Development of Consensus-Based Best Practice Guidelines for the Perioperative and Postoperative Care of Pediatric Patients With Spinal Deformity and Programmable Implanted Devices

STUDY DESIGN

Modified Delphi consensus study.

OBJECTIVE

To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the perioperative period are not available.

METHODS

A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuroelectrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on a literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculoperitoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologist participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of 3 survey rounds and 1 virtual meeting were conducted.

RESULTS

Consensus was reached on 39 total postulates across 6 IPD types. Postulates addressed general spine surgery considerations, the use of intraoperative monitoring and cautery, the use of magnetically controlled growing rods (MCGRs), and the use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4% to 100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types.

CONCLUSION

Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. The final postulates from this study can inform the perioperative and postoperative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs.

LEVEL OF EVIDENCE

V-Expert opinion.

Brazilian Society of Otology task force - cochlear implant ‒ recommendations based on strength of evidence

OBJECTIVE

To make evidence-based recommendations for the indications and complications of Cochlear Implant (CI) surgery in adults and children.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on cochlear implantation were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) Evaluation of candidate patients and indications for CI surgery; (2) CI surgery - techniques and complications.

CONCLUSIONS

CI is a safe device for auditory rehabilitation of patients with severe-to-profound hearing loss. In recent years, indications for unilateral hearing loss and vestibular schwannoma have been expanded, with encouraging results. However, for a successful surgery, commitment of family members and patients in the hearing rehabilitation process is essential.

Risk of Monopolar Electrosurgery in Cochlear Implant Recipients is Nominal: Evidence to Guide Clinical Practice

OBJECTIVE

Comprehensively assess the prevalence of monopolar electrosurgery-related device complications among cochlear implant (CI) recipients.

STUDY DESIGN

Multifaceted retrospective review and survey.

SETTING

Tertiary medical center.

METHODS

Multifaceted approach including: (i) review of the current literature; (ii) historical review of institutional data from an academic, tertiary CI center; (iii) review of industry data provided by 3 Food and Drug Administration-approved CI manufacturers; and (iv) survey of high-volume CI centers.

RESULTS

Literature review identified 9 human studies, detailing 84 devices with 199 episodes of device-cautery exposure. From studies reporting on patients records, no implant showed evidence of damage after exposure. One cadaveric study using dental cautery reported 1 episode of device damage. Review of institutional records did not identify any CI damage in 84 instances of exposure. Data from the 3 major implant manufacturers showed a single report of damage that could be reasonably linked to monopolar electrosurgery, out of a possible 689,426 CIs. Last, a survey of 8 high-volume CI centers did not identify any adverse events associated with monopolar cautery.

CONCLUSION

These data estimate the risk of adverse device-related events or tissue injury to be extraordinarily low. Short of operating in immediate proximity to the CI (ie, the ipsilateral temporoparietal scalp), these data indicate that monopolar electrosurgery can be used in the body and the head-and-neck of CI recipients with nominal risk. These findings may guide decision-making in cases that are optimally or preferably performed with monopolar electrocautery and can be used to counsel CI patients following inadvertent exposures.

Use of monopolar cautery in patient with a vagal nerve stimulator during neuromuscular scoliosis surgery

It is a historic and common practice while performing spine surgery on patients with a VNS has been to have the patient's neurologist turn off the VNS generator in the pre-operative anesthetic care unit and to use bipolar rather than monopolar electrocautery. Here we report a case of a 16-year-old male patient with cerebral palsy and refractory epilepsy managed with an implanted VNS who had scoliosis surgery (and subsequent hip surgery) conducted with the use of monopolar cautery. Although VNS manufacturer guidelines suggest that monopolar cautery should be avoided, perioperative care providers should consider its selective use in high-risk instances (with greater risks of morbidity and mortality due to blood loss which outweigh the risk of surgical re-insertion of a VNS) such as cardiac or major orthopedic surgery. Considering the number of patients with VNS devices presenting for major orthopedic surgery is increasing, it is important to have an approach and strategy for perioperative management of VNS devices.

Monopolar Electrosurgery With Cochlear Implants

OBJECTIVE

To evaluate safety of monopolar electrosurgery (MES) in patients with cochlear implants (CIs) by reporting outcomes of a series of patients who underwent MES after CI.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Patients with indwelling CI subsequently undergoing surgery with operative note specifically detailing MES use.

MAIN OUTCOME MEASURES

Adverse outcomes in post-operative audiology/otolaryngology documentation; speech recognition scores.

RESULTS

Thirty-five patients (10 with bilateral CI) experienced 63 unique MES exposure events, 85.7% below and 14.3% above the clavicle. No adverse events or decreased performance due to MES use were reported for any patient. Pre- and immediate postoperative speech recognition scores were not significantly different for patients using either consonant-nucleus-consonant (CNC; n = 23, 68%-66%, p = 0.80) or AzBio (n = 15, 82%-88%, p = 0.60). For individual CNC performance, 21 (91%) patients demonstrated stability, 1 improved >15%, and 1 declined >15%, although this patient had become a non-user due to magnet issues and, after resolution of these issues, exceeded baseline pre-operative score. For individual AzBio performance, 12 (80%) patients demonstrated stability, 3 improved >15%, and none declined >15%.

CONCLUSIONS

No adverse events resulted from MES use in CI patients. Given the increased prevalence and expansion of indications for CIs, and widespread utility of MES, we suggest clarification and improved guidance from device manufacturers regarding safety and use of MES for patients with these devices. We hope that data regarding electrosurgery exposure events will better inform clinician decision-making with regards to relative benefits and risks for MES use for CI patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:933-937, 2023.

Monopolar Cautery Use in Pediatric Cochlear Implant Users

OBJECTIVES

To determine the incidence and impact of monopolar cautery use in a cohort of pediatric cochlear implant (CI) users.

STUDY DESIGN

Case series from a retrospective chart review and a systematic review of the literature.

SETTING

Tertiary academic referral center.

METHODS

CI patient charts from 2012 to 2021 were reviewed from a single pediatric hospital system to determine if monopolar cautery was used during a subsequent surgical procedure. In addition, a systematic review of the literature was performed to identify additional, relevant patients. Postoperative CI function was the primary outcome measure.

RESULTS

In total, 190 patients underwent a surgical procedure following cochlear implantation in a single pediatric hospital system. Fifteen patients (7.9%) and 17 distinct surgical procedures were identified in which monopolar cautery was used. Seven of these 17 cases (41.2%) involved the head and neck, and 10 were performed below the clavicles. No patients experienced a device failure or a decline in CI performance following surgery. A systematic review identified an additional 4 patients who underwent a surgery that used monopolar cautery following cochlear implantation, and no change in CI function was identified.

CONCLUSIONS

The present study adds additional support to the notion that monopolar cautery does not necessarily injure CI functionality. While the most risk adverse strategy when planning a surgical procedure for a CI patient is to avoid monopolar cautery use altogether, the use of cautery should not immediately be associated with implant dysfunction.

Does the presence of programmable implanted devices in patients with early onset scoliosis alter typical operative and postoperative practices? A survey of spine surgeons

PURPOSE

Operative and postoperative management of early onset scoliosis (EOS) patients with programmable implanted devices has not been well characterized in the literature. The aim of this study was to describe current practices for pediatric spine surgeons who operate on patients with these devices.

METHODS

An electronic survey was distributed to 167 pediatric spine surgeons between January and March of 2021. The survey queried participants on operative and postoperative management of patients with the following implanted devices: vagal nerve stimulators, ventriculoperitoneal shunts, intrathecal baclofen pumps, pacemakers, and cochlear implants. Descriptive statistics were used to assess survey data.

RESULTS

Fifty-three respondents (31.7% response rate) with a mean 16.5 (SD 12.0) years in practice completed the survey. Depending on the type of device present, surgeons report changing their operative plan anywhere from 28.6 to 60.1% of the time when inserting magnetically controlled growing rods. Most respondents reported performing transcranial motor evoked potentials (80.0-98.0%) and monopolar cautery (70.0-92.9%) across implanted devices. Only 10% (n = 5) of surgeons reported complications related to operative and/or postoperative management of these patients. No complications were related to cautery, neuromonitoring, or surgical placement of MCGRs.

CONCLUSIONS

This study demonstrates variation in operative and postoperative management of these patients with various programmable implanted devices. Much of this inconsistency in practice is likely due to decades old case reports, constantly changing device manufacturer recommendations, and/or published simulation studies. Reported heterogeneity in management across surgeons necessitates development of published guidelines regarding proper operative and postoperative management of patients with EOS and implanted devices.

Neurophysiological Intraoperative Monitoring in Patients with Cochlear Implant Undergoing Posterior Spinal Fusion: A Case Report

CASE

Transcranial electric stimulation motor-evoked potentials (tcMEPs) are the most sensitive technique in multimodality intraoperative neuromonitoring (IONM) for posterior spinal fusion (PSF). The presence of a cochlear implant (CI) is considered a contraindication to IONM because of theoretical risk of implant device and local tissue damage from voltages induced by tcMEPs. We present the case of a 10-year-old girl with CI who underwent successful PSF with tcMEP and monopolar electrocautery (MoEC) without perioperative complications or CI damage.

CONCLUSION

With proper precautions, such as MoEC usage at a minimal voltage, motor-evoked potential monitoring can be safely performed in pediatric patients with CI undergoing PSF.

Pacemakers, Deep Brain Stimulators, Cochlear Implants, and Nerve Stimulators: A Review of Common Devices Encountered in the Dermatologic Surgery Patient

BACKGROUND

In dermatologic and procedural surgery settings, there are commonly encountered devices in patients. Safe surgical planning requires familiarity with these devices.

OBJECTIVE

To review the current implanted devices in patients and recommendations for surgical planning around these devices.

METHODS AND MATERIALS

A comprehensive review using PubMed and published device recommendations was performed, searching for those most relevant to dermatologic surgery.

RESULTS

Devices such as pacemakers and implantable cardiac defibrillators, deep brain stimulators, cochlear implants, and various nerve stimulators are potential devices that may be encountered in patients and specific recommendations exist for each of these devices.

CONCLUSION

Dermatologic surgeons' knowledge of implanted devices in patients is paramout to safe surgical procedures.

Cochlear Implant

Cochlear implant is the first approved cranial nerve stimulator that works by directly stimulating the cochlear nerve. The medical and societal impact of this revolutionary device cannot be understated. This article reviews the evolving indications for cochlear implant, patient assessment, surgical approach, and outcomes for pediatric and adult cochlear implant that demonstrate its impact. Future concepts in cochlear implant are introduced briefly. This article covers a breadth of information; however, it is not intended be entirely comprehensive. Rather, it should serve as a foundation for understanding cochlear implant.

Safety of radiofrequency ablation for adenotonsillectomy after cochlear implantation

OBJECTIVE

While a cadaveric animal study has suggested that radiofrequency ablation can be safely used in patients with cochlear implants, no in vivo studies have been published to confirm that radiofrequency ablation does not alter the integrity of the cochlear implant device.

METHODS

Cochlear implant impedance and functional performance were studied through a prospective case series in five children with seven functioning multichannel implants before and after radiofrequency ablation adenotonsillectomy.

RESULTS

There were 4 females and 1 male patient, aged 6-10 years (mean 8.5 ± 1.95 years) with 7 functioning implants. Pre- and post-surgical impedance testing revealed all electrodes were within normal operating limits. There was no statistically significant difference between the mean pre and post-operative impedances in 5 of the 7 tested implants (P = 0.2-0.8). The other two implants showed statistically significant improvement in impedance values which were not clinically significant (P = 0.02 and P < 0.001). Speech perception was unchanged as was functional performance for all 7 tested implants.

CONCLUSIONS

We found that radiofrequency ablation used in the oropharynx during adenotonsillectomy did not alter the integrity of the cochlear implant devices when assessed using electrode impedance testing, audiometry and speech perception evaluation. These results confirm those reported in previous in vitro studies and confirm the safety of radiofrequency ablation adenotonsillectomy for children who have undergone previous cochlear implant placement.

Spinal Surgery With Electrically Evoked Potential Monitoring and Monopolar Electrocautery: Is Prior Removal of a Cochlear Implant Necessary?

: Transcranial electric stimulation to generate motor evoked potentials in lower limb muscles is the standard technique used to monitor spinal cord efferent pathways during surgical correction for spinal deformities. Monopolar electrical cauterization is also used by default in the thoracic and lumbar area of the spine during this kind of surgery to prevent major blood loss. Owing to the high levels of current used, both techniques are considered contraindicative if the patient has a cochlear implant (CI). Here, we present a CI patient who underwent corrective spinal fusion surgery for a severe kyphoscoliotic spinal deformity on whom both techniques were used without any negative effects on the CI function. A major improvement in sagittal body balance was achieved with no loss in implant-aided hearing levels. These results add to reports that CI manufactures should review their evidence underlying recommendations that transcranial electric stimulation and upper thoracic monopolar electrical cauterization are high risk for CI users, possibly initiating verification studies.

Cautery selection for oculofacial plastic surgery in patients with implantable electronic devices

PURPOSE

To discover oculofacial plastic surgeon practice patterns for cautery selection in the setting of implantable electronic devices and present guidelines based on a review of current literature.

METHODS

A 10-Question web-based survey was sent to the email list serve of the American Society of Ophthalmic Plastic and Reconstructive Surgery to determine surgeon cautery preference in the setting of various implantable electronic devices and comfort level with the guidelines for cautery selection in their practice or institution. The relationship between survey questions was assessed for statistical significance using Pearson's Chi-square tests.

RESULTS

Two hundred ninety-three (41% response rate) surveys were completed and included for analysis. Greater than half of respondents either had no policy (36%) or were unaware of a policy (19%) in their practice or institution regarding cautery selection in patients with a cardiac implantable electronic device. Bipolar cautery was favored for use in patients with a cardiac implantable electronic device (79%-80%) and this number dropped in patients with implantable neurostimulators (30%). Overall, one-third of respondents did not feel comfortable with their practice/institution policy.

CONCLUSION

Choices and comfort level among oculofacial plastic surgeons for cautery selection in patients with implantable electronic devices vary considerably, and some choices may increase the risk for interference-related complications. Practice patterns vary significantly in the setting of a neurostimulator or cochlear implant, where interference can cause thermal injury to the brain and implant damage, respectively. Guidelines are proposed for cautery selection in patients with implantable electronic devices undergoing oculofacial plastic surgery.

Safe Intraoperative Neurophysiologic Monitoring During Posterior Spinal Fusion in a Patient With Cochlear Implants

OBJECTIVE

Cochlear implants are generally considered a contraindication for any procedure requiring electrical stimulation near the implant. We present a case of a patient undergoing intraoperative transcranial electrical motor-evoked potential monitoring with a cochlear implant without adverse outcomes.

PATIENT

A 12-year-old girl with a history of VACTERL presented with worsening congenital kyphosis and bilateral severe-to-profound hearing loss. Since age 7 the patient used a cochlear implant in the right ear and hearing aid in the left ear. Physical examination and magnetic resonance imaging in 2016 revealed a left-sided 66-degree thoracolumbar kyphosis at T11 making the patient a candidate for surgical correction.

INTERVENTIONS

She underwent a posterior spinal fusion surgery, performed with intraoperative transcranial electrical motor-evoked potential monitoring. Steps were taken to mitigate electrical stimulation of the patient's cochlear implant.

MAIN OUTCOME MEASURES

Postoperative impedance of individual channels, audiometry, and neural response testing were compared with preoperative measurements.

RESULTS

Significant (>10%) impedance changes were observed postoperatively in channels 1, 2, 4, and 6; however, the net variation across all the channels was low (3%). The patient reported no hearing changes, and no significant changes in hearing threshold were seen in postoperative audiometric testing or neural response testing.

CONCLUSION

We present a case of successful posterior spinal fusion with intraoperative neurophysiological monitoring via transcranial electrical stimulation, in a patient with a cochlear implant. With proper precautions, motor-evoked potential monitoring can be safely performed in a patient with a cochlear implant.