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Oliva AM, Montejano J, Simmons CG, Vogel SA, Isaza CF, Clavijo CF. New frontiers in intraoperative neurophysiologic monitoring: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:388. [PMID: 37970609 PMCID: PMC10632568 DOI: 10.21037/atm-22-4586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 06/25/2023] [Indexed: 11/17/2023]
Abstract
Background and Objective Neurological insults during surgery arise from anatomic and/or physiologic perturbations. Intraoperative neurophysiologic monitoring (IONM) fills a critical role of ensuring that any neurological insults during certain surgical procedures are caught in real-time to prevent patient harm. IONM provides immediate feedback to the surgeon and anesthesiologist about the need for an intervention to prevent a neurologic deficit postoperatively. As important as it seems to have IONM available to any patient having surgery where a neurological injury is possible, the truth is that IONM is unavailable to large swaths of people around the world. This review is intended to bring attention to all of the ways IONM is critically important for a variety of surgeries and highlight the barriers preventing most patients around the world from benefiting from the technology. Expansion of IONM to benefit patients from all over the world is the new frontier. Methods We searched all English language original papers and reviews using Embase and MEDLINE/PubMed databases published from 1995 to 2022. Different combinations of the following search terms were used: intraoperative neuromonitoring, neurosurgery, low-income countries, cost, safety, and efficacy. Key Content and Findings We describe common IONM modalities used during surgery as well as explore barriers to implementation of IONM in resource-limited regions. Additionally, we describe ongoing efforts to establish IONM capabilities in new locations around the world. Conclusions In this paper, we performed a review of the literature on IONM with an emphasis on the basic understanding of clinical applications and the barriers for expansion into resource-limited settings. Finally, we provide our interpretation of "new frontiers" in IONM quite literally facilitating access to the tools and education so a hospital in Sub-Saharan Africa can incorporate IONM for their high-risk surgeries.
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Affiliation(s)
- Anthony M. Oliva
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Julio Montejano
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Colby G. Simmons
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Scott A. Vogel
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carlos F. Isaza
- Departments of Surgery and Anesthesiology, University of Caldas, Manizales, Colombia
| | - Claudia F. Clavijo
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
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Amick M, Ottesen TD, O'Marr J, Frenkel MY, Callahan B, Grauer JN. Effects of anode position on pedicle screw testing during lumbosacral spinal fusion surgery. Spine J 2022; 22:2000-2005. [PMID: 35843532 DOI: 10.1016/j.spinee.2022.07.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/11/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
OF BACKGROUND DATA Pedicle screws are commonly placed with lumbar/lumbosacral fusions. Triggered electromyography (tEMG), which employs the application of electrical current between the screw and a complementary anode to determine thresholds of conduction, may be utilized to confirm the safe placement of such implants. While previous research has established clinical thresholds associated with safe screw placement, there is variability in clinical practice of anode placement which could lead to unreliable measurements. PURPOSE To determine the variance in pedicle screw stimulation thresholds when using four unique anode locations (ipsilateral/contralateral and paraspinal/gluteal relative to tested pedicle screws). STUDY DESIGN Prospective cohort study. Tertiary medical center. PATIENT SAMPLE Twenty patients undergoing lumbar/lumbosacral fusion with pedicle screws using tEMG OUTCOME MEASURES: tEMG stimulation return values are used to assess varied anode locations and reproducibility based on anode placement. METHODS Measurements were assessed across node placement in ipsilateral/contralateral and paraspinal/gluteal locations relative to the screw being assessed. R2 coefficients of correlation were determined, and variances were compared with F-tests. RESULTS A total of 94 lumbosacral pedicle screws from 20 patients were assessed. Repeatability was verified using two stimulations at each location for a subset of the screws with an R2 of 0.96. Comparisons between the four anode locations demonstrated R2 values ranging from 0.76 to 0.87. F-tests comparing thresholds between each anode site demonstrated all groups not to be statistically different. CONCLUSION The current study, a first-of-its-kind formal evaluation of anode location for pedicle screw tEMG testing, demonstrated very strong repeatability and strong correlation with different locations of anode placement. These results suggest that there is no need to change the side of the anode for testing of left versus right screws, further supporting that placing an anode electrode into gluteal muscle is sufficient and will avoid a sharp ground needle in the surgical field.
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Affiliation(s)
- Michael Amick
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA; Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA, 02114, USA
| | - Jamieson O'Marr
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Mikhail Y Frenkel
- Nuvasive Clinical Services 10275 Little Patuxent Pkwy Ste 300 Columbia, MD 21044, USA; UConn Main Campus 2131 Hillside Road, Unit 3088 Storrs, CT 06269-3088
| | - Brooke Callahan
- Nuvasive Clinical Services 10275 Little Patuxent Pkwy Ste 300 Columbia, MD 21044, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
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De Vega B, Navarro AR, Gibson A, Kalaskar DM. Accuracy of Pedicle Screw Placement Methods in Pediatrics and Adolescents Spinal Surgery: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:677-688. [PMID: 33733907 PMCID: PMC9109561 DOI: 10.1177/21925682211003552] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE Various methods of pedicle screw (PS) placement in spinal fusion surgery existed, which can be grouped into conventional freehand (FH), modified freehand (MF), and image-guided methods (including fluoroscopy-based navigation (FL), computed tomography-based navigation (CT-nav), robot-assisted (RA), and ultrasound-guided (UG)). However, the literature showed mixed findings regarding their accuracy and complications. This review aimed to discover which method of PS placement has the highest accuracy and lowest complication rate in pediatric and adolescent spinal fusion surgery. METHODS A comprehensive search in MEDLINE (PubMed), EMBASE (OVID), CENTRAL, and Web of Science was conducted until May 2020 by 2 independent reviewers, followed by bias assessment with ROB 2 and ROBINS-I tools and quantification with meta-analysis. Overall evidence quality was determined with GRADE tool. RESULTS Four RCTs and 2 quasi-RCTs/CCTs comprising 3,830 PS placed in 291 patients (4-22 years old) were analyzed. The lowest accuracy was found in FH (78.35%) while the highest accuracy was found in MF (95.86%). MF was more accurate than FH (OR 3.34 (95% CI, 2.33-4.79), P < .00 001, I2 = 0%). Three-dimensional printed drill template (as part of MF) was more accurate than FH (OR 3.10 (95% CI, 1.98-4.86), P < .00 001, I2 = 14%). Overall, complications occurred in 5.84% of the patients with 0.34% revision rate. Complication events in MF was lower compared to FH (OR 0.47 (95% CI, 0.10-2.15), P = .33, I2 = 0%). CONCLUSIONS Meta-analysis shows that MF is more accurate than FH in pediatric and adolescent requiring PS placement for spinal fusion surgery.
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Affiliation(s)
- Brigita De Vega
- UCL Institute of Orthopaedic &
Musculoskeletal Science, Division of Surgery & Interventional Science,
University College London, Royal National Orthopaedic Hospital, Stanmore,
London, United Kingdom
| | - Aida Ribera Navarro
- UCL Institute of Orthopaedic &
Musculoskeletal Science, Division of Surgery & Interventional Science,
University College London, Royal National Orthopaedic Hospital, Stanmore,
London, United Kingdom
| | - Alexander Gibson
- Royal National Orthopaedic Hospital
NHS Trust, Spinal Surgery Unit, Stanmore, London, United Kingdom
| | - Deepak M. Kalaskar
- UCL Institute of Orthopaedic &
Musculoskeletal Science, Division of Surgery & Interventional Science,
University College London, Royal National Orthopaedic Hospital, Stanmore,
London, United Kingdom,Royal National Orthopaedic Hospital
NHS Trust, Spinal Surgery Unit, Stanmore, London, United Kingdom,Deepak M. Kalaskar, UCL Institute of
Orthopaedic & Musculoskeletal Science, Division of Surgery &
Interventional Science, University College London, Royal National Orthopaedic
Hospital, Stanmore, London, United Kingdom; Royal National Orthopaedic Hospital
NHS Trust, Spinal Surgery Unit, Stanmore, London, United Kingdom.
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Pearson HB, Dobbs CJ, Grantham E, Niebur GL, Chappuis JL, Boerckel JD. Intraoperative biomechanics of lumbar pedicle screw loosening following successful arthrodesis. J Orthop Res 2017; 35:2673-2681. [PMID: 28387967 DOI: 10.1002/jor.23575] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/28/2017] [Indexed: 02/04/2023]
Abstract
UNLABELLED Pedicle screw loosening has been implicated in recurrent back pain after lumbar spinal fusion, but the degree of loosening has not been systematically quantified in patients. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. Here, we quantified pedicle screw loosening by measuring screw insertion and/or removal torque at high statistical power (beta = 0.02) in N = 108 patients who experienced pain recurrence despite successful fusion after posterior instrumented lumbar fusion with anterior lumbar interbody fusion (L2-S1). Between implantation and removal, pedicle screw torque was reduced by 58%, indicating significant loosening over time. Loosening was greater in screws with evoked EMG threshold under 11 mA, indicative of screw misplacement. A theoretical stress analysis revealed increased local stresses at the screw interface in pedicles with decreased difference in pedicle thickness and screw diameter. Loosening was greatest in vertebrae at the extremities of the fused segments, but was significantly lower in segments with one level of fusion than in those with two or more. CLINICAL SIGNIFICANCE These data indicate that pedicle screws can loosen significantly in patients with recurrent back pain and warrant further research into methods to reduce the incidence of screw loosening and to understand the risks and potential benefits of instrumentation removal. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2673-2681, 2017.
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Affiliation(s)
- Hope B Pearson
- Department of Aerospace and Mechanical Engineering, University of Notre Dame, 142 Multidisciplinary Research Building, Notre Dame, Indiana 46557
| | - Christopher J Dobbs
- Spine Center Atlanta, 3161 Howell Mill RoadSuite 400, Atlanta, Georgia 30327
| | - Eric Grantham
- Spine Center Atlanta, 3161 Howell Mill RoadSuite 400, Atlanta, Georgia 30327
| | - Glen L Niebur
- Department of Aerospace and Mechanical Engineering, University of Notre Dame, 142 Multidisciplinary Research Building, Notre Dame, Indiana 46557
| | - James L Chappuis
- Spine Center Atlanta, 3161 Howell Mill RoadSuite 400, Atlanta, Georgia 30327
| | - Joel D Boerckel
- Department of Aerospace and Mechanical Engineering, University of Notre Dame, 142 Multidisciplinary Research Building, Notre Dame, Indiana 46557.,Departments of Orthopaedic Surgery and Bioenegineering, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, Pennsylvania 19104
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Kaliya-Perumal AK, Charng JR, Niu CC, Tsai TT, Lai PL, Chen LH, Chen WJ. Intraoperative electromyographic monitoring to optimize safe lumbar pedicle screw placement - a retrospective analysis. BMC Musculoskelet Disord 2017; 18:229. [PMID: 28558816 PMCID: PMC5450215 DOI: 10.1186/s12891-017-1594-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/22/2017] [Indexed: 12/16/2022] Open
Abstract
Background The foremost concern of a surgeon during pedicle screw fixation is safety. Assistive modalities, especially intraoperative electromyographic monitoring (EMG) can function as an essential tool to recognize screw malposition that compromise neural integrity, so that the screws can be repositioned immediately rather than later. We intend to study the efficacy of intraoperative EMG monitoring to detect potential pedicle breach and evaluate whether reoperation rates were significantly reduced. Methods Retrospectively, patients who underwent posterior stabilization with pedicle screws for various pathologies were analysed and those with screws among L1-S1 levels were shortlisted. They were divided into two groups. Group 1 included patients in whom trigger EMG (t-EMG) was used to confirm appropriate screw placement and Group 2 included those in whom it was not used. Responses to t-EMG and corresponding stimulation thresholds were recorded for Group 1 patients. The sensitivity and specificity of the test was calculated. Reoperation rates due to postoperative neurologic compromise caused by malpositioned screws were compared between both the groups. Results A total of 518 patients had 3112 pedicle screws between L1-S1 levels. Among Group 1 [n = 296; Screws = 1856], 145 screws (7.8%) showed a positive response for t-EMG at stimulation thresholds ranging between 2.6 to 19.8 mA. The sensitivity and specificity of t-EMG to diagnose potential pedicle breach was found to be 93.33% and 92.88% respectively. Only one patient among Group 1 required reoperation. However, among Group 2 [n = 222; screws = 1256], six patients required reoperation. This indicated a significant decrease in the number of malpositioned screws that caused neurological compromise [p = 0.02], leading to subsequent decrease in reoperation rates [p = 0.04] among Group 1 patients. Conclusions Trigger EMG is well efficient in detecting potential pedicle screw breaches that might endanger neural integrity. In combination with palpatory and radiographic assessment, it will certainly aid safe and secure pedicle screw placement. It can also efficiently reduce reoperation rates due to neurologic compromise provoked by a malpositioned screw.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan.,Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Jiun-Ran Charng
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Chi-Chien Niu
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan.
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Wen-Jer Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
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