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- Title
Responding To Intra-Operative Neuromonitoring Alerts In Spinal Deformity Surgery: A Pilot Data Form Can Summarize Key Intra-Operative Data.
- Authors
Lewis, Stephen; Akula, Maheswara; Nielsen, Christopher J.; Strantzas, Samuel; Holmes, Laura; G. Lenke, Lawrence; Germscheid, Niccole; de Kleuver, Marinus
- Abstract
Introduction: Controversy exists in monitoring and interpreting intraoperative neurophysiological data. Significant debate remains in determining which changes are significant and what actions, if any, are required in response to intra-operative changes. The purpose of this study was to develop a data collection form to prospectively collect intra-operative neuromonitoring and operative data, to capture the timing of alerts and correlate them with surgical and nonsurgical manoeuvres performed in response to these changes. The effectiveness and utility of the form was analysed and will serve as a pilot to a larger multicentre project with the goal to develop a care pathway in the use of intra-operative neuromonitoring for spinal deformity surgery. Material and Methods: Pediatric patients undergoing cord level spinal deformity surgery were consecutively enrolled. Detailed intraoperative real time neuro monitoring data was prospectively collected on the data sheets providing the specific information related to patient characteristics, radiological parameters, timing and actions performed in response. Results were analysed using appropriate statistical methods. Patients were divided into two groups based on presence or absence of significant alerts which were defined as > 50% loss of MEP or SSEP amplitude relative to baseline. Results: Over 6 months, 54 consecutive patients in a single centre underwent cord level spinal deformity corrective surgery. 17 significant intra-operative alerts occurred in 12 patients. The alert group consisted of 9 idiopathic scoliosis, 2 neuromuscular and one syndromic. The mean age of the alert group was 15.0 ± 2.3 years with a mean Cobb of 87°, compared with 14.2 ± 3.1 and 77° in the non-alert group (p > 0.5). 92% of alerts were MEP and 8% SSEP. 30% of alerts were blood pressure related, 28% occurred during osteotomies, 23% during reduction manoeuvres and 19% related to traction and positioning. Measures taken to revert the alerts included correcting hypotension, adjusting anaesthesia, pausing surgery, reducing the reduction, temporarily removing the rods and decreasing the traction. Multiple actions were employed in 10 alerts. 9 MEP alerts were bilateral and 7 unilateral, of which 3 were associated with SSEP changes. Seven bilateral MEP alerts recovered completely, with the time to resolution in 2 cases of > 60 minutes, 20 - 60 minutes in 2, and < 20 minutes in 3 cases. Two MEP alerts did not recover to baseline: one to 25% and the other to 75% of baseline by the end of surgery. Of the 7 unilateral alerts, 2 recovered completely in < 10 minutes, 4 cases recovered to 75% of baseline in < 20 minutes, and one recovered to 25% of baseline at closure. There were no post-operative neurological deficits. Conclusions: The real-time intraoperative information provided the necessary information to direct key surgical decisions. After the systemic causes, reduction measures and osteotomies were the leading causes for MEP alerts. Responding to these alerts reversed the MEP changes, potentially preventing permanent neurological damage. The data form provided an excellent summary of each case and can serve as a basis for a large scale randomised prospective study for development of a clinical care pathway.
- Publication
Global Spine Journal, 2018, Vol 8, p266S
- ISSN
2192-5682
- Publication type
Article
- DOI
10.1177/2192568218771072