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Zhang P, Tao F, Song W, Wu S, Wang D, Zhou D, Liu F. Salvage of Iatrogenic Sciatic Nerve Injury Caused by Operatively Treated Acetabular Fractures: Two Cases and Literature Review. Orthop Surg 2024; 16:2100-2106. [PMID: 38925614 PMCID: PMC11293912 DOI: 10.1111/os.14153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND While sciatic nerve injury has been described as a complication of acetabular fractures, iatrogenic nerve injury remains sparsely reported. This study aims to assess iatrogenic sciatic nerve injuries occurring during acetabular fracture surgery, tracking their neurological recovery and clinical outcomes, and investigating any correlation between recovery and the severity of neurologic injury to facilitate physicians in providing prediction of prognosis. CASE PRESENTATION We present two cases of male patients, aged 56 and 22, who developed sciatic palsy due to iatrogenic nerve injury during acetabular fracture surgery. Iatrogenic sciatic nerve injury resulted from operatively treated acetabular fractures. Surgical exploration, involving internal fixation removal and nerve decompression, successfully alleviated symptoms in both cases postoperatively. At the latest follow-up, one patient achieved full recovery with excellent function, while the other exhibited residual deficits at the L5/S1 root level along with minimal pain. CONCLUSION Sciatic nerve injury likely stemmed from reduction techniques and internal fixation procedures for the posterior column, particularly when performed with the hip flexed, thereby placing tension on the sciatic nerve. Our case reports underscore the significance of liberal utilization of electrophysiologic examinations and intraoperative monitoring for the prediction of prognosis. Surgical exploration, encompassing internal fixation removal and nerve decompression, represents an effective intervention for resolving sciatic palsy, encompassing both sensory neuropathy and motor symptoms.
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Affiliation(s)
- Peng Zhang
- Department of OrthopaedicsShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Fulin Tao
- Department of OrthopaedicsShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Wenhao Song
- Department of OrthopaedicsShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Shuai Wu
- Department of OrthopaedicsShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Dawei Wang
- Department of OrthopaedicsShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Dongsheng Zhou
- Department of OrthopaedicsShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Fanxiao Liu
- Department of OrthopaedicsShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanChina
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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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Epstein NE, Agulnick MA. Perspective: Triple intraoperative neurophysiological monitoring (IONM) should be considered the standard of care (SOC) for performing cervical surgery for ossification of the posterior longitudinal ligament (OPLL). Surg Neurol Int 2023; 14:336. [PMID: 37810312 PMCID: PMC10559385 DOI: 10.25259/sni_710_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023] Open
Abstract
Background Triple Intraoperative Neurophysiological Monitoring (IONM) should be considered the standard of care (SOC) for performing cervical surgery for Ossification of the Posterior Longitudinal Ligament (OPLL). IONM's three modalities and their alerts include; Somatosensory Evoked Potentials (SEP: =/> 50% amplitude loss; =/>10% latency loss), Motor Evoked Potentials (MEP: =/> 70% amplitude loss; =/>10-15% latency loss), and Electromyography (loss of EMG, including active triggered EMG (t-EMG)). Methods During cervical OPLL operations, the 3 IONM alerts together better detect intraoperative surgical errors, enabling spine surgeons to immediately institute appropriate resuscitative measures and minimize/avoid permanent neurological deficits/injuries. Results This focused review of the literature regarding cervical OPLL surgery showed that SEP, MEP, and EMG monitoring used together better reduced the incidence of new nerve root (e.g., mostly C5 but including other root palsies), brachial plexus injuries (i.e., usually occurring during operative positioning), and/or spinal cord injuries (i.e., one study of OPLL patients documented a reduced 3.79% incidence of cord deficits utilizing triple IONM vs. a higher 14.06% frequency of neurological injuries occurring without IONM). Conclusions Triple IONM (i.e., SEP, MEP, and EMG) should be considered the standard of care (SOC) for performing cervical OPLL surgery. However, the positive impact of IONM on OPLL surgical outcomes critically relies on spinal surgeons' immediate response to SEP, MEP, and/or EMG alerts/significant deterioration with appropriate resuscitative measures to limit/avert permanent neurological deficits.
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of NY at Stony Brook and Editor-in-Chief Surgical Neurology International NY and c/o Dr. Marc Agulnick 1122 Franklin Avenue Suite 106, Garden City, New York, United States
| | - Marc A Agulnick
- Assistant Clinical Professor of Orthopedic Surgery, NYU Hospital Long Island c/o Dr. Marc Agulnick 1122 Franklin Avenue Suite 106, Garden City, NY, United States
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Hoang L, Jasiukaitis P. Confirming a C5 Palsy with a Motor Evoked Potential Trending Algorithm during Insertion of Cervical Facet Spacers: A Case Study. Neurodiagn J 2022; 62:206-221. [PMID: 36459540 DOI: 10.1080/21646821.2022.2136926] [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: 03/29/2022] [Accepted: 10/12/2022] [Indexed: 06/17/2023]
Abstract
The use of cervical facet spacers has shown favorable clinical results in the treatment of cervical spondylotic disease; however, there are limited data regarding neurological complications associated with the procedure. This case report demonstrates the specificity of multi-myotomal motor evoked potentials (MEPs) in detecting acute postoperative C5 palsy following placement of facet spacers. A posterior cervical fusion with decompression and instrumentation involving DTRAX (Providence Medical Technology; Lafayette, CA) was used to treat a patient with cervical stenosis and myelopathy. Intraoperative neurophysiological monitoring (IONM) consisting of MEPs, somatosensory evoked potentials (SSEPs), and free-run electromyography (EMG), was used throughout the procedure. Immediately following the placement of the DTRAX spacers at C4-5, a decrease in amplitudes from the right deltoid and biceps MEP recordings (>65%) was detected. All other IONM modalities remained stable; it is noteworthy that there was an absence of mechanically elicited EMG. A novel post-alert regression analysis trending algorithm of MEP amplitudes confirmed the visual alert. This warning along with an intraoperative computed tomography (CT) scan of the cervical spine subsequently resulted in the decision to remove one of the facet spacers. Surgical intervention did not result in recovery of the aforementioned MEP recordings, which remained attenuated at the time of wound closure. Postoperatively, the patient exhibited an immediate right C5 palsy (2/5). A post-surgery application of the trending algorithm demonstrated that it correlated to the visual alert until the end of monitoring.
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Affiliation(s)
- Ly Hoang
- Department of Surgical Neurophysiology University of California - San Francisco (UCSF), San Francisco, California
| | - Paul Jasiukaitis
- Department of Surgical Neurophysiology University of California - San Francisco (UCSF), San Francisco, California
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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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Wilent WB, Tesdahl EA, Trott JT, Tassone S, Harrop JS, Klineberg EO, Sestokas AK. Impact of inhalational anesthetic agents on the baseline monitorability of motor evoked potentials during spine surgery: a review of 22,755 cervical and lumbar procedures. Spine J 2021; 21:1839-1846. [PMID: 34274500 DOI: 10.1016/j.spinee.2021.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/01/2021] [Accepted: 07/02/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT During spine surgery, motor evoked potentials (MEPs) are often utilized to monitor both spinal cord function and spinal nerve root or plexus function. While there are reports evaluating the impact of anesthesia on the ability of MEPs to monitor spinal cord function, less is known about the impact of anesthesia on the ability of MEPs to monitor spinal nerve root and plexus function. PURPOSE To compare the baseline monitorability and amplitude of MEPs during cervical and lumbar procedures between two cohorts based on the maintenance anesthetic regimen: a total intravenous anesthesia (TIVA) versus a regimen balanced with volatile inhalational and intravenous agents. STUDY DESIGN Baseline MEP data from a total of 16,559 cervical and 6,196 lumbar extradural spine procedures utilizing multimodality intraoperative neuromonitoring (IONM) including MEPs between January 2017 and March 2020 were obtained from a multi-institutional database. Two cohorts for each region of spine surgery were delineated based on the anesthetic regimen: a TIVA cohort and a Balanced anesthesia cohort. PATIENT SAMPLE Age 18 and older. Fellowship support for 65,000 for year 2021. OUTCOME MEASURES Percent monitorability and amplitudes of baseline MEPs. METHODS The baseline monitorability of each muscle MEP was evaluated by the IONM team in real-time and recorded in the patient's electronic medical record. The relation between anesthetic regimen and baseline monitorability was estimated using mixed effects logistic regression, with distinct models for cervical and lumbar procedures. Subsets of cervical and lumbar procedures from each anesthesia cohort in which all MEPs were deemed monitorable were randomly selected and the average peak-to-trough amplitude of each muscle MEP was retrospectively measured. Mixed-effects linear regression models were estimated (one each for cervical and lumbar procedures) to assess possible differences in average amplitude associated with anesthesia regimen. RESULTS At the time of surgery, baseline MEPs were reported monitorable from all targeted muscles in 86.8% and 83.0% of cervical and lumbar procedures, respectively, for the TIVA cohort, but were reported monitorable in just 59.3% and 61.0% of cervical and lumbar procedures, respectively, in the Balanced cohort, yielding disparities of 27.5% and 22.0%, respectively. The model-adjusted monitorability disparity between cohorts for a given muscle MEP ranged from 0.2% to 16.6% but was smallest for distal intrinsic hand and foot muscle MEPs (0.2%-1.1%) and was largest for proximal muscle MEPs (deltoid: 10.8%, biceps brachii: 8.8%, triceps: 13.0%, quadriceps: 16.6%, gastrocnemius: 7.8%, and tibialis anterior: 3.7%) where the monitorability was significantly decreased in the Balanced cohort relative to the TIVA cohort (p<.0001). Relative to the TIVA cohort, the model-adjusted amplitude of an MEP in the Balanced cohort was smaller for all muscles measured, ranging from 27.5% to 78.0% smaller. Relative to the TIVA cohort, the model-adjusted amplitude of an MEP was significantly decreased (p<.01) in the Balanced cohort for the most proximal muscles (Percent smaller: deltoid: 74.3%, biceps: 78.0%, triceps: 54.9%, quadriceps: 54.8%). CONCLUSIONS TIVA is the preferred anesthetic regimen for optimizing MEP monitoring during spine surgery. Inhalational agents significantly decrease MEP monitorability and amplitudes for most muscles, and this effect is especially pronounced for proximal limb muscles such as the deltoid, biceps, triceps, and quadriceps.
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Affiliation(s)
- W Bryan Wilent
- SpecialtyCare, 3 Maryland Farms, Suite 200, Brentwood, TN 37027.
| | - Eric A Tesdahl
- SpecialtyCare, 3 Maryland Farms, Suite 200, Brentwood, TN 37027
| | - Julie T Trott
- SpecialtyCare, 3 Maryland Farms, Suite 200, Brentwood, TN 37027
| | - Shakira Tassone
- SpecialtyCare, 3 Maryland Farms, Suite 200, Brentwood, TN 37027
| | - James S Harrop
- Jefferson University Hospital, 909 Walnut Street Clinical Office Building: 2nd Floor, Philadelphia, PA 19107
| | - Eric O Klineberg
- University of California Davis, 3301 C St., Suite 1500, Sacramento, CA 95816
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Patel MS, Wilent WB, Gutman MJ, Abboud JA. Incidence of peripheral nerve injury in revision total shoulder arthroplasty: an intraoperative nerve monitoring study. J Shoulder Elbow Surg 2021; 30:1603-1612. [PMID: 33096272 DOI: 10.1016/j.jse.2020.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The incidence of nerve injuries in revision total shoulder arthroplasty (TSA) is not well defined in the literature and may be higher than that in primary procedures, with 1 study reporting a complication rate of 50% for shoulder revisions. Given that continuous intraoperative nerve monitoring (IONM) can be an effective tool in diagnosing evolving neurologic dysfunction and preventing postoperative injuries, the purpose of this study was to report on IONM data and nerve injury rates in a series of revision TSAs. METHODS A retrospective cohort review of consecutive patients who underwent revision TSA was performed from January 2016 to March 2020. Indications for revision included infection (n = 7); failed total arthroplasty and hemiarthroplasty secondary to pain, dysfunction, and/or loose components (n = 36); and periprosthetic fracture (n = 1). Of the shoulders, 32 underwent revision to a reverse TSA, 6 underwent revision to an anatomic TSA, and 6 underwent spacer placement. IONM data included transcranial electrical motor evoked potentials (MEPs), somatosensory evoked potentials, and free-run electromyography. The motor alert threshold was set at ≥80% signal attenuation in any peripheral nerve. Patients were screened for neurologic deficits immediately following surgery, prior to administration of an interscalene nerve block, and during the first 2 postoperative visits. Additional data collection included surgical indication, sex, laterality, age at surgery, procedure performed, body mass index, history of tobacco use, Charlson Comorbidity Index, medical history, and preoperative range of motion. RESULTS A total of 44 shoulders in 38 patients were included, with a mean age of 63.2 years (standard deviation, 13.0 years). Of the procedures, 22.4% (n = 10) had an MEP alert, with 8 isolated to a single nerve (7 axillary and 1 radial) and 1 isolated to the axillary and musculocutaneous nerves. Only 1 patient experienced a major brachial plexus alert involving axillary, musculocutaneous, radial, ulnar, and median nerve MEP alerts, as well as ulnar and median nerve somatosensory evoked potential alerts. Age, sex, body mass index, Charlson Comorbidity Index, and preoperative range of motion were not found to be significantly different between cases in which an MEP alert occurred and cases with no MEP alerts. In the postoperative period, no minor or major nerve injuries were found whereas distal peripheral neuropathy developed in 4 patients (9.1%). CONCLUSION Among 44 surgical procedures, no patients (0%) had a major or minor nerve injury postoperatively and 4 patients (9.1%) complained of distal peripheral neuropathy postoperatively. In this study, we have shown that through the use of IONM, the rate of minor and major nerve injuries can be minimized in revision shoulder arthroplasty.
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Affiliation(s)
- Manan S Patel
- Department of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA.
| | | | - Michael J Gutman
- Department of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Joseph A Abboud
- Department of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Wilent WB, Trott JM, Sestokas AK. Roadmap for Motor Evoked Potential (MEP) Monitoring for Patients Undergoing Lumbar and Lumbosacral Spinal Fusion Procedures. Neurodiagn J 2021; 61:27-36. [PMID: 33945448 DOI: 10.1080/21646821.2021.1866934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
MEPs are recommended for patients undergoing lumbar and lumbosacral procedures in which intraoperative neuromonitoring (IONM) is being utilized. While electromyography (EMG) provides critical nerve root proximity information, spontaneous EMG discharges are relatively poor at reliably diagnosing spinal nerve root dysfunction. In contrast, research indicates that MEPs are both sensitive and specific in diagnosing evolving spinal nerve root dysfunction. There is conflicting evidence, however, and it must be emphasized that the value of adding MEPs is only realized when practices and techniques are optimized. The ideal anesthetic plan is an optimized total intravenous anesthetic (TIVA) regimen. Selection of appropriate anesthetics and dosing is important for optimizing baseline response amplitudes and promoting diagnostic confidence in analyzing signal changes. An adaptive set of alert criteria that account for baseline amplitude and morphology fluctuations should guide the determination of significant signal change. The therapeutic impact of accurate diagnostic information depends on the timeliness of diagnosis and intervention. Prior to the start of surgery, a plan to obtain MEPs at least once every 10 minutes during the active part of the procedure and after every significant surgical maneuver should be agreed upon, and the intervention plan should include but not be limited to possible removal of hardware and release of retraction or distractive forces. In summary, MEPs can improve monitoring of at-risk nerve root function, but the accuracy and therapeutic impact of such monitoring depend on perioperative planning and communication that optimize use of this modality.
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Affiliation(s)
| | - Julie M Trott
- Medical Department, SpecialtyCare, Brentwood, Tennessee
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Lubelski D, Pennington Z, Planchard RF, Hoke A, Theodore N, Sciubba DM, Belzberg AJ. Use of electromyography to predict likelihood of recovery following C5 palsy after posterior cervical spine surgery. Spine J 2021; 21:387-396. [PMID: 33035659 DOI: 10.1016/j.spinee.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/15/2020] [Accepted: 10/01/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND C5 palsy affects approximately 5% to 10% of patients undergoing cervical spine surgery. It has a significant negative impact on patient quality-of-life outcomes and healthcare costs. Although >80% of patients improve, some are left with persistent, debilitating deficits. Our objective was to examine if electrodiagnostic testing could be used to successfully identify patients likely to experience complete, partial, and no recovery. METHODS Patients undergoing posterior cervical decompression and fusion at a single institution over a 10-year period were identified. Those experiencing postoperative C5 palsy were included. Outcomes examined included motor recovery of the affected deltoid as a function of time, and changes in electrodiagnostic testing as a function of time since injury. Electrodiagnostic testing included electromyography and was sub-analyzed by time of acquisition postinjury. Deltoid strength was graded on manual motor testing using the 5-point medical research council grading system. RESULTS Of 77 patients experiencing C5 palsy, 29 had postoperative electrodiagnostic testing. Patients experiencing complete recovery on average achieved functional (4/5) strength by 6-weeks post injury and 4+ per 5 strength by 6-months. Those experiencing partial recovery only achieved antigravity strength (3/5) by 6-weeks and low-function (4-/5) strength by 6-months. Electrodiagnostic testing performed 6-weeks to 6-months postinjury demonstrated that those experiencing complete recovery were more likely to have normal motor unit (MU) recruitment than those experiencing partial (p<.001) or no recovery (p=.008). The presence of ≥2+ fibrillation on tests acquired ≤6-weeks of injury identified patients unlikely to experience any recovery with a positive predictive value (PPV) of 88.9%. The presence of normal MU recruitment on tests acquired 6-weeks to 6-months postinjury identified patients likely to experience complete recovery with a PPV of 87.5%. CONCLUSIONS Electrodiagnostic testing may be a valuable means of differentiating between patients with C5 palsy likely to experience complete, partial, or no recovery. Testing between 6-weeks and 6-months post onset may aid in identifying those least likely to have a complete recovery. No MUs at 4 to 6-months, or reduced units with strength that is not improving, portends a poor long-term outcome. In this population, peripheral nerve transfers may be considered sooner.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St Phipps 454, Baltimore 21287, MD, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St Phipps 454, Baltimore 21287, MD, USA
| | - Ryan F Planchard
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St Phipps 454, Baltimore 21287, MD, USA
| | - Ahmet Hoke
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St Phipps 454, Baltimore 21287, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St Phipps 454, Baltimore 21287, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St Phipps 454, Baltimore 21287, MD, USA
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St Phipps 454, Baltimore 21287, MD, USA.
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Therapeutic Impact of Traction Release After C5 Nerve Root Motor Evoked Potential (MEP) Alerts in Cervical Spine Surgery. Clin Spine Surg 2020; 33:E442-E447. [PMID: 32205523 DOI: 10.1097/bsd.0000000000000969] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN A retrospective review of 40,919 cervical spine surgeries monitored with motor evoked potentials (MEPs) from a multi-institutional intraoperative neuromonitoring database. OBJECTIVE The objective of this study was to determine the clinical impact of interventions prompted by C5 spinal nerve root MEP alerts. SUMMARY OF BACKGROUND DATA MEPs have been shown to diagnose acute C5 palsies, but additional data are needed regarding the clinical impact of interventions in response to C5 MEP alerts. MATERIALS AND METHODS Procedures with isolated C5 MEP alerts were categorized as fully resolved, partially resolved, or unresolved based on the status of signals at closure. Clinical outcomes were based on neurological assessment in the immediate postoperative period. The sensitivity, specificity, likelihood ratios, and odds ratios (ORs) of C5 MEP alerts for acute C5 palsies were calculated. RESULTS The odds of an acute C5 palsy greatly increased if there was a C5 MEP alert [OR=340.9; 95% confidence (CI): 173.0, 671.6; P<0.0001], and increased further if the alert persisted through closure (OR=820.8; 95% CI: 398.1, 1692.0; P<0.0001). Relative to procedures with unresolved C5 MEP alerts, the risk of an acute C5 palsy significantly decreased if a C5 MEP alert was fully resolved by closure (OR=0.07; 95% CI: 0.02, 0.25; P<0.0001). For alerts resolved during positioning or exposure, 90.9% were resolved with the release of positional traction, and for resolved alerts that occurred after exposure, 36.3% involved just traction release, 14.1% involved both traction release and surgical action, and 30.3% involved just surgical action. The sensitivity of C5 MEP alerts for acute C5 palsies was anesthetic dependent: 89.7% (26/29) in the total intravenous regimen cohort but just 50.0% (10/20) in the inhalational anesthesia cohort. CONCLUSIONS The timely release of positional traction is an effective intervention for resolving C5 MEP alerts and reducing the odds of an acute postoperative C5 palsy. Surgical maneuvers, such as the release of distraction or graft adjustment, should be attempted in conjunction with traction release depending on the surgical context of the alert. LEVEL OF EVIDENCE Level IV.
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Fournier S, Clark JP, Lieberman JA. Letter to the Editor. Incorrect analysis of motor evoked potential efficacy for pedicle subtraction osteotomy. J Neurosurg Spine 2020; 32:779-780. [PMID: 31923891 DOI: 10.3171/2019.8.spine19909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Oh JK, Hong JT, Kang DH, Kim SW, Kim SW, Kim YJ, Chung CK, Shin JJ, Yi S, Lee JK, Lee JH, Lee CH, Lee HJ, Chun HJ, Cho DC, Cho YE, Jin YJ, Choi KC, Han IH, Hyun SJ, Hur JW, Kim KJ. Epidemiology of C5 Palsy after Cervical Spine Surgery: A 21-Center Study. Neurospine 2019; 16:558-562. [PMID: 31607088 PMCID: PMC6790722 DOI: 10.14245/ns.1938142.071] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/19/2019] [Indexed: 11/30/2022] Open
Abstract
Objective C5 palsy is a severe complication after cervical spine surgery, the pathophysiology of which remains unclear. This multicenter study investigated the incidence of C5 palsy following cervical spine surgery in Korea.
Methods We conducted a retrospective multicenter study involving 21 centers from the Korean Cervical Spine Study Group. The inclusion criteria were cervical spine surgery patients between 2012 and 2016, excluding cases of neck surgery. In patients with C5 palsy, the operative methods, disease category, onset time of C5 palsy, recovery time, C5 manual muscle testing (MMT) grade, and post-C5 palsy management were analyzed.
Results We collected 15,097 cervical spine surgery cases from 21 centers. C5 palsy occurred in 88 cases (0.58%). C5 palsy was more common in male patients (p=0.019) and after posterior approach procedures (p<0.001). C5 palsy usually occurred within 3 days after surgery (77 of 88, 87.5%) and most C5 palsy patients recovered within 6 months (51 of 88, 57.95%). Thirty C5 palsy patients (34.09%) had motor weakness, with an MMT grade≤2. Only four C5 palsy patients (4.5%) did not recover during follow-up. Posterior cervical foraminotomy was performed in 7 cases (7.95%), and steroids were used in 56 cases (63.63%). Twenty-six cases (29.55%) underwent close observation only.
Conclusion The overall incidence of C5 palsy was relatively low (0.58%). C5 palsy was more common after posterior cervical surgery and in male patients. C5 palsy usually developed within 3 days after surgery, and more than half of patients with C5 palsy recovered within 6 months.
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Affiliation(s)
- Jae Keun Oh
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Taek Hong
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Dong Ho Kang
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sang-Woo Kim
- Department of Neurosurgery, Yeungnam University Medical Center, Daegu, Korea
| | - Seok Won Kim
- Department of Neurosurgery, Chosun University Hospital, Gwangju, Korea
| | - Young Jin Kim
- Department of Neurosurgery, Dankook University Hospital, Cheonan, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Jae Shin
- Department of Neurosurgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Seong Yi
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Kil Lee
- Department of Neurosurgery, Chonnam University Hospital, Chonnam University College of Medicine, Gwangju, Korea
| | - Jun Ho Lee
- Department of Neurosurgery, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Chang-Hyun Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Ho Jin Lee
- Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Seoul Hospital, Seoul, Korea
| | - Dae-Chul Cho
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Jun Jin
- Department of Neurosurgery, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Kyung-Chul Choi
- Department of Neurosurgery, The Leon Wiltse Memorial Hospital, Anyang, Korea
| | - In Ho Han
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jung-Woo Hur
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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C5 Motor Palsy After Single- and Multi-level Anterior Cervical Diskectomy and Fusion: A Retrospective Review. J Am Acad Orthop Surg 2019; 27:e390-e394. [PMID: 30216246 DOI: 10.5435/jaaos-d-17-00764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Postoperative C5 nerve root palsy is a known complication after cervical surgery. The effect of increasing number of levels fused on the prevalence of C5 palsy after anterior cervical diskectomy and fusion (ACDF) is unclear. METHODS Medical records of ACDF patients that included the C4-5 level at one institution were retrospectively reviewed. C5 palsy was defined as motor decline of the deltoid and/or biceps brachii muscle function by at least 1 level on standard manual muscle testing. RESULTS A total of 196 patients met the inclusion criteria, with no significant differences noted between groups undergoing single- or multi-level ACDF. The overall C5 palsy rate was 5.1%. Palsy rates were not statistically significant based on the number of levels fused. Six of the 10 patients with C5 palsy had complete recovery of motor strength, whereas 2 patients had at least some level of strength recovery. CONCLUSION The overall C5 palsy rate was 5.1% for all patients undergoing up to four-level ACDF. The rate of postoperative motor decline was lowest in the patients undergoing two-level ACDF and highest in the single-level group, but this finding did not reach statistical significance. The prognosis for strength recovery by final follow-up is excellent. LEVEL OF EVIDENCE Level III, Case-control.
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Abstract
STUDY DESIGN A retrospective design. OBJECTIVE We aim to report our experience with multimodal intraoperative neuromonitoring (IONM) in metastatic spine tumor surgery (MSTS). SUMMARY OF BACKGROUND DATA IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS. METHODS A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute, were studied retrospectively. After excluding seven with no baseline signals, 128 patients were analyzed. The data collected comprised of demographics, pre and postoperative American Spinal Injury Association (ASIA) grades and neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEPs), transcranial electric motor-evoked potentials (tcMEP), and free running electromyography (EMG). RESULTS The 128 patients included 61 males and 67 females with a mean age of 61 years. One hundred sixteen underwent posterior procedures; nine anterior and three both. The frequency of preoperative ASIA Grades were A = 0, B = 0, C = 10, D = 44, and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain, and 8 for intractable pain.Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, one false negative, and no false positives. Among the 13 true positives, four (30%) underwent minimally invasive and nine (70%) open procedures. Eight (69.2%) patients had posterior approach. Seven (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression, while five (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation, and one (8.3%) during lateral approach, which reversed after changing the plane of dissection. Of the seven patients without baseline, five were ASIA-A and two were ASIA-C. The sensitivity, specificity, positive, and negative predictive values were 99.1%, 100%, 100%, and 92.9%, respectively. CONCLUSION Multimodal IONM in MSTS helped in preventing postoperative neurological deficit in 9.4% of patients. Its high sensitivity and specificity to detect intraoperative neurological events envisage its use in ASIA-grade D/E patients requiring instrumented decompression. LEVEL OF EVIDENCE 3.
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Incidence of C5 Palsy: Meta-Analysis and Potential Etiology. World Neurosurg 2019; 122:e828-e837. [DOI: 10.1016/j.wneu.2018.10.159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/21/2018] [Accepted: 10/23/2018] [Indexed: 11/15/2022]
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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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Sasaki H, Nagano S, Yokouchi M, Setoguchi T, Shimada H, Yamamoto T, Ishidou Y, Komiya S. Utility of intraoperative monitoring with motor-evoked potential during the surgical enucleation of peripheral nerve schwannoma. Oncol Lett 2018; 15:9327-9332. [PMID: 29844829 DOI: 10.3892/ol.2018.8456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/17/2017] [Indexed: 11/05/2022] Open
Abstract
Although it is thought that the surgical enucleation of schwannomas can be easily performed, certain patients present with postoperative neurological symptoms. The present study examined the utility of intraoperative motor-evoked potential (MEP) in predicting neurological deficits following the surgical enucleation of peripheral nerve schwannoma. The current study included 23 patients and MEP was performed using transcranial electrical stimulation. In three cases, the MEP decreased to <50% of the preoperative value; however, in two cases that involved the peroneal nerve and tibial nerve, results appeared to be false positives induced by a tourniquet during surgery. In another case, the MEP was completely lost following enucleation of the tumor from the sciatic nerve, which recovered to 61% of the original MEP within 10 min. This patient presented with common peroneal palsy postoperatively. By contrast, another case involving the lumbar nerve root and in which there was reversible postoperative motor loss, the MEP did not change intraoperatively. Postoperative neurological deficit occurred in 22% of patients in the present study, which is similar to that of previous reports. The present study also demonstrated that even if a nerve is not transected or injured, traction or compression of a peripheral nerve may induce ischemia, which can be monitored using MEP. Although MEP alone was not able to predict postoperative transient sensory or motor deficits, the combination of MEP with other methods of neurological monitoring may improve accuracy and should be investigated in future studies.
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Affiliation(s)
- Hiromi Sasaki
- Department of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Satoshi Nagano
- Department of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Masahiro Yokouchi
- Department of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Takao Setoguchi
- The Near-Future Locomotor Organ Medicine Creation Course, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Hirofumi Shimada
- Department of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Takuya Yamamoto
- Department of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Yasuhiro Ishidou
- Department of Medical Joint Materials, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Setsuro Komiya
- Department of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
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Ando M, Tamaki T, Matsumoto T, Maio K, Teraguchi M, Takiguchi N, Iwahashi H, Onishi M, Nakagawa Y, Iwasaki H, Tsutsui S, Takami M, Yamada H. Can postoperative deltoid weakness after cervical laminoplasty be prevented by using intraoperative neurophysiological monitoring? J Clin Monit Comput 2018; 33:123-132. [PMID: 29667095 DOI: 10.1007/s10877-018-0141-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/06/2018] [Indexed: 11/25/2022]
Abstract
Laminoplasty, frequently performed in patients with cervical myelopathy, is safe and provides relatively good results. However, motor palsy of the upper extremities, which occurs after decompression surgery for cervical myelopathy, often reduces muscle strength of the deltoid muscle, mainly in the C5 myotome. The aim of this study was to investigate prospectively whether postoperative deltoid weakness (DW) can be predicted by performing intraoperative neurophysiological monitoring (IONM) during cervical laminoplasty and to clarify whether it is possible to prevent palsy using IONM. We evaluated the 278 consecutive patients (175 males and 103 females) who underwent French-door cervical laminoplasty for cervical myelopathy under IONM between November 2008 and December 2016 at our hospital. IONM was performed using muscle evoked potential after electrical stimulation to the brain [Br(E)-MsEP] from the deltoid muscle. Seven patients (2.5%) developed DW after surgery (2 with acute and 5 with delayed onset). In all patients, deltoid muscle strength recovered to ≥ 4 on manual muscle testing 3-6 months after surgery. Persistent IONM alerts occurred in 2 patients with acute-onset DW. To predict the acute onset of DW, Br(E)-MsEP alerts in the deltoid muscle had both a sensitivity and specificity of 100%. The PPV of persistent Br(E)-MsEP alerts had both a sensitivity and specificity of 100% for acute-onset DW. There was no change in Br(E)-MsEP in patients with delayed-onset palsy. The incidence of deltoid palsy was relatively low. Persistent Br(E)-MsEP alerts of the deltoid muscle had a 100% sensitivity and specificity for predicting a postoperative acute deficit. IONM was unable to predict delayed-onset DW. In only 1 patient were we able to prevent postoperative DW by performing a foraminotomy.
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Affiliation(s)
- Muneharu Ando
- Department of Orthopedic Surgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, Wakayama, 640-8505, Japan.
| | - Tetsuya Tamaki
- Aitoku Medical and Welfare Center, 3-5-41 Imafuku, Wakayama, Wakayama, 641-0044, Japan
| | - Takuji Matsumoto
- Department of Orthopedic Surgery, Nokami Kosei General Hospital, 198 Kobata, Nokami cho, Kaiso gun, 640-1141, Japan
| | - Kazuhiro Maio
- Department of Orthopedic Surgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, Wakayama, 640-8505, Japan
| | - Masatoshi Teraguchi
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi cho, Ito gun, 649-7113, Japan
| | - Noboru Takiguchi
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 kimiidera, Wakayama, Wakayama, 641-8510, Japan
| | - Hiroki Iwahashi
- Department of Orthopedic Surgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, Wakayama, 640-8505, Japan
| | - Makiko Onishi
- Department of Orthopedic Surgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, Wakayama, 640-8505, Japan
| | - Yukihiro Nakagawa
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama, 641-8510, Japan
| | - Hiroshi Iwasaki
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama, 641-8510, Japan
| | - Shunji Tsutsui
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama, 641-8510, Japan
| | - Masanari Takami
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama, 641-8510, Japan
| | - Hiroshi Yamada
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama, 641-8510, Japan
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Perils of intraoperative neurophysiological monitoring: analysis of "false-negative" results in spine surgeries. Spine J 2018; 18:276-284. [PMID: 28713053 DOI: 10.1016/j.spinee.2017.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/12/2017] [Accepted: 07/06/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although some authors have published case reports describing false negatives in intraoperative neurophysiological monitoring (IONM), a systematic review of causes of false-negative IONM results is lacking. PURPOSE The objective of this study was to analyze false-negative IONM findings in spine surgery. STUDY DESIGN This is a retrospective cohort analysis. PATIENT SAMPLE A cohort of 109 patients with new postoperative neurologic deficits was analyzed for possible false-negative IONM reporting. OUTCOME MEASURES The causes of false-negative IONM reporting were determined. MATERIALS AND METHODS From a cohort of 62,038 monitored spine surgeries, 109 consecutive patients with new postoperative neurologic deficits were reviewed for IONM alarms. RESULTS Intraoperative neurophysiological monitoring alarms occurred in 87 of 109 surgeries. Nineteen patients with new postoperative neurologic deficits did not have an IONM alarm and surgeons were not warned. In addition, three patients had no interpretable IONM baseline data and no alarms were possible for the duration of the surgery. Therefore, 22 patients were included in the study. The absence of IONM alarms during these 22 surgeries had different origins: "true" false negatives where no waveform changes meeting the alarm criteria occurred despite the appropriate IONM (7); a postoperative development of a deficit (6); failure to monitor the pathway, which became injured (5); the absence of interpretable IONM baseline data which precluded any alarm (3); and technical IONM application issues (1). CONCLUSIONS Overall, the rate of IONM method failing to predict the patient's outcome was very low (0.04%, 22/62,038). Minimizing false negatives requires the application of a proper IONM technique with the limitations of each modality considered in their selection and interpretation. Multimodality IONM provides the most inclusive information, and although it might be impractical to monitor every neural structure that can be at risk, a thorough preoperative consideration of available IONM modalities is important. Delayed development of postoperative deficits cannot be predicted by IONM. Absent baseline IONM data should be treated as an alarm when inconsistent with the patient's preoperative neurologic status. Alarm criteria for IONM may need to be refined for specific procedures and deserves continued study.
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Aleem AW, Wilent WB, Narzikul AC, Kuntz AF, Chang ES, Williams GR, Abboud JA. Incidence of peripheral nerve injury during shoulder arthroplasty when motor evoked potentials are monitored. J Clin Monit Comput 2017; 32:897-906. [DOI: 10.1007/s10877-017-0080-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
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The Accuracy of Multimodality Intraoperative Neuromonitoring to Predict Postoperative Neurologic Deficits Following Cervical Laminoplasty. World Neurosurg 2017; 106:17-25. [DOI: 10.1016/j.wneu.2017.06.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/03/2017] [Accepted: 06/05/2017] [Indexed: 11/21/2022]
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Hadley MN, Shank CD, Rozzelle CJ, Walters BC. Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery 2017; 81:713-732. [DOI: 10.1093/neuros/nyx466] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/05/2017] [Indexed: 01/12/2023] Open
Affiliation(s)
- Mark N Hadley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher D Shank
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Curtis J Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Takenaka S, Nagamoto Y, Aono H, Kaito T, Hosono N. Differences in the time of onset of postoperative upper limb palsy among surgical procedures: a meta-analysis. Spine J 2016; 16:1486-1499. [PMID: 27725308 DOI: 10.1016/j.spinee.2016.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/24/2016] [Accepted: 09/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The time of onset of postoperative upper limb palsy (ULP), also referred to as C5 palsy, varies among patients. Although some studies addressed the relationship between the time of onset of ULP and the potential etiologies, no meta-analysis has been conducted regarding the association between the time of onset of ULP and other factors such as surgical procedure type and treated diseases. PURPOSE This study aimed to elucidate differences in the time of onset of ULP among spinal surgical procedures and treated diseases to understand its etiology. STUDY DESIGN This is a meta-analysis. OUTCOME MEASURES The time of onset of ULP after cervical decompression surgery. METHODS We conducted a meta-analysis via searches of the PubMed, EMBASE, and Cochrane Library databases. Upper limb palsy within 2 days postoperatively or at 3 days or more postoperatively was defined as early- and late-onset, respectively. We calculated the pooled prevalence of early- and late-onset ULP with regard to surgical procedures and diseases using a random effects model. The proportion of early-onset ULP relative to all ULP was also determined. Surgical procedures were categorized into four procedures: (1) anterior cervical discectomy and fusion (ACDF); (2) anterior cervical corpectomy and fusion (ACCF); (3) laminoplasty or laminectomy (LPN); and (4) posterior spinal fusion with decompression (PSF). Treated diseases were classified as ossification of the posterior longitudinal ligament (OPLL) and non-OPLL. RESULTS The pooled prevalence of early-onset ULP was significantly stratified across three groups of surgical procedures (PSF [9.0%]>ACCF [3.7%] and LPN [2.5%]>ACDF [0.6%]). In the pooled analysis of late-onset ULP prevalence, three procedures (PSF [4.3%], ACCF [2.8%], and LPN [2.9%]) were similar, but ACDF (1.0%) was associated with a significantly lower prevalence than LPN. The prevalence of both early- and late-onset ULP was significantly higher with OPLL than without OPLL. However, the proportion of early-onset ULP relative to all ULP was similar between non-OPLL and OPLL (50.8% vs. 49.5%). CONCLUSIONS The high prevalence of early-onset ULP in PSF is attributable to a lag correction effect, which is triggered by posterior correction and fusion through comparison with LPN. The combination of our meta-analysis results and previous knowledge facilitates our understanding of the etiology of ULP.
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Affiliation(s)
- Shota Takenaka
- Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan.
| | - Yukitaka Nagamoto
- Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Hiroyuki Aono
- Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Takashi Kaito
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Osaka 553-0003, Japan
| | - Noboru Hosono
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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Kim DG, Choi YD, Jin SH, Kim CH, Lee KW, Park KS, Chung CK, Kim SM. Intraoperative Motor-Evoked Potential Disappearance versus Amplitude-Decrement Alarm Criteria During Cervical Spinal Surgery: A Long-Term Prognosis. J Clin Neurol 2016; 13:38-46. [PMID: 27730765 PMCID: PMC5242147 DOI: 10.3988/jcn.2017.13.1.38] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 06/19/2016] [Accepted: 06/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose We studied the clinical significance of amplitude-reduction and disappearance alarm criteria for transcranial electric muscle motor-evoked potentials (MEPs) during cervical spinal surgery according to different lesion locations [intramedullary (IM) vs. nonintramedullary (NIM)] by evaluating the long-term postoperative motor status. Methods In total, 723 patients were retrospectively dichotomized into the IM and NIM groups. Each limb was analyzed respectively. One hundred and sixteen limbs from 30 patients with IM tumors and 2,761 limbs from 693 patients without IM tumors were enrolled. Postoperative motor deficits were assessed up to 6 months after surgery. Results At the end of surgery, 61 limbs (2.2%) in the NIM group and 14 limbs (12.1%) in the IM group showed MEP amplitudes that had decreased to below 50% of baseline, with 13 of the NIM limbs (21.3%) and 2 of the IM limbs (14.3%) showing MEP disappearance. Thirteen NIM limbs (0.5%) and 5 IM limbs (4.3%) showed postoperative motor deficits. The criterion for disappearance showed a lower sensitivity for the immediate motor deficit than did the criterion for amplitude decrement in both the IM and NIM groups. However, the disappearance criterion showed the same sensitivity as the 70%-decrement criterion in IM (100%) and NIM (83%) surgeries for the motor deficit at 6 months after surgery. Moreover, it has the highest specificity for the motor deficits among diverse alarm criteria, from 24 hours to 6 months after surgery, in both the IM and NIM groups. Conclusions The MEP disappearance alarm criterion had a high specificity in predicting the long-term prognosis after cervical spinal surgery. However, because it can have a low sensitivity in predicting an immediate postoperative deficit, combining different MEP alarm criteria according to the aim of specific instances of cervical spinal surgery is likely to be useful in practical intraoperative monitoring.
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Affiliation(s)
- Dong Gun Kim
- Department of Neurology, Myung Diagnostic Radiology Clinic, Seoul, Korea
| | - Young Doo Choi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hyun Jin
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Woo Lee
- Department of Neurology, Gachon University Gil Medical Center, Inchon, Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Sung Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Planchard RF, Maloney PR, Mallory GW, Puffer RC, Spinner RJ, Nassr A, Fogelson JL, Krauss WE, Clarke MJ. Postoperative Delayed Cervical Palsies: Understanding the Etiology. Global Spine J 2016; 6:571-83. [PMID: 27555999 PMCID: PMC4993617 DOI: 10.1055/s-0035-1570084] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 10/16/2015] [Indexed: 11/10/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE This study reviews 1,768 consecutive cervical decompressions with or without instrumented fusion to identify patient-specific and procedural risk factors significantly correlated with the development of delayed cervical palsy (DCP). METHODS Baseline demographic and procedural information was collected from the electronic medical record. Particular attention was devoted to reviewing each chart for recognized risk factors of postsurgical inflammatory neuropathy: autoimmune disease, blood transfusions, diabetes, and smoking. RESULTS Of 1,669 patients, 56 (3.4%) developed a DCP. Although 71% of the palsies involved C5, 55% of palsies were multimyotomal and 18% were bilateral. Significant risk factors on univariate analysis included age (p = 0.0061, odds ratio [OR] = 1.07, 95% confidence interval [CI] 1.008 to 1.050), posterior instrumented fusion (p < 0.0001, OR = 3.30, 95% CI 1.920 to 5.653), prone versus semisitting/sitting position (p = 0.0036, OR = 3.58, 95% CI 1.451 to 11.881), number of operative levels (p < 0.0001, OR = 1.42, 95% CI 1.247 to 1.605), intraoperative transfusions (p = 0.0231, OR = 2.57, 95% CI 1.152 to 5.132), and nonspecific autoimmune disease (p = 0.0107, OR = 3.83, 95% CI 1.418 to 8.730). On multivariate analysis, number of operative levels (p = 0.0053, OR = 1.27, 95% CI 1.075 to 1.496) and nonspecific autoimmune disease (p = 0.0416, OR 2.95, 95% CI 1.047 to 7.092) remained significant. CONCLUSIONS Although this study partially supports a mechanical etiology in the pathogenesis of a DCP, we also describe a notable correlation with autoimmune risk factors. Bilateral and multimyotomal involvement provides additional support that some DCPs may result from an inflammatory response and thus an underlying multifactorial etiology for this complication.
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Affiliation(s)
- Ryan F. Planchard
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Patrick R. Maloney
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Grant W. Mallory
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ross C. Puffer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Robert J. Spinner
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Jeremy L. Fogelson
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - William E. Krauss
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michelle J. Clarke
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States,Address for correspondence Michelle J. Clarke, MD Department of Neurosurgery, Mayo Clinic200 First Street SW, Rochester, MN 55905United States
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Clinical analysis of C5 palsy after cervical decompression surgery: relationship between recovery duration and clinical and radiological factors. 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 2016; 26:1101-1110. [DOI: 10.1007/s00586-016-4664-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 05/18/2016] [Accepted: 06/15/2016] [Indexed: 11/30/2022]
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The Efficacy of Intraoperative Neurophysiological Monitoring Using Transcranial Electrically Stimulated Muscle-evoked Potentials (TcE-MsEPs) for Predicting Postoperative Segmental Upper Extremity Motor Paresis After Cervical Laminoplasty. Clin Spine Surg 2016; 29:E188-95. [PMID: 26147699 PMCID: PMC4841153 DOI: 10.1097/bsd.0000000000000311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Prospective study. OBJECTIVE To investigate the efficacy of transcranial electrically stimulated muscle-evoked potentials (TcE-MsEPs) for predicting postoperative segmental upper extremity palsy following cervical laminoplasty. SUMMARY OF BACKGROUND DATA Postoperative segmental upper extremity palsy, especially in the deltoid and biceps (so-called C5 palsy), is the most common complication following cervical laminoplasty. Some papers have reported that postoperative C5 palsy cannot be predicted by TcE-MsEPs, although others have reported that it can be predicted. METHODS This study included 160 consecutive cases that underwent open-door laminoplasty, and TcE-MsEP monitoring was performed in the biceps brachii, triceps brachii, abductor digiti minimi, tibialis anterior, and abductor hallucis. A >50% decrease in the wave amplitude was defined as an alarm point. According to the monitoring alarm, interventions were performed, which include steroid administration, foraminotomies, etc. RESULTS Postoperative deltoid and biceps palsy occurred in 5 cases. Among the 155 cases without segmental upper extremity palsy, there were no monitoring alarms. Among the 5 deltoid and biceps palsy cases, 3 had significant wave amplitude decreases in the biceps during surgery, and palsy occurred when the patients awoke from anesthesia (acute type). In the other 2 cases in which the palsy occurred 2 days after the operation (delayed type), there were no significant wave decreases. In all of the cases, the palsy was completely resolved within 6 months. DISCUSSION The majority of C5 palsies have been reported to occur several days after surgery, but some of them have been reported to occur immediately after surgery. Our results demonstrated that TcE-MsEPs can predict the acute type, whereas the delayed type cannot be predicted. CONCLUSIONS A >50% wave amplitude decrease in the biceps is useful to predict acute-type segmental upper extremity palsy. Further examination about the interventions for monitoring alarm will be essential for preventing palsy.
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Spitz S, Felbaum D, Aghdam N, Sandhu F. Delayed postoperative C5 root palsy and the use of neurophysiologic monitoring. 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 2015; 24:2866-71. [DOI: 10.1007/s00586-015-4252-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/23/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
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Complications of minimally invasive, tubular access surgery for cervical, thoracic, and lumbar surgery. Minim Invasive Surg 2014; 2014:451637. [PMID: 25097785 PMCID: PMC4109131 DOI: 10.1155/2014/451637] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/23/2014] [Indexed: 11/17/2022] Open
Abstract
The object of the study was to review the author's large series of minimally invasive spine surgeries for complication rates. The author reviewed a personal operative database for minimally access spine surgeries done through nonexpandable tubular retractors for extradural, nonfusion procedures. Consecutive cases (n = 1231) were reviewed for complications. There were no wound infections. Durotomy occurred in 33 cases (2.7% overall or 3.4% of lumbar cases). There were no external or symptomatic internal cerebrospinal fluid leaks or pseudomeningoceles requiring additional treatment. The only motor injuries were 3 C5 root palsies, 2 of which resolved. Minimally invasive spine surgery performed through tubular retractors can result in a low wound infection rate when compared to open surgery. Durotomy is no more common than open procedures and does not often result in the need for secondary procedures. New neurologic deficits are uncommon, with most observed at the C5 root. Minimally invasive spine surgery, even without benefits such as less pain or shorter hospital stays, can result in considerably lower complication rates than open surgery.
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