The efficacy of intraoperative multimodal monitoring in pedicle subtraction osteotomies of the lumbar spine

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

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OBJECTIVE

Iatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors’ aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine.

METHODS

All patients older than 18 years who underwent lumbar PSOs at the authors’ institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson’s Disease Questionnaire–39 (PDQ-39) and Patient Health Questionnaire–9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined.

RESULTS

A total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively).

CONCLUSIONS

In this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.

ABBREVIATIONS EMG = electromyography; IOM = intraoperative multimodal monitoring; MCID = minimal clinically important difference; MEP = motor evoked potential; PDQ-39 = Parkinson’s Disease Questionnaire–39; PHQ-9 = Patient Health Questionnaire–9; PSO = pedicle subtraction osteotomy; QOL = quality of life; SSEP = somatosensory evoked potential.
Article Information

Contributor Notes

Correspondence Jianning Shao: Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH. shaoj2@ccf.org.INCLUDE WHEN CITING Published online July 26, 2019; DOI: 10.3171/2019.5.SPINE19125.Disclosures Steinmetz: consultant for Globus Medical and Intellirod, royalties from Elsevier and Zimmer Biomet, honorarium from Globus Medical and Stryker, and research support from Globus Medical. Mroz: consultant for Globus Medical and royalties from Stryker. Savage: consultant for Stryker Spine and Wright Medical, and editorial or governing board of Clinical Spine Surgery.
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