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Gorijala VK, Reddy RP, Anetakis KM, Balzer J, Crammond DJ, Shandal V, Shaw JD, Christie MR, Thirumala PD. Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery. 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 2024; 33:1644-1656. [PMID: 38285275 DOI: 10.1007/s00586-023-08063-y] [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: 09/24/2023] [Revised: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). METHODS Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated. RESULTS Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively. CONCLUSION Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery. LEVEL OF EVIDENCE Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Vamsi Krishna Gorijala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Rajiv P Reddy
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeffrey Balzer
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Donald J Crammond
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Varun Shandal
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michelle R Christie
- Department of Neurology and Rehabilitation Medicine, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA.
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Wang S, Lin X, Guo L, He L, Liu Y, Zhao Y, Zhang J. Validity of evoked potential as biomarker for predicting early neural function changes after thoracic spinal decompression surgery in patients with neurological deficits. 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 2024; 33:924-931. [PMID: 38008871 DOI: 10.1007/s00586-023-07893-0] [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: 12/21/2022] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE To evaluate the validity of intraoperative evoked potential (EP) including motor evoked potential (MEP) and somatosensory evoked potentials (SEP) as a biomarker for predicting neural function changes after thoracic spinal decompression (TSD) surgery. METHOD A consecutive series of 336 TSD surgeries were reviewed between 2010 and 2021 from four spine center. All patients with TSD were divided into 3 groups according to different intraoperative EP results: group 1, EP alerts; group 2, no obvious EP deterioration; group 3, EP improvement compared with baselines. The lower limb Japanese Orthopedic Association (JOA) scores (as well as early and long-term JOA recovery rate) were utilized to quantitatively assess pre- and postoperative neural function change. RESULTS Among the 3 subgroups according to the different EP changes, the early JOA recovery rate (RR%) in the EP improvement group was significantly better than the other two groups (51.3 ± 58.6* vs. 27.5 ± 31.2 and 33.3 ± 43.1; p < 0.01) after 3-month follow-up. The mean MEP and SEP amplitude were from 116 ± 57 µV to 347 ± 71 µV (p < 0.01) and from 1.86 ± 0.24 µV to 2.65 ± 0.29 µV (p < 0.01) between spinal cord pre-decompression and post-decompression. Moreover, multivariate logistic regression analysis revealed that risk factors of EP improvement were duration of symptom (p < 0.001, OR 10.9) and Preop. neurologic deficit degree (p = 0.013, OR 7.46). CONCLUSION The intraoperative EP can predict postoperative neural function changes as a biomarker during TSD. Patient with EP improvement probably has better prognosis for early neural function recovery. The duration of symptom and preoperative neurologic deficit degree may be related to intraoperative EP improvement.
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Affiliation(s)
- Shujie Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Xiangquan Lin
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, 350007, Fujian, People's Republic of China
| | - Lanjun Guo
- Neurophysiological Monitoring Service, University of California, San Francisco, CA, USA
| | - Li He
- Department of Orthopedics, Yinchuan Guolong Hospital, Yinchuan, 750001, People's Republic of China
| | - Yong Liu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Yu Zhao
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Melachuri SR, Stopera C, Melachuri MK, Anetakis K, Crammond DJ, Castellano JF, Balzer JR, Thirumala PD. The efficacy of somatosensory evoked potentials in evaluating new neurological deficits after spinal thoracic fusion and decompression. J Neurosurg Spine 2020; 33:35-40. [PMID: 32114528 DOI: 10.3171/2019.12.spine191157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior thoracic fusion (PTF) is used as a surgical treatment for a wide range of pathologies. The monitoring of somatosensory evoked potentials (SSEPs) is used to detect and prevent injury during many neurological surgeries. The authors conducted a study to evaluate the efficacy of SSEPs in predicting perioperative lower-extremity (LE) neurological deficits during spinal thoracic fusion surgery. METHODS The authors included patients who underwent PTF with SSEP monitoring performed throughout the entire surgery from 2010 to 2015 at the University of Pittsburgh Medical Center (UPMC). The sensitivity, specificity, odds ratio, and receiver operating characteristic curve were calculated to evaluate the diagnostic accuracy of SSEP changes in predicting postoperative deficits. Univariate analysis was completed to determine the impact of age exceeding 65 years, sex, obesity, abnormal baseline testing, surgery type, and neurological deficits on the development of intraoperative changes. RESULTS From 2010 to 2015, 771 eligible patients underwent SSEP monitoring during PTF at UPMC. Univariate and linear regression analyses showed that LE SSEP changes significantly predicted LE neurological deficits. Significant changes in LE SSEPs had a sensitivity and specificity of 19% and 96%, respectively, in predicting LE neurological deficits. The diagnostic odds ratio for patients with new LE neurological deficits who had significant changes in LE SSEPs was 5.86 (95% CI 2.74-12.5). However, the results showed that a loss of LE waveforms had a poor predictive value for perioperative LE deficits (diagnostic OR 1.58 [95% CI 0.19-12.83]). CONCLUSIONS Patients with new postoperative LE neurological deficits are 5.9 times more likely to have significant changes in LE SSEPs during PTF. Surgeon awareness of an LE SSEP loss may alter surgical strategy and positively impact rates of postoperative LE neurological deficit status. The relatively poor sensitivity of LE SSEP monitoring may indicate a need for multimodal neurophysiological monitoring, including motor evoked potentials, in thoracic fusion surgery.
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Affiliation(s)
- Samyuktha R Melachuri
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Carolyn Stopera
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Manasa K Melachuri
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Katherine Anetakis
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - James F Castellano
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Jeffrey R Balzer
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
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5
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Cui H, Li H, Li G, Kang C, Yao X, Feng S, Hu Y. Utility of Trial-to-Trial Latency Variability of Somatosensory Evoked Potentials for Diagnosis of Spinal Cord Demyelination. J Neurotrauma 2019; 36:3356-3362. [PMID: 31030618 DOI: 10.1089/neu.2018.6293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hongyan Cui
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hanlei Li
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Guangsheng Li
- Spinal division, Department of Orthopaedics, Affiliated Hospital of Guangdong Medical University, Guangdong, China
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China
| | - Cheng Kang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China
| | - Xue Yao
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, China
| | - Shiqing Feng
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, China
| | - Yong Hu
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Spinal division, Department of Orthopaedics, Affiliated Hospital of Guangdong Medical University, Guangdong, China
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China
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Kashkoush AI, Nguyen C, Balzer J, Habeych M, Crammond DJ, Thirumala PD. Diagnostic accuracy of somatosensory evoked potentials during intracranial aneurysm clipping for perioperative stroke. J Clin Monit Comput 2019; 34:811-819. [PMID: 31399827 DOI: 10.1007/s10877-019-00369-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/29/2019] [Indexed: 11/24/2022]
Abstract
Somatosensory evoked potentials (SSEPs) are utilized during aneurysm clipping to detect intraoperative ischemia. We assess the diagnostic accuracy of SSEPs in predicting perioperative stroke during aneurysm clipping. A retrospective review was conducted of 429 consecutive patients who underwent surgical clipping for ruptured and unruptured cerebral aneurysms with intraoperative SSEP monitoring from 2006 to 2013. The relationship between perioperative stroke and SSEP changes was analyzed by calculating the sensitivity, specificity, and area under a Receiving Operating Characteristic curve. Sensitivity and specificity were 42% and 90%, respectively. Area under the curve was 0.66 (95% confidence interval, 0.53-0.79). Reclassification of reversible temporary clip changes to correct for paradoxical classification of SSEP false positives raised the sensitivity from 42 to 65% (p = 0.041, Chi squared test). EEG (electroencephalography) changes increased the specificity (98% vs. 90%, p < 0.001, McNemar's test), but not sensitivity (48% vs. 42%, p = 0.621, McNemar's test) of SSEPs for perioperative stroke. A stepwise logistic regression model selected SSEP amplitude loss (p = 0.006, OR = 3.7 [95% CI 1.5-9.2]) and the SSEP change duration (p = 0.034, OR = 1.8 [95% CI 1.1-3.1]) as independent predictors of perioperative stroke. SSEP changes induced by temporary clipping were highly reversible compared to other SSEP changes (94% vs. 60%, p = 0.003, Fisher exact test), and typically responded to clip removal or readjustment. SSEP changes have high specificity and modest sensitivity for perioperative stroke. Stroke risk is a function of both the magnitude of SSEP amplitude loss and the duration of its loss. Given the modest sensitivity, patients may benefit from multimodal monitoring including motor-evoked potentials during cerebral aneurysm surgery.
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Affiliation(s)
- Ahmed I Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - Miguel Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA.
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Melachuri SR, Kaur J, Melachuri MK, Ninaci D, Crammond DJ, Balzer JR, Thirumala PD. The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1057 lumbar interbody fusions. J Clin Neurosci 2018; 61:78-83. [PMID: 30528129 DOI: 10.1016/j.jocn.2018.10.140] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Lumbar interbody spinal fusion (LIF) surgeries are performed to treat or prevent back pain in patients with degenerated intervertebral discs and a variety of spinal diseases. However, post-operative neurological complications may ensue. Intraoperative monitoring techniques have been used to predict and potentially reduce the risk of complications. METHODS This study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict post-operative neurological deficits after LIF. All patients underwent LIF at UPMC from 2010 to 2012. One thousand fifty-seven patients had pre-operative baseline and continuous intraoperative SSEP monitoring. Statistical analysis was completed using SPSS version 22. No relevant disclosure. RESULTS Patient outcomes were not significantly affected by age over 65, gender, obesity, and abnormal baselines. Lower extremity (LE) significant changes in SSEPs and LE loss of responses resulted in a sensitivity/specificity of 0.03/0.99 and 0.03/0.99; they had an AUC of 0.54/0.73 with a 95% confidence interval (CI) of [0.34, 0.74]/[0.29, 1.00]. CONCLUSIONS Significant SSEP changes during LIF are a very specific but poorly sensitive indicator of perioperative neurological deficits. The odds ratio for LE loss of responses was 29.14 with a 95% CI of 1.79-475.5, so LE SSEP loss of responses can serve as a biomarker of perioperative neurological deficits after LIF.
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Affiliation(s)
| | - Jaspreet Kaur
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manasa K Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Ninaci
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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Risk factors for positioning-related somatosensory evoked potential changes in 3946 spinal surgeries. J Clin Monit Comput 2018; 33:333-339. [PMID: 29855850 DOI: 10.1007/s10877-018-0148-x] [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: 10/06/2017] [Accepted: 04/25/2018] [Indexed: 10/14/2022]
Abstract
The goal of this study was to evaluate the risk factors associated with positioning-related SSEP changes (PRSC). The study investigated the association between 18 plausible risk factors and the occurrence of intraoperative PRSC. Risk factors investigated included demographic variables, comorbidities, and procedure related variables. All patients were treated by the University of Pittsburgh Medical Center from 2010 to 2012. We used univariate and multivariate statistical methods. 69 out of the 3946 (1.75%) spinal surgeries resulted in PRSC changes. The risk of PRSC was increased for women (p < 0.001), patients older than 65 years of age (p = 0.01), higher BMI (p < 0.001) patients, smokers (p < 0.001), and patients with hypertension (p < 0.001). No associations were found between PRSC and age greater than 80 years, diabetes mellitus, cardiovascular disease, and peripheral vascular disease. Three surgical situations were associated with PRSC including abnormal baselines (p < 0.001), patients in the "superman" position (p < 0.001), and patients in surgical procedures that extended over 200 min (p = 0.03). Patients with higher BMIs and who are undergoing spinal surgery longer than 200 min, with abnormal baselines, must be positioned with meticulous attention. Gender, hypertension, and smoking were also found to be risk factors from their odds ratios.
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Melachuri SR, Kaur J, Melachuri MK, Crammond DJ, Balzer JR, Thirumala PD. The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1036 posterior spinal fusions. Neurol Res 2017; 39:1073-1079. [DOI: 10.1080/01616412.2017.1378413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Samyuktha R. Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jaspreet Kaur
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manasa K. Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J. Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R. Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D. Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Clinical Neurophysiology, Department of Neurological Surgery, UPMC Presbyterian, Pittsburgh, PA, USA
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Diagnostic Accuracy of Somatosensory Evoked Potentials in Evaluating New Neurological Deficits After Posterior Cervical Fusions. Spine (Phila Pa 1976) 2017; 42:490-496. [PMID: 27557451 DOI: 10.1097/brs.0000000000001882] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict postoperative neurological deficits after posterior cervical fusions (PCF). Eight hundred forty six eligible patients underwent PCF at the University of Pittsburgh Medical Center (UPMC), from 2010 to 2012. OBJECTIVE To assess the specificity and sensitivity of intraoperative monitoring in predicting postoperative neurological deficits during PCF. SUMMARY OF BACKGROUND DATA We calculated the predictive value, including sensitivity and specificity, of changes in SSEPs to identify neurological deficits postoperatively. We used a receiver operating characteristic (ROC) curve with SSEP categories as cutoff values to further evaluate the diagnostic accuracy of change in SSEPs and postoperative neurological deficit. METHODS All patients had preposition baselines and continuous SSEP monitoring throughout the surgery. Statistical analysis was completed using SPSS version 22 (IBM Corp., Armonk, NY). RESULTS Age and sex did not influence outcomes. Obesity affected patient outcome. The SSEP categories of significant changes and loss of responses resulted in a sensitivity/specificity of 0.30/0.96 and 0.16/0.98, respectively. The receiver operating characteristic curve has an area under the curve for significant change in/loss of SSEPs of 0.62/0.65 with a 95% confidence interval of 0.525 to 0.714/0.509 to 0.797. CONCLUSION Significant SSEP changes during PCF are a very specific but poorly sensitive indicator of postoperative neurological deficits. The odds ratio for significant changes in SSEPs and loss of waveforms was 9.80 and 11.82, respectively, with a 95% confidence interval of 4.695 to 20.46 and 4.45 to 31.41, respectively. LEVEL OF EVIDENCE 1.
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Samdani AF, Bennett JT, Ames RJ, Asghar JK, Orlando G, Pahys JM, Yaszay B, Miyanji F, Lonner BS, Lehman RA, Newton PO, Cahill PJ, Betz RR. Reversible Intraoperative Neurophysiologic Monitoring Alerts in Patients Undergoing Arthrodesis for Adolescent Idiopathic Scoliosis: What Are the Outcomes of Surgery? J Bone Joint Surg Am 2016; 98:1478-83. [PMID: 27605692 DOI: 10.2106/jbjs.15.01379] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Confidence in intraoperative neurophysiologic monitoring (IONM) data can allow scoliosis surgeons to proceed with surgery even after a monitoring alert, assuming the recovery of signals. We sought to determine the outcomes of surgical treatment of adolescent idiopathic scoliosis (AIS) after a notable IONM alert. METHODS We identified 676 patients who underwent arthrodesis with use of IONM for the treatment of AIS. The patients were divided into 2 cohorts: those who experienced a lower-extremity IONM alert and those who did not. An alert was defined as a notable change in IONM data, specifically, a ≥50% drop in somatosensory evoked potentials (SSEPs) and/or in transcranial motor evoked potentials (tcMEPs). RESULTS Of the 676 patients, 36 (5.3%) experienced IONM alerts. Those patients had a larger preoperative major Cobb angle (mean of 61° ± 13° compared with 55° ± 12° for the no-alert group; p < 0.01), a greater number of levels fused (mean of 12 ± 2 compared with 11 ± 2; p < 0.01), a longer operative duration (mean of 357 ± 157 minutes compared with 298 ± 117 minutes; p < 0.01), a higher estimated blood loss (1,857 ± 1,323 mL compared with 999 ± 796 mL; p < 0.01), and a greater volume of autologous blood transfused (mean of 527 ± 525 mL compared with 268 ± 327 mL; p < 0.01). Among patients who experienced an alert and had a completed operation (34 of 36 patients), mean postoperative radiographic measurements were similar to those of the no-alert group in terms of the percentage of correction of the major Cobb angle (alert, 66% ± 13%; no alert, 64% ± 19%; p = 0.53) and of rib prominence (alert, 49% ± 36%; no alert, 47% ± 46%; p = 0.83) and measurement of thoracic kyphosis (alert, 23° ± 10°; no alert, 22° ± 2°; p = 0.58). The Scoliosis Research Society (SRS)-22 outcome scores were also similar between the 2 cohorts. CONCLUSIONS Notable IONM changes occurred in 5.3% of the patients who underwent arthrodesis for AIS. Those patients had larger preoperative deformity, a longer operative duration, a greater number of levels fused, a higher estimated blood loss, and a greater volume of autologous blood transfused. Return of IONM data guided the surgeon to safely complete the procedure in 34 of 36 patients, with correction similar to that of patients who did not experience an alert. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania
| | - James T Bennett
- Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania
| | - Robert J Ames
- Temple University School of Medicine, Philadelphia, Pennsylvania
| | | | - Giuseppe Orlando
- Department of Orthopaedics and Traumatology, University of Messina, Messina, Italy
| | - Joshua M Pahys
- Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania
| | - Burt Yaszay
- Rady Children's Hospital, San Diego, California
| | - Firoz Miyanji
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Ronald A Lehman
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Randal R Betz
- Institute for Spine & Scoliosis, Lawrenceville, New Jersey
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Thirumala PD, Cheng HL, Loke YK, Kojo Hamilton D, Balzer J, Crammond DJ. Diagnostic accuracy of somatosensory evoked potential monitoring during scoliosis fusion. J Clin Neurosci 2016; 30:8-14. [DOI: 10.1016/j.jocn.2016.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/04/2016] [Accepted: 01/17/2016] [Indexed: 11/30/2022]
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Cheng HL, Thirumala PD, Crammond DJ, Habeych ME, Balzer J. Comparison of Subdermal Needle and Surface Adhesive Stimulating Electrodes for Somatosensory Evoked Potential Monitoring during Anterior Cervical Discectomy and Fusion. Neurodiagn J 2016; 56:186-200. [PMID: 28436771 DOI: 10.1080/21646821.2016.1202695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Needle stick injuries remain a physical and psychological burden to healthcare workers. Noninvasive surface adhesive stimulating electrodes used to generate somatosensory evoked potentials can help decrease this risk. METHODS We performed a retrospective observational study of patients who underwent anterior cervical discectomy and fusion (ACDF) surgery to determine the utility and variability of using surface adhesive stimulating electrodes. Our analysis for utility compared alarm (significant changes) frequency, defined by established alarm criteria, between subdermal needle (Group I) and surface adhesive electrodes (Group II). We compared the variability by comparing the frequency of alarms based on establishing baselines during various stages of the procedure. RESULTS Between Group I and Group II, no significant differences were found in demographic, age, number of levels decompressed and fused, and length of surgery variability. However, stimulation intensity was significantly higher in Group II. Significant differences in the mean frequency of alarm of cortical, subcortical, and Erb's somatosensory evoked potential (SSEP) responses for the upper extremities between the two groups were only observed for the upper left Erb's point amplitude (p = 0.03) at retraction and upper right cortical amplitude at incision (p = 0.02). The frequency of alarms of the amplitude of left ulnar cortical responses from SSEPs using surface adhesives when baselines were established at the beginning of the procedure, at the time of incision, and at placement of retractors were 13.83 % (±14.08%), 7.50 % (±7.56%) and 3.42 % (±3.48%), respectively. Comparatively, the frequencies of alarms of the amplitude of left ulnar cortical responses from SSEPs using needle electrodes were 18.07 % (±22.85%), 12.13 % (±17.30%) and 7.37 % (±11.82%), respectively. Similar results were observed from frequency for alarms from the right ulnar SSEPs. CONCLUSION This study found little significant difference between the frequencies of alarm in patients who had SSEP responses obtained using surface adhesive electrodes when compared to needle electrodes. This lack of significant difference was observed even when alarms were established at various stages of the surgery before any major manipulation. For short procedures monitoring the upper extremities only, surface adhesive electrodes may provide a reliable alternative to invasive needle electrodes.
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Affiliation(s)
- Hannah L Cheng
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Parthasarathy D Thirumala
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania.,b Department of Neurology , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Donald J Crammond
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Miguel E Habeych
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Jeffrey Balzer
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania.,c Department of Neuroscience , University of Pittsburgh , Pittsburgh , Pennsylvania
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Takata Y, Sakai T, Higashino K, Matsuura T, Suzue N, Hamada D, Goto T, Nishisho T, Tsutsui T, Goda Y, Morimoto M, Abe M, Mineta K, Kimura T, Nitta A, Hama S, Higuchi T, C. Jha S, Takahashi R, Fukuta S, Sairyo K. State of the art: Intraoperative neuromonitoring in spinal deformity surgery. THE JOURNAL OF MEDICAL INVESTIGATION 2015; 62:103-8. [DOI: 10.2152/jmi.62.103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | | | | | - Naoto Suzue
- Department of Orthopedics, Tokushima University
| | | | | | | | | | | | | | | | | | | | | | - Shingo Hama
- Department of Orthopedics, Tokushima University
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Appropriate time to establish baseline responses for brain stem auditory evoked potentials during microvascular decompression for hemifacial spasm. J Clin Neurophysiol 2014; 31:500-4. [PMID: 25271691 DOI: 10.1097/wnp.0000000000000078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To evaluate the appropriate time to establish baseline responses for brain stem auditory evoked potentials (BAEPs) during microvascular decompression for hemifacial spasm and its implications on the alarm criteria and outcomes. METHODS Overall, 61 patients who had intraoperative monitoring with BAEP during microvascular decompression were retrospectively identified. The latencies and amplitudes of wave V before skin incision and at dura opening (before major manipulation) were compared with the latency and amplitude of wave V at change start (first alarm reported to the surgeon). Also, the results with respect to postoperative outcomes were evaluated. RESULTS More alarms would have been communicated to the surgeon when baseline values were set at the beginning of the procedure, when compared with baseline values reset at dura opening (before major manipulation). CONCLUSIONS Significant variations in BAEP latency exist before any major manipulations during microvascular decompression. Despite a false-negative case, baselines can be set before any major manipulations (e.g., just before dura opening), with an understanding of the etiology of changes to BAEPs during microvascular decompression. SIGNIFICANCE This is the first study to establish that during intraoperative BAEP monitoring, baselines that are reset before any significant manipulations are performed, rather than at the beginning of the procedure, have a higher level of sensitivity with regards to hearing outcomes.
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Thirumala PD, Bodily L, Tint D, Ward WT, Deeney VF, Crammond DJ, Habeych ME, Balzer JR. Somatosensory-evoked potential monitoring during instrumented scoliosis corrective procedures: validity revisited. Spine J 2014; 14:1572-80. [PMID: 24361128 DOI: 10.1016/j.spinee.2013.09.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 08/16/2013] [Accepted: 09/19/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intraoperative monitoring (IOM) using somatosensory-evoked potentials (SSEPs) plays an important role in reducing iatrogenic neurologic deficits during corrective pediatric idiopathic procedures for scoliosis. However, for unknown reasons, recent reports have cited that the sensitivity of SSEPs to detect neurologic deficits has decreased, in some to be less than 50%. This current trend, which is coincident with the addition of transcranial motor-evoked potentials, is surprising given that SSEPs are robust, reproducible responses that were previously shown to have sensitivity and specificity of >90%. PURPOSE Our primary aim was to assess whether SSEPs alone can detect impending neurologic deficits with similar sensitivity and specificity as originally reported. Our secondary aim was to estimate the potential predictive value of adding transcranial motor-evoked potentials to SSEP monitoring in idiopathic scoliosis procedures. DESIGN This was a retrospective review to analyze the efficacy of SSEP monitoring in the group of pediatric instrumented scoliosis fusion cases. PATIENT SAMPLE We retrospectively reviewed all consecutive cases of patients who underwent idiopathic scoliosis surgery between 1999 and 2009 at Children's Hospital of Pittsburgh. We identified 477 patients who had the surgery with SSEP monitoring alone. Exclusion criteria included any patients with neuromuscular disorders or unreliable SSEP monitoring. Patients who had incomplete neurophysiology data or incomplete postoperative records were also excluded. OUTCOME MEASURES Major outcomes measured were clinically significant postoperative sensory or motor deficits, as well as significant intraoperative SSEP changes. METHODS Continuous interleaved upper- and lower-extremity SSEPs were obtained throughout the duration of all procedures. We considered a persistent 50% reduction in primary somatosensory cortical amplitude or a prolongation of response latency by >10% from baseline to be significant. Persistent changes represent significant deviation in SSEP amplitude or latency in more than two consecutive averaged trials. Patients were classified into one of four categories with respect to SSEP monitoring: true positive, false positive, true negative, and false negative. The sensitivity, specificity, positive predictive value, and negative predictive value were then calculated accordingly. RESULTS Our review of 477 idiopathic scoliosis surgeries monitored using SSEPs alone revealed a new deficit rate of 0.63% with no cases of permanent injury. Sensitivity = 95.0%, specificity = 99.8%, positive predictive value = 95%, negative predictive value = 99.8%. Using evidence-based epidemiologic measures, we calculated that the number needed to treat was 1,587 patients for one intervention to be performed that would have been missed by SSEP monitoring alone. In addition, the number needed to harm, which represents the increase in false positives with the addition of transcranial electrical motor-evoked potentials, was 200. CONCLUSION SSEP monitoring alone during idiopathic scoliosis continues to be a highly reliable method for the detection and prevention of iatrogenic injury. Our results confirm the high sensitivity and specificity of SSEP monitoring alone published in earlier literature. As such, we suggest the continued use of SSEP alone in idiopathic scoliosis surgeries. At this time we do not believe there are sufficient data to support the addition of MEP monitoring, although more studies and revised criteria for the use of MEP may provide added value for its use in the future.
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Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400, 200 Lothrop St, Pittsburgh, PA 15213, USA.
| | - Lance Bodily
- Department of Neurological Surgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Derrick Tint
- Department of Neurological Surgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - W Timothy Ward
- Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Dr, 4401 Penn Ave, 2nd Floor, Pittsburgh, PA 15224, USA
| | - Vincent F Deeney
- Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Dr, 4401 Penn Ave, 2nd Floor, Pittsburgh, PA 15224, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Miguel E Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400, 200 Lothrop St, Pittsburgh, PA 15213, USA
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Shah PA. Transcranial motor evoked potential monitoring outcome in the high-risk brain and spine surgeries: Correlation of clinical and neurophysiological data - An Indian perspective. Ann Indian Acad Neurol 2013; 16:609-13. [PMID: 24339590 PMCID: PMC3841611 DOI: 10.4103/0972-2327.120490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/13/2013] [Indexed: 12/02/2022] Open
Abstract
Objective: The objective of this study is to assess the safety, feasibility and clinical value of transcranial motor evoked potential (MEP) monitoring by electrical stimulation. Setting: Clinical neurophysiology department of tertiary reach hospital. Materials and Methods: MEP monitoring was attempted in 44 “high risk” patients. Intraoperative surgical, anesthesia and neurophysiological findings were documented prospectively. MEP monitoring results were correlated with motor outcome. Results: The success for reliable MEP recording from the lower limbs was 75%. Incidence of new permanent post-operative motor deficit was zero. Nearly, 76.5% of the cases (13 out of 17 cases) who showed unobtainable and unstable MEP outcome had lesion location in the spine as compared with 23.5% (4 out of 17 cases) that had lesion location in the brain. Chi-square test demonstrated a statistically significant difference between these two groups (P = 0.0020). Out of these 13 spine surgery cases, 8 (62%) were operated for deformity. Seven out of 12 (60%) patients less than 12 years of age had a poor MEP monitoring outcome suggesting that extremes of age and presence of a spine deformity may be associated with a lesser incidence of successful MEP monitoring. No complications related to the repetitive transcranial electrical stimulation for eliciting MEP were observed. Conclusion: MEP monitoring is safe. The protocol used in this study is simple, feasible for use and has a fairly high success rate form the lower limbs. Pediatric age group and spine lesions, particularly deformities have an adverse effect on stable MEP recording.
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Affiliation(s)
- Poornima Amit Shah
- Department of Clinical Neurophysiology, Centre for Brain and Nervous System, Kokilaben Dhirubhai Ambani Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Thirumala P, Lai D, Engh J, Habeych M, Crammond D, Balzer J. Predictive Value of Somatosensory Evoked Potential Monitoring during Resection of Intraparenchymal and Intraventricular Tumors Using an Endoscopic Port. J Clin Neurol 2013; 9:244-51. [PMID: 24285966 PMCID: PMC3840135 DOI: 10.3988/jcn.2013.9.4.244] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 01/28/2013] [Accepted: 01/28/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Intraoperative neurophysiological monitoring (IONM) using upper and lower somatosensory evoked potentials (SSEPs) is an established technique used to predict and prevent neurologic injury during intracranial tumor resections. Endoscopic port surgery (EPS) is a minimally-invasive approach to deep intraparenchymal and intraventricular brain tumors. The authors intended to evaluate the predictive value of SSEP monitoring during resection of intracranial brain tumors using a parallel endoscopic technique. METHODS A retrospective review was conducted of patients operated on from 2007-2010 utilizing IONM in whom endoscopic ports were used to remove either intraparenchymal or intraventricular tumors. Cases were eligible for review if an endoscopic port was used to resect an intracranial tumor and the electronic chart included all intraoperative monitoring data as well as pre- and post-operative neurologic exams. RESULTS 139 EPS cases met criteria for inclusion. Eighty five patients (61%) had intraparenchymal and fifty four (39%) had intraventricular tumors or colloid cysts. SSEP changes were seen in eleven cases (7.9%), being irreversible in three (2.2%) and reversible in eight cases (5.8%). Seven patients (5.0%) with intraparenchymal tumors had SSEP changes which met our criterea for significant changes while there were four (2.9%) with intraventricular (p-value=0.25). Five patients suffered post operative deficits, two reversible and two irreversible SSEP changes. Only one case exhibited post operative hemiparesis with no SSEP changes. The positive predictive value of SSEP was 45.4% and the negative predictive value was 99.2%. CONCLUSIONS Based on the high negative and low positive predictive values, the utility of SSEP monitoring for cylindrical port resections may be limited. However, the use of SSEP monitoring can be helpful in reducing the impact of endoscopic port manipulation when the tumor is closer to the somatosensory pathway.
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Affiliation(s)
- Parthasarathy Thirumala
- Center for Clinical Neurophysiology, Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Thirumala PD, Kodavatiganti HS, Habeych M, Wichman K, Chang YF, Gardner P, Snyderman C, Crammond DJ, Balzer J. Value of multimodality monitoring using brainstem auditory evoked potentials and somatosensory evoked potentials in endoscopic endonasal surgery. Neurol Res 2013; 35:622-30. [PMID: 23561292 DOI: 10.1179/1743132813y.0000000174] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES To evaluate the value of intraoperative neurophysiological monitoring (IONM) using brainstem auditory evoked potential (BAEP) and somatosensory evoked potential (SSEP) monitoring to predict and/or prevent postoperative neurological deficits during endoscopic endonasal surgery (EES). METHODS We retrospectively identified 138 consecutive patients who had BAEP monitoring in addition to SSEP monitoring during EES at our institution. We reviewed the postoperative clinical outcomes and neurophysiological changes independently. RESULTS The total of number of patients with any IONM changes was 10. The incidence of BAEP changes was 3.62%. The incidence of SSEP changes was 3.62% as well. One patient had changes in both BAEPs and SSEPs. Majority of the changes were observed during changes in mean arterial pressure (MAP) without any postoperative neurological deficits. There were two postoperative neurological deficits. DISCUSSION BAEPs and SSEPs provide unique information about integrity of brainstem function during EES procedures involving tumors in the and around clival region. We advocate a comprehensive multimodality approach to IONM during EESs including BAEPs and SSEPs depending on the location of the neural structures at risk.
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Stecker MM. A review of intraoperative monitoring for spinal surgery. Surg Neurol Int 2012; 3:S174-87. [PMID: 22905324 PMCID: PMC3422092 DOI: 10.4103/2152-7806.98579] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 04/25/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Intraoperative neurophysiologic monitoring (IONM) is a technique that is helpful for assessing the nervous system during spine surgery. METHODS This is a review of the field describing the basic mechanisms behind the techniques of IONM. These include the most often utilized trancranial motor evoked potentials (Tc-MEPs), somatosensory evoked potentials (SSEPs), and stimulated and spontaneous EMG activity. It also describes some of the issues regarding practices and qualifications of practitioners. RESULTS Although the anatomic pathways responsible for the Tc-MEP and SSEP are well known and these clinical techniques have a high sensitivity and specificity, there is little published data showing that monitoring actually leads to improved patient outcomes. It is evident that IONM has high utility when the risk of injury is high, but may be only marginally helpful when the risk of injury is very low. The monitoring team must be well trained, be able to provide the surgeon feedback in real time, and coordinate activities with those of the surgical and anesthesia teams. CONCLUSIONS Although IONM is a valuable technique that provides sensitive and specific indications of neurologic injury, it does have limitations that must be understood. Maintaining a high quality of practice with appropriately trained personnel is critical.
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Affiliation(s)
- Mark M. Stecker
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY, USA
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Hernández-Godínez B, Ibáñez-Contreras A, Reyes-Pantoja S, Durand-Rivera A, Galvan-Montaño A, Perdigón-Castañeda G, Carmen Climent-Palmer M, Tena-Betancourt E. Preliminary studies of neurosensory and cardiopulmonary health compromise in captive- bred Rhesus macaques (Macaca mulatta) suffering scoliosis. J Med Primatol 2012; 41:163-71. [DOI: 10.1111/j.1600-0684.2012.00539.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Time-frequency analysis of somatosensory evoked potentials for intraoperative spinal cord monitoring. J Clin Neurophysiol 2012; 28:504-11. [PMID: 21946365 DOI: 10.1097/wnp.0b013e318231c15c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the potential use of time-frequency analysis and its reliability in intraoperative somatosensory evoked potential (SEP) monitoring. METHODS One hundred ninety-one patients undergoing thoracic and/or lumbar spinal surgery were studied retrospectively. The SEP signals were recorded during different stages of surgery. Averaged SEP was analyzed by short-time Fourier transform. The main peak in the time-frequency interpretation of SEP was measured in peak power, peak time, and peak frequency. The variability of these parameters was compared with that of amplitude and latency during different stages of surgery. The reliability of these parameters was also compared in true-positive and false-positive cases. RESULTS During different surgical stages for the posterior tibial nerve SEP, the intrasubject variability of peak power was found to be more stable than that of amplitude, while the intrasubject variability of peak time did not show any difference compared with that of latency. The peak frequency presented stable during surgery. Moreover, the true-positive SEP case showed that peak power may detect the potential injury earlier than amplitude does. The false-positive outcomes could be reduced by the proposed method. CONCLUSIONS The SEP peak component was found stable and reliable during the different stages of surgery. For clinical application purpose, time-frequency analysis was suggested to be an additional monitoring method besides the conventional amplitude/latency measurement since it provided a more reproducible and prompt response to the potential injury in intraoperative SEP monitoring.
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Thirumala PD, Kassasm AB, Habeych M, Wichman K, Chang YF, Gardner P, Prevedello D, Snyderman C, Carrau R, Crammond DJ, Balzer J. Somatosensory Evoked Potential Monitoring During Endoscopic Endonasal Approach to Skull Base Surgery: Analysis of Observed Changes. Oper Neurosurg (Hagerstown) 2011; 69:ons64-76; discussion ons76. [PMID: 21415780 DOI: 10.1227/neu.0b013e31821606e4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Intraoperative neurophysiological monitoring, including upper- and lower-extremity somatosensory evoked potentials (SSEPs), has been used to identify and prevent injury to neurovascular structures during conventional skull base surgery. The expanded endonasal approach (EEA) is a novel minimally invasive approach to skull base surgery. However, it carries the risk of injury to neurovascular structures, including the internal carotid artery, anterior cerebral artery, and cranial nerves.
OBJECTIVE:
To evaluate the value of SSEP monitoring to predict and/or prevent neurovascular deficits during EEA to skull base surgery.
METHODS:
We retrospectively identified 999 consecutive patients who had intraoperative neurophysiological monitoring during EEA skull base surgery at our institution. A total of 976 patients had SSEP monitoring and a documented postoperative neurological examination.
RESULTS:
The incidence of changes in SSEP during the procedure was 20 of 976 (2%). The incidence of new postoperative neurological deficits was 5 of 976 (0.5%). The positive and negative predictive values of SSEPs during EEA to predict neurovascular deficits were 80.00% and 99.79%, respectively.
CONCLUSION:
Intraoperative SSEP monitoring was able to identify impending risk to neurovascular structures to prevent permanent postoperative neurological deficits. We advocate a comprehensive approach to neurophysiological monitoring during EEAs, including SSEPs, spontaneous and triggered electromyography of the cranial nerves III through XII, brainstem auditory evoked potentials, and electroencephalogram, depending on the surgical approach and location of the neural structures at risk.
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Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amin B. Kassasm
- Department of The Chan Soon-Shiong Neuroscience Institute and the John Wayne Cancer Institute at St. John Health Center, Santa Monica, California, The Ohio State University, Columbus, Ohio
| | - Miguel Habeych
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
| | - Kelley Wichman
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yue-Fang Chang
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
| | - Paul Gardner
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
| | - Daniel Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
| | - Carl Snyderman
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ricardo Carrau
- Department of Otolaryngology, The Ohio State University, Columbus, Ohio
| | - Donald J. Crammond
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
| | - Jeffrey Balzer
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kundnani VK, Zhu L, Tak HH, Wong HK. Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: Evaluation of 354 consecutive cases. Indian J Orthop 2010; 44:64-72. [PMID: 20165679 PMCID: PMC2822422 DOI: 10.4103/0019-5413.58608] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Multimodal intraoperative neuromonitoring is recommended during corrective spinal surgery, and has been widely used in surgery for spinal deformity with successful outcomes. Despite successful outcomes of corrective surgery due to increased safety of the patients with the usage of spinal cord monitoring in many large spine centers, this modality has not yet achieved widespread popularity. We report the analysis of prospectively collected intraoperative neurophysiological monitoring data of 354 consecutive patients undergoing corrective surgery for adolescent idiopathic scoliosis (AIS) to establish the efficacy of multimodal neuromonitoring and to evaluate comparative sensitivity and specificity. MATERIALS AND METHODS The study group consisted of 354 (female = 309; male = 45) patients undergoing spinal deformity corrective surgery between 2004 and 2008. Patients were monitored using electrophysiological methods including somatosensory-evoked potentials and motor-evoked potentials simultaneously. RESULTS Mean age of patients was 13.6 years (+/-2.3 years). The operative procedures involved were instrumented fusion of the thoracic/lumbar/both curves, Baseline somatosensory-evoked potentials (SSEP) and neurogenic motor-evoked potentials (NMEP) were recorded successfully in all cases. Thirteen cases expressed significant alert to prompt reversal of intervention. All these 13 cases with significant alert had detectable NMEP alerts, whereas significant SSEP alert was detected in 8 cases. Two patients awoke with new neurological deficit (0.56%) and had significant intraoperative SSEP + NMEP alerts. There were no false positives with SSEP (high specificity) but 5 patients with false negatives with SSEP (38%) reduced its sensitivity. There was no false negative with NMEP but 2 of 13 cases were false positive with NMEP (15%). The specificity of SSEP (100%) is higher than NMEP (96%); however, the sensitivity of NMEP (100%) is far better than SSEP (51%). Due to these results, the overall sensitivity, specificity and positive predictive value of combined multimodality neuromonitoring in this adult deformity series was 100, 98.5 and 85%, respectively. CONCLUSION Neurogenic motor-evoked potential (NMEP) monitoring appears to be superior to conventional SSEP monitoring for identifying evolving spinal cord injury. Used in conjunction, the sensitivity and specificity of combined neuromonitoring may reach up to 100%. Multimodality monitoring with SSEP + NMEP should be the standard of care.
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Affiliation(s)
- Vishal K Kundnani
- University Spine Center, National University Hospital, Singapore,Address for correspondence: Dr. Vishal Kundnani, Bombay Hospital & Medical Research Centre, 12, Marine Lines, Mumbai. E-mail:
| | - Lisa Zhu
- University Spine Center, National University Hospital, Singapore
| | - HH Tak
- University Spine Center, National University Hospital, Singapore
| | - HK Wong
- University Spine Center, National University Hospital, Singapore
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Schwartz DM, Auerbach JD, Dormans JP, Flynn J, Bowe JA, Laufer S, Shah SA, Bowen JR, Pizzutillo PD, Jones KJ, Drummond DS. Neurophysiological Detection of Impending Spinal Cord Injury During Scoliosis Surgery. J Bone Joint Surg Am 2007. [DOI: 10.2106/00004623-200711000-00015] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Zainea OF, Kostopoulos GK, Ioannides AA. Clustering of early cortical responses to median nerve stimulation from average and single trial MEG and EEG signals. Brain Topogr 2005; 17:219-36. [PMID: 16110772 DOI: 10.1007/s10548-005-6031-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Median nerve electrical stimulation (MNES) produces early and strong averaged magnetoencephalography (MEG) or electroencephalography (EEG) signals, despite considerable single trial (ST) variability, demonstrated in separate MEG and EEG studies. Here, simultaneous MEG/EEG recordings are used to assess whether same or different aspects of ST variability are influencing EEG and MEG. Clustering techniques provided groupings for the ST timeseries for cortical responses to MNES derived from one modality. These groupings were applied to the corresponding ST timeseries derived from the other modality to quantify the similarity in variability captured by MEG and EEG signals. Estimates of early cortical activity elicited by MNES derived from MEG and EEG signals were very similar, provided ongoing mu rhythm was removed. Similarity between EEG and MEG estimates included both results based on average signals and measures of ST variability. Either MEG or EEG can provide a robust measure of the early cortical activity elicited by MNES as well as of its variability. Reliable indices of early cortical responses to MNES can be derived from either MEG or EEG data. These indices can be based on average signals, as is routinely done with clinical EEG, but it could also rely on hitherto little utilized measures of ST variability.
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Affiliation(s)
- Ovidiu F Zainea
- Department of Physiology, Medical School, University of Patras, Patras, Greece
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