Advertisement

European Spine Journal

, Volume 28, Issue 3, pp 599–610 | Cite as

The impact and value of uni- and multimodal intraoperative neurophysiological monitoring (IONM) on neurological complications during spine surgery: a prospective study of 2728 patients

  • Martin Sutter
  • Andreas Eggspuehler
  • Dezsoe Jeszenszky
  • Frank Kleinstueck
  • Tamàs F. Fekete
  • Daniel Haschtmann
  • François Porchet
  • Jiri DvorakEmail author
Original Article

Abstract

Purpose

We compared the value of different uni- and multimodal intraoperative neurophysiological monitoring (IONM) methods on the detection of neurological complications during spine surgery.

Methods

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.

Results

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.

Conclusion

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.

Graphical abstract

These slides can be retrieved from Electronic Supplementary Material.

Keywords

Spine surgery Intraoperative neuromonitoring Sensitivity Specificity Complications 

Notes

Acknowledgements

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.

Supplementary material

586_2018_5861_MOESM1_ESM.pptx (231 kb)
Supplementary material 1 (PPTX 230 kb)

References

  1. 1.
    Sala F, Bricolo A, Faccioli F, Lanteri P, Gerosa M (2007) Surgery for intramedullary spinal cord tumors: the role of intraoperative (neurophysiological) monitoring. Eur Spine J 16(Suppl 2):S130–S139CrossRefGoogle Scholar
  2. 2.
    Deletis V, Sala F (2004) Intraoperative neurophysiological monitoring during spine surgery: an update. Curr Opin Orthop 15:154–158CrossRefGoogle Scholar
  3. 3.
    Sutter M, Eggspuehler A, Muller A, Dvorak J (2007) Multimodal intraoperative monitoring: an overview and proposal of methodology based on 1,017 cases. Eur Spine J 16(Suppl 2):S153–S161CrossRefGoogle Scholar
  4. 4.
    Iwasaki H, Tamaki T, Yoshida M, Ando M, Yamada H, Tsutsui S, Takami M (2003) Efficacy and limitations of current methods of intraoperative spinal cord monitoring. J Orthop Sci 8:635–642CrossRefGoogle Scholar
  5. 5.
    Kothbauer KF, Deletis V, Epstein FJ (1998) Motor-evoked potential monitoring for intramedullary spinal cord tumor surgery: correlation of clinical and neurophysiological data in a series of 100 consecutive procedures. Neurosurg Focus 4:e1CrossRefGoogle Scholar
  6. 6.
    Sala F, Krzan MJ, Deletis V (2002) Intraoperative neurophysiological monitoring in pediatric neurosurgery: why, when, how? Childs Nerv Syst 18:264–287CrossRefGoogle Scholar
  7. 7.
    Sala F, Palandri G, Basso E, Lanteri P, Deletis V, Faccioli F, Bricolo A (2006) Motor evoked potential monitoring improves outcome after surgery for intramedullary spinal cord tumors: a historical control study. Neurosurgery 58:1129–1143CrossRefGoogle Scholar
  8. 8.
    Raynor BL, Bright JD, Lenke LG, Rahman RK, Bridwell KH, Riew KD, Buchowski JM, Luhmann SJ, Padberg AM (2013) Significant change or loss of intraoperative monitoring data: a 25-year experience in 12,375 spinal surgeries. Spine (Phila Pa 1976) 38:E101–E118CrossRefGoogle Scholar
  9. 9.
    Raynor BL, Padberg AM, Lenke LG, Bridwell KH, Riew KD, Buchowski JM, Luhmann SJ (2016) Failure of intraoperative monitoring to detect postoperative neurologic deficits: a 25-year experience in 12,375 spinal surgeries. Spine (Phila Pa 1976) 41:1387–1393CrossRefGoogle Scholar
  10. 10.
    Malhotra NR, Shaffrey CI (2010) Intraoperative electrophysiological monitoring in spine surgery. Spine (Phila Pa 1976) 35:2167–2179CrossRefGoogle Scholar
  11. 11.
    Fehlings MG, Brodke DS, Norvell DC, Dettori JR (2010) The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference? Spine 35:S37–S46CrossRefGoogle Scholar
  12. 12.
    Dormans JP (2010) Establishing a standard of care for neuromonitoring during spinal deformity surgery. Spine (Phila Pa 1976) 35:2180–2185CrossRefGoogle Scholar
  13. 13.
    Thuet ED, Winscher JC, Padberg AM, Bridwell KH, Lenke LG, Dobbs MB, Schootman M, Luhmann SJ (2010) Validity and reliability of intraoperative monitoring in pediatric spinal deformity surgery: a 23-year experience of 3436 surgical cases. Spine (Phila Pa 1976) 35:1880–1886CrossRefGoogle Scholar
  14. 14.
    Zuccaro M, Zuccaro J, Samdani AF, Pahys JM, Hwang SW (2017) Intraoperative neuromonitoring alerts in a pediatric deformity center. Neurosurg Focus 43:E8CrossRefGoogle Scholar
  15. 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
  16. 16.
    Sutter M, Eggspuehler A, Grob D, Jeszenszky D, Benini A, Porchet F, Mueller A, Dvorak J (2007) The diagnostic value of multimodal intraoperative monitoring (MIOM) during spine surgery: a prospective study of 1,017 patients. Eur Spine J 16:S162–S170CrossRefGoogle Scholar
  17. 17.
    Eggspuehler A, Sutter MA, Grob D, Jeszenszky D, Dvorak J (2007) Multimodal intraoperative monitoring during surgery of spinal deformities in 217 patients. Eur Spine J 16:S188–S196CrossRefGoogle Scholar
  18. 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
  19. 19.
    Sutter M, Deletis V, Dvorak J, Eggspuehler A, Grob D, Macdonald D, Mueller A, Sala F, Tamaki T (2007) Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries. Eur Spine J 16:S232–S237CrossRefGoogle Scholar
  20. 20.
    Daniel JW, Botelho RV, Milano JB, Dantas FR, Onishi FJ, Neto ER, Bertolini EF, Borgheresi MAD, Joaquim AF (2018) Intraoperative neurophysiological monitoring in spine surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976) 43:1154–1160CrossRefGoogle Scholar
  21. 21.
    Tamaki T, Kubota S (2007) History of intraoperative spinal cord monitoring. Eur Spine J 16:S140–S146CrossRefGoogle Scholar
  22. 22.
    Tamaki T, Yamashita T, Kobayashi H (1972) Spinal cord monitoring. Jpn J Electroencephalogr Electromyogr 1:196Google Scholar
  23. 23.
    Deletis V, Sala F (2001) The role of intraoperative neurophysiology in the protection or documentation of surgically induced injury to the spinal cord. Ann N Y Acad Sci 939:137–144CrossRefGoogle Scholar
  24. 24.
    Deletis V (2002) Intraoperative neurophysiology and methodologies used to monitor the functional integrity of the motor system. In: Deletis V, Shils JL (eds) Neurophysiology in neurosurgery. Academic Press, California, pp 25–51CrossRefGoogle Scholar
  25. 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
  26. 26.
    Wang S, Yang Y, Li Q, Zhu J, Shen J, Tian Y, Hu Y, Li Z, Xu W, Jiao Y, Cao R, Zhang J (2018) High-risk surgical maneuvers for impending true-positive intraoperative neurologic monitoring alerts: experience in 3139 consecutive spine surgeries. World Neurosurg 115:e738–e747CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Martin Sutter
    • 1
  • Andreas Eggspuehler
    • 1
  • Dezsoe Jeszenszky
    • 2
  • Frank Kleinstueck
    • 2
  • Tamàs F. Fekete
    • 2
  • Daniel Haschtmann
    • 2
  • François Porchet
    • 2
  • Jiri Dvorak
    • 1
    Email author
  1. 1.Spine Unit, Department of NeurologySchulthess ClinicZurichSwitzerland
  2. 2.Spine Unit, Department of Spine SurgerySchulthess ClinicZurichSwitzerland

Personalised recommendations