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Toleikis JR, Pace C, Jahangiri FR, Hemmer LB, Toleikis SC. Intraoperative somatosensory evoked potential (SEP) monitoring: an updated position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2024; 38:1003-1042. [PMID: 39068294 PMCID: PMC11427520 DOI: 10.1007/s10877-024-01201-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Somatosensory evoked potentials (SEPs) are used to assess the functional status of somatosensory pathways during surgical procedures and can help protect patients' neurological integrity intraoperatively. This is a position statement on intraoperative SEP monitoring from the American Society of Neurophysiological Monitoring (ASNM) and updates prior ASNM position statements on SEPs from the years 2005 and 2010. This position statement is endorsed by ASNM and serves as an educational service to the neurophysiological community on the recommended use of SEPs as a neurophysiological monitoring tool. It presents the rationale for SEP utilization and its clinical applications. It also covers the relevant anatomy, technical methodology for setup and signal acquisition, signal interpretation, anesthesia and physiological considerations, and documentation and credentialing requirements to optimize SEP monitoring to aid in protecting the nervous system during surgery.
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Affiliation(s)
| | | | - Faisal R Jahangiri
- Global Innervation LLC, Dallas, TX, USA
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
| | - Laura B Hemmer
- Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Tetreault LA, Kwon BK, Evaniew N, Alvi MA, Skelly AC, Fehlings MG. A Clinical Practice Guideline on the Timing of Surgical Decompression and Hemodynamic Management of Acute Spinal Cord Injury and the Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury: Introduction, Rationale, and Scope. Global Spine J 2024; 14:10S-24S. [PMID: 38632715 PMCID: PMC10964894 DOI: 10.1177/21925682231183969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
STUDY DESIGN Protocol for the development of clinical practice guidelines following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. OBJECTIVES Acute SCI or intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. The treatment of SCI has dramatically evolved over the last century as a result of preclinical and clinical research that has addressed important knowledge gaps, including injury mechanisms, disease pathophysiology, medical management, and the role of surgery. In an acute setting, clinicians are faced with critical decisions on how to optimize neurological recovery in patients with SCI that include the role and timing of surgical decompression and the best strategies for hemodynamic management. The lack of consensus surrounding these treatments has prevented standardization of care across centers and has created uncertainty with respect to how to best manage patients with SCI. ISCI is a feared complication that can occur in the best of hands. Unfortunately, there are no systematic reviews or clinical practice guidelines to assist spine surgeons in the assessment and management of ISCI in adult patients undergoing spinal surgery. Given these limitations, it is the objective of this initiative to develop evidence-based recommendations that will inform the management of both SCI and ISCI. This protocol describes the rationale for developing clinical practice guidelines on (i) the timing of surgical decompression in acute SCI; (ii) the hemodynamic management of acute SCI; and (iii) the prevention, identification, and management of ISCI in patients undergoing surgery for spine-related pathology. METHODS Systematic reviews were conducted according to PRISMA standards in order to summarize the current body of evidence and inform the guideline development process. The guideline development process followed the approach proposed by the GRADE working group. Separate multidisciplinary, international groups were created to perform the systematic reviews and formulate the guidelines. All potential conflicts of interest were vetted in advance. The sponsors exerted no influence over the editorial process or the development of the guidelines. RESULTS This process resulted in both systematic reviews and clinical practice guidelines/care pathways related to the role and timing of surgery in acute SCI; the optimal hemodynamic management of acute SCI; and the prevention, diagnosis and management of ISCI. CONCLUSIONS The ultimate goal of this clinical practice guideline initiative was to develop evidence-based recommendations for important areas of controversy in SCI and ISCI in hopes of improving neurological outcomes, reducing morbidity, and standardizing care across settings. Throughout this process, critical knowledge gaps and future directions were also defined.
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Affiliation(s)
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Alvi MA, Kwon BK, Hejrati N, Tetreault LA, Evaniew N, Skelly AC, Fehlings MG. Accuracy of Intraoperative Neuromonitoring in the Diagnosis of Intraoperative Neurological Decline in the Setting of Spinal Surgery-A Systematic Review and Meta-Analysis. Global Spine J 2024; 14:105S-149S. [PMID: 38632716 PMCID: PMC10964897 DOI: 10.1177/21925682231196514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES In an effort to prevent intraoperative neurological injury during spine surgery, the use of intraoperative neurophysiological monitoring (IONM) has increased significantly in recent years. Using IONM, spinal cord function can be evaluated intraoperatively by recording signals from specific nerve roots, motor tracts, and sensory tracts. We performed a systematic review and meta-analysis of diagnostic test accuracy (DTA) studies to evaluate the efficacy of IONM among patients undergoing spine surgery for any indication. METHODS The current systematic review and meta-analysis was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis statement for Diagnostic Test Accuracy Studies (PRISMA-DTA) and was registered on PROSPERO. A comprehensive search was performed using MEDLINE, EMBASE and SCOPUS for all studies assessing the diagnostic accuracy of neuromonitoring, including somatosensory evoked potential (SSEP), motor evoked potential (MEP) and electromyography (EMG), either on their own or in combination (multimodal). Studies were included if they reported raw numbers for True Positives (TP), False Negatives (FN), False Positives (FP) and True Negative (TN) either in a 2 × 2 contingency table or in text, and if they used postoperative neurologic exam as a reference standard. Pooled sensitivity and specificity were calculated to evaluate the overall efficacy of each modality type using a bivariate model adapted by Reitsma et al, for all spine surgeries and for individual disease groups and regions of spine. The risk of bias (ROB) of included studies was assessed using the quality assessment tool for diagnostic accuracy studies (QUADAS-2). RESULTS A total of 163 studies were included; 52 of these studies with 16,310 patients reported data for SSEP, 68 studies with 71,144 patients reported data for MEP, 16 studies with 7888 patients reported data for EMG and 69 studies with 17,968 patients reported data for multimodal monitoring. The overall sensitivity, specificity, DOR and AUC for SSEP were 71.4% (95% CI 54.8-83.7), 97.1% (95% CI 95.3-98.3), 41.9 (95% CI 24.1-73.1) and .899, respectively; for MEP, these were 90.2% (95% CI 86.2-93.1), 96% (95% CI 94.3-97.2), 103.25 (95% CI 69.98-152.34) and .927; for EMG, these were 48.3% (95% CI 31.4-65.6), 92.9% (95% CI 84.4-96.9), 11.2 (95% CI 4.84-25.97) and .773; for multimodal, these were found to be 83.5% (95% CI 81-85.7), 93.8% (95% CI 90.6-95.9), 60 (95% CI 35.6-101.3) and .895, respectively. Using the QUADAS-2 ROB analysis, of the 52 studies reporting on SSEP, 13 (25%) were high-risk, 10 (19.2%) had some concerns and 29 (55.8%) were low-risk; for MEP, 8 (11.7%) were high-risk, 21 had some concerns and 39 (57.3%) were low-risk; for EMG, 4 (25%) were high-risk, 3 (18.75%) had some concerns and 9 (56.25%) were low-risk; for multimodal, 14 (20.3%) were high-risk, 13 (18.8%) had some concerns and 42 (60.7%) were low-risk. CONCLUSIONS These results indicate that all neuromonitoring modalities have diagnostic utility in successfully detecting impending or incident intraoperative neurologic injuries among patients undergoing spine surgery for any condition, although it is clear that the accuracy of each modality differs.PROSPERO Registration Number: CRD42023384158.
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Affiliation(s)
- Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
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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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Wilson JP, Vallejo JB, Kumbhare D, Guthikonda B, Hoang S. The Use of Intraoperative Neuromonitoring for Cervical Spine Surgery: Indications, Challenges, and Advances. J Clin Med 2023; 12:4652. [PMID: 37510767 PMCID: PMC10380862 DOI: 10.3390/jcm12144652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Intraoperative neuromonitoring (IONM) has become an indispensable surgical adjunct in cervical spine procedures to minimize surgical complications. Understanding the historical development of IONM, indications for use, associated pitfalls, and recent developments will allow the surgeon to better utilize this important technology. While IONM has shown great promise in procedures for cervical deformity, intradural tumors, or myelopathy, routine use in all cervical spine cases with moderate pathology remains controversial. Pitfalls that need to be addressed include human error, a lack of efficient communication, variable alarm warning criteria, and a non-standardized checklist protocol. As the techniques associated with IONM technology become more robust moving forward, IONM emerges as a crucial solution to updating patient safety protocols.
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Affiliation(s)
- John Preston Wilson
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Javier Brunet Vallejo
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Deepak Kumbhare
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Stanley Hoang
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
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Gamblin AS, Awad AW, Karsy M, Guan J, Mazur MD, Bisson EF, Bican O, Dailey AT. Efficacy of Intraoperative Neuromonitoring during the Treatment of Cervical Myelopathy. INDIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1055/s-0043-1764455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Objective The accuracy of intraoperative neuromonitoring (IONM) during surgery for cervical spondylotic myelopathy (CSM) to detect iatrogenic nervous system injuries while they are reversible remains unknown. We evaluated a cohort of patients who had IONM during surgery to assess accuracy.
Methods Patients who underwent surgical treatment of CSM that included IONM from January 2018 through August 2018 were retrospectively identified. A standardized protocol was used for operative management. Clinical changes and postoperative neurological deficits were evaluated.
Results Among 131 patients in whom IONM was used during their procedure, 42 patients (age 58.2 ± 16.3 years, 54.8% males) showed IONM changes and 89 patients had no change. The reasons for IONM changes varied, and some patients had changes detected via multiple modalities: electromyography (n = 25, 59.5%), somatosensory-evoked potentials (n = 14, 33.3%), motor evoked potentials (n = 13, 31.0%). Three patients, all having baseline deficits before surgery, had postoperative deficits. Among the 89 patients without an IONM change, 4 showed worsened postoperative deficits, which were also seen at last follow-up. The sensitivity of IONM for predicting postoperative neurological change was 42.86% and the specificity was 68.55%. However, most patients (124, 94.7%) in whom IONM was used showed no worsened neurological deficit.
Conclusions IONM shows potential in ensuring stable postoperative neurological outcomes in most patients; however, its clinical use and supportive guidelines remain controversial. In our series, prediction of neurological deficits was poor in contrast to some previous studies. Further refinement of clinical and electrophysiological variables is needed to uniformly predict postoperative neurological outcomes.
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Chandra AA, Vaishnav A, Shahi P, Song J, Mok J, Alluri RK, Chen D, Gang CH, Qureshi S. The Role of Intraoperative Neuromonitoring Modalities in Anterior Cervical Spine Surgery. HSS J 2023; 19:53-61. [PMID: 36776519 PMCID: PMC9837402 DOI: 10.1177/15563316221110572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/20/2022] [Indexed: 02/14/2023]
Abstract
Background: Intraoperative neuromonitoring (IONM) is frequently used during spine surgery to mitigate the risk of neurological injuries. Yet, its role in anterior cervical spine surgery remains controversial. Without consensus on which anterior cervical spine surgeries would benefit the most from IONM, there is a lack of standardized guidelines for its use in such procedures. Purpose: We sought to assess the alerts generated by each IONM modality for 4 commonly performed anterior cervical spinal surgeries: anterior cervical diskectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), cervical disk replacement (CDR), or anterior diskectomy. In doing so, we sought to determine which IONM modalities (electromyography [EMG], motor evoked potentials [MEP], and somatosensory evoked potentials [SSEP]) are associated with alert status when accounting for procedure characteristics (number of levels, operative level). Methods: We conducted a retrospective review of IONM data collected by Accurate Neuromonitoring, LLC, a company that supports spine surgeries conducted by 400 surgeons in 8 states, in an internally managed database from December 2009 to September 2018. The database was queried for patients who underwent ACCF, ACDF, anterior CDR, or anterior diskectomy in which at least 1 IONM modality was used. The IONM modalities and incidence of alerts were collected for each procedure. The search identified 8854 patients (average age, 50.6 years) who underwent ACCF (n = 209), ACDF (n = 8006), CDR (n = 423), and anterior diskectomy (n = 216) with at least 1 IONM modality. Results: Electromyography was used in 81.3% (n = 7203) of cases, MEP in 64.8% (n = 5735) of cases, and SSEP in 99.9% (n = 8844) of cases. Alerts were seen in 9.3% (n = 671), 0.5% (n = 30), and 2.7% (n = 241) of cases using EMG, MEP and SSEP, respectively. In ACDF, a significant difference was seen in EMG alerts based on the number of spinal levels involved, with 1-level ACDF (6.9%, n = 202) having a lower rate of alerts than 2-level (10.0%, n = 272), 3-level (15.2%, n = 104), and 4-level (23.4%, n = 15). Likewise, 2-level ACDF had a lower rate of alerts than 3-level and 4-level ACDF. A significant difference by operative level was noted in EMG use for single-level ACDF, with C2-C3 having a lower rate of use than other levels. Conclusions: This retrospective review of anterior cervical spinal surgeries performed with at least 1 IONM modality found that SSEP had the highest rate of use across procedure types, whereas MEP had the highest rate of nonuse. Future studies should focus on determining the most useful IONM modalities by procedure type and further explore the benefit of multimodal IONM in spine surgery.
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Affiliation(s)
| | - Avani Vaishnav
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Pratyush Shahi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Junho Song
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jung Mok
- Department of Orthopaedic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - R. Kiran Alluri
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Darren Chen
- Department of Orthopaedic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Catherine Himo Gang
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopaedic Surgery, Weill Cornell Medicine, New York, NY, USA
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Intraoperative Monitoring During Neurosurgical Procedures and Patient Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Clinical Application of Evoked Potentials in the Operation of Cervical Spondylotic Myelopathy with Different Imaging. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4154278. [PMID: 36299827 PMCID: PMC9576426 DOI: 10.1155/2022/4154278] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 01/26/2023]
Abstract
Objective To observe the effects of improvement of cervical spondylotic myelopathy with different imaging signals after cortical somatosensory-evoked potentials on the functional recovery of postoperative patients and the effect of surgery. Methods A total of 60 patients with cervical spondylotic myelopathy who were hospitalized in our hospital from January 2020 to December 2020 were selected and divided into a case group (30 cases) with MRI-indicated changes in intramedullary signals and a control group (30 cases) with MRI-indicated spinal cord changes. Intragroup and intergroup control studies were conducted through general observation indexes, neurological evaluation indexes, imaging, and evoked potential observation indexes. Somatosensory-evoked potentials were performed before operation, 1 week after operation, and 24 weeks after operation, and the JOA score of each patient was obtained before operation, 1 week after operation, and 24 weeks after operation. Results The JOA score of 1 week after operation of the case group is (16.25 ± 1.54) and the control group is (11.89 ± 1.63), and there is a statistically significant difference (P < 0.05). The JOA score of the case group 24 weeks after operation is (25.27 ± 1.03) and the control group is (13.28 ± 1.03), and the difference is statistically significant (P < 0.05). The improvement rate of 1 week after operation and 24 weeks after operation was statistically significant between the two groups (P < 0.05). The case group improvement rate is (70.5 ± 8.72)% and the control group is (40.5 ± 9.81)%, and the difference is statistically significant between the two groups (P < 0.05). Conclusion The preoperative intramedullary signal changes can be used as an effective index for patients with cervical spondylotic myelopathy to use somatosensory-evoked potentials to assess the prognosis of patients after surgery.
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Revilla-Pacheco F, Watanabe S, Rodríguez-Reyes J, Sánchez-Torres C, Shkurovich-Bialik P, Herrada-Pineda T, Rodríguez-Salgado P, Franco-Granillo J, Calderón-Juárez M. Transcranial electric stimulation motor evoked potentials for cervical spine intraoperative monitoring complications: systematic review and illustrative case of cardiac arrest. 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 2022; 31:2723-2732. [PMID: 35790650 DOI: 10.1007/s00586-022-07297-6] [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: 11/03/2021] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE We show a systematic review of known complications during intraoperative neuromonitoring (IONM) using transcranial electric stimulation motor evoked potentials (TES-MEP) on cervical spine surgery, which provides a summary of the main findings. A rare complication during this procedure, cardiac arrest by cardioinhibitory reflex, is also described. METHODS Findings of 523 scientific papers published from 1995 onwards were reviewed in the following databases: CENTRAL, Cochrane Library, Embase, Google Scholar, Ovid, LILACS, PubMed, and Web of Science. This study evaluated only complications on cervical spine surgery undergoing TES-MEP IONM. RESULTS The review of the literature yielded 13 studies on the complications of TES-MEP IONM, from which three were excluded. Five studies are case series; the rest are case reports. Overall, 169 complications on 167 patients were reported in a total of 38,915 patients, a global prevalence of 0.43%. The most common complication was tongue-bite in 129 cases, (76.3% of all complication events). Tongue-bite had a prevalence of 0.33% (CI 95%, 0.28-0.39%) in all patients on TES-MEP IONM. A relatively low prevalence of severe complications was found: cardiac-arrhythmia, bradycardia and seizure, the prevalence of this complications represents only one case in all the sample. Alongside, we report the occurrence of cardiac arrest attributable to TES-MEP IONM. CONCLUSIONS This systematic review shows that TES-MEP is a safe procedure with a very low prevalence of complications. To our best knowledge, asystole is reported for the first time as a complication during TES-MEP IONM.
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Affiliation(s)
| | - Shoko Watanabe
- Department of Neurosurgery, ABC Medical Center, Mexico City, Mexico
| | | | | | | | | | | | | | - Martín Calderón-Juárez
- Plan de Estudios Combinados en Medicina, Faculty of Medicine, National Autonomous University of Mexico, Circuto Escolar 411A, Coyoacán, 04360, Mexico City, Mexico.
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Hobson SL, Yolcu YU, Oishi T, Sebastian AS, Freedman BA, Elder BD, Laughlin RS, Bydon M, Hoffman EM. Estimating Intraoperative Neurophysiological Monitoring Rates for Anterior Cervical Discectomy and Fusion: Are Diagnostic or Procedural Codes Accurate? Int J Spine Surg 2022; 16:208-214. [PMID: 35444031 PMCID: PMC9930663 DOI: 10.14444/8205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The utility of intraoperative neurophysiological monitoring (IONM) is well established for some spine surgeries (eg, intramedullary tumor resection, scoliosis deformity correction), but its benefit for most degenerative spine surgery, including anterior cervical discectomy and fusion (ACDF), remains debated. National datasets provide "big data" approaches to study the impact of IONM on spine surgery outcomes; however, if administrative coding in these datasets misrepresents actual IONM usage, conclusions will be unreliable. The objective of this study was to compare estimated rates (administrative coding) to actual rates (chart review) of IONM for ACDF at our institution and extrapolate findings to estimated rates from 2 national datasets. METHODS Patients were included from 3 administrative coding databases: the authors' single institution database, the Nationwide Inpatient Sample (NIS), and the National Surgical Quality Improvement Program (NSQIP). Estimated and actual institutional rates of IONM during ACDF were determined by administrative codes (International Classification of Diseases [ICD] or Current Procedural Terminology [CPT]) and chart review, respectively. National rates of IONM during ACDF were estimated using the NIS and NSQIP datasets. RESULTS Estimated institutional rates of IONM for ACDF were much higher with CPT than ICD coding (73.2% vs 16.5% in 2019). CPT coding for IONM better approximated actual IONM usage at our institution (74.6% in 2019). Estimated IONM utilization rates for ACDF in national datasets varied widely: 0.76% in CPT-based NSQIP and 18.4% in ICD-based NIS. CONCLUSIONS ICD coding underestimated IONM usage during ACDF at our institution, whereas CPT coding was more accurate. Unfortunately, the CPT-based NSQIP is nearly devoid of IONM codes, as it has not been a collection focus of that surgical registry. ICD-based datasets, such as the NIS, likely fail to accurately capture IONM usage. Multicenter and/or national datasets with accurate IONM utilization data are needed to inform surgeons, insurers, and guideline authors on whether IONM has benefit for various spine surgery types. LEVEL OF EVIDENCE: 4 CLINICAL RELEVANCE Currently available national databases based on administrative codes do not accurately reflect IONM usage.
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Affiliation(s)
- Sandra L. Hobson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA,Present Affiliation: Department of Orthopaedics, Emory University, Atlanta, GA, USA
| | - Yagiz U. Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tatsuya Oishi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Funaba M, Kanchiku T, Yoshida G, Imagama S, Kawabata S, Fujiwara Y, Ando M, Yamada K, Taniguchi S, Iwasaki H, Tadokoro N, Takahashi M, Wada K, Yamamoto N, Shigematsu H, Kobayashi K, Yasuda A, Ushirozako H, Ando K, Hashimoto J, Morito S, Takatani T, Tani T, Matsuyama Y. Efficacy of Intraoperative Neuromonitoring Using Transcranial Motor-Evoked Potentials for Degenerative Cervical Myelopathy: A Prospective Multicenter Study by the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Spine (Phila Pa 1976) 2022; 47:E27-E37. [PMID: 34224513 DOI: 10.1097/brs.0000000000004156] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective multicenter observational study. OBJECTIVE To elucidate the efficacy of transcranial motor-evoked potentials (Tc(E)-MEPs) in degenerative cervical myelopathy (DCM) surgery by comparing cervical spondylotic myelopathy (CSM) to cervical ossification of the posterior longitudinal ligament (OPLL) and investigate the timing of Tc(E)-MEPs alerts and types of interventions affecting surgical outcomes. SUMMARY OF BACKGROUND DATA Although CSM and OPLL are the most commonly encountered diseases of DCM, the benefits of Tc(E)-MEPs for DCM remain unclear and comparisons of these two diseases have not yet been conducted. METHODS We examined the results of Tc(E)-MEPs from 1176 DCM cases (840 CSM /336 OPLL) and compared patients background by disease, preoperative motor deficits, and the type of surgical procedure. We also assessed the efficacy of interventions based on Tc(E)-MEPs alerts. Tc(E)-MEPs alerts were defined as an amplitude reduction of more than 70% below the control waveform. Rescue cases were defined as those in which waveform recovery was achieved after interventions in response to alerts and no postoperative paralysis. RESULTS Overall sensitivity was 57.1%, and sensitivity was higher with OPLL (71.4%) than with CSM (42.9%). The sensitivity of acute onset segmental palsy including C5 palsy was 40% (OPLL/CSM: 66.7%/0%) whereas that of lower limb palsy was 100%. The most common timing of Tc(E)-MEPs alerts was during decompression (63.16%), followed by screw insertion (15.79%). The overall rescue rate was 57.9% (OPLL/CSM: 58.3%/57.1%). CONCLUSION Since Tc(E)-MEPs are excellent for detecting long tract injuries, surgeons need to consider appropriate interventions in response to alerts. The detection of acute onset segmental palsy by Tc(E)-MEPs was partially possible with OPLL, but may still be difficult with CSM. The rescue rate was higher than 50% and appropriate interventions may have prevented postoperative neurological complications.Level of Evidence: 3.
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Affiliation(s)
- Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
| | - Tsukasa Kanchiku
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan
| | - Go Yoshida
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shiro Imagama
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigenori Kawabata
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasushi Fujiwara
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Muneharu Ando
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan
| | - Kei Yamada
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Kurume University, Kurume, Japan
| | - Shinichirou Taniguchi
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan
| | - Hiroshi Iwasaki
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama, Japan
| | - Nobuaki Tadokoro
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Kochi University, Kochi, Japan
| | - Masahito Takahashi
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Kyorin University, Tokyo, Japan
| | - Kanichiro Wada
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Hirosaki University, Hirosaki, Japan
| | - Naoya Yamamoto
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Hideki Shigematsu
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Kazuyoshi Kobayashi
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akimasa Yasuda
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hiroki Ushirozako
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kei Ando
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Hashimoto
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinji Morito
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Kurume University, Kurume, Japan
| | - Tsunenori Takatani
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Division of Central Clinical Laboratory, Nara Medical University, Nara, Japan
| | - Toshikazu Tani
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Kubokawa Hospital, Kochi, Japan
| | - Yukihiro Matsuyama
- The Monitoring Committee of the Japanese Society for Spine Surgery and Related Research, Japan
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Nuwer MR, MacDonald DB, Gertsch J. Monitoring scoliosis and other spinal deformity surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:179-204. [PMID: 35772886 DOI: 10.1016/b978-0-12-819826-1.00014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Surgery to correct a spinal deformity incurs a risk of injury to the spinal cord and roots. Injuries include postoperative paraplegia. Surgery for cervical myelopathy also incurs risk for postoperative motor deficits, as well as nerve injury most commonly at the C5 root. Risks can be mitigated by monitoring the nervous system during surgery. Ideally, monitoring detects an impending injury in time to intervene and correct the impairment before it becomes permanent. Monitoring includes several modalities of testing. Somatosensory evoked potentials measure axonal conduction in the spinal cord posterior columns. This can be checked almost continuously during surgery. Motor evoked potentials measure conduction along the lateral corticospinal tracts. Because motor pathway stimulation often produces a patient movement on the table, these often are tested periodically rather than continuously. Electromyography observes for spontaneous discharges accompanying injuries, and is useful to assess misplacement of pedicle screws. Literature demonstrates the usefulness of these techniques, their association with reducing motor adverse outcomes, and the relative value of the techniques. Neurophysiologic monitoring for scoliosis, kyphosis, and cervical myelopathy surgery are addressed, along with background information about those conditions.
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Affiliation(s)
- Marc R Nuwer
- Departments of Neurology and Clinical Neurophysiology, David Geffen School of Medicine, University of California Los Angeles, and Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States.
| | | | - Jeffrey Gertsch
- Department of Neurology, UC San Diego Health, San Diego, CA, United States
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Weir TB, Usmani MF, Camacho J, Sokolow M, Bruckner J, Jazini E, Jauregui JJ, Gopinath R, Sansur C, Davis R, Koh EY, Banagan KE, Gelb DE, Buraimoh K, Ludwig SC. Effect of Surgical Setting on Cost and Hospital Reported Outcomes for Single-Level Anterior Cervical Discectomy and Fusion. Int J Spine Surg 2021; 15:701-709. [PMID: 34266936 DOI: 10.14444/8092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hospitals seek to reduce costs and improve patient outcomes by decreasing length of stay (LOS), 30-day all-cause readmissions, and preventable complications. We evaluated hospital-reported outcome measures for elective single-level anterior cervical discectomy and fusions (ACDFs) between tertiary (TH) and community hospitals (CH) to determine location-based differences in complications, LOS, and overall costs. METHODS Patients undergoing elective single-level ACDF in a 1-year period were retrospectively reviewed from a physician-driven database from a single medical system consisting of 1 TH and 4 CHs. Adult patients who underwent elective single-level ACDF were included. Patients with trauma, tumor, prior cervical surgery, and infection were excluded. Outcomes measures included all-cause 30-day readmissions, preventable complications, LOS, and hospital costs. RESULTS A total of 301 patients (60 TH, 241 CH) were included. CHs had longer LOS (1.25 ± 0.50 versus 1.08 ± 0.28 days, P = .01). There were no differences in complication and readmission rates between hospital settings. CH, orthopaedic subspecialty, female sex, and myelopathy were predictors for longer LOS. Overall, costs at the TH were significantly higher than at CHs ($17 171 versus $11 737; Δ$ = 5434 ± 3996; P < .0001). For CHs, the total costs of drugs, rooms, supplies, and therapy were significantly higher than at the TH. TH status, orthopaedic subspecialty, and myelopathy were associated with higher costs. CONCLUSION Patients undergoing single-level ACDFs at CHs had longer LOS, but similar complications and readmission rates as those at the TH. However, cost of ACDF was 1.5 times greater in the TH. To improve patient outcomes, optimize value, and reduce hospital costs, modifiable factors for elective ACDFs should be evaluated. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Tristan B Weir
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - M Farooq Usmani
- Department of General Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jael Camacho
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sokolow
- Quality Management Division, University of Maryland Medical System, Baltimore, Maryland
| | - Jacob Bruckner
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Julio J Jauregui
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rohan Gopinath
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randy Davis
- Department of Orthopaedics, University of Maryland Baltimore Washington Medical Center, Baltimore, Maryland
| | - Eugene Y Koh
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kelley E Banagan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel E Gelb
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kendall Buraimoh
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Steven C Ludwig
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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Díaz-Baamonde A, Peláez-Cruz R, Téllez MJ, Chen J, Lara-Reyna J, Ulkatan S. Quadriplegia, an Unusual Outcome After Anterior Cervical Discectomy and Fusion: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00128. [PMID: 34161306 DOI: 10.2106/jbjs.cc.20.00487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
CASE A 68-year-old woman who underwent a C5 to C6 anterior cervical discectomy and fusion (ACDF) surgery presented with new-onset postoperative quadriplegia. During discectomy, intraoperative neurophysiological monitoring alerted of a spinal cord (SC) dysfunction. The surgery was halted, and measures to ensure adequate SC perfusion were initiated. In the next 2-week follow-up, patient's motor deficit progressively improved. CONCLUSIONS We report an unusual and devastating outcome of new-onset quadriplegia after an elective ACDF and highlight the relevance of intraoperative monitoring during cervical spine surgery to early recognize and treat SC impending injury.
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Affiliation(s)
- Alba Díaz-Baamonde
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York
| | - Roberto Peláez-Cruz
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York
| | - Maria J Téllez
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York
| | - Junping Chen
- Department of Anesthesiology, Mount Sinai West Hospital, New York, New York
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Mount Sinai West Hospital, New York, New York
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York
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Austerman RJ, Sulhan S, Steele WJ, Sadrameli SS, Holman PJ, Barber SM. The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:132-140. [PMID: 34296025 DOI: 10.21037/jss-20-679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Several studies have demonstrated the utility of intraoperative neuromonitoring (IOM) including somatosensory evoked potentials (SSEPs), motor-evoked potentials (MEPs), and electromyography (EMG), in decreasing the risk of neurologic injury in spinal deformity procedures. However, there is limited evidence supporting the routine use of IOM in elective posterolateral lumbar fusion (PLF). METHODS The National Inpatient Sample (NIS) was analyzed for the years 2012-2015 to identify patients undergoing elective PLF with (n=22,404) or without (n=111,168) IOM use. Statistical analyses were conducted to assess the impact of IOM on length of stay, total charges, and development of neurologic complications. These analyses controlled for age, gender, race, income percentile, primary expected payer, number of reported comorbidities, hospital teaching status, and hospital size. RESULTS The overall use of IOM in elective PLFs was found to have increased from 14.6% in the year 2012 to 19.3% in 2015. The total charge in hospitalization cost for all patients who received IOM increased from $129,384.72 in 2012 to $146,427.79 in 2015. Overall, the total charge of hospitalization was 11% greater in the IOM group when compared to those patients that did not have IOM (P<0.001). IOM did not have a statistically significant impact on the likelihood of developing a neurological complication. CONCLUSIONS While there may conceivably be benefits to the use of this technology in complex revision fusions or pathologies, we found no meaningful benefit of its application to single-level index PLF for degenerative spine disease.
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Affiliation(s)
- Ryan J Austerman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Suraj Sulhan
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - William J Steele
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Saeed S Sadrameli
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Paul J Holman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
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Intraoperative Neuromonitoring Use Patterns in Degenerative, Nondeformity Cervical Spine Surgery: A Survey of the Cervical Spine Research Society. Clin Spine Surg 2021; 34:E160-E165. [PMID: 32991365 DOI: 10.1097/bsd.0000000000001083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN A cross-sectional survey study. OBJECTIVE To determine the neuromonitoring (NM) usage patterns among cervical spine surgeons when performing degenerative, nondeformity cervical spine surgery. SUMMARY OF BACKGROUND DATA Intraoperative NM is frequently used in spine surgery. Although there is literature to support the use of NM in deformity surgery, its utility in degenerative cervical spine surgery remains unclear. MATERIALS AND METHODS A survey was distributed to members of the Cervical Spine Research Society to assess practice patterns of NM use during degenerative cervical spine surgery. The survey consisted of 17 multiple choice questions. The first 3 questions focus on practice experience. The remaining 14 questions pertain to NM practice patterns in the setting of radiculopathy and myelopathy. RESULTS Significantly more surgeons routinely (>75% of the time) used NM for myelopathy versus radiculopathy (64% vs. 38%, P<0.001). Private practitioners were overall more likely to use NM than academicians (55% vs. 28%, P=0.007 for radiculopathy; 75% vs. 57%, P=0.09 for myelopathy). No significant difference in NM usage was found comparing neurosurgeons and orthopedic spine surgeons. The most commonly cited primary reasons for NM usage were prevention of positioning/hypotension-related neurological complications, and medicolegal protection. CONCLUSIONS Routine NM use during degenerative cervical surgery is significantly more common in myelopathy and is thought to be of more value than in radiculopathy. However, the most common reasons for usage were to provide medicolegal cover and to mitigate neurological complications related to positioning/hypotension, rather than to protect against direct surgical events. These findings contrast the prevailing notion that NM is beneficial in reducing complications related to events occurring in the surgical site when performing spinal deformity correction. We believe that these data provide an important baseline for informing best practice guidelines and further study regarding appropriate NM use for degenerative, nondeformity, cervical spine surgery.
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Philipp LR, Leibold A, Mahtabfar A, Montenegro TS, Gonzalez GA, Harrop JS. Achieving Value in Spine Surgery: 10 Major Cost Contributors. Global Spine J 2021; 11:14S-22S. [PMID: 33890804 PMCID: PMC8076814 DOI: 10.1177/2192568220971288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Narrative Review. OBJECTIVES The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement. METHODS We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive. RESULTS We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing. CONCLUSIONS In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.
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Affiliation(s)
- Lucas R. Philipp
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA,Lucas R. Philipp, Thomas Jefferson University, 909 Walnut St., 3 rd Floor, Department of Neurosurgery, Philadelphia, PA 19107, USA.
| | - Adam Leibold
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Aria Mahtabfar
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thiago S. Montenegro
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Glenn A. Gonzalez
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Modi HN, Goel SA, Desai YJ, Modi PN. Clinical Correlation of Intraoperative Neuromonitoring in 319 Individuals Undergoing Posterior Decompression and Fixation of Spine. Clin Spine Surg 2021; 34:109-118. [PMID: 33003049 DOI: 10.1097/bsd.0000000000001090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/24/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a prospective study. OBJECTIVES To correlate improvement in motor evoked potential (MEP) during spine surgery with postoperative clinical improvement. MATERIALS AND METHODS Three hundred fifty-three patients operated for posterior spinal decompression and fixation surgeries were prospectively selected and followed up. Patients who underwent lumbar, dorsal, and cervical surgeries were grouped into-group A, B, and C, respectively. Intraoperative neuromonitoring was done using MEP with free-running electromyography. Improvements in MEP scores were calculated in percentage. Similarly, postoperative improvement in Oswestry disability index (ODI) and visual analog scale (VAS) scores at 3 months were calculated in percentage. Improvements in MEP scores were correlated with clinical improvement using the Spearman ρ test and the r value was calculated to find out the association. RESULTS Of 353 patients, 319 (250-group A, 38-group B, and 31-group C) were included for the study. VAS and ODI improved significantly from preoperative 8.5±0.8 and 62.9±14.5, to postoperative 2.3±1.1 and 15.9±11.5, respectively, in the entire group. Average preoperative MEP were 127.8±191.0 mV on the right side and 132.3±206.6 mV on the left side, which significantly improved to 163.7±231.2 mV (P=0.0001) and 155.2±219.6 mV (P=0.0001), respectively, showing 157.0% and 178.5% improvement. Correlating MEP improvement with postoperative improvement in ODI showed poor correlation (r=0.088 right and 0.030 left sides). Similarly, correlating MEP improvement with improvement in VAS showed r=0.110 on the right and -0.023 on the left side suggesting poor correlation. Postoperative neurological complications (0.56%) were found in 2 patients in the form of screw malpositioning. CONCLUSIONS Intraoperative neuromonitoring showed significant improvement during posterior decompression and fixation surgery, and reduction in postoperative neurological complication. The study also exhibited significant postoperative clinical improvement. However, improvement in MEP did not correlate with postoperative clinical improvement suggesting that it has no predictive role.
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Affiliation(s)
| | | | | | - Poonam N Modi
- Physiotherapy and Neurophysiology, Zydus Hospital and Healthcare Research Pvt Ltd, Ahmedabad, India
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20
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Neurophysiological monitoring during anterior cervical discectomy and fusion for ossification of the posterior longitudinal ligament. Clin Neurophysiol Pract 2021; 6:56-62. [PMID: 33665517 PMCID: PMC7905394 DOI: 10.1016/j.cnp.2021.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/18/2020] [Accepted: 01/01/2021] [Indexed: 11/23/2022] Open
Abstract
Postoperative neurological complications are not rare in ACDF for OPLL pathology. Multimodal IONM may reduce neurological damage in ACDF surgery for OPLL. IONM and preoperative myelopathy were associated with neurological complications.
Objective This study aimed to investigate the value of intraoperative neurophysiological monitoring (IONM) in anterior cervical spine discectomy with fusion (ACDF) for ossification of the posterior longitudinal ligament (OPLL). Methods Patients who underwent multimodal IONM (transcranial electrical motor-evoked potentials [tcMEP], somatosensory-evoked potentials, and continuous electromyography) for ACDF from 2009 to 2019 were compared to historical controls from 2003 to 2009. The rates of postoperative neurological deficits, neurophysiological warnings, and their characteristics were analyzed. Results Among 196 patients, postoperative neurological deficit rates were 3.79% and 14.06% in the IONM and historical control (non-IONM) groups, respectively (p < 0.05). The use of IONM (OR: 0.139, p = 0.003) and presence of myelopathy (OR: 8.240, p = 0.013) were associated with postoperative neurological complications on multivariate regression. In total, 23 warnings were observed during IONM (17 tcMEP and/or electromyography; six electromyography). Sensitivity and specificity of IONM warnings for detecting neurological complications were 84.2% and 93.7%, respectively. Conclusions IONM, especially multimodal IONM, may be a useful tool to detect neurological damage in ACDF for high-risk conditions such as OPLL with pre-existing myelopathy. Significance The utility of IONM in ACDF for OPLL has not been evaluated due to its rarity. This study supports the use of IONM in cervical OPLL with myelopathy.
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Decruz J, Kaliya-Perumal AK, Wong KHY, Kumar DS, Yang EW, Oh JYL. Neuromonitoring in Cervical Spine Surgery: When Is a Signal Drop Clinically Significant? Asian Spine J 2020; 15:317-323. [PMID: 33260284 PMCID: PMC8217856 DOI: 10.31616/asj.2020.0074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/11/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective cohort study. Purpose To identify the clinical significance of different patterns of intraoperative neuromonitoring (IONM) signal alerts. Overview of Literature IONM is a long-established valuable adjunct to complex spine surgeries. IONM for cervical spine surgery is in the form of somatosensory evoked potential (SSEP) and motor evoked potential (MEP). The efficacy of both modalities (individually or in combination) to detect clinically significant neurological compromise is constantly being debated and requires conclusive suggestions. Methods Clinical and neuromonitoring data of 207 consecutive adult patients who underwent cervical spine surgeries at multiple surgical centers using bimodal IONM were analyzed. Signal changes were divided into three groups. Group 0 had transient signal changes in either MEPs or SSEPs, group 1 had sustained unimodal changes, and group 2 had sustained changes in both MEPs and SSEPs. The incidences of true neurological deficits in each group were recorded. Results A total of 25% (52/207) had IONM signal alerts. Out of these signal drops, 96% (50/52) were considered to be false positives. Groups 0 and 1 had no incidence of neurological deficits, while group 2 had a 29% (2/7) rate of true neurological deficits. The sensitivities of both MEP and SSEP were 100%. SSEP had a specificity of 96.6%, while MEP had a lower specificity at 76.6%. C5 palsy rate was 6%, and there was no correlation with IONM signal alerts (p=0.73). Conclusions This study shows that we can better predict its clinical significance by dividing IONM signal drops into three groups. A sustained, bimodal (MEP and SSEP) signal drop had the highest risk of true neurological deficits and warrants a high level of caution. There were no clear risk factors for false-positive alerts but there was a trend toward patients with cervical myelopathy.
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Affiliation(s)
- Joshua Decruz
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
| | - Arun-Kumar Kaliya-Perumal
- Division of Spine, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - Kevin Ho-Yin Wong
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore
| | | | - Eugene Weiren Yang
- Division of Neurosurgery, Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | - Jacob Yoong-Leong Oh
- Division of Spine, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
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Hatef J, Katzir M, Toop N, Islam M, Clark T, Roscoe C, Khan S, Mendel E. Damned if you monitor, damned if you don't: medical malpractice and intraoperative neuromonitoring for spinal surgery. Neurosurg Focus 2020; 49:E19. [PMID: 33130617 DOI: 10.3171/2020.8.focus20580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to identify trends in medical malpractice litigation related to intraoperative neuromonitoring. METHODS The Westlaw Edge legal research service was queried for malpractice litigation related to neuromonitoring in spine surgery. Cases were reviewed to determine if the plaintiff's assertion of negligence was due to either failure to use neuromonitoring or negligent monitoring. Comparative statistics and a detailed qualitative analysis of the resulting cases were performed. RESULTS Twenty-six cases related to neuromonitoring were identified. Spinal fusion was the procedure in question in all cases, and defendants were nearly evenly divided between orthopedic surgeons and neurosurgeons. Defense verdicts were most common (54%), followed by settlements (27%) and plaintiff verdicts (19%). Settlements resulted in a mean $7,575,000 damage award, while plaintiff verdicts resulted in a mean $4,180,213 damage award. The basis for litigation was failure to monitor in 54% of the cases and negligent monitoring in 46%. There were no significant differences in case outcomes between the two allegations of negligence. CONCLUSIONS The use and interpretation of intraoperative neuromonitoring findings can be the basis for a medical malpractice litigation. Spine surgeons can face malpractice risks by not monitoring when required by the standard of care and by interpreting or reacting to neuromonitoring findings inappropriately.
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Affiliation(s)
- Jeffrey Hatef
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center
| | - Miki Katzir
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center.,5Department of Neurological Surgery, The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Nathaniel Toop
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center
| | - Monica Islam
- 2Section of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University
| | - Trevor Clark
- 3Associate General Counsel, Office of Legal Affairs and Risk Management, The Ohio State University Wexner Medical Center
| | - Catherine Roscoe
- 3Associate General Counsel, Office of Legal Affairs and Risk Management, The Ohio State University Wexner Medical Center
| | - Safdar Khan
- 4Division of Spine Surgery, Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center; and
| | - Ehud Mendel
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center.,5Department of Neurological Surgery, The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
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Guiroy A, Valacco M, Gagliardi M, Cabrera JP, Emmerich J, Willhuber GC, Falavigna A. Barriers of neurophysiology monitoring in spine surgery: Latin America experience. Surg Neurol Int 2020; 11:130. [PMID: 32547817 PMCID: PMC7294159 DOI: 10.25259/sni_44_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/14/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Intraoperative neurophysiological monitoring (IOM) has become valuable in spine surgery. Unfortunately, it is not always available in many spine centers, especially in developing countries. Our aim was to evaluate the accessibility and barriers to IOM in spine surgery in Latin America. Methods: We designed a questionnaire to evaluate the characteristics of surgeons and their opinions on the usefulness of IOM for different spine operations. The survey was sent to 9616 members and registered users of AO Spine Latin America (AOSLA) from August 1, 2019, to August 21, 2019. Major variables studied included nationality, years of experience, specialty (orthopedics or neurosurgery), level of complexity of the hospital, number of spine surgeries performed per year by the spine surgeon, the types of spinal pathologies commonly managed, and how important IOM was to the individual surgeon. General questions to evaluate use included accessibility, limitations of IOM usage, management of IOM changes, and the legal value of IOM. The results were analyzed and compared between neurosurgeon and orthopedics, level of surgeon experience, and country of origin. Results: Questionnaires were answered by 200 members of AOSLA from 16 different countries. The most common responses were obtained from orthopedic surgeons (62%), those with more than 10 years of practice (54%); majority of surgeons performed more than 50 spine surgeries per year (69%) and treated mainly spine degenerative diseases (76%). Most surgeons think that IOM has a real importance during surgeries (92%) and not just a legal value. Although surgeons mostly considered IOM essential to scoliosis surgery in adolescents (70%), thoracolumbar kyphosis correction (68%), and intramedullary tumors (68%), access to IOM was limited to 57% for economic reasons. Of interest, in 64% of cases, where IOM was available and significant change occurred, the actual operative procedures were significantly altered. Conclusion: Despite the fact that 68% of spine surgeons believe IOM to be indispensable for complex spine surgery, cost remains the main barrier to its use/availability in Latin America.
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Affiliation(s)
- Alfredo Guiroy
- Department of Orthopedics, Hospital Español, Mendoza, Argentina
| | - Marcelo Valacco
- Department of Orthopedics, Hospital Churruca Visca, Argentina
| | | | - Juan Pablo Cabrera
- Department of Neurosurgery, Hospital Clinico Regional, Concepcion, Chile
| | - Juan Emmerich
- Department of Neurosurgery, Hospital Español de La Plata, La Plata, Argentina
| | | | - Asdrubal Falavigna
- Department of Neurosurgery, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
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24
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Charalampidis A, Jiang F, Wilson JRF, Badhiwala JH, Brodke DS, Fehlings MG. The Use of Intraoperative Neurophysiological Monitoring in Spine Surgery. Global Spine J 2020; 10:104S-114S. [PMID: 31934514 PMCID: PMC6947672 DOI: 10.1177/2192568219859314] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE To summarize relevant studies regarding the utilization of intraoperative neurophysiological monitoring (IONM) techniques in spine surgery implemented in recent years. METHODS A literature search of the Medline database was performed. Relevant studies from all evidence levels have been included. Titles, abstracts, and reference lists of key articles were included. RESULTS Multimodal intraoperative neurophysiological monitoring (MIONM) has the advantage of compensating for the limitations of each individual technique and seems to be effective and accurate for detecting perioperative neurological injury during spine surgery. CONCLUSION Although there are no prospective studies validating the efficacy of IONM, there is a growing body of evidence supporting its use during spinal surgery. However, the lack of validated protocols to manage intraoperative alerts highlights a critical knowledge gap. Future investigation should focus on developing treatment methodology, validating practice protocols, and synthesizing clinical guidelines.
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Affiliation(s)
- Anastasios Charalampidis
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Fan Jiang
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jamie R. F. Wilson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jetan H. Badhiwala
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst St, Toronto, Ontario M5T2S8, Canada.
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25
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Wilent WB, Ney JP, Balzer J, Donohue ML, Gertsch JH, Holdefer R, Jahangiri FR, Overzet K, Shils J, Vogel R. Letter to the Editor. Intraoperative neurophysiological monitoring and ACDF. J Neurosurg Spine 2020; 32:152-153. [PMID: 31585415 DOI: 10.3171/2019.6.spine19641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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26
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Malik AT, Phillips FM, Retchin S, Xu W, Yu E, Kim J, Khan SN. Refining risk adjustment for bundled payment models in cervical fusions-an analysis of Medicare beneficiaries. Spine J 2019; 19:1706-1713. [PMID: 31226386 DOI: 10.1016/j.spinee.2019.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/05/2019] [Accepted: 06/05/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The current Bundled Payment for Care Improvement model relies on the use of "Diagnosis Related Groups" (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1-3 level vs. >3 level), and cause/indication of surgery (fracture vs. degenerative pathology). PURPOSE To understand factors responsible for cost variation in a 90-day episode of care following cervical fusions. STUDY DESIGN Retrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5). OUTCOME MEASURES To calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473. METHODS The 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement. RESULTS Following application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age <65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (-$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164), >3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (-$7,492) and Iowa (-$3,393) having the lowest reimbursements, as compared with Michigan. CONCLUSIONS The current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.
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Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA.
| | - Frank M Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Sheldon Retchin
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Wendy Xu
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA
| | - Jeffery Kim
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA
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Zileli M, Borkar SA, Sinha S, Reinas R, Alves ÓL, Kim SH, Pawar S, Murali B, Parthiban J. Cervical Spondylotic Myelopathy: Natural Course and the Value of Diagnostic Techniques -WFNS Spine Committee Recommendations. Neurospine 2019; 16:386-402. [PMID: 31607071 PMCID: PMC6790728 DOI: 10.14245/ns.1938240.120] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022] Open
Abstract
Objective This study presents the results of a systematic literature review conducted to determine most up-to-date information on the natural outcome of cervical spondylotic myelopathy (CSM) and the most reliable diagnostic techniques.
Methods A literature search was performed for articles published during the last 10 years.
Results The natural course of patients with cervical stenosis and signs of myelopathy is quite variable. In patients with no symptoms, but significant stenosis, the risk of developing myelopathy with cervical stenosis is approximately 3% per year. Myelopathic signs are useful for the clinical diagnosis of CSM. However, they are not highly sensitive and may be absent in approximately one-fifth of patients with myelopathy. The electrophysiological tests to be used in CSM patients are motor evoked potential (MEP), spinal cord evoked potential, somatosensory evoked potential, and electromyography (EMG). The differential diagnosis of CSM from other neurological conditions can be accomplished by those tests. MEP and EMG monitoring are useful to reduce C5 root palsy during CSM surgery. Notable spinal cord T2 hyperintensity on cervical magnetic resonance imaging (MRI) is correlated with a worse outcome, whereas lighter signal changes may predict better outcomes. T1 hypointensity should be considered a sign of more advanced disease.
Conclusion The natural course of CSM is quite variable. Signal changes on MRI and some electrophysiological tests are valuable adjuncts to diagnosis.
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Affiliation(s)
- Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
| | - Sachin A Borkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sumit Sinha
- Neurosurgery and Spine Services, Paras Hospitals, Gurugram, India
| | - Rui Reinas
- Neurosurgical Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Hospital Lusíadas, Porto, Portugal
| | - Óscar L Alves
- Department of Neurosurgery, Hospital Lusíadas, Porto, Portugal
| | - Se-Hoon Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University Medical Center, Seoul, Korea
| | | | - Bala Murali
- Kauvery Advanced Spine Centre, Chennai, India
| | - Jutty Parthiban
- Department Neurosurgery and Spine Unit, Kovai Medical Center and Hospital, Tamilnadu, India
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28
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Yoshihara H, Pivec R, Naam A. Positioning-Related Neuromonitoring Change During Anterior Cervical Discectomy and Fusion. World Neurosurg 2018; 117:238-241. [DOI: 10.1016/j.wneu.2018.06.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/28/2022]
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Neurophysiological monitoring during cervical spine surgeries: Longitudinal costs and outcomes. Clin Neurophysiol 2018; 129:2245-2251. [PMID: 30216908 DOI: 10.1016/j.clinph.2018.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 08/06/2018] [Accepted: 08/23/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Well-designed longitudinal studies assessing effectiveness of intraoperative neurophysiologic monitoring (IONM) are lacking. We investigate IONM effects on cost and administrative markers for health outcomes in the year after cervical spine surgery. METHODS We identified single-level cervical spine surgeries in commercial claims. We constructed linear regression models estimating the effect of IONM (controlling for patient demographics, pre-operative health, services during index admission) on total spending, neurological complications, readmissions, and outpatient opiate usage in the year following index surgery. RESULTS IONM was associated with increased spending during index admission of $1229 (p = 0.001), but decreased spending post-discharge of $1615 (p = 0.010), for a net - $386 (p = 0.608) for the year after surgery. Shorter length of stay (0.116 days, p = 0.004) and fewer readmissions (20.5 per thousand, p = 0.036) accounted for some post-discharge savings. IONM was associated with decreased rates of nervous system complications (4/1000, p = 0.048) and post-discharge opiate use (17 prescriptions/1000, p = 0.050) in the year after index admission. CONCLUSIONS IONM was associated with administrative markers suggesting improved health outcomes after cervical spine surgery without greater costs for the year. SIGNIFICANCE This study suggests IONM may have lasting health and cost benefits.
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30
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Daniel JW, Botelho RV, Milano JB, Dantas FR, Onishi FJ, Neto ER, Bertolini EDF, Borgheresi MAD, Joaquim AF. Intraoperative Neurophysiological Monitoring in Spine Surgery: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2018; 43:1154-1160. [PMID: 30063222 DOI: 10.1097/brs.0000000000002575] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic literature review and meta-analysis. OBJECTIVE The objective of this systematic literature review was to evaluate if intraoperative neurophysiological monitoring (IONM) can prevent neurological injury during spinal operative surgical procedures. SUMMARY OF BACKGROUND DATA IONM seems to have presumable positive effects in identifying neurological deficits. However, the role of IONM in the decrease of new neurological deficits remains unclear. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and Meta-analysis, we reviewed clinical comparative studies who evaluate the rate of new neurological events in patients who had a spinal surgery with and without IONM. Studies were then classified according to their level of evidence. Methodological quality was assessed according to methodological index for non-randomized studies instrument. RESULTS Six studies were evaluated comparing neurological events with and without IONM use by the random effects model. There was a great statistical heterogeneity. The pooled odds ratio (OR) was 0.72 {0.71; 1.79}, P = 0.4584. A specific analysis was done for two studies reporting the results of IONM for spinal surgery of intramedullary lesions. The OR was 0.1993 (0.0384; 1.0350), P = 0.0550. CONCLUSION IONM did not result into fewer neurological events with the obtained evidence of the included studies. For intramedullary lesions, there was a trend to fewer neurological events in patients who underwent surgery with IONM. Further prospective randomized studies are necessary to clarify the indications of IONM in spinal surgeries. LEVEL OF EVIDENCE 2.
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Affiliation(s)
| | | | | | | | - Franz Jooji Onishi
- Neurosurgeon - Federal University of São Paulo (UNIFESP), São Paulo-SP, Brazil
| | - Eloy Rusafa Neto
- Neurosurgeon - University of São Paulo (USP), São Paulo-SP, Brazil
| | | | | | - Andrei Fernandes Joaquim
- Neurosurgeon - State University of Campinas (UNICAMP), Campinas-SP, Brazil
- A document from the Spine Department - Brazilian Society of Neurosurgery
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Laratta JL, Shillingford JN, Ha A, Lombardi JM, Reddy HP, Saifi C, Ludwig SC, Lehman RA, Lenke LG. Utilization of intraoperative neuromonitoring throughout the United States over a recent decade: an analysis of the nationwide inpatient sample. JOURNAL OF SPINE SURGERY (HONG KONG) 2018; 4:211-219. [PMID: 30069509 PMCID: PMC6046319 DOI: 10.21037/jss.2018.04.05] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/14/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND To identify temporal changes to the demographics and utilization of intraoperative neuromonitoring (IONM) throughout the United States (U.S.). METHODS The National Inpatient Sample (NIS) database was queried for IONM of central and peripheral nervous electrical activity (ICD-9-CM 00.94) between 2008 and 2014. The NIS database represents a 20% sample of discharges from U.S. Hospitals, weighted to provide national estimates. Demographic and economic data were obtained which included the annual number of surgeries, age, sex, insurance type, location, and frequency of routine discharge. RESULTS The estimated use of IONM of central and peripheral nervous electrical activity increased 296%, from 31,762 cases in 2008 to 125,835 cases in 2014. Based on payer type, privately insured patients (45.0%), rather than Medicare (36.8%) or Medicaid patients (9.2%), were more likely to undergo IONM during spinal procedures. When stratifying by median income for patient zip code, there was a substantial difference in the rates of IONM between low (19.9%) and high-income groups (78.1%). IONM was significantly more likely to be utilized at urban teaching hospitals (72.9%) rather than nonteaching hospitals (25.0%) or rural centers (2.2%). CONCLUSIONS Over the last decade, there has been a massive increase of 296% in utilization of IONM during spine surgery. This is likely due to its proven benefit in reducing neurologic morbidity in spinal deformity surgery, while introducing minimal additional risk. While IONM may improve patient care, it is still rather isolated to teaching hospitals and patients from higher income zip codes.
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Affiliation(s)
- Joseph L. Laratta
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Jamal N. Shillingford
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Alex Ha
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Joseph M. Lombardi
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Hemant P. Reddy
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Comron Saifi
- Penn Orthopaedics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Steven C. Ludwig
- Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Ronald A. Lehman
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Lawrence G. Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
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Liu Y, Tian L, Raj MS, Cotton M, Ma Y, Ma S, McGrane B, Pendharkar AV, Dahaleh N, Olson L, Luan H, Block O, Suleski B, Zhou Y, Jayaraman C, Koski T, Aranyosi AJ, Wright JA, Jayaraman A, Huang Y, Ghaffari R, Kliot M, Rogers JA. Intraoperative monitoring of neuromuscular function with soft, skin-mounted wireless devices. NPJ Digit Med 2018; 1. [PMID: 30882044 PMCID: PMC6419749 DOI: 10.1038/s41746-018-0023-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Peripheral nerves are often vulnerable to damage during surgeries, with risks of significant pain, loss of motor function, and reduced quality of life for the patient. Intraoperative methods for monitoring nerve activity are effective, but conventional systems rely on bench-top data acquisition tools with hard–wired connections to electrode leads that must be placed percutaneously inside target muscle tissue. These approaches are time and skill intensive and therefore costly to an extent that precludes their use in many important scenarios. Here we report a soft, skin-mounted monitoring system that measures, stores, and wirelessly transmits electrical signals and physical movement associated with muscle activity, continuously and in real-time during neurosurgical procedures on the peripheral, spinal, and cranial nerves. Surface electromyography and motion measurements can be performed non-invasively in this manner on nearly any muscle location, thereby offering many important advantages in usability and cost, with signal fidelity that matches that of the current clinical standard of care for decision making. These results could significantly improve accessibility of intraoperative monitoring across a broad range of neurosurgical procedures, with associated enhancements in patient outcomes. A small skin-mounted biosensing device accurately and non-invasively monitors neuromuscular activity in real-time during surgery. With many surgical procedures there is a risk of nerve damage. Although this is often temporary, in some cases it can significantly affect patients’ quality of life. Existing monitoring systems that rely on the accurate placement of needle electrodes into target nerves are cumbersome and expensive. The device developed by a team led by John Rogers, at Northwestern University, and Michel Kliot, at Stanford University, can easily be accommodated to any part of the body to monitor muscle activity in response to nerve impulses and stimulation during surgery. Furthermore, it can wirelessly transmit signals of comparable quality to needle-based systems. These devices could not only increase the use of intraoperative monitoring in hospitals but also contribute to make surgery safer.
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Affiliation(s)
- Yuhao Liu
- Department of Materials Science and Engineering, Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Limei Tian
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | | | - Matthew Cotton
- Department of Neurosurgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | - Yinji Ma
- Department of Engineering Mechanics, AML, Center for Mechanics and Materials, Tsinghua University, 100084 Beijing, China.,Department of Civil and Environmental Engineering, Mechanical Engineering, and Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Siyi Ma
- Department of Materials Science and Engineering, Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | | | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Nader Dahaleh
- Department of Neurosurgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | | | - Haiwen Luan
- Department of Civil and Environmental Engineering, Mechanical Engineering, and Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Orin Block
- Department of Neurosurgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | | | - Yadong Zhou
- Department of Civil and Environmental Engineering, Mechanical Engineering, and Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA.,Department of Engineering Mechanics, Southeast University, 210096 Nanjing, China
| | - Chandrasekaran Jayaraman
- Max Nader Lab for Rehabilitation Technologies and Outcomes Research, Center for Bionic Medicine, Rehabilitation Institute of Chicago, Chicago, IL 60611, USA.,Departments of Physical Medicine & Rehabilitation and Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - Tyler Koski
- Department of Neurosurgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | | | | | - Arun Jayaraman
- Max Nader Lab for Rehabilitation Technologies and Outcomes Research, Center for Bionic Medicine, Rehabilitation Institute of Chicago, Chicago, IL 60611, USA.,Departments of Physical Medicine & Rehabilitation and Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - Yonggang Huang
- Department of Civil and Environmental Engineering, Mechanical Engineering, and Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA.,Center for Bio-Integrated Electronics, Departments of Materials Science and Engineering, Biomedical Engineering, Chemistry, Mechanical Engineering, Electrical Engineering and Computer Science, Neurological Surgery, Simpson Querrey Institute for Nano/Biotechnology, McCormick School of Engineering, Feinberg School of Medicine, Northwestern University, Evanston, IL 60208, USA
| | - Roozbeh Ghaffari
- MC10 Inc., Lexington, MA 02421, USA.,Center for Bio-Integrated Electronics, Departments of Materials Science and Engineering, Biomedical Engineering, Chemistry, Mechanical Engineering, Electrical Engineering and Computer Science, Neurological Surgery, Simpson Querrey Institute for Nano/Biotechnology, McCormick School of Engineering, Feinberg School of Medicine, Northwestern University, Evanston, IL 60208, USA
| | - Michel Kliot
- Department of Neurosurgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - John A Rogers
- Department of Materials Science and Engineering, Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA.,Center for Bio-Integrated Electronics, Departments of Materials Science and Engineering, Biomedical Engineering, Chemistry, Mechanical Engineering, Electrical Engineering and Computer Science, Neurological Surgery, Simpson Querrey Institute for Nano/Biotechnology, McCormick School of Engineering, Feinberg School of Medicine, Northwestern University, Evanston, IL 60208, USA
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Doan A, Vogel R. TO THE EDITOR. Spine (Phila Pa 1976) 2017; 42:E991. [PMID: 28538592 DOI: 10.1097/brs.0000000000002249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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TO THE EDITOR. Spine (Phila Pa 1976) 2017; 42:E565. [PMID: 28441299 DOI: 10.1097/brs.0000000000002127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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TO THE EDITOR. Spine (Phila Pa 1976) 2017; 42:E564-E565. [PMID: 28441298 DOI: 10.1097/brs.0000000000002126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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TO THE EDITOR. Spine (Phila Pa 1976) 2017; 42:E564. [PMID: 28441297 DOI: 10.1097/brs.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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