650) and 20.6 (-183.5:297.5) (p <0.001), respectively. Corresponding values from right FDI were 2153.4 (1400:4536.8) and 55(-65.2:480.8) (p=<0.001). CONCLUSION Our study showed that there was a 200% increase in the MEP amplitude in the first dorsal interosseous muscle at 3 min following reversal of residual neuromuscular blockade with sugammadex. By ensuring that maximal MEP amplitude is recorded at baseline, early commencement of neuromonitoring can be achieved. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION The study was registered at http://clinicaltrials.gov , ID NCT03087513, Feb 5th 2018.
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Delgado-López PD, Montalvo-Afonso A, Araus-Galdós E, Isidro-Mesa F, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A. Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00031-2. [PMID: 33875378 DOI: 10.1016/j.neucir.2021.03.001] [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: 01/05/2021] [Revised: 02/10/2021] [Accepted: 03/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.
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Affiliation(s)
| | | | - Elena Araus-Galdós
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
| | - Francisco Isidro-Mesa
- Servicio de Neurofisiología Clínica, Hospital Universitario de Burgos, Burgos, Spain
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Reddy RP, Chang R, Rosario BP, Sudadi S, Anetakis KM, Balzer JR, Crammond DJ, Shaw JD, Thirumala PD. What is the predictive value of intraoperative somatosensory evoked potential monitoring for postoperative neurological deficit in cervical spine surgery?-a meta-analysis. Spine J 2021; 21:555-570. [PMID: 33460808 DOI: 10.1016/j.spinee.2021.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/13/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical decompression and fusion surgery remains a mainstay of treatment for a variety of cervical pathologies. Potential intraoperative injury to the spinal cord and nerve roots poses nontrivial risk for consequent postoperative neurologic deficits. Although neuromonitoring with intraoperative somatosensory evoked potentials (SSEPs) is often used in cervical spine surgery, its therapeutic value remains controversial. PURPOSE The purpose of the present study was to evaluate whether significant SSEP changes can predict postoperative neurologic complications in cervical spine surgery. A subgroup analysis was performed to compare the predictive power of SSEP changes in both anterior and posterior approaches. STUDY DESIGN The present study was a meta-analysis of the literature from PubMed, Web of Science, and Embase to identify prospective/retrospective studies with outcomes of patients who underwent cervical spine surgeries with intraoperative SSEP monitoring. PATIENT SAMPLE The total cohort consisted of 7,747 patients who underwent cervical spine surgery with intraoperative SSEP monitoring. METHODS Inclusion criteria for study selection were as follows: (1) prospective or retrospective cohort studies, (2) studies conducted in patients undergoing elective cervical spine surgery not due to aneurysm, tumor, or trauma with intraoperative SSEP monitoring, (3) studies that reported postoperative neurologic outcomes, (4) studies conducted with a sample size ≥20 patients, (5) studies with only adult patients ≥18 years of age, (6) studies published in English, (7) studies inclusive of an abstract. OUTCOME MEASURES The sensitivity, specificity, diagnostic odds ratio (DOR), and likelihood ratios of overall SSEP changes, reversible SSEP changes, irreversible SSEP changes, and SSEP loss for predicting postoperative neurological deficit were calculated. RESULTS The total rate of postoperative neurological deficits was 2.50% (194/7,747) and the total rate of SSEP changes was 7.36% (570/7,747). The incidence of postoperative neurological deficit in patients with intraoperative SSEP changes was 16.49% (94/570) while only 1.39% (100/7,177) in patients without. All significant intraoperative SSEP changes had a sensitivity of 46.0% and specificity of 96.7% with a DOR of 27.32. Reversible and irreversible SSEP changes had sensitivities of 17.7% and 37.1% and specificities of 97.5% and 99.5%, respectively. The DORs for reversible and irreversible SSEP changes were 9.01 and 167.90, respectively. SSEP loss had a DOR of 51.39, sensitivity of 17.3% and specificity 99.6%. In anterior procedures, SSEP changes had a DOR of 9.60, sensitivity of 34.2%, and specificity of 94.7%. In posterior procedures, SSEP changes had a DOR of 13.27, sensitivity of 42.6%, and specificity of 94.0%. CONCLUSIONS SSEP monitoring is highly specific but weakly sensitive for postoperative neurological deficit following cervical spine surgery. The analysis found that patients with new postoperative neurological deficits were nearly 27 times more likely to have had significant intraoperative SSEP change. Loss of SSEP signals and irreversible SSEP changes seem to indicate a much higher risk of injury than reversible SSEP changes.
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Affiliation(s)
- Rajiv P Reddy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Chang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian P Rosario
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shreya Sudadi
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D Shaw
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Shim HK, Lee JM, Kim DH, Nam KH, Choi BK, Han IH. Successful Motor Evoked Potential Monitoring in Cervical Myelopathy : Related Factors and the Effect of Increased Stimulation Intensity. J Korean Neurosurg Soc 2020; 64:78-87. [PMID: 33355842 PMCID: PMC7819792 DOI: 10.3340/jkns.2020.0111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Intraoperative neurophysiological monitoring (IONM) has been widely used during spine surgery to reduce or prevent neurologic deficits, however, its application to the surgical management for cervical myelopathy remains controversial. This study aimed to assess the success rate of IONM in patients with cervical myelopathy and to investigate the factors associated with successful baseline monitoring and the effect of increasing the stimulation intensity by focusing on motor evoked potentials (MEPs).
Methods The data of 88 patients who underwent surgery for cervical myelopathy with IONM between January 2016 and June 2018 were retrospectively reviewed. The success rate of baseline MEP monitoring at the initial stimulation of 400 V was investigated. In unmonitorable cases, the stimulation intensity was increased to 999 V, and the success rate final MEP monitoring was reinvestigated. In addition, factors related to the success rate of baseline MEP monitoring were investigated using independent t-test, Wilcoxon rank-sum test, chi-squared test, and Fisher’s exact probability test for statistical analysis. The factors included age, sex, body mass index, diabetes mellitus, smoking history, symptom duration, Torg-Pavlov ratio, space available for the cord (SAC), cord compression ratio (CCR), intramedullary increased signal intensity (SI) on magnetic resonance imaging, SI length, SI ratio, the Medical Research Council (MRC) grade, the preoperative modified Nurick grade and Japanese Orthopedic Association (JOA) score.
Results The overall success rate for reliable MEP response was 52.3% after increasing the stimulation intensity. No complications were observed to be associated with increased intensity. The factors related to the success rate of final MEP monitoring were found to be SAC (p<0.001), CCR (p<0.001), MRC grade (p<0.001), preoperative modified Nurick grade (p<0.001), and JOA score (p<0.001). The cut-off score for successful MEP monitoring was 5.67 mm for SAC, 47.33% for the CCR, 3 points for MRC grade, 2 points for the modified Nurick grade, and 12 points for the JOA score.
Conclusion Increasing the stimulation intensity could significantly improve the success rate of baseline MEP monitoring for unmonitorable cases at the initial stimulation in cervical myelopathy. In particular, the SAC, CCR, MRC grade, preoperative Nurick grade and JOA score may be considered as the more important related factors associated with the success rate of MEP monitoring. Therefore, the degree of preoperative neurological functional deficits and the presence of spinal cord compression on imaging could be used as new detailed criteria for the application of IONM in patients with cervical myelopathy.
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Affiliation(s)
- Hyok Ki Shim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Meen Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Hwan Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Kwan Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - In Ho Han
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Michaeli A, Appel S, Korn A, Danto J, Ashkenazi E. Intraoperative monitoring of corticospinal tracts in anterior cervical decompression and fusion surgery: Excitability differentials of lower extremity muscles. Clin Neurophysiol Pract 2020; 5:59-63. [PMID: 32258833 PMCID: PMC7110302 DOI: 10.1016/j.cnp.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/28/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
Lower extremity (LE) muscles demonstrate intraoperative excitability differences. Abductor hallucis is a suitable LE muscle for monitoring the corticospinal tract (CST). CST monitoring with two LE muscles includes advantages but also practical limitations.
Objective This study examines and compares excitability characteristics of tibialis anterior (TA) and abductor hallucis (AH) transcranial motor evoked potentials (tcMEP) during anterior cervical decompression and fusion (ACDF) surgery. Methods Electrophysiological and clinical data of 89 patients who underwent ACDF procedure were retrospectively reviewed. TcMEP data of TA and AH muscles from 178 limbs were analyzed for availability, robustness and stability during the procedure. Results TA tcMEP was available at 83% whereas AH tcMEP was available at 99% of the monitored lower limbs at preposition baseline. Availability of both TA and AH tcMEP was demonstrated in 147/178 limbs. The baseline amplitude of AH tcMEP was significantly greater than that of TA tcMEP recorded from the same limb (744.6 ± 54.0 and 326.9 ± 33.3 µV, respectively). Simultaneous deterioration of TA and AH tcMEP data was demonstrated in 10/147 limbs. Deterioration of either TA or AH tcMEP data accompanied by unchanged tcMEP data from the other lower limb muscle was noted in 32/147 compared to 1/147 limbs, respectively. The deteriorated TA and AH tcMEP data returned to baseline before closing at incidence of 17% compared to 46%, respectively. No new lower extremity (LE) neurological deficit was presented postoperatively in any patient. Conclusions AH tcMEP is a more reliable candidate than TA tcMEP for intraoperative LE monitoring in ACDF procedure. Significance The excitability differentials in LE tcMEP in ACDF is a variable that need to be considered while interpreting intraoperative neurophysiological data.
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Affiliation(s)
| | - Shmuel Appel
- Surgical Monitoring Services LTD, Beit Shemesh, Israel.,Department of Neurology, Barzilai Medical Center, Ashkelon, Israel, Affiliated with the Joyce & Irving Goldman School of Medicine, Ben Gurion University of the Negev, Israel
| | - Akiva Korn
- Surgical Monitoring Services LTD, Beit Shemesh, Israel.,Departmet of Pediatric Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated with the Sackler School of Medicine of Tel Aviv University, Israel
| | - Joseph Danto
- Surgical Monitoring Services LTD, Beit Shemesh, Israel
| | - Ely Ashkenazi
- Israel Spine Center, Assuta Medical Center, Tel Aviv, Israel
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Neurophysiological monitoring during neurosurgery: anesthetic considerations based on outcome evidence. Curr Opin Anaesthesiol 2019; 32:580-584. [PMID: 31145200 DOI: 10.1097/aco.0000000000000753] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the recent outcome studies that investigated intraoperative neurophysiological monitoring (IONM) during spine, neurovascular and brain tumor surgery. RECENT FINDINGS Several recent studies have focused on identifying which types of neurosurgical procedures might benefit most from IONM use. Despite conflicting literature regarding its efficacy in improving neurological outcomes, many experts have advocated for the use of IONM in neurosurgery. Several themes have emerged from the recent literature: the entire perioperative team must always work together to ensure adequate communication and intervention; systems and checklists, in which each member of the perioperative team has a clearly defined role, can be useful in the event of a sudden intraoperative changes in electrophysiological signals; regardless of the IONM modality used, any sudden change in electrophysiological signal should prompt an immediate and appropriate intervention; a multimodal IONM approach is often, but not always, advantageous over a single IONM approach. SUMMARY For neurosurgical procedures that can be complicated by neural injury, the use of IONM should be considered according to specific patient and surgical factors. Future studies should focus on improving IONM technology and optimizing sensitivity and specificity for detecting any impending neural damage.
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