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European Spine Journal

, Volume 25, Issue 10, pp 3208–3213 | Cite as

Causal factors for position-related SSEP changes in spinal surgery

  • Justin W. Silverstein
  • Eric Matthews
  • Laurence E. Mermelstein
  • Hargovind DeWal
Original Article

Abstract

Background context

Somatosensory evoked potentials (SSEPs) are effective in detecting upper extremity positional injuries; however, causal factors for which patient population is most at risk are not well established.

Purpose

To review causal factors for intraoperative SSEP changes due to patient positioning.

Study design

A case series with retrospective chart analysis was performed.

Patient sample

398 patient charts and intraoperative neurophysiological monitoring data from patients who underwent thoracolumbar and lumbosacral spine surgery were reviewed in a consecutive sequence from 2012 to 2013.

Outcome measures

Adverse events (AE) with the upper extremity SSEP recordings were compared to the independent variables, sex, positioning, length of procedure, and body habitus.

Methods

Thoracolumbar and lumbosacral spine surgeries using contemporaneous ulnar and median nerve SSEPs were reviewed. The one-way analysis of variance (ANOVA) test, Chi-square, and independent samples t test were used to determine statistical significance in having an upper extremity SSEP AE to the aforementioned independent variables.

Results

The sample consisted of 209 males (52.5 %) and 189 females (47.5 %) (n = 398). AE to the upper extremity SSEP was seen in 44 patients. Sex was found to be statistically significant for isolated ulnar nerve AE (P ≤ 0.001) with males being most at risk (87.5 %). AE for isolated median nerve SSEP was statistically significant for supine and prone positions (P = 0.043). Length of procedure was statically significant for isolated ulnar nerve SSEP AE (P = 0.039). BMI was statistically significant for generalized upper extremity SSEP AE (P = 0.016), as well as isolated ulnar SSEP AE (P = 0.006), isolated median SSEP AE (P ≤ 0.001) and contemporaneous median and ulnar SSEP AE of the same limb (P ≤ 0.001).

Conclusion

Sex, patient positioning, length of procedure, and BMI are determinants for upper extremity neural compromise during thoracolumbar and lumbosacral spine surgeries.

Keywords

Somatosensory evoked potentials Spine surgery Positional nerve injury Intraoperative neurophysiological monitoring Patient positioning 

Notes

Compliance with ethical standards

Conflict of interest

None.

References

  1. 1.
    Schwartz DM, Drummond DS, Hahn M et al (2000) Prevention of positional brachial plexopathy during surgical correction of scoliosis. J Spinal Disord 13(2):178–182PubMedCrossRefGoogle Scholar
  2. 2.
    Yonenobu K, Hosono N, Iwasaki M et al (1991) Neurologic complications of surgery for cervical compression myelopathy. Spine 16:1277–1282PubMedCrossRefGoogle Scholar
  3. 3.
    Balzer JR, Rose RD, Welch WC et al (1998) Simultaneous somatosensory evoked potential and electromyographic recordings during lumbosacral decompression and instrumentation. Neurosurgery 42(6):1318–1324PubMedCrossRefGoogle Scholar
  4. 4.
    Brown RH, Nash CL, Berilla JA et al (1984) Cortical evoked potential monitoring. A system for intraoperative monitoring of spinal cord function. Spine 9:256–261PubMedCrossRefGoogle Scholar
  5. 5.
    Fisher RS, Raudzens P, Nunemacher M (1995) Efficacy of intraoperative neurophysiological monitoring. J Clin Neurophysiol 12:97–109PubMedGoogle Scholar
  6. 6.
    Guérit JM (1998) New methods on the subject of peroperative neurophysiological monitoring in vascular and orthopedic surgery. Bull Mem Acad R Med Belg 153:325–331PubMedGoogle Scholar
  7. 7.
    Guérit JM (1998) Neuromonitoring in the operating room: why, when, and how to monitor? Electroencephalogr Clin Neurophysiol 106:1–21PubMedCrossRefGoogle Scholar
  8. 8.
    Krieger D, Sclabassi RJ (2001) Real-time intraoperative neurophysiological monitoring. Methods 25:272–287PubMedCrossRefGoogle Scholar
  9. 9.
    Wiedemayer H, Fauser B, Sandalcioglu IE et al (2002) The impact of neurophysiological intraoperative monitoring on surgical decisions: a critical analysis of 423 cases. J Neurosurg 96:255–262PubMedCrossRefGoogle Scholar
  10. 10.
    Padberg AM, Wilson-Holden TJ, Lenke LG et al (1998) Somatosensory- and motor-evoked potential monitoring without a wake-up test during idiopathic scoliosis surgery. An accepted standard of care. Spine 23:1392–1400PubMedCrossRefGoogle Scholar
  11. 11.
    Krassioukov AV, Sarjeant R, Arkia H et al (2004) Multimodality intraoperative monitoring during complex lumbosacral procedures: indications, techniques, and long-term follow-up review of 61 consecutive cases. J Neurosurg Spine 1:243–253PubMedCrossRefGoogle Scholar
  12. 12.
    Kundnani VK, Zhu L, Tak H et al (2010) Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: evaluation of 354 consecutive cases. Indian J Orthop 44:64–72PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Nishijima Y, Okada M, Yasuaki Y et al (1992) Intraoperative monitoring for thoracolumbar or lumbar surgery with somatosensory evoked potentials after double stimuli. Spine 17(11):1304–1308PubMedCrossRefGoogle Scholar
  14. 14.
    Nuwer MR, Dawson EG, Carlson LG et al (1995) Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 96:6–11PubMedCrossRefGoogle Scholar
  15. 15.
    Nuwer M, Emerson R, Galloway G et al (2012) Evidence-based guideline update: intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials. J Clin Neurophysiol 29(1):101–108PubMedCrossRefGoogle Scholar
  16. 16.
    Pastorelli F, Di Silvestre M, Plasmati R et al (2011) The prevention of neural complications in the surgical treatment of scoliosis: the role of the neurophysiological intraoperative monitoring. Eur Spine J 20(Suppl 1):S105–S114PubMedCrossRefGoogle Scholar
  17. 17.
    Widhalm G, Novak K, de Camargo AB et al (2012) The value of intraoperative motor evoked potential monitoring during surgical intervention for thoracic idiopathic spinal cord herniation. J Neurosurg Spine 16(2):114–126PubMedCrossRefGoogle Scholar
  18. 18.
    Jellish WS, Martucci J, Blakeman B et al (1994) Somatosensory evoked potential monitoring of the brachial plexus to predict nerve injury during internal mammary artery harvest: intraoperative comparisons of the Rultract and Pittman sternal retractors. J Cardiothorac Vasc Anesth 8:398–403PubMedCrossRefGoogle Scholar
  19. 19.
    Mostegl A, Bauer R (1984) The application of somatosensory-evoked potentials in orthopedic spine surgery. Arch Orthop Trauma Surg 103(3):179–184PubMedCrossRefGoogle Scholar
  20. 20.
    Räf L, Netz P (1999) How to avoid injuries in connection with surgery? Perioperative nerve injuries are probably underreported. Lakartidningen 96:1951–1958PubMedGoogle Scholar
  21. 21.
    Uribe JS, Kolla J, Omar H et al (2010) Brachial plexus injury following spinal surgery. J Neurosurg Spine 13:552–558PubMedCrossRefGoogle Scholar
  22. 22.
    Moller A (2006) Intraoperative neurophysiological monitoring, 2nd edn. Humana Press, TotowaGoogle Scholar
  23. 23.
    Chung I, Glow JA, Dimopoulos V et al (2009) Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury. Spine J 9:287–295PubMedCrossRefGoogle Scholar
  24. 24.
    Fountas K, Dimopoulos V, Chung I (1995) Intraoperative monitoring. J Neurosurg Spine 2(3):399–400Google Scholar
  25. 25.
    Jones SC, Fernau R, Woeltjen BL (2004) Use of somatosensory evoked potentials to detect peripheral ischemia and potential injury resulting from positioning of the surgical patient: case reports and discussion. Spine J 4(3):360–362PubMedCrossRefGoogle Scholar
  26. 26.
    Kamel IR, Drum ET, Koch SA et al (2006) The use of somatosensory evoked potentials to determine the relationship between patient positioning and impending upper extremity nerve injury during spine surgery: a retrospective analysis. Anesth Analg 102:1538–1542PubMedCrossRefGoogle Scholar
  27. 27.
    American Clinical Neurophysiology Society (2009) Guideline 11B: recommended standards for intraoperative monitoring of somatosensory evoked potentials. Retrieved from ACNS.orgGoogle Scholar
  28. 28.
    Cooper DE, Jenkins RS, Bready L et al (1988) The prevention of injuries of the brachial plexus secondary to malposition of the patient during surgery. Clin Orthop Relat Res 228:33–41PubMedGoogle Scholar
  29. 29.
    Mitterschiffthaler G, Theiner A, Posch G et al (1987) Lesion of the brachial plexus, caused by wrong positioning during surgery. Anasth Intensivther Notfallmed 22(4):177–180PubMedCrossRefGoogle Scholar
  30. 30.
    O’Brien MF, Lenke LG, Bridwell KH et al (1994) Evoked potential monitoring of the upper extremities during thoracic and lumbar spinal deformity surgery: a prospective study. J Spinal Disord 7:277–284PubMedCrossRefGoogle Scholar
  31. 31.
    Saady A (1981) Brachial plexus palsy after anaesthesia in the sitting position. Anaesthesia 36(2):194–195PubMedCrossRefGoogle Scholar
  32. 32.
    Lorenzini NA, Poterack KA (1996) Somatosensory evoked potentials are not a sensitive indicator of potential positioning injury in the prone patient. J Clin Monit 12:171–176PubMedCrossRefGoogle Scholar
  33. 33.
    Baumann SB, Welch WC, Bloom MJ (2000) Intraoperative SSEP detection of ulnar nerve compression or ischemia in an obese patient: a unique complication associated with a specialized spinal retraction system. Arch Phys Med Rehabil 81(1):130–132PubMedCrossRefGoogle Scholar
  34. 34.
    Labrom RD, Hoskins M, Reilly CW et al (2005) Clinical usefulness of somatosensory evoked potentials for detection of brachial plexopathy secondary to malpositioning in scoliosis surgery. Spine 30:2089–2093PubMedCrossRefGoogle Scholar
  35. 35.
    Brodal P (2004) The central nervous system, 3rd edn. Oxford University Press, North CarolinaGoogle Scholar
  36. 36.
    Blumenfeld H (2010) Neuroanatomy through clinical cases, 2nd edn. Sinauer Associates Inc, SunderlandGoogle Scholar
  37. 37.
    Davenport J (1986) Shunting during carotid endarterectomy. Arch Neurol 43(12):1222–1223PubMedCrossRefGoogle Scholar
  38. 38.
    Fiori L, Parenti G (1995) Electrophysiological monitoring for selective shunting during carotid endarterectomy. J Neurosurg Anesthesiol 7:168–173PubMedCrossRefGoogle Scholar
  39. 39.
    Inoue T, Ohwaki K, Tamura A et al (2013) Subclinical ischemia verified by somatosensory evoked potential amplitude reduction during carotid endarterectomy: negative effects on cognitive performance. J Neurosurg 118(5):1023–1029PubMedCrossRefGoogle Scholar
  40. 40.
    Jacobs LA, Brinkman SD, Morrell RM et al (1983) Long-latency somatosensory evoked potentials during carotid endarterectomy. Am Surgeon 49:338–344PubMedGoogle Scholar
  41. 41.
    Lam AM, Manninen PH, Ferguson GG et al (1991) Monitoring electrophysiologic function during carotid endarterectomy: a comparison of somatosensory evoked potentials and conventional electroencephalogram. Anesthesiology 75:15–21PubMedCrossRefGoogle Scholar
  42. 42.
    Malek BN, Mohrhaus CA, Sheth AK (2011) Use of multi-modality intraoperative monitoring during carotid endarterectomy surgery: a case study. Am J Electroneurodiagn Technol 51(1):42–53Google Scholar
  43. 43.
    Manninen P, Sarjeant R, Joshi M (2004) Posterior tibial nerve and median nerve somatosensory evoked potential monitoring during carotid endarterectomy. Can J Anaesth 51:937–941PubMedCrossRefGoogle Scholar
  44. 44.
    Manninen PH, Tan TK, Sarjeant RM (2001) Somatosensory evoked potential monitoring during carotid endarterectomy in patients with a stroke. Anesth Analg 93(1):39–44PubMedCrossRefGoogle Scholar
  45. 45.
    Mussack T, Biberthaler P, Geisenberger T et al (2002) Assessment of early brain damage in carotid endarterectomy: evaluation of S-100B serum levels and somatosensory evoked potentials in a pilot study. World J Surg 26:1251–1255PubMedCrossRefGoogle Scholar
  46. 46.
    Schwartz ML, Panetta TF, Kaplan BJ et al (1996) Somatosensory evoked potential monitoring during carotid surgery. Cardiovasc Surg 4:77–80PubMedCrossRefGoogle Scholar
  47. 47.
    Ying T, Wang X, Sun H et al (2015) Clinical usefulness of somatosensory evoked potentials for detection of peripheral nerve and brachial plexus injury secondary to malpositioning in microvascular decompression. J Clin Neurophysiol 32(6):512–515PubMedCrossRefGoogle Scholar
  48. 48.
    Jellish WS, Sherazee G, Patel J et al (2013) Somatosensory evoked potentials help prevent positioning-related brachial plexus injury during skull base surgery. Otolaryngol Head Neck Surg 149(1):168–173PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Justin W. Silverstein
    • 1
    • 2
  • Eric Matthews
    • 2
  • Laurence E. Mermelstein
    • 3
  • Hargovind DeWal
    • 3
  1. 1.Neuro Protective Solutions, LLCHauppaugeUSA
  2. 2.A.T. Still UniversityMesaUSA
  3. 3.Long Island Spine Specialists, PCCommackUSA

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