Diagnostic and therapeutic values of intraoperative electrophysiological neuromonitoring during resection of intradural extramedullary spinal tumors: a single-center retrospective cohort and meta-analysis

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OBJECTIVE

With the advent of intraoperative electrophysiological neuromonitoring (IONM), surgical outcomes of various neurosurgical pathologies, such as brain tumors and spinal deformities, have improved. However, its diagnostic and therapeutic value in resecting intradural extramedullary (ID-EM) spinal tumors has not been well documented in the literature. The objective of this study was to summarize the clinical results of IONM in patients with ID-EM spinal tumors.

METHODS

A retrospective patient database review identified 103 patients with ID-EM spinal tumors who underwent tumor resection with IONM (motor evoked potentials, somatosensory evoked potentials, and free-running electromyography) from January 2010 to December 2015. Patients were classified as those without any new neurological deficits at the 6-month follow-up (group A; n = 86) and those with new deficits (group B; n = 17). Baseline characteristics, clinical outcomes, and IONM findings were collected and statistically analyzed. In addition, a meta-analysis in compliance with the PRISMA guidelines was performed to estimate the overall pooled diagnostic accuracy of IONM in ID-EM spinal tumor resection.

RESULTS

No intergroup differences were discovered between the groups regarding baseline characteristics and operative data. In multivariate analysis, significant IONM changes (p < 0.001) and tumor location (thoracic vs others, p = 0.018) were associated with new neurological deficits at the 6-month follow-up. In predicting these changes, IONM yielded a sensitivity of 82.4% (14/17), specificity of 90.7% (78/86), positive predictive value (PPV) of 63.6% (14/22), negative predictive value (NPV) of 96.3% (78/81), and area under the curve (AUC) of 0.893. The diagnostic value slightly decreased in patients with schwannomas (AUC = 0.875) and thoracic tumors (AUC = 0.842). Among 81 patients who did not demonstrate significant IONM changes at the end of surgery, 19 patients (23.5%) exhibited temporary intraoperative exacerbation of IONM signals, which were recovered by interruption of surgical maneuvers; none of these patients developed new neurological deficits postoperatively. Including the present study, 5 articles encompassing 323 patients were eligible for this meta-analysis, and the overall pooled diagnostic value of IONM was a sensitivity of 77.9%, a specificity of 91.1%, PPV of 56.7%, and NPV of 95.7%.

CONCLUSIONS

IONM for the resection of ID-EM spinal tumors is a reasonable modality to predict new postoperative neurological deficits at the 6-month follow-up. Future prospective studies are warranted to further elucidate its diagnostic and therapeutic utility.

ABBREVIATIONS AUC = area under the curve; CEL = clinical evidence level; EBL = estimated blood loss; EEG = electroencephalography; EMG = electromyography; GTR = gross-total resection; ID-EM = intradural extramedullary; IONM = intraoperative neuromonitoring; MEP = motor evoked potential; NMJB = neuromuscular junction blockade; NPV = negative predictive value; PPV = positive predictive value; SSEP = somatosensory evoked potential.

Article Information

Correspondence Sheng-fu L. Lo: Johns Hopkins University School of Medicine, Baltimore, MD. larrylo@jhmi.edu.

INCLUDE WHEN CITING Published online March 1, 2019; DOI: 10.3171/2018.11.SPINE181095.

W.I. and J.C. contributed equally to this work.

Disclosures Mr. Casaos is an HHMI Medical Student Research Fellow. Dr. Theodore is a consultant to Globus Medical. Dr. Gokaslan receives non−study-related research support from AOSpine North America and honoraria from AO Foundation and is a shareholder of Spinal Kinetic as well as US Spine. Dr. Sciubba is a consultant to Medtronic, DePuy-Synthes, Stryker, NuVasive, K2M, Baxter, and Misonix. Dr. Witham receives non–study-related support from the Gordon and Marilyn Macklin Foundation as well as Eli Lilly and Co. Dr. Wolinsky is a consultant to Siemens and DePuy-Synthes. Dr. Lo receives non–study-related financial support from the AO Foundation and Chordoma Foundation.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    PRISMA flowchart depicting our Web-based literature search strategy. ED = extradural.

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    Overall pooled diagnostic value of intraoperative neuromonitoring in predicting postoperative neurological deficits at long-term follow-ups: sensitivity (A), specificity (B), PPV (C), and NPV (D).

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    Funnel plots describing logit event rates and standard errors of included studies (white dots) and imputed studies (black dots, indicating potential bias) as well as pooled diagnostic value (white rhomboid) and adjusted diagnostic value (black rhomboid, with imputed studies taken into consideration): sensitivity (A), specificity (B), PPV (C), and NPV (D).

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