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Gupta MC, Lenke LG, Gupta S, Farooqi AS, Boachie-Adjei O, Erickson MA, Newton PO, Samdani AF, Shah SA, Shufflebarger HL, Sponseller PD, Sucato DJ, Kelly MP. Intraoperative neuromonitoring predicts postoperative deficits in severe pediatric spinal deformity patients. Spine Deform 2024; 12:109-118. [PMID: 37555880 DOI: 10.1007/s43390-023-00745-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE To evaluate intraoperative monitoring (IOM) alerts and neurologic deficits during severe pediatric spinal deformity surgery. METHODS Patients with a minimum Cobb angle of 100° in any plane or a scheduled vertebral column resection (VCR) with minimum 2-year follow-up were prospectively evaluated (n = 243). Preoperative, immediate postoperative, and 2-year postoperative neurologic status were reported. Radiographic data included preoperative and 2-year postoperative coronal and sagittal Cobb angles and deformity angular ratios (DAR). IOM alert type and triggering event were recorded. SRS-22r scores were collected preoperatively and 2-years postoperatively. RESULTS IOM alerts occurred in 37% of procedures with three-column osteotomy (n = 36) and correction maneuver (n = 32) as most common triggering events. Patients with IOM alerts had greater maximum kyphosis (101.4° vs. 87.5°) and sagittal DAR (16.8 vs. 12.7) (p < 0.01). Multivariate regression demonstrated that sagittal DAR independently predicted IOM alerts (OR 1.05, 95% CI 1.02-1.08) with moderate sensitivity (60.2%) and specificity (64.8%) using a threshold value of 14.3 (p < 0.01). IOM alerts occurred more frequently in procedures with new postoperative neurologic deficits (17/24), and alerts with both SSEP and TCeMEP signals were associated with new postoperative deficits (p < 0.01). Most patients with new deficits experienced resolution at 2 years (16/20) and had equivalent postoperative SRS-22r scores. However, patients with persistent deficits had worse SRS-22r total score (3.8 vs. 4.2), self-image subscore (3.5 vs. 4.1), and function subscore (3.8 vs. 4.3) (p ≤ 0.04). CONCLUSION Multimodal IOM alerts are associated with sagittal kyphosis, and predict postoperative neurologic deficits. Most patients with new deficits experience resolution of their symptoms and have equivalent 2-year outcomes. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Munish C Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, Saint Louis, MO, 63110, USA.
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center New York, New York, USA
| | - Sachin Gupta
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Ali S Farooqi
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Mark A Erickson
- Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, USA
| | - Peter O Newton
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, USA
| | - Amer F Samdani
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Philadelphia, Philadelphia, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, Nemours/Alfred I duPont Hospital for Children, Wilmington, USA
| | - Harry L Shufflebarger
- Department of Orthopaedic Surgery, Paley Orthopedic and Spine Institute at St. Mary's Medical Center, West Palm Beach, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Daniel J Sucato
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, Saint Louis, MO, 63110, USA
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Gupta MC, Lenke LG, Gupta S, Farooqi AS, Asghar JK, Boachie-Adjei O, Cahill PJ, Erickson MA, Garg S, Newton PO, Samdani AF, Shah SA, Shufflebarger HL, Sponseller PD, Sucato DJ, Bumpass DB, McCarthy RE, Yaszay B, Pahys JM, Ye J, Kelly MP. Perioperative Complications and Health-related Quality of Life Outcomes in Severe Pediatric Spinal Deformity. Spine (Phila Pa 1976) 2023; 48:1492-1499. [PMID: 37134134 DOI: 10.1097/brs.0000000000004696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/03/2023] [Indexed: 05/04/2023]
Abstract
STUDY DESIGN Prospective multicenter cohort study. OBJECTIVE To evaluate perioperative complications and mid-term outcomes for severe pediatric spinal deformity. SUMMARY OF BACKGROUND DATA Few studies have evaluated the impact of complications on health-related quality of life (HRQoL) outcomes in severe pediatric spinal deformity. METHODS Patients from a prospective, multicenter database with severe pediatric spinal deformity (minimum of 100 degree curve in any plane or planned vertebral column resection (VCR)) with a minimum of 2-years follow-up were evaluated (n=231). SRS-22r scores were collected preoperatively and at 2-years postoperatively. Complications were categorized as intraoperative, early postoperative (within 90-days of surgery), major, or minor. Perioperative complication rate was evaluated between patients with and without VCR. Additionally, SRS-22r scores were compared between patients with and without complications. RESULTS Perioperative complications occurred in 135 (58%) patients, and major complications occurred in 53 (23%) patients. Patients that underwent VCR had a higher incidence of early postoperative complications than patients without VCR (28.9% vs. 16.2%, P =0.02). Complications resolved in 126/135 (93.3%) patients with a mean time to resolution of 91.63 days. Unresolved major complications included motor deficit (n=4), spinal cord deficit (n=1), nerve root deficit (n=1), compartment syndrome (n=1), and motor weakness due to recurrent intradural tumor (n=1). Patients with complications, major complications, or multiple complications had equivalent postoperative SRS-22r scores. Patients with motor deficits had lower postoperative satisfaction subscore (4.32 vs. 4.51, P =0.03), but patients with resolved motor deficits had equivalent postoperative scores in all domains. Patients with unresolved complications had lower postoperative satisfaction subscore (3.94 vs. 4.47, P =0.03) and less postoperative improvement in self-image subscore (0.64 vs. 1.42, P =0.03) as compared to patients with resolved complications. CONCLUSION Most perioperative complications for severe pediatric spinal deformity resolve within 2-years postoperatively and do not result in adverse HRQoL outcomes. However, patients with unresolved complications have decreased HRQoL outcomes.
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Affiliation(s)
- Munish C Gupta
- Department of Orthopaedic Surgery, Washington University in St Louis, St. Louis, MO
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center New York, New York, NY
| | - Sachin Gupta
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ali S Farooqi
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jahangir K Asghar
- Department of Orthopaedic Surgery, Miami Children's Hospital Miami, Miami, FL
| | | | - Patrick J Cahill
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark A Erickson
- Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, CO
| | - Sumeet Garg
- Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, CO
| | - Peter O Newton
- Department of Orthopaedic Surgery, Rady Children's Hospital - San Diego, San Diego, CA
| | - Amer F Samdani
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Philadelphia, Philadelphia, PA
| | - Suken A Shah
- Department of Orthopaedic Surgery, Nemours/Alfred I duPont Hospital for Children, Wilmington, DE
| | - Harry L Shufflebarger
- Department of Orthopaedic Surgery, Paley Orthopedic and Spine Institute at St. Mary's Medical Center, West Palm Beach, FL
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Daniel J Sucato
- Texas Scottish Rite Hospital for Children, Department of Orthopaedic Surgery, Dallas, TX
| | - David B Bumpass
- Department of Orthopaedic Surgery, Arkansas Children's Hospital, Little Rock, AR
| | - Richard E McCarthy
- Department of Orthopaedic Surgery, Arkansas Children's Hospital, Little Rock, AR
| | - Burt Yaszay
- Department of Orthopaedic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Joshua M Pahys
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Philadelphia, Philadelphia, PA
| | - Jichao Ye
- Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University in St Louis, St. Louis, MO
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Angelliaume A, Alhada TL, Parent HF, Royer J, Harper L. Intraoperative neurophysiological monitoring in scoliosis surgery: literature review of the last 10 years. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3072-3076. [PMID: 37434021 DOI: 10.1007/s00586-023-07837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Patients with spinal deformities undergoing corrective surgery are at risk for iatrogenic spinal cord injury (SCI) and subsequent neurological deficit. Intraoperative neurophysiological monitoring (IONM) allows early detection of SCI which enables early intervention resulting in a better prognosis. The primary aim of this literature review was to search if there are threshold values of TcMEP and SSEP in the literature that are widely accepted as alert during IONM. The secondary aim was to update knowledge concerning IONM during scoliosis surgery. METHOD PubMed/MEDLINE and Cochrane library electronic databases were used to search publication from 2012 to 2022. The following keywords were used: evoked potential, scoliosis, surgery, intraoperative monitoring and neurophysiological. We included all studies dealing with SSEP and TcMEP monitoring during scoliosis surgery. Two authors reviewed all titles and abstracts to identify studies that met the inclusion criteria. RESULTS We included 43 papers. Rates of IONM alert and neurological deficit varied from 0.56 to 64% and from 0.15 to 8.3%, respectively. Threshold values varied from a loss of 50 to 90% for TcMEP amplitude, whereas it seems that a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted for SSEP. Causes of IONM changes most frequently reported were surgical maneuver. CONCLUSION Concerning SSEP, a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted as an alert. For TcMEP, it seems that the use of highest threshold values can avoid unnecessary surgical procedure for the patient without increasing risk of neurological deficit.
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Affiliation(s)
| | - Toul-la Alhada
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | | | - Julia Royer
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Luke Harper
- Department of Pediatric Surgery, Pellegrin University Hospital, Place Amélie Raba-Léon, 33000, Bordeaux, France
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Al-Mohrej OA, Aldakhil SS, Al-Rabiah MA, Al-Rabiah AM. Surgical treatment of adolescent idiopathic scoliosis: Complications. Ann Med Surg (Lond) 2020; 52:19-23. [PMID: 32153775 PMCID: PMC7052396 DOI: 10.1016/j.amsu.2020.02.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/23/2020] [Accepted: 02/18/2020] [Indexed: 12/21/2022] Open
Abstract
Despite the fact that spinal surgeries for adolescent idiopathic scoliosis (AIS) result in good outcomes for most patients, they are not without complications either medically or surgically. Neurologic injury represents the most severe complication and is, as such, the most feared. Further complications include dural tears, peripheral neuropathy, surgical-site infections, implant-related issues, thromboembolic events, visual loss, pseudarthrosis, Crankshaft phenomenon, flatback phenomenon, proximal junctional kyphosis, and mortality. It is vital that all spine surgeons to be fully conversant with the possible complications and the proper responses for each of them. Surgeons should know how to manage complications of surgery for AIS. Patients should know about potential complications prior to surgery. Neurologic injury represents the most severe complication.
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Affiliation(s)
- Omar A Al-Mohrej
- Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Sahar S Aldakhil
- Department of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Anwar M Al-Rabiah
- Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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The Recognition, Incidence, and Management of Spinal Cord Monitoring Alerts in Pediatric Cervical Spine Surgery. J Pediatr Orthop 2018; 38:e572-e576. [PMID: 30074586 DOI: 10.1097/bpo.0000000000001235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perioperative spinal cord injury and postoperative neurological deficits are the major complications in spinal surgery. Monitoring of spinal cord function is of crucial importance. Somatosensory evoked potentials and transcranial electric motor-evoked potentials are now widely used in cervical spine surgery. Although much has been written on spinal cord monitoring in adult spinal surgery, very little has been published on the incidence and management of monitoring of cervical spine surgery in the pediatric population. The goal of this research was to review the recognition, incidence, and management of spinal cord monitoring in pediatric patients undergoing cervical spine surgery over the course of twenty years in a single institution. We postulate spinal cord monitoring alerts in pediatric cervical spine surgery are underreported. METHODS An IRB-approved retrospective single institution review of pediatric cervical spine cases from 1997 to 2017 was performed. Both the surgeon's dictated operative note and the neuromonitoring team's dictated note were reviewed for each case, and both were cross referenced and correlated with one another to ensure no alerts were missed. All monitoring changes were assumed to be significant and reported. The incidence of alerts, type of changes, and corrective maneuvers were noted. New postoperative neurological injuries were recorded. RESULTS From 1997 to 2017 fifty-three patients underwent a total of 69 procedures involving the cervical spine. Fourteen procedures (20%) were not monitored, whereas 55 procedures were 80%. There were 12 procedures (21.8%) complicated by neuromonitoring alerts. CONCLUSIONS The number of cases complicated by alerts doubles that previously reported, and it is important to note there were no new permanent neurological deficits recorded over the study period. Corrective strategies were implemented once the operating surgeon was notified of the neuromonitoring alert. Aborting the case was then considered if corrective strategies failed to restore baseline neurophysiology. LEVEL OF EVIDENCE Level IV.
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