Multimodal intraoperative monitoring during reduction of spine burst fracture and dislocation prevents neurologic injury

Accuracy of Intraoperative Neuromonitoring in the Diagnosis of Intraoperative Neurological Decline in the Setting of Spinal Surgery-A Systematic Review and Meta-Analysis

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.

Intraoperative Transcranial Electrical Motor Evoked Potential (TceMEP) as a Therapeutic Tool in Spine Surgery: A Case Series Report

We report two cases of unilateral loss of TceMEP secondary to spinal instrumentation errors and the subsequent recovery of TceMEP responses following prompt intervention. During the period of TceMEP loss, there were no concomitant SSEP changes beyond the threshold criteria. Postoperative physical examination revealed normal strength and motion in the affected extremities in both patients. These cases illustrate that in addition to being a reliable intraoperative diagnostic tool, TceMEP monitoring displays therapeutic usefulness in appraising corrective actions to the existential risk of neurological injuries.

Zina percutaneous screw fixation combined with endoscopic lumbar intervertebral fusion under intraoperative neuromonitoring: A case report

INTRODUCTION

Traditional open discectomy and intervertebral fusion surgery is the common strategy for lumbar disc herniation (LDH). However, it has the disadvantages of long recovery time and severe paravertebral soft tissue injury. Zina percutaneous screw fixation combined with endoscopic lumbar intervertebral fusion (ZELIF), as a novel minimally invasive surgical technique for LDH, has the advantages in quicker recovery, less soft tissue destruction, shorter hospital stays and less pain. We report a novel technique of ZELIF under intraoperative neuromonitoring (INM) for the treatment of LDH.

PATIENT CONCERNS

A 51-year-old male presented to our hospital with left lower extremity pain and numbness for 1 year.

DIAGNOSIS

Lumbar disc herniation (LDH).

INTERVENTIONS

This patient was treated with Zina percutaneous screw fixation combined with endoscopic neural decompression, endplate preparation, and intervertebral fusion through Kambin's triangle. Each step of the operation was performed under INM.

OUTCOMES

The follow-up period lasted 12 months; the hospitalization lasted 4 nights; the blood loss volume was 65 ml, and the time of operation was 266 min. INM showed no neurological damage during the surgery. No surgical complications, including neurological deterioration, cage migration, non-union, instrumentation failure or revision operation, were observed during the follow-up period. Visual Analogue Scale (VAS) score reduced from 7 to 1; the Oswestry Disability Index (ODI) decreased from 43 to 14; the EQ-5D score was 10 preoperatively and 15 at the final follow-up visit; the Physical Component Summary of the 36-Item Short Form Health Survey (SF-36) was 48 preoperatively and 49 at the last follow up visit; the SF-36 Mental Component Summary was 47 before surgery and decreased to 41 postoperatively.

CONCLUSION

ZELIF under INM may represent a feasible, safe and effective alternative to endoscopic intervertebral fusion and percutaneous screw fixation, for decompressing the lumbar's exiting nerve root directly with minimal invasion in selected patients.

Neurological deterioration as a result of improper neck position detected by intraoperative neurophysiological monitoring in a cervical stenosis patient: A case report

RATIONALE

Intraoperative neurophysiological monitoring (IONM) is widely used in spinal surgeries to prevent iatrogenic spinal cord injury (SCI). Most surgeons focus on avoiding neurological compromise intraoperatively, while ignoring the possibility of nerve damage preoperatively, such as neck positioning. Thus, this study aims to report a case with transient neurological deterioration due to improper neck position detected by IONM during cervical surgery.

PATIENT CONCERNS

A 63-year-old male patient had been suffering from hypoesthesia of the upper and lower extremities for three years.

DIAGNOSES

Severe cervical stenosis (C5-C7) and cervical ossification of a posterior longitudinal ligament.

INTERVENTIONS

The cervical stenosis patient underwent an anterior cervical corpectomy decompression and fusion (ACDF) surgery with the assistance of IONM. When the lesion segment was exposed, the SSEP and MEP suddenly elicited difficulty indicating that the patient may have developed SCI. All the technical causes of IONM events were eliminated, and the surgeon suspended operation immediately and suspected that the IONM alerts were caused by cervical SCI due to the improper position of the neck. Subsequently, the surgeon repositioned the neck of the patient by using a thinner shoulders pad.

OUTCOMES

At the end of the operation, the MEP and SSEP signals gradually returned to 75% and 80% of the baseline, respectively. Postoperatively, the muscle strength of bilateral biceps decreased from grade IV to grade III. Besides, the sensory disturbance of both upper extremities aggravated. However, the muscle power and hypoesthesia were significantly improved after three months of neurotrophic therapy and rehabilitation training, and no complications of nerve injury were found at the last follow-up visit.

LESSONS

IONM, consisting of SSEP and MEP, should be applied throughout ACDF surgery from the neck positioning to suture incisions. Besides, in the ward 1to 2 days before operation, it is necessary for conscious patients with severe cervical stenosis to simulate the intraoperative neck position. If the conscious patients present signs of nerve damage, they can adjust the neck position immediately until the neurological symptoms relieve. Therefore, intraoperatively, the unconscious patient can be placed in a neck position that was confirmed preoperatively to prevent SCI.

Comparative evaluation of posterior percutaneous endoscopy cervical discectomy using a 3.7 mm endoscope and a 6.9 mm endoscope for cervical disc herniation: a retrospective comparative cohort study

Background

Posterior percutaneous endoscopy cervical discectomy (p-PECD) is an effective strategy for the treatment of cervical diseases, with a working cannula ranging from 3.7 mm to 6.9 mm in diameter. However, to date, no studies have been performed to compare the clinical outcomes of the use of endoscopes with different diameters in cervical disc herniation (CDH) patients. The purpose of this study was to compare the clinical outcomes of patients with unilateral CDH treated with p-PECD using a 3.7 mm endoscope and a 6.9 mm endoscope.

Methods

From January 2016 to June 2018, a total of 28 consecutive patients with single-level CDH who received p-PECD using either the 3.7 mm or the 6.9 mm endoscope were enrolled. The clinical results, including the surgical duration, hospitalization, visual analog scale (VAS) score and modified MacNab criteria, were evaluated. Cervical fluoroscopy, CT, and MRI were also performed during follow-up.

Results

Tthere was a significant difference in regard to the average identification time of the “V” point (18.608 ± 3.7607 min vs. 11.256 ± 2.7161 min, p < 0.001) and the mean removal time of the overlying tissue (16.650 ± 4.1730 min vs. 12.712 ± 3.3079 min, p < 0.05) for the use of the 3.7 mm endoscope and the 6.9 mm endoscope, respectively. The postoperative VAS and MacNab scores of the two endoscopes were significantly improved compared with those the preoperative scores (p < 0.05).

Conclusion

The application of both the 3.7 mm endoscope and 6.9 mm endoscope represent an effective method for the treatment of CDH in selected patients, and no significant difference can be observed in the clinical outcomes of the endoscopes. The 6.9 mm endoscope shows superiority to the 3.7 mm endoscope in terms of the efficiency of “V” point identification, the removal of overlying soft tissue and the prevention of spinal cord injury. However, the 6.9 mm endoscope may be inferior to the 3.7 mm endoscope in regards to anterior foraminal decompression due to its large diameter; this result needs to be further evaluated with the support of a large number of randomized controlled trials.

A novel computer navigation model guided unilateral percutaneous vertebroplasty for vertebral compression fracture: A case report

RATIONAL

Vertebral compression fracture (VCF) is one of the most common diseases in spinal surgery. Traditional percutaneous vertebroplasty (PVP) under fluoroscopy is an effective method to treat vertebral compression fracture. However, there is still a risk of vascular nerve injury and infection caused by inaccurate or repeated puncture. Therefore, the purpose of this paper was to assess the accuracy of unilateral PVP guided by screw view model of navigation (SVMN) for VCF.

PATIENT CONCERNS

A 59-year-old female patient suffered high falling injury, and with back pain as its main clinical symptom.

DIAGNOSES

The patient was diagnosed with a L1 VCF.

INTERVENTIONS

We placed the puncture needle under the guidance of SVMN to reach the ideal position designed before operation, and then injected the bone cement to complete the percutaneous kyphoplasty (PKP).

OUTCOMES

The operative time was 29.5 minutes, the puncture time was 1 time, the fluoroscopy time was 2.9 minutes, and the bone cement distribution was satisfactory. VAS and ODI scores were significant improved postoperatively. No surgical complications, including neurovascular injury and infection, were observed during 28-month follow up.

LESSONS

The SVMN guided percutaneous puncture needle insertion in PKP operation for VCF is an effective and safety technique. Besides, the SVMN has also been a contributor to reduce radiation doses and replace conventional fluoroscopy.

Treatment of Thoracolumbar Fractures Through Different Short Segment Pedicle Screw Fixation Techniques: A Finite Element Analysis

Objective

To compare the von Mises stresses of the pedicle screw system and the displacement of injured vertebrae using 3‐D finite element analysis, and to evaluate the curative effect of the pedicle screw system.

Methods

Finite element methods were used for biomechanical comparison of four posterior short segment pedicle screw fixation techniques. The different pedicle screw models are traditional trajectory (TT), Universal Spine System (USS), cortical bone trajectory (CBT), and CBT at the cranial level and pedicle screw (PS) at the caudal level (UP‐CBT). The stress distribution of the screws and connecting rods under different working conditions and the displacement of the injured vertebrae were compared and analyzed.

Results

After the pedicle screw system was fixed, the stress under vertical compression was mainly concentrated at the proximal end of the screw, while the stress was mainly concentrated on the connecting rod during flexion, extension, lateral flexion, and rotation. The TT group had the greatest stress during the flexion, extension, and left and right rotation. The UP‐CBT group was most stressed when the left and right sides were flexed; the stress of the USS screw system was less than that of the other three models during flexion, lateral flexion, and rotation. The maximum von Mises stress values of pedicle screws in all exercise states were 556.2, 340.7, 458.1, and 533.4 MPa, respectively. In the USS group, the displacement of the injured vertebra was small in the flexion, and the left and right lateral flexion and the right rotation were higher than in the TT group and the CBT group. The maximum displacements of the injured vertebrae in all motion states were 1.679, 1.604, 1.752, and 1.777 mm, respectively.

Conclusion

Universal Spine System pedicle screws are relatively less stressed under different working conditions, the risk of breakage is small, and the model is relatively stable; CBT screws do not exhibit better mechanical properties than conventional pedicle screws and USS pedicle screws.

Multimodal intraoperative monitoring during surgical correction of scoliosis to avoid neurologic damage

The purpose of this study was to evaluate the application of multimodal intraoperative monitoring (MIOM) system in patients with congenital scoliosis (CS) and adolescent idiopathic scoliosis (AIS).Twelve patients who underwent posterior surgical correction of scoliosis for CS and AIS from June 2014 to July 2018 were enrolled in this study. During the operation, we monitored the functional status of the spinal cord by MIOM. An abnormal somatosensory evoked potential was defined as a prolonged latency of more than 10% or a peak-to-peak amplitude decline of more than 50% when compared to baseline. An abnormal transcranial motor evoked potential (TcMEP) was defined as a TcMEP amplitude decrease of more than 50%. A normal triggered electromyography response, which presented with the absence of an electrical response on stimulation at 8.2 mA, indicated that the pedicle screw was not in contact with the spinal cord or nerve root.A total of 12 patients underwent MIOM surgery, of which 9 patients with negative MIOM had no significant deterioration of neurological function postoperatively, and exhibited satisfactory surgical correction of scoliosis during follow-ups. However, the remaining 3 patients suffered from MIOM events, 2 patients had normal neurological function, and 1 patient had deteriorated neurological function postoperatively.Using MIOM in CS and AIS surgery could promptly detect iatrogenic neurological injury at the early stage. Therefore, rapid response by appropriate intraoperative interventions can be taken to minimize the injury. Besides, stable MIOM recordings encourage surgeons to correct scoliosis even when the Cobb angle of scoliosis was extremely large.

Screw view model of navigation in posterior corrective surgery for adolescent idiopathic scoliosis: A case report and technique note

RATIONALE

The purpose of this study is to introduce the application of screw view model of navigation (SVMN) for adolescent idiopathic scoliosis (AIS). It is a challenge to insert pedicle screw into the vertebral body of scoliosis, and the misplaced screw may lead to neurovascular injury. In order to minimize surgical complications, we used a novel method of SVMN technology to facilitate pedicle screw insertion.

PATIENT CONCERNS

Her mother brought her to our outpatient department upon noticing the girl's different heights of shoulders and unbalance of the trunk.

DIAGNOSES

She was diagnosed with AIS and syringomyelia.

INTERVENTIONS

We used an SVMN technology to assist pedicle screw insertion and correction surgery in this 20-year-old patient.

OUTCOMES

This study indicates that the SVMN could obtain a satisfactory surgical effect for AIS. The Cobb angle of segmental scoliosis (T7-L2) was 55° before surgery, and 3.5° after surgery, and the rate of correction was 93.6%. The segmental kyphosis (T7-L1) was 56.8° preoperatively and 32° postoperatively with the rate of correction of 43.6%. The distance between the center sacral vertical line (CSVL) and the C7 plumb line (CPL) was reduced from 56.2 mm to 0.2 mm, and the sagittal imbalance of 35.8 mm was improved to 3.5 mm. In addition, the misplacement of pedicle screws, the volume of blood loss, the operation time, and surgical complications were also recorded. The follow-up duration was 33 months.

LESSONS

The utilization of SVMN in AIS might reduce the incidence of screw misplacement and avoid neurovascular damage, as well as a satisfactory correction. The application of SVMN for AIS is an efficacious and safe method.

A novel computer navigation method for accurate percutaneous sacroiliac screw implantation: A technical note and literature review

The purpose of this study was to assess the accuracy of percutaneous sacroiliac screw (PSS) placement assisted by screw view model of navigation system for treatment of sacroiliac fractures.Data pertaining to 18 consecutive patients with posterior pelvic ring fracture who received sacroiliac screw fixation between January 2015 and July 2018 at the Second Hospital of Jilin University were retrospectively analyzed. Kirschner wires were placed under the guidance of navigation's screw view mode. The position of the screws was evaluated by computed tomography (CT) scan postoperatively. Fracture dislocation of sacroiliac joint was measured in axial, sagittal, and coronal views of 3 dimensional (3D) CT images preoperatively, postoperatively and at the last follow-up visit. The duration of trajectory planning, guide wire implantation time, screw placement time, intraoperative blood loss, and incidence of screw loosening and clinical complications were also assessed.A total of 27 screws were placed unilaterally or bilaterally into segments S1 or S2. Screw placement was rated as excellent for 88.9% of screws (n = 24), good for 7.4% (n = 2), and poor for 3.7% (n = 1). Preoperatively, the average fracture dislocation of sacroiliac joint on axial, sagittal, and coronal views was 14.3 mm, 9.6 mm, and 7.4 mm, respectively, and the corresponding postoperative figures were 5.6 mm, 3.2 mm, 4.1 mm, respectively. The corresponding correction rates were 60.8%, 66.7%, and 44.6%, respectively. The mean duration of trajectory planning was 6.5 min (2.7-8.9 min). Mean screw implantation time was 32 min (range, 20-53 min), and the mean guide wire implantation time was 3.7 min (range, 2.1-5.3 min). No clinical complications such as neurovascular injury, infection or screw loosening were observed on follow-up.The PSS placement under guidance of screw view model of navigation is a convenient, safe and reliable method.

Accuracy and safety of percutaneous periacetabular screw insertion using screw view model of navigation in acetabular fracture: A case report

RATIONALE

The purpose of this study was to estimate the efficacy and safety of percutaneous periacetabular screw (PPS) insertion assisted by screw view model of navigation (SVMN) to treat fracture of acetabulum.

PATIENT CONCERNS

A 61-year-old male patient was injured in a motorcycle accident, which caused pain, swelling, deformity and limited mobility on his right hip.

DIAGNOSES

He was diagnosed with fracture of acetabulum.

INTERVENTIONS

We used PPS insertion assisted by SVMN to treat fracture of acetabulum in this patient.

OUTCOMES

The follow up lasted 24 months. Totally 2 screws were inserted into anterior and posterior column of acetabulum respectively and both of them displayed grade 0. Compared with the preoperative gap and step of fracture displacement, the postoperative ones were significantly reduced. It took 11.7 minutes for designing the screws, 6.7 minutes for implanting the guide wire, and 45.5 minutes for placing the screws. Intraoperative blood loss was 29 mL and total fluoroscopic time was 4.1 minutes. No clinical complications such as nerve vascular injury, infection and screw loosening were found after the operation.

LESSONS

The study indicated that SVMN is favorable to the PPS insertion for acetabular fracture. Our lesson is that the relative position between the acetabular and the patient tracker must be static to ensure the accuracy of the entire system throughout the operation.