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Rhee PC, Spinner RJ, Bishop AT, Shin AY. Iatrogenic brachial plexus injuries associated with open subpectoral biceps tenodesis: a report of 4 cases. Am J Sports Med 2013; 41:2048-53. [PMID: 23876520 DOI: 10.1177/0363546513495646] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Choo J, Wilhelmi BJ, Kasdan ML. Iatrogenic Injury to the Median Nerve During Palmaris Longus Harvest: An Overview of Safe Harvesting Techniques. Hand (N Y) 2017; 12:NP6-NP9. [PMID: 28082854 PMCID: PMC5207290 DOI: 10.1177/1558944716648313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: A rare and disastrous complication of harvesting a tendon graft is the misidentification of the median nerve for the palmaris longus. Methods: The authors report a referred case in which the median nerve was harvested as a free tendon graft. Results: Few reports of this complication are found in the literature despite the frequency of palmaris longus tendon grafting and the proximity of the palmaris tendon to the median nerve. Given the obvious medicolegal implications, the true incidence of this complication is difficult to assess. Discussion: Safe harvesting of the palmaris longus mandates a thorough understanding of the relevant anatomy, in particular the proper differentiation between nerve and tendon and recognition of when the palmaris longus tendon is absent. Techniques to facilitate proper identification of the palmaris longus are outlined.
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Walley KC, Saloky KL, Updegrove GF, Lopez H, Armstrong AD. Characterization of an anatomic safe zone surrounding the lower subscapular nerve during an open deltopectoral approach. J Shoulder Elbow Surg 2019; 28:671-677. [PMID: 30509609 DOI: 10.1016/j.jse.2018.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/06/2018] [Accepted: 09/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Due to anatomic variance in subscapular nerve innervation patterns, it is theorized that the dysfunction of the subscapularis could be the result of iatrogenic denervation during mobilization of the subscapularis while exposing the anterior glenohumeral joint in anterior surgical approaches. The purpose of this study was to describe innervation patterns of the subscapularis and to characterize a safe zone when conducting an anterior surgical approach. METHODS The study used 6 human cadaveric shoulder specimens (12 shoulders total). A deltopectoral approach was used to expose the axillary nerve back to the posterior cord of the brachial plexus and reveal the origins of the upper and lower subscapularis nerves. An anatomic safe zone was characterized by measuring distances from both the upper and lower subscapularis nerve insertions with respect to that of the lateral border of the conjoint tendon, the bicipital groove, superior border of the subscapularis, and the axillary nerve (for the lower subscapular nerve only) with the arm in 30° abduction. RESULTS The anatomic safe zone of the subscapular nerves medial to the conjoint tendon is less than 32 mm. In relation to the axillary nerve, the safe zone is less than 10 mm inferiorly and 15 mm medially. CONCLUSIONS This described safe zone with respect to the lateral border of the conjoint tendon and axillary nerve is aimed to provide guidance to reduce iatrogenic injury of the subscapular nerves during anterior shoulder exposure. Extra care should be undertaken while dissecting past this safe zone to prevent iatrogenic subscapular nerve injury.
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Fort NM, Victoria C, Ko L, Wolfe SW, Lee SK, Nwawka OK. High resolution ultrasound for the evaluation of radial nerve pathology adjacent to metallic hardware. J Orthop Res 2022; 40:2557-2564. [PMID: 35088459 DOI: 10.1002/jor.25278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 01/08/2022] [Accepted: 01/16/2022] [Indexed: 02/04/2023]
Abstract
Accurate localization and characterization of peripheral nerve injuries adjacent to metallic hardware is difficult with magnetic resonance imaging (MRI) due to susceptibility artifact. This study sought to present the use of high-resolution ultrasound (US) in accurate characterization of radial nerve injury adjacent to metallic hardware, using findings at the time of operative exploration as confirmation of the US assessment. A retrospective chart review of cases with clinically identified radial nerve injuries evaluated by the high-resolution US was performed from January 2015 through December 2019. Preoperative clinical data, US reports, MRI reports, electrodiagnostic (EDx) reports, and operative reports were reviewed for each case. Preoperative US correctly characterized the affected nerve component, type, and location of injury in all 13 cases (100%), when correlated with intraoperative findings. Nerve injury was directly adjacent to metallic hardware in 12 cases (92%). Out of the seven cases evaluated by both US and MRI, US correctly accurately diagnosed radial nerve injuries in all cases, whereas MRI accurately diagnosed in four cases (57%). In 3/7 cases (43%) MRI was nondiagnostic due to susceptibility artifact. MRI evaluation of the nerve was limited to some degree by metallic artifact in 6/7 cases (85%).
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Shields LBE, Iyer VG, Zhang YP, Shields CB. Iatrogenic median and ulnar nerve injuries during carpal tunnel release: clinical, electrodiagnostic, and ultrasound features in 12 patients. Patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22543. [PMID: 36880513 PMCID: PMC10550664 DOI: 10.3171/case22543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/01/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Nerve injuries during carpal tunnel release (CTR) are rare. Electrodiagnostic (EDX) and ultrasound (US) studies may be helpful in evaluating iatrogenic nerve injuries during CTR. OBSERVATIONS Nine patients sustained a median nerve injury, and 3 patients experienced ulnar nerve damage. Decreased sensation occurred in 11 patients, and dysesthesia occurred in 1 patient. Abductor pollicis brevis (APB) weakness occurred in all patients with median nerve injury. Of the 9 patients with median nerve injury, the compound muscle action potentials (CMAPs) of the APB and sensory nerve action potentials (SNAPs) of the 2nd or 3rd digit were not recordable in 6 and 5 patients, respectively. Of the 3 patients sustaining ulnar nerve injuries, the CMAPs of the abductor digiti minimi (ADM) and SNAPs of the 5th digit were not recordable in 1 patient; 2 patients showed prolonged latency and decreased amplitude of CMAPs/SNAPs. US studies of 8 patients with a median nerve injury showed a neuroma within the carpal tunnel. One patient underwent surgical repair urgently, and 6 did so after variable intervals. LESSONS Surgeons should be cognizant of nerve injuries during CTR. EDX and US studies are useful in evaluating iatrogenic nerve injuries during CTR.
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Ozcan M, Altinoz O, Erem M, Ciftdemir M, Copuroglu C, Turan FN. Prognosis and risk factors of nerve injuries in displaced pediatric supracondylar humerus fractures. Niger J Clin Pract 2020; 23:647-653. [PMID: 32367871 DOI: 10.4103/njcp.njcp_575_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Supracondylar humerus (SCH) fractures are serious injuries due to the neighborhood of critical neural and vascular structures. One of the most devastating complications of SCH fractures is neurological damage, since it may cause permanent disability. The aim of this study is to categorize neurological complications, to report long-term functional outcomes, and to determine risk factors associated with childhood SCH fractures. Methods The records of 375 children were reviewed retrospectively. Data about amount and direction of displacement, the shape of the fracture, age at the time of fracture, gender, time from impaction to surgery, time of surgery, type of neurological injury, and recovery time were recorded. Results Neurological complications were seen in 37 (9.85%) children. Thirteen (35.1%) of the children had an iatrogenic nerve injury. All iatrogenic injuries were fully recovered in this study. However, 2 children who had combined neurological injury of radial, ulnar, and median nerves did not recover. Nearly 95% of all children who had neurological injury recovered fully. An anterior long and sharp bone fragment (spike) was observed in most of the children with neurological injury, and this spike was seen in 14 (58.3%) patients who had a trauma-related injury (n = 24). Conclusion The prognosis of these nerve injuries is excellent, especially the iatrogenic ones. A long and sharp bone fragment (spike) may be responsible for nerve injuries in some children. Surgical exploration is not necessary after an iatrogenic nerve injury when there is no neurotmesis. Patience and care are utmost needed to handle neurological complications.
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Shields LB, Iyer VG, Zhang YP, Shields CB. Iatrogenic Ulnar Nerve Neuropathy Following Reverse Total Shoulder Arthroplasty: Electrodiagnostic Findings in 18 Patients. Cureus 2023; 15:e39089. [PMID: 37378144 PMCID: PMC10292086 DOI: 10.7759/cureus.39089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 06/29/2023] Open
Abstract
Background A reverse total shoulder arthroplasty (RTSA) is often recommended for rotator cuff pathology and may be associated with a myriad of complications, including prosthetic instability, infection, humeral problems, and glenoid loosening. Neurological injuries following an RTSA are infrequent and are usually related to brachial plexus or proximal nerve injury in the affected arm. Iatrogenic ulnar nerve neuropathy is exceedingly rare. Aims This study describes the clinical and electrodiagnostic (EDX) features of 18 patients with ulnar nerve neuropathy complicating RTSA. Materials and methods All patients underwent EDX studies, and 14 had an ultrasound (US) study. Results All patients complained of numbness, tingling, hyperalgesia, and/or allodynia in the distribution of the ulnar nerve. Eight (44%) patients reported hand weakness, and one (6%) noted wasting of the intrinsic hand muscles. Decreased pinprick sensation in the ulnar nerve distribution was detected in all patients. Seventeen (94%) patients had weakness of the ulnar nerve-innervated intrinsic hand muscles. All patients had focal slowing of the motor conduction of the ulnar nerve across the elbow. Sensory potentials were either absent or of a low amplitude over the digital and/or dorsal cutaneous branch of the ulnar nerve in all patients. Twelve (86%) patients showed an increase in the cross-sectional area (CSA) of the ulnar nerve at the elbow; six (43%) had a hypoechoic ulnar nerve. Ulnar nerve neuropathy was confirmed at the elbow in all 18 patients. Of the 14 (78%) patients who underwent surgical intervention for ulnar nerve neuropathy following an RTSA, only four had complete symptom resolution. Conclusions Surgeons should be cognizant of ulnar nerve neuropathy as a potential complication of an RTSA and take precautions to avoid damage to the ulnar nerve intraoperatively. EDX and US studies should be performed to confirm and assess the site and severity of the injury.
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Shields LBE, Iyer VG, Zhang YP, Shields CB. Proximal median nerve neuropathy: electrodiagnostic and ultrasound findings in 62 patients. Front Neurol 2024; 15:1468813. [PMID: 39703354 PMCID: PMC11655337 DOI: 10.3389/fneur.2024.1468813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 11/11/2024] [Indexed: 12/21/2024] Open
Abstract
Objectives Proximal median nerve (PMN) neuropathies are caused by lesions proximal to the carpal tunnel, which include the forearm, elbow, upper arm, and brachial plexus. Differentiating between carpal tunnel syndrome and PMN neuropathies is important to guide management and is based on clinical, electrodiagnostic (EDX), and ultrasound (US) findings. This study describes the clinical, EDX, and US features in 62 patients with PMNs. Methods All patients underwent EDX studies, and 52 (83.9%) had a US study. The patients were assigned to one of the following four localization zones of PMN neuropathies based on clinical and EDX criteria: Zone 1: extends from the fascicles in the brachial plexus contributing to the median nerve to the innervation of the pronator teres (PT); Zone 2: distal to the branch to the PT and proximal to the origin of the anterior interosseous nerve (AIN); Zone 3: involves the origin of the AIN; and Zone 4: distal to the origin of the AIN and proximal to the carpal tunnel. The localization was based on the pattern of muscle weakness, topography of EMG abnormalities, and US study findings. Results The anatomical locations of the PMN neuropathies based on clinical, EDX, and US findings were as follows: Zone 1 in 38 patients (61.3%), Zone 2 in 6 patients (9.7%), Zone 3 in 7 patients (11.3%), and Zone 4 in 11 patients (17.7%). The most common etiology among all 62 patients was iatrogenic injury (30 [48.4%]), followed by non-iatrogenic trauma (20 [32.2%]). The following EDX findings were noted: prolonged distal motor latency (29 [46.8%]), decreased motor nerve conduction velocity in the forearm (22 [35.5%]), low amplitude or absent compound muscle action potentials (50 [80.6%]), and abnormal or absent sensory nerve action potentials (50 [80.6%]). Of the 52 (83.9%) patients who underwent US studies, a total of 22 (42.3%) patients showed an increased cross-sectional area of the median nerve. A neuroma was observed in 9 patients (17.4%). Conclusion It is often possible to localize the site of the median nerve involvement and gain insight into the underlying cause based on clinical and EMG findings, but in certain cases, a US study may be necessary to confirm the location.
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Togioka BM, Harriman KA, Ye S, Berli J. Frequency and Characteristics of Postoperative Neuropathy in Individuals on Gender-Affirming Hormone Therapy Undergoing Gender Affirmation Surgery: A Retrospective Cohort Study. Cureus 2023; 15:e47988. [PMID: 38034215 PMCID: PMC10686520 DOI: 10.7759/cureus.47988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction Gender affirmation surgery includes procedures of the face, larynx, chest, reproductive system, external genitalia, and adipose tissue performed to ameliorate incongruence between gender identity and phenotype. The annual number of gender affirmation surgeries performed in the United States has increased significantly. There have been no investigations into the frequency of peripheral neuropathy after gender affirmation surgery, which is an important topic, given transgender individuals are at increased risk for delaying necessary medical care. After appreciating a number of cases of postoperative neuropathy in our clinical practice, we hypothesized that gender affirmation surgery is a high-risk procedure for postoperative neuropathy. Methods We conducted a one-year, monocentric, retrospective cohort study utilizing clinical data of individuals on gender-affirming hormone therapy undergoing gender-affirmation surgery under general anesthesia. The study included transgender women, assigned male at birth, receiving antiandrogen, progesterone, or estrogen therapy (target range plasma estradiol concentration 90-200 pg/ml) and transgender men, assigned female at birth, receiving antiestrogen or testosterone therapy (target range plasma testosterone concentration 320-1000 ng/dl). The primary objective was to estimate the incidence of postoperative peripheral neuropathy, defined as new numbness, paresthesia, neuropathic pain, or muscle weakness occurring in a peripheral innervation territory. Secondary objectives were to summarize the clinical presentation of neuropathy and investigate for associations between procedure characteristics and neuropathy. Results We identified nine cases of postoperative peripheral nerve injury in 232 consecutive gender affirmation procedures establishing an incidence of 3.9%. All injuries were associated with surgery longer than six hours and were characterized by sensory deficits including numbness 89% (8/9) and tingling 56% (5/9), which were diagnosed by postoperative day one. Conclusions Our results suggest that gender affirmation surgery is a high-risk procedure for postoperative neuropathy, with an incidence similar to other high-risk procedures, and an incidence that is higher than the general surgical population. However, given this has not been previously reported and our study includes a heterogenous population from a single institution, our results should be considered hypothesis generating. Additional studies that include multiple institutions are needed to confirm our findings and identify modifiable risk factors for postoperative neuropathy.
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Harada T, Iwasaki H, Taniguchi T, Taniguchi W, Nishiyama D, Fukui D, Yamanaka M, Yamada H. Role of Intraoperative Nerve Monitoring in Preventing Peripheral Nerve Injury During Total Hip Arthroplasty in High-Risk Patients. Cureus 2025; 17:e80233. [PMID: 40190955 PMCID: PMC11972831 DOI: 10.7759/cureus.80233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2025] [Indexed: 04/09/2025] Open
Abstract
Background Intraoperative nerve monitoring (IONM) plays a crucial role in preventing peripheral nerve injury during total hip arthroplasty (THA). However, its efficacy in THA remains controversial. This study aimed to evaluate the efficacy of IONM in preventing peripheral nerve injury during THA. Methods This study retrospectively included 79 hips in 72 patients (primary THA: 43 hips; revision THA: 36 hips) with risk factors for intraoperative nerve injury who underwent motor evoked potential (MEP) monitoring combined with THA between July 2011 and March 2019. A concerning MEP change was defined as a decrease to <30%. The frequency and cause of the MEP change and the presence of postoperative neurological symptoms were investigated. Results Motor evoked potential changes were detected in five of the 79 hips (6.3%). In one of these cases, the potential amplitude did not recover, and transient postoperative muscle weakness was observed due to the delayed detection of MEP changes. In the remaining cases, the potential change was quickly detected by IONM, including the regular-interval monitoring method, without any subsequent postoperative muscle weakness. Conclusions Intraoperative nerve monitoring effectively prevented peripheral nerve injury during THA, particularly in patients with developmental dysplasia of the hip (DDH) or a history of hip surgery. To prevent irreversible postoperative neuropathy, regular interval nerve monitoring, and free-run electromyography should be considered routine techniques in THA for patients with DDH or a history of hip surgery.
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Iyer VG, Shields LBE, Daniels MW, Zhang YP, Shields CB. A Retrospective Study of Lateral Antebrachial Cutaneous Nerve Neuropathy: Electrodiagnostic Findings and Etiologies in 49 Cases. Neurol Int 2024; 16:1143-1157. [PMID: 39452688 PMCID: PMC11510289 DOI: 10.3390/neurolint16050086] [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: 08/27/2024] [Revised: 10/01/2024] [Accepted: 10/07/2024] [Indexed: 10/26/2024] Open
Abstract
BACKGROUND The lateral antebrachial cutaneous nerve (LACN) is the terminal sensory branch of the musculocutaneous nerve and is rarely entrapped or injured. This study describes the electrodiagnostic (EDX) findings and etiologies of LACN neuropathy. METHODS This is a review of 49 patients with pain and/or paresthesia of the forearm who underwent EDX studies. The diagnosis of LACN neuropathy was based on clinical and sensory conduction abnormalities. RESULTS The most common etiology of LACN neuropathy was iatrogenic injury in 30 (61.2%) patients, primarily due to biceps tendon repair at the elbow (11 [36.7%]) and phlebotomy (5 [16.7%]). Fifteen (30.6%) patients sustained a non-iatrogenic injury at the proximal forearm/elbow, consisting of six (60%) laceration injuries and five (33.3%) stretch injuries. Four (8.2%) patients comprised the "other" etiology category, including two mass lesions causing LACN compression. Pain, paresthesia, and/or numbness in the LACN distribution were reported in 33 (67.3%), 27 (55.1%), and 23 (46.9%) patients, respectively. Hypoesthesia was detected in 45 (91.8%) patients, and dysesthesia in 7 (14.3%). The sensory nerve action potentials (SNAPs) of the LACN on the symptomatic side were absent in 44 (89.8%) patients. Of the five patients whose SNAPs of the LACN were detected, all had a decreased amplitude, and two had increased sensory latency. CONCLUSIONS The most common etiology for LACN neuropathy in this series was iatrogenic injury; repair of biceps tendon at the elbow was the most frequent provoking cause. Protection of the LACN during surgical procedures at the elbow and forearm is vital to prevent iatrogenic injury.
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Blumenthal SL, Edionwe JI, Courtois EC, Guyer RD, Satin AM, Ohnmeiss DD. Is the Use of Intraoperative Neuromonitoring Justified During Lumbar Anterior Approach Surgery? Int J Spine Surg 2024; 18:217-221. [PMID: 38471741 PMCID: PMC11292559 DOI: 10.14444/8589] [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: 03/14/2024] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) became widely used in spine surgery to reduce the risk of iatrogenic nerve injury. However, the proliferation of IONM has fallen into question based on effectiveness and costs, with a lack of evidence supporting its benefit for specific spine surgery procedures. The purpose of this study was to evaluate the use of IONM and the rate of neurological injury associated with anterior lumbar spinal surgery. METHODS This was a retrospective study on a consecutive series of 359 patients undergoing lumbar anterior approach surgery for anterior lumbar interbody fusion (ALIF), total disc replacement (TDR), or hybrid (ALIF with TDR) for the treatment of symptomatic disc degeneration. Patients undergoing any posterior spine surgery were excluded. Operative notes were reviewed to identify any changes in IONM and the surgeon's response. Clinic notes were reviewed up to 3 months postoperatively for indications of iatrogenic nerve injury. RESULTS There were 3 aberrant results with respect to IONM. Changes in IONM of a lower extremity occurred for 1 patient (0.3%). The surgeon evaluated the situation and there was no observable reason for the IONM change. Upon waking, the patient was found to have no neurological deficit. There were 2 cases of neurologic deficits in this population, which were classified as false-negatives of IONM (0.56%, 95% CI: 0.1% to 1.8%). In both cases, the patients were found to have a foot drop after the anterior approach surgery. CONCLUSION In this study, there was 1 false-positive and 2 false-negative results of IONM. These data suggest that IONM is not beneficial in this population. However, many surgeons may feel obligated to use IONM for medicolegal reasons. There is a need for future studies to delineate cases in which IONM is beneficial and the type of monitoring to use, if any, for specific spine surgery types. CLINICAL RELEVANCE This study questions the routine use of IONM in anterior lumbar approach surgery for the treatment of symptomatic disc degeneration. This has significant implications related to the cost of this practice. LEVEL OF EVIDENCE: 4
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