Investigating the utility of intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion: analysis of over 140,000 cases from the National (Nationwide) Inpatient Sample data set

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  • 1 Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
  • 2 Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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OBJECTIVE

Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF.

METHODS

This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score–matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars).

RESULTS

A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score–matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges.

CONCLUSIONS

The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; CCI = Charlson Comorbidity Index; HCUP = Healthcare Cost and Utilization Project; IONM = intraoperative neurophysiological monitoring; LOS = length of stay; NIS = National (Nationwide) Inpatient Sample; OPLL = ossification of the posterior longitudinal ligament; SSEP = somatosensory evoked potential; tceMEP = transcranial electrical motor evoked potential.

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Contributor Notes

Correspondence Jefferson R. Wilson: University of Toronto, St. Michael’s Hospital, Toronto, ON, Canada. wilsonjeff@smh.ca.

INCLUDE WHEN CITING Published online March 29, 2019; DOI: 10.3171/2019.1.SPINE181110.

Disclosures Dr. Wilson reports being a consultant for Stryker Canada.

  • 1

    Badhiwala J, Wilson JR, Kreitz TM, Hilibrand AS: Is neuromonitoring necessary for all patients undergoing anterior cervical discectomy and fusion? Clin Spine Surg 30:13, 2017

    • Search Google Scholar
    • Export Citation
  • 2

    Davis SF, Corenman D, Strauch E, Connor D: Intraoperative monitoring may prevent neurologic injury in non-myelopathic patients undergoing ACDF. Neurodiagn J 53:114120, 2013

    • Search Google Scholar
    • Export Citation
  • 3

    Deyo RA, Cherkin DC, Ciol MA: Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45:613619, 1992

    • Search Google Scholar
    • Export Citation
  • 4

    Hadley MN, Shank CD, Rozzelle CJ, Walters BC: Guidelines for the use of electrophysiological monitoring for surgery of the human spinal column and spinal cord. Neurosurgery 81:713732, 2017

    • Search Google Scholar
    • Export Citation
  • 5

    Hilibrand AS, Schwartz DM, Sethuraman V, Vaccaro AR, Albert TJ: Comparison of transcranial electric motor and somatosensory evoked potential monitoring during cervical spine surgery. J Bone Joint Surg Am 86-A:12481253, 2004

    • Search Google Scholar
    • Export Citation
  • 6

    Jones SJ, Buonamassa S, Crockard HA: Two cases of quadriparesis following anterior cervical discectomy, with normal perioperative somatosensory evoked potentials. J Neurol Neurosurg Psychiatry 74:273276, 2003

    • Search Google Scholar
    • Export Citation
  • 7

    Lee JY, Hilibrand AS, Lim MR, Zavatsky J, Zeiller S, Schwartz DM, : Characterization of neurophysiologic alerts during anterior cervical spine surgery. Spine (Phila Pa 1976) 31:19161922, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    May DM, Jones SJ, Crockard HA: Somatosensory evoked potential monitoring in cervical surgery: identification of pre- and intraoperative risk factors associated with neurological deterioration. J Neurosurg 85:566573, 1996

    • Search Google Scholar
    • Export Citation
  • 9

    Ney JP, van der Goes DN, Nuwer MR: Does intraoperative neurophysiologic monitoring matter in noncomplex spine surgeries? Neurology 85:21512158, 2015

    • Search Google Scholar
    • Export Citation
  • 10

    Nuwer MR, Dawson EG, Carlson LG, Kanim LE, Sherman JE: Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 96:611, 1995

    • Search Google Scholar
    • Export Citation
  • 11

    Resnick DK, Anderson PA, Kaiser MG, Groff MW, Heary RF, Holly LT, : Electrophysiological monitoring during surgery for cervical degenerative myelopathy and radiculopathy. J Neurosurg Spine 11:245252, 2009

    • Search Google Scholar
    • Export Citation
  • 12

    Sala F, Bricolo A, Faccioli F, Lanteri P, Gerosa M: Surgery for intramedullary spinal cord tumors: the role of intraoperative (neurophysiological) monitoring. Eur Spine J 16 (Suppl 2):S130S139, 2007

    • Search Google Scholar
    • Export Citation
  • 13

    Smith PN, Balzer JR, Khan MH, Davis RA, Crammond D, Welch WC, : Intraoperative somatosensory evoked potential monitoring during anterior cervical discectomy and fusion in nonmyelopathic patients—a review of 1,039 cases. Spine J 7:8387, 2007

    • Search Google Scholar
    • Export Citation
  • 14

    Taunt CJ Jr, Sidhu KS, Andrew SA: Somatosensory evoked potential monitoring during anterior cervical discectomy and fusion. Spine (Phila Pa 1976) 30:19701972, 2005

    • Search Google Scholar
    • Export Citation
  • 15

    Thirumala PD, Bodily L, Tint D, Ward WT, Deeney VF, Crammond DJ, : Somatosensory-evoked potential monitoring during instrumented scoliosis corrective procedures: validity revisited. Spine J 14:15721580, 2014

    • Search Google Scholar
    • Export Citation
  • 16

    Traynelis VC, Abode-Iyamah KO, Leick KM, Bender SM, Greenlee JD: Cervical decompression and reconstruction without intraoperative neurophysiological monitoring. J Neurosurg Spine 16:107113, 2012

    • Search Google Scholar
    • Export Citation
  • 17

    Witiw CD, Smieliauskas F, O’Toole JE, Fehlings MG, Fessler RG: Comparison of anterior cervical discectomy and fusion to posterior cervical foraminotomy for cervical radiculopathy: utilization, costs, and adverse events 2003 to 2014. Neurosurgery 84:413420, 2019

    • Search Google Scholar
    • Export Citation

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