Utility of neuromonitoring during lumbar pedicle subtraction osteotomy for adult spinal deformity

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OBJECTIVE

The benefits and utility of routine neuromonitoring with motor and somatosensory evoked potentials during lumbar spine surgery remain unclear. This study assesses measures of performance and utility of transcranial motor evoked potentials (MEPs) during lumbar pedicle subtraction osteotomy (PSO).

METHODS

This is a retrospective study of a single-surgeon cohort of consecutive adult spinal deformity (ASD) patients who underwent lumbar PSO from 2006 to 2016. A blinded neurophysiologist reviewed individual cases for MEP changes. Multivariate analysis was performed to determine whether changes correlated with neurological deficits. Measures of performance were calculated.

RESULTS

A total of 242 lumbar PSO cases were included. MEP changes occurred in 38 (15.7%) cases; the changes were transient in 21 cases (55.3%) and permanent in 17 (44.7%). Of the patients with permanent changes, 9 (52.9%) had no recovery and 8 (47.1%) had partial recovery of MEP signals. Changes occurred at a mean time of 8.8 minutes following PSO closure (range: during closure to 55 minutes after closure). The mean percentage of MEP signal loss was 72.9%. The overall complication rate was 25.2%, and the incidence of new neurological deficits was 4.1%. On multivariate analysis, MEP signal loss of at least 50% was not associated with complication (p = 0.495) or able to predict postoperative neurological deficits (p = 0.429). Of the 38 cases in which MEP changes were observed, the observation represented a true-positive finding in only 3 cases. Postoperative neurological deficits without MEP changes occurred in 7 cases. Calculated measures of performance were as follows: sensitivity 30.0%, specificity 84.9%, positive predictive value 7.9%, and negative predictive value 96.6%. Regarding the specific characteristics of the MEP changes, only a signal loss of 80% or greater was significantly associated with a higher rate of neurological deficit (23.0% vs 0.0% for loss of less than 80%, p = 0.021); changes of less than 80% were not associated with postoperative deficits.

CONCLUSIONS

Neuromonitoring has a low positive predictive value and low sensitivity for detecting new neurological deficits. Even when neuromonitoring is unchanged, patients can still have new neurological deficits. The utility of transcranial MEP monitoring for lumbar PSO remains unclear but there may be advantages to its use.

ABBREVIATIONS ASD = adult spinal deformity; IONM = intraoperative neuromonitoring; MEP = motor evoked potential; NPV = negative predictive value; PPV = positive predictive value; PSO = pedicle subtraction osteotomy; SSEP = somatosensory evoked potential; UIV = uppermost instrumented vertebra.

Article Information

Correspondence Darryl Lau: University of California, San Francisco, CA. darryl.lau@ucsf.edu.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.3.SPINE181409.

Disclosures Dr. Smith reports consultant relationships with K2M, AlloSource, Cerapedics, Zimmer Biomet, and NuVasive; support from DePuy Synthes for the study described as well as for other clinical or research efforts; fellowship funding from NREF and AOSpine; and royalties from Zimmer Biomet. Dr. Shaffrey reports consultant relationships with Medtronic and NuVasive; direct stock ownership in NuVasive; patent holder relationships with Medtronic, NuVasive, and Zimmer Biomet; and support of non–study-related clinical or research efforts from ISSG Foundation. Dr. Ames reports consultant relationships with DePuy Synthes, Medtronic, Stryker, Medicrea, K2M, and Zimmer Biomet; receipt of royalties from Stryker, Zimmer Biomet Spine; DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; research support from Titan Spine, DePuy Synthes, and ISSG; membership on the editorial board of Operative Neurosurgery; grant funding from SRS; membership on the executive committee of ISSG; and directorship of Global Spine Analytics.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Preoperative (left) and postoperative (right) standing radiographs of a patient who underwent an L3 PSO. The preoperative standing radiographs demonstrate flattening of the thoracic and lumbar spine and scoliosis. Lumbar pelvic parameters were as follows: sagittal vertical axis (SVA) of 3.0 cm, lumbar lordosis (LL) of −7° (kyphosis), pelvic incidence (PI) of 46°, and scoliosis of 29°. After L3 PSO, the lumbar pelvic parameters were as follows: SVA of 3.5 cm, LL of 65°, and scoliosis of 7°.

  • View in gallery

    Loss of multimyotomal signals following closure of L3 PSO. A greater than 80% loss in the right rectus femoris, 50% loss in the right vastus medialis, and 60% loss in the right anterior tibialis can be seen 3 minutes following closure of the osteotomy. REHL = right extensor hallucis longus; RFT = right foot; RGAS = right gastrocnemius; RRF = right rectus femoris; RTA = right tibialis anterior; R VM-R = right vastus medialis. Figure is available in color online only.

References

  • 1

    Auerbach JDLenke LGBridwell KHSehn JKMilby AHBumpass D: Major complications and comparison between 3-column osteotomy techniques in 105 consecutive spinal deformity procedures. Spine (Phila Pa 1976) 37:119812102012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Baldus CRBridwell KHLenke LGOkubadejo GO: Can we safely reduce blood loss during lumbar pedicle subtraction osteotomy procedures using tranexamic acid or aprotinin? A comparative study with controls. Spine (Phila Pa 1976) 35:2352392010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bianco KNorton RSchwab FSmith JSKlineberg EObeid I: Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36(5):E182014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Bjerke BTZuchelli DMNemani VMEmerson RGKim HJBoachie-Adjei O: Prognosis of significant intraoperative neurophysiologic monitoring events in severe spinal deformity surgery. Spine Deform 5:1171232017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Buchowski JMBridwell KHLenke LGKuhns CALehman RA JrKim YJ: Neurologic complications of lumbar pedicle subtraction osteotomy: a 10-year assessment. Spine (Phila Pa 1976) 32:224522522007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Eager MJahangiri FShimer AShen FArlet V: Intraoperative neuromonitoring: lessons learned from 32 case events in 2095 spine cases. Evid Based Spine Care J 1:58612010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Kamerlink JRErrico TXavier SPatel APatel ACohen A: Major intraoperative neurologic monitoring deficits in consecutive pediatric and adult spinal deformity patients at one institution. Spine (Phila Pa 1976) 35:2402452010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Kelly MPLenke LGShaffrey CIAmes CPCarreon LYLafage V: Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study. Neurosurg Focus 36(5):E172014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Kundnani VKZhu LTak HWong H: Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: evaluation of 354 consecutive cases. Indian J Orthop 44:64722010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Lieberman JALyon RFeiner JHu SSBerven SH: The efficacy of motor evoked potentials in fixed sagittal imbalance deformity correction surgery. Spine (Phila Pa 1976) 33:E414E4242008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Lu YQureshi SA: Cost-effective studies in spine surgeries: a narrative review. Spine J 14:274827622014

  • 12

    Magit DPHilibrand ASKirk JRechtine GAlbert TJVaccaro AR: Questionnaire study of neuromonitoring availability and usage for spine surgery. J Spinal Disord Tech 20:2822892007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Melachuri SRKaur JMelachuri MKCrammond DJBalzer JRThirumala PD: The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1036 posterior spinal fusions. Neurol Res 39:107310792017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Quraishi NALewis SJKelleher MOSarjeant RRampersaud YRFehlings MG: Intraoperative multimodality monitoring in adult spinal deformity: analysis of a prospective series of one hundred two cases with independent evaluation. Spine (Phila Pa 1976) 34:150415122009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 76 (Suppl 1):S33S412015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Smith JSKlineberg ELafage VShaffrey CISchwab FLafage R: Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 25:1142016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Smith JSSansur CADonaldson WF IIIPerra JHMudiyam RChoma TJ: Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976) 36:9589642011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Soroceanu ABurton DCOren JHSmith JSHostin RShaffrey CI: Medical complications after adult spinal deformity surgery: incidence, risk factors, and clinical impact. Spine (Phila Pa 1976) 41:171817232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Tamkus ARice KSHoffman G: Transcranial motor evoked potential alarm criteria to predict foot drop injury during lumbosacral surgery. Spine (Phila Pa 1976) 43:E227E2332018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Thirumala PDBodily LTint DWard WTDeeney VFCrammond DJ: Somatosensory-evoked potential monitoring during instrumented scoliosis corrective procedures: validity revisited. Spine J 14:157215802014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Thirumala PDHuang JThiagarajan KCheng HBalzer JCrammond DJ: Diagnostic accuracy of combined multimodality somatosensory evoked potential and transcranial motor evoked potential intraoperative monitoring in patients with idiopathic scoliosis. Spine (Phila Pa 1976) 41:E1177E11842016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Thuet EDWinscher JCPadberg AMBridwell KHLenke LGDobbs MB: Validity and reliability of intraoperative monitoring in pediatric spinal deformity surgery: a 23-year experience of 3436 surgical cases. Spine (Phila Pa 1976) 35:188018862010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Trobisch PDHwang SWDrange S: PSO without neuromonitoring: analysis of peri-op complication rate after lumbar pedicle subtraction osteotomy in adults. Eur Spine J 25:262926322016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Vitale MGSkaggs DLPace GIWright MLMatsumoto HAnderson RC: Best practices in intraoperative neuromonitoring in spine deformity surgery: development of an intraoperative checklist to optimize response. Spine Deform 2:3333392014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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