The impact and value of uni- and multimodal intraoperative neurophysiological monitoring (IONM) on neurological complications during spine surgery: a prospective study of 2728 patients
We compared the value of different uni- and multimodal intraoperative neurophysiological monitoring (IONM) methods on the detection of neurological complications during spine surgery.
IONM data derived from sensory spinal and cortical evoked potentials combined with continuous electromyography monitoring, motor evoked potentials and spinal recording were evaluated in relation to subsequent post-operative neurological changes. Patients were categorised based on their true-positive or true-negative post-operative neurological status.
In 2728 consecutive patients we had 909 (33.3%) IONM alerts. We had 8 false negatives (0.3%) with post-operative radicular deficit that completely recovered within 3 months, except for one. There was no false negative for spinal cord injury. 107 were true positives, and 23 were false positives. Multimodal IONM sensitivity and specificity were 93.0% and 99.1%, respectively. The frequency of neurological complications including minor deficits was 4.2% (n = 115), of which 0.37% (n = 10) were permanent. Analysis of the single IONM modalities varied between 13 and 81% to detect neurological complications compared with 93% when using all modalities.
Multimodal IONM is more effective and accurate in assessing spinal cord and nerve root function during spine surgeries to reduce both neurological complications and false-negative findings compared to unimodal monitoring. We recommend multimodal IONM in all complex spine surgeries.
KeywordsSpine surgery Intraoperative neuromonitoring Sensitivity Specificity Complications
The authors wish to thank the Dr. Lote Medicus fund for financial support in the development of IONM at the Schulthess Clinic as well as Dave O’Riordan for manuscript preparation and Melissa Wilhelmi, Ph.D., and Anne Mannion, Ph.D., for their critical review of the manuscript.
Compliance with ethical standards
Conflict of interest
All support for this research was provided by Schulthess Clinic. On behalf of all authors, the corresponding author states that there is no conflict of interest. All authors also state that they have full control of all primary data and agree to allow the journal to review their data if requested.
- 15.Ito Z, Matsuyama Y, Ando M, Kawabata S, Kanchiku T, Kida K, Fujiwara Y, Yamada K, Yamamoto N, Kobayashi S, Saito T, Wada K, Satomi K, Shinomiya K, Tani T (2016) What is the best multimodality combination for intraoperative spinal cord monitoring of motor function? a multicenter study by the monitoring committee of the Japanese Society for Spine Surgery and Related Research. Glob Spine J 6:234–241CrossRefGoogle Scholar
- 18.Winkler T, Sharma HS, Stalberg E, Westman J (1998) Spinal cord bioelectric activity, edema and cell injury following a focal trauma to the rat spinal cord. An experimental study using pharmacological and morphological approaches. In: Stalberg E, Sharma H, Olsson Y (eds) Spinal cord monitoring. Springer, New York, pp 283–363CrossRefGoogle Scholar
- 22.Tamaki T, Yamashita T, Kobayashi H (1972) Spinal cord monitoring. Jpn J Electroencephalogr Electromyogr 1:196Google Scholar
- 25.Schär RT, Sutter M, Mannion AF, Eggspühler A, Jeszenszky D, Fekete TF, Kleinstück F, Haschtmann D (2017) Outcome of L5 radiculopathy after reduction and instrumented transforaminal lumbar interbody fusion of high-grade L5–S1 isthmic spondylolisthesis and the role of intraoperative neurophysiological monitoring. Eur Spine J 26:679–690CrossRefGoogle Scholar