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Published by: anon_432008426 on Mar 09, 2011
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Matthew R. Eager, MD Adam L. Shimer, MD Faisal Jahangiri, MD Francis H.

Shen, MD Vincent Arlet, MD
Department of Orthopaedic Surgery Division of Spine Surgery Charlottesville, Virginia, USA

Intraoperative Neuromonitoring – V Arlet

Intraoperative neuromonitoring is being employed for an increasing number of spinal surgeries Deformity correction Instrumentation Question: How has multimodality intraoperative neuromonitoring affected our ability to avoid potential neurologic injury during spine surgery?

Intraoperative Neuromonitoring – V Arlet

All neuromonitored spine cases at UVA 2006-2010 Total 2095 cases Possible intraoperative event documented by neurophysiologist 32 cases with possible intraoperative events Retrospective analysis Intraoperative and postoperative clinical findings IRB approved study

Intraoperative Neuromonitoring – V Arlet

32 cases
17 intraoperative “saves” (true event) Intraoperative neuromonitoring caused an intervention during the surgery
Hypotention (5) Patient positioning/external force (4) Deformity correction (7) Screw malposition, low triggered EMG, repositioned (1)

No postoperative deficits

Intraoperative Neuromonitoring – V Arlet

Neuromonitoring changes during a deformity correction case Decreased MEPs of the left foot of 80 % amplitude, tibialis anterior has dropped 30 % after convex rod insertion Right side remained normal Correction was decreased and left LE MEPs returned to baseline.

Intraoperative Neuromonitoring – V Arlet

32 cases Controls (4) Intradural cord biopsies or tumor resections Neuromonitoring changes seen intraoperatively Expected postoperative deficits in all cases False-positives (4) Needle position, SSEP changes / incongruities No postoperative deficits Improved signals (4) SSEPs improved during surgery after neural decompression
3 cervical corpectomies, 1 thoracic discectomy

Intraoperative Neuromonitoring – V Arlet

32 cases
False-negatives (3)
Posterior lumbar instrumentation Passive EMGs quiet during surgery, no triggered EMGs performed Postoperative radiculopathy / motor weakness

Intraoperative Neuromonitoring – V Arlet

Did we learn any lessons?
1.5% incidence of possible intraoperative events Did we capture every case? Data recorded dependent on neurophysiologist Majority of the 32 cases were “saves” (53%) What would happen without intervention? Passive vs. triggered EMGs Could have prevented a second surgery in 3 cases Cost? Neuromonitoring cost per case? Cost of revision surgery Cost of poor patient outcome with postoperative deficit

Intraoperative Neuromonitoring – V Arlet

Weaknesses of the study
Did we capture every possible case with an intraoperative event? The true incidence of false-negative findings is not able to be elucidated with this database Relatively low numbers, single center

Intraoperative Neuromonitoring – V Arlet

Further work to be done
Can these cases be stratified to predict the need for neuromonitoring?
Look at the relative risks of an intraoperative event occurring based on the type of surgery
Deformity correction Instrumentation Decompression Location: Cord level, cauda equina level

Intraoperative Neuromonitoring – V Arlet

Overall, this review reinforces the importance of multimodality neuromonitoring for spinal surgery. Two major questions remain unanswered:
1. When is intraoperative neuromonitoring necessary for spine surgery? (risks vs. cost) 2. What are the true false-positive and falsenegative rates?

Intraoperative Neuromonitoring – V Arlet

Disclosure: None of the authors of this study has identified any conflicts of interest Thank you: for your attention

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