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CreveCoeur TS, Iyer RR, Goldstein HE, Delgardo MW, Hankinson TC, Erickson MA, Garg S, Skaggs DL, Andras L, Kennedy BC, Cahill PJ, Lenke LG, Angevine PD, Roye BD, Vitale MG, Mendiratta A, Anderson RCE. Timing of intraoperative neurophysiological monitoring (IONM) recovery and clinical recovery after termination of pediatric spinal deformity surgery due to loss of IONM signals. Spine J 2024; 24:1740-1749. [PMID: 38614157 DOI: 10.1016/j.spinee.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/04/2024] [Accepted: 04/06/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND CONTEXT Intraoperative neurophysiological monitoring (IONM) is used to reduce the risk of spinal cord injury during pediatric spinal deformity surgery. Significant reduction and/or loss of IONM signals without immediate recovery may lead the surgeon to acutely abort the case. The timing of when monitorable signals return remains largely unknown. PURPOSE The goal of this study was to investigate the correlation between IONM signal loss, clinical examination, and subsequent normalization of IONM signals after aborted pediatric spinal deformity surgery to help determine when it is safe to return to the operating room. STUDY DESIGN/SETTING This is a multicenter, multidisciplinary, retrospective study of pediatric patients (<18 years old) undergoing spinal deformity surgery whose surgery was aborted due to a significant reduction or loss of IONM potentials. PATIENT SAMPLE Sixty-six patients less than 18 years old who underwent spinal deformity surgery that was aborted due to IONM signal loss were enrolled into the study. OUTCOME MEASURES IONM data, operative reports, and clinical examinations were investigated to determine the relationship between IONM loss, clinical examination, recovery of IONM signals, and clinical outcome. METHODS Information regarding patient demographics, deformity type, clinical history, neurologic and ambulation status, operative details, IONM information (eg, quality of loss [SSEPs, MEPs], laterality, any recovery of signals, etc.), intraoperative wake-up test, postoperative neurologic exam, postoperative imaging, and time to return to the operating were all collected. All factors were analyzed and compared with univariate and multivariate analysis using appropriate statistical analysis. RESULTS Sixty-six patients were enrolled with a median age of 13 years [IQR 11-14], and the most common sex was female (42/66, 63.6%). Most patients had idiopathic scoliosis (33/66, 50%). The most common causes of IONM loss were screw placement (27/66, 40.9%) followed by rod correction (19/66, 28.8%). All patients had either complete bilateral (39/66, 59.0%), partial bilateral (10/66, 15.2%) or unilateral (17/66, 25.8%) MEP loss leading to termination of the case. Overall, when patients were returned to the operating room 2 weeks postoperatively, nearly 75% (40/55) had monitorable IONM signals. Univariate analysis demonstrated that bilateral SSEP loss (p=.019), bilateral SSEP and MEP loss (p=.022) and delayed clinical neurologic recovery (p=.008) were significantly associated with having unmonitorable IONM signals at repeat surgery. Multivariate regression analysis demonstrated that delayed clinical neurologic recovery (> 72 hours) was significantly associated with unmonitorable IONM signals when returned to the operating room (p=.006). All patients ultimately made a full neurologic recovery. CONCLUSIONS In children whose spinal deformity surgery was aborted due to intraoperative IONM loss, there was a strong correlation between combined intraoperative SSEP/MEP loss, the magnitude of IONM loss, the timing of clinical recovery, and the time of electrophysiological IONM recovery. The highest likelihood of having a prolonged postoperative neurological deficit and undetectable IONM signals upon return to the OR occurs with bilateral complete loss of SSEPs and MEPs.
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Affiliation(s)
- Travis S CreveCoeur
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY, USA.
| | - Rajiv R Iyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/Primary Children's Hospital, Salt Lake City, UT, USA
| | | | - Mychael W Delgardo
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY, USA
| | | | | | - Sumeet Garg
- Children's Hospital Colorado, Aurora, CO, USA
| | - David L Skaggs
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lindsay Andras
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles; CA, USA
| | - Benjamin C Kennedy
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick J Cahill
- Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lawrence G Lenke
- Columbia University, Department of Orthopedic Surgery, New York, NY, USA
| | - Peter D Angevine
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY, USA
| | - Benjamin D Roye
- Columbia University, Department of Orthopedic Surgery, New York, NY, USA
| | - Michael G Vitale
- Columbia University, Department of Orthopedic Surgery, New York, NY, USA
| | - Anil Mendiratta
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Richard C E Anderson
- Department of Neurosurgery, New York University, New York, NY, USA; NYU Neurosurgery Network, Ridgewood, NJ, USA
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Berends HI, Stadhouder A, van Royen BJ, Journée HL, Gouw AA. Risk factors for neurophysiological events related to intraoperative halo-femoral traction in spinal deformity surgery. 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 2024; 33:2476-2485. [PMID: 38578448 DOI: 10.1007/s00586-024-08221-w] [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: 10/03/2023] [Revised: 02/01/2024] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE This study identifies risk factors for neurophysiological events caused by intraoperative halo-femoral traction (IOHFT) in patients with adolescent idiopathic scoliosis (AIS), and neuromuscular scoliosis (NMS). METHODS Neurophysiological integrity was monitored using motor evoked potentials (MEPs). IONM event was defined as a decreased MEP amplitude of more than 80% of baseline in, at least, one muscle. Time between application of IOHFT and event, affected muscles, surgical stage, and time between removal of IOHFT and recovery of MEPs were described. Characteristics (age, height, weight, diagnosis, Cobb angle, and flexibility of the curve) of patients with and without IOHFT-events were compared using analysis of variance. Binary logistic regression analyses were performed to identify predictors. RESULTS The study included 81 patients (age 15.6 ± 2.4 years, 53 females, AIS: n = 47, NMS n = 34). IOHFT-events occurred in 11 patients (13%; AIS n = 4, NMS n = 7). IOHFTevents affecting all limbs occurred pre-incision in NMS. Events affecting only the legs occurred during all stages of surgery. Patients with IOHFT-events were smaller (p = 0.009) and had stiffer curves (p = 0.046). Height was a predictor (odds ratio, 0.941; 95% confidence interval = 0.896-0.988). All MEPs recovered after removing IOHFT. CONCLUSION Neurophysiologic events due to IOHFT were common, with the majority in patients with NMS. A shorter stature was a risk factor, and larger Cobb angle and stiffer curve were associated with IOHFT-events. Events occurred at any stage of surgery and involved upper and lower limbs. With an adequate response on IOHFT events, none of the patients had postoperative neurological impairments due to IOHFT.
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Affiliation(s)
- Hanneke I Berends
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Movement Sciences, [Musculoskeletal Health], Amsterdam, The Netherlands.
| | - Agnita Stadhouder
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, [Musculoskeletal Health], Amsterdam, The Netherlands
| | - Barend J van Royen
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, [Musculoskeletal Health], Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henricus L Journée
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Neurosurgery University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Alida A Gouw
- Department of Neurology, Clinical Neurophysiology and MEG Center, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Amsterdam, The Netherlands
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3
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Manning E, Emerson R. Intraoperative Monitoring of Scoliosis Surgery in Young Patients. J Clin Neurophysiol 2024; 41:138-147. [PMID: 38306222 DOI: 10.1097/wnp.0000000000001058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
SUMMARY Intraoperative neurophysiologic monitoring has added substantially to the safety of spinal deformity surgery correction since its introduction over four decades ago. Monitoring routinely includes both somatosensory evoked potentials and motor evoked potentials. Either modality alone will detect almost all instances of spinal cord injury during deformity correction. The combined use of the two modalities provides complementary information, can permit more rapidly identification of problems, and enhances safety though parallel redundancy should one modality fail. Both techniques are well established and continue to be refined. Although there is room for provider preference, proper monitoring requires attention to technical detail, understanding of the underlying physiology, and familiarity with effects of commonly used anesthetic agents.
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Affiliation(s)
- Erin Manning
- Hospital for Special Surgery, New York, New York, U.S.A.; and
| | - Ronald Emerson
- Weill Cornell Medical Center, Hospital for Special Surgery, New York, New York, U.S.A
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Gamble JJ, Goobie SM. Dexmedetomidine and neurophysiologic monitoring-A call for evidence to guide contemporary best practice for pediatric anesthesiologists. Paediatr Anaesth 2024; 34:101-103. [PMID: 37983954 DOI: 10.1111/pan.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Jonathan J Gamble
- Department of Anesthesia, Perioperative Medicine, and Pain Management, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Kerdoncuff A, Henry P, Compagnon R, Accadbled F, Sales de Gauzy J, Langlais T. Feasibility, Safety and Reliability of Surgeon-Directed Transcranial Motor Evoked Potentials Monitoring in Scoliosis Surgery. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1560. [PMID: 37761521 PMCID: PMC10528034 DOI: 10.3390/children10091560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023]
Abstract
(1) Background: Neuromonitoring is essential in corrective surgery for scoliosis. Our aim was to assess the feasibility, safety and reliability of "surgeon-directed" intraoperative monitoring transcranial motor evoked potentials (MEP) of patients. (2) Methods: A retrospective single-center study of a cohort of 190 scoliosis surgeries, monitored by NIM ECLIPSE (Medtronic), between 2017 and 2021. Girls (144) and boys (46) (mean age of 15 years) were included. There were 149 idiopathic and 41 secondary scoliosis. The monitoring consisted of stimulating the primary motor cortex to record the MEP with muscular recording on the thenar, vastus lateralis, tibialis anterior and adductor hallucis muscles. (3) Results: The monitoring data was usable in 180 cases (94.7%), with 178 true negatives, no false negatives and one false positive. There was one true positive case. The predictive negative value was 100%. The monitoring data was unusable in 10 cases (i.e., three idiopathic and seven secondary scoliosis). (4) Conclusions: Simplified transcranial MEP monitoring known as "surgeon-directed module" is usable, safety and reliable in surgery for moderate scoliosis. It is feasible in 95% of cases with a negative predictive value of 100%.
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Affiliation(s)
- Aude Kerdoncuff
- Department of Paediatric Orthopedic Surgery, Children’s Hospital, Toulouse University, 31062 Toulouse, France; (A.K.); (R.C.); (F.A.); (J.S.d.G.)
| | - Patrice Henry
- Department of Neurology, Purpan Hospital, Toulouse University, 31062 Toulouse, France;
| | - Roxane Compagnon
- Department of Paediatric Orthopedic Surgery, Children’s Hospital, Toulouse University, 31062 Toulouse, France; (A.K.); (R.C.); (F.A.); (J.S.d.G.)
| | - Franck Accadbled
- Department of Paediatric Orthopedic Surgery, Children’s Hospital, Toulouse University, 31062 Toulouse, France; (A.K.); (R.C.); (F.A.); (J.S.d.G.)
| | - Jérôme Sales de Gauzy
- Department of Paediatric Orthopedic Surgery, Children’s Hospital, Toulouse University, 31062 Toulouse, France; (A.K.); (R.C.); (F.A.); (J.S.d.G.)
| | - Tristan Langlais
- Department of Paediatric Orthopedic Surgery, Children’s Hospital, Toulouse University, 31062 Toulouse, France; (A.K.); (R.C.); (F.A.); (J.S.d.G.)
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Toki T, Fujita N, Ichikawa T, Ochi N, Yokota I, Sudo H, Morimoto Y. Factors Affecting Transcranial Motor-Evoked Potential Measurements Using Single-Train Stimulation with an Increased Number of Pulses during Adolescent Scoliosis Surgery: A Prospective Observational Study. J Clin Med 2023; 12:4433. [PMID: 37445468 DOI: 10.3390/jcm12134433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Measurement of transcranial motor-evoked potentials (TcMEPs) during scoliosis surgery helps detect postoperative new neurological defects. However, TcMEP interpretation is difficult owing to the influence of intraoperative physiological, pharmacological, and time-related factors as well as stimulation conditions. In this study, we aimed to investigate the effect of the abovementioned factors on TcMEP amplitude using single-train stimulation with an increased number of pulses (STS-INP) during adolescent scoliosis surgery; moreover, we evaluated the complications of TcMEP measurement. We included 50 patients and 706 TcMEP measurements. A total of 1412 TcMEP waveforms were analyzed, each on the bilateral abductor pollicis brevis, tibialis anterior, and abductor hallucis muscles. We estimated the mean difference (95% confidence interval (CI)) and predicted mean difference (95% CI) evaluated using the interquartile range of each factor, based on a mixed-effect model with random intercepts for TcMEP amplitude. The predicted mean differences in TcMEP amplitude were clinically small compared with the actual TcMEP amplitude, suggesting that each factor had a limited effect on TcMEP amplitude. No intraoperative bite injuries or seizures were observed. Using STS-INP during adolescent scoliosis surgery may enable accurate measurement of TcMEP amplitude with neither complications nor the influence of various intraoperative factors.
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Affiliation(s)
- Takayuki Toki
- Department of Anesthesiology, Hokkaido University Hospital, N14W5, Sapporo 060-8648, Japan
| | - Noriaki Fujita
- Department of Anesthesiology, Hokkaido University Hospital, N14W5, Sapporo 060-8648, Japan
| | - Tomohiro Ichikawa
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, N14W5, Sapporo 060-8648, Japan
| | - Noriki Ochi
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, N14W5, Sapporo 060-8648, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan
| | - Hideki Sudo
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo 060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology, Hokkaido University Hospital, N14W5, Sapporo 060-8648, Japan
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Morito S, Yamada K, Nakae I, Sato K, Yokosuka K, Yoshida T, Shimazaki T, Hazemoto Y, Saruwatari R, Nishida K, Okazaki S, Hiraoka K. Intradural extramedullary tumor location in the axial view affects the alert timing of intraoperative neurophysiologic monitoring. J Clin Monit Comput 2023; 37:775-782. [PMID: 36635568 DOI: 10.1007/s10877-022-00971-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/28/2022] [Accepted: 12/31/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Intraoperative neurophysiologic monitoring (IONM) reportedly helps prevent postoperative neurological complications following high-risk spinal cord surgeries. There are negative and positive reports about using IONM for intradural extramedullary (IDEM) tumors. We investigated factors affecting alerts of IONM in IDEM tumor surgery. METHODS We analyzed 39 patients with IDEM tumors who underwent surgery using IONM at our hospital between January 2014 and March 2021. Neurological symptoms were evaluated pre- and postoperatively using the manual muscle test (MMT). All patients were evaluated to ascertain the tumor level and location in the axial view, the operative time, intraoperative bleeding volume, and histological type. Additionally, the intraoperative procedure associated with significant IONM changes in transcranial electrical stimulation muscle-evoked potential was investigated. RESULTS There were 11 false-positive and 16 true-negative cases. There was one true-positive case and one false-negative case; the monitoring accuracy achieved a sensitivity of 50%, a specificity of 59%, a positive predictive value of 8%, and a negative predictive value of 94%. In the 22 alert cases, if the tumor was located anterolateral in the axial view, alerts were triggered with a significant difference (p = 0.02) during tumor resection. Alerts were generated for fifteen patients during tumor resection; nine (60%) showed waveform improvement by intervention and were classified as rescue cases. CONCLUSION Alert is probably triggered during tumor resection for anterolaterally located tumors. Alerts during tumor resection procedures were more likely to be rescued than other procedures in IDEM tumor surgery.
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Affiliation(s)
- Shinji Morito
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kei Yamada
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan.
| | - Ichirou Nakae
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kimiaki Sato
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kimiaki Yokosuka
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Tatsuhiro Yoshida
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Takahiro Shimazaki
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Yutaro Hazemoto
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Rikiya Saruwatari
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Kota Nishida
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Shingo Okazaki
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
| | - Koji Hiraoka
- Department of Orthopedic Surgery, Kurume University School of Medicine, 830-0011, Kurume City, Fukuoka Prefecture, Japan
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Xiang B, Jiao S, Zhang Y, Wang L, Yao Y, Yuan F, Chen R, Zhou Q. Effects of desflurane and sevoflurane on somatosensory-evoked and motor-evoked potential monitoring during neurosurgery: a randomized controlled trial. BMC Anesthesiol 2021; 21:240. [PMID: 34620093 PMCID: PMC8496030 DOI: 10.1186/s12871-021-01463-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/30/2021] [Indexed: 01/27/2023] Open
Abstract
Background Better protection can be provided during neurosurgery due to the establishment of somatosensory-evoked potential (SEP) and motor-evoked potential (MEP) monitoring technologies. However, some studies have showed that inhaled halogenated anesthetics have a significant impact on neurophysiological monitoring. Methods A total of 40 consecutive patients undergoing neurosurgery were randomly assigned to two groups receiving inhaled anesthetics, either desflurane or sevoflurane. Multiples levels (concentrations of 0.3, 0.6 and 0.9) of anesthetics were administered at minimum alveolar concentration (MAC), and then the latencies and amplitudes of SEPs and MEPs were recorded. Results SEP and MEP signals were well preserved in patients who underwent neurosurgery under general anesthesia supplemented with desflurane or sevoflurane at concentrations of 0.3, 0.6 and 0.9 MAC. In each desflurane or sevoflurane group, the amplitudes of SEPs and MEPs decreased and the latencies of SEPs were prolonged significantly as the MAC increased (P < 0.05). The SEP latencies of both the upper and lower limbs in the desflurane group were significantly longer, and the SEP amplitudes were significantly lower than those in the sevoflurane group (P < 0.05). The MEP amplitudes in the desflurane group were significantly lower than those in the sevoflurane group (P < 0.05), only the amplitudes of the upper limbs at 0.3 MAC did not vary significantly. Conclusions SEPs and MEPs were inhibited in a dose-dependent manner by both desflurane and sevoflurane. At the same MAC concentration, desflurane appeared to have a stronger inhibitory effect than sevoflurane. All patients studied had normal neurological examination findings, hence, these results may not be applicable to patients with preexisting deficits. Trial registration The study registered on the Chinese Clinical Trial Registry (www.chictr.org.cn), Clinical Trials identifier ChiCTR2100045504 (18/04/2021).
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Affiliation(s)
- Bingbing Xiang
- Department of Anesthesiology, Chengdu Fifth People's Hospital, Chengdu, 611130, China
| | - Shulan Jiao
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People's Republic of China.
| | - Yulong Zhang
- Department of Anesthesiology, Kunming Children's Hospital, Kunming, 650101, China
| | - Lu Wang
- Department of Anesthesiology, First People's Hospital of Yunnan Province, Kunming, 650101, China
| | - Yuting Yao
- Department of Anesthesiology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 401331, China
| | - Feng Yuan
- Department of Anesthesiology, Chengdu Fifth People's Hospital, Chengdu, 611130, China
| | - Rui Chen
- Department of Anesthesiology, Chengdu Fifth People's Hospital, Chengdu, 611130, China
| | - Qijun Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People's Republic of China
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Streltzov NA, Evans LT, Dustin Boone M, Root BK, Calnan DR, Kobylarz EJ, Song Y. Intraoperative neurophysiological monitoring of T9-T10 fracture in a patient with morbid obesity and ankylosing spondylitis: A case report with literature review. Clin Neurophysiol Pract 2021; 6:115-122. [PMID: 33948523 PMCID: PMC8080406 DOI: 10.1016/j.cnp.2021.02.004] [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: 06/17/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022] Open
Abstract
Obese patients have elevated risk of perioperative injury during spine surgery. IONM identified true-positive changes from unexpected worsening of spinal fracture. IONM changed the course of the surgery and prevented further injury to the patient. Need more research on using IONM in spine surgery with morbidly obese patients.
Introduction As the prevalence of obesity continues to rise, there is a growing need to identify practices that protect overweight patients from injury during spine surgery. Intraoperative neurophysiological monitoring (IONM) has been recommended for complex spine surgery, but its use in obese and morbidly obese patients is understudied. Case report This case report describes a patient with morbid obesity and ankylosing spondylitis who was treated for a T9-T10 3-column fracture with a planned, minimally invasive approach. Forty minutes after positioning the patient to prone, the IONM team identified a positive change in the patient’s motor responses in the bilateral lower extremities and alerted the surgical team in a timely manner. It turned out that the pressure exerted by gravity on the patient’s large pannus resulted in further dislocation of the fracture and narrowing of the spinal canal. The surgical team acknowledged the serious risk of spinal cord compression and, hence, immediately changed the surgical plan to an urgent, open approach for decompression and reduction of the fracture. The patient’s lower extremities’ motor responses improved after decompression. The patient was ambulatory on post-operative day 2 and pain-free at six-weeks with no other neurologic symptoms. Significance The use of IONM in this planned minimally invasive spine surgery for a patient with morbid obesity prevented potentially serious iatrogenic injury. The authors include a literature review that situates this case study in the existing literature and highlights a gap in current knowledge. There are few studies that have examined the use of IONM during spine surgery for morbidly obese patients. More research is needed to elucidate best practices for the use of IONM in spine surgery for morbidly obese patients.
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Affiliation(s)
- Nicholas A Streltzov
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Linton T Evans
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - M Dustin Boone
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Brandon K Root
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Daniel R Calnan
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Erik J Kobylarz
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
| | - Yinchen Song
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
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Rao S, Kurfess J, Treggiari MM. Basics of Neuromonitoring and Anesthetic Considerations. Anesthesiol Clin 2021; 39:195-209. [PMID: 33563382 DOI: 10.1016/j.anclin.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
It is important anesthesiologists understand the pharmacologic interactions of anesthetics and monitoring of evoked potentials or electroencephalography. Intravenous and inhaled anesthetics have varying degrees of influence on different monitoring modalities and can affect amplitude and latency of evoked potentials or voltage and frequency of electroencephalography. Sudden and abrupt changes in monitoring are concerning and should be evaluated promptly. The source of the changes is related to sudden modifications of anesthesia delivery, variations in vital parameters, or the result of surgical manipulation. Identifying sources of abnormal signals and determining the reason for the change should be addressed immediately and corrected accordingly.
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Affiliation(s)
- Shilpa Rao
- Division of Neuroanesthesia, Department of Anesthesiology, Yale School of Medicine, Yale University, PO Box 208051, 333 Cedar Street, TMP 3, New Haven, CT 06510, USA.
| | - James Kurfess
- Department of Anesthesiology, Yale University, PO Box 208051, 333 Cedar Street, TMP 3, New Haven, CT 06510, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Yale School of Medicine, Yale University, PO Box 208051, 333 Cedar Street, TMP 3, New Haven, CT 06510, USA
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11
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Ito S, Ando K, Kobayashi K, Nakashima H, Machino M, Kanbara S, Inoue T, Yamaguchi H, Segi N, Koshimizu H, Imagama S. Larger muscle mass of the upper limb correlates with lower amplitudes of deltoid MEPs following transcranial stimulation. J Clin Neurosci 2020; 81:426-430. [PMID: 33222955 DOI: 10.1016/j.jocn.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/14/2020] [Accepted: 10/03/2020] [Indexed: 11/18/2022]
Abstract
To perform spinal surgery safely, it is important to understand the risk factors, including factors that negatively influence intraoperative neuromonitoring (IONM). Transcranial motor evoked potentials (TcMEPs) are important in IONM. Therefore, we aimed to investigate whether muscle mass affects the waveforms of TcMEPs to understand the risk factors influencing TcMEPs. We enrolled 48 patients with thoracolumbar spinal diseases who underwent surgery at our facility between April 2015 and March 2018. Before surgery, the body composition, including muscle mass and fat mass, of all patients was measured using bioelectrical impedance analysis (BIA). During surgery, cranial stimulation under general anesthesia was used to derive TcMEPs, enabling us to measure the amplitude, using the control wave of the TcMEPs of the deltoid muscles and the abductor digiti minimi (ADM) muscles. We found a negative correlation between the amplitude of deltoid-muscle TcMEPs and muscle mass of the upper limb. The amplitude of deltoid-muscle TcMEPs did not correlate with the skeletal muscle index (SMI), muscle mass of the lower limb, or body fat mass. The amplitude of ADM-muscle TcMEPs did not correlate with SMI, muscle mass of any limb, or body fat mass. In conclusion, a larger muscle mass of the upper limb correlated with a lower amplitude of deltoid-muscle TcMEPs. By contrast, there was no correlation between the muscle mass of the upper limb and the amplitude of ADM-muscle TcMEPs. These findings suggest that TcMEPs of the ADM are less influenced by muscle mass and are more stable than those of the deltoid.
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Affiliation(s)
- Sadayuki Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shunsuke Kanbara
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
| | - Taro Inoue
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Hiroyuki Koshimizu
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
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12
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Que Y, Xue J. Propofol activates autophagic activity of vascular endothelial cells by inhibiting SENP1 expression and attenuates vascular endothelial injury induced by ischemia-reperfusion in orthopedic surgery. BIOTECHNOL BIOTEC EQ 2019. [DOI: 10.1080/13102818.2019.1673208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Yuanyuan Que
- Department of Anesthesiology, Guizhou Provincial People’s Hospital, Guiyang, Guizhou, People's Republic of China
| | - Jinpei Xue
- Department of Anesthesiology, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
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