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Does an improvement in cord-level intraoperative neuromonitoring data lead to a reduced risk for postoperative neurologic deficit in spine deformity surgery?

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Abstract

Purpose

To determine if an improvement in cord-level intraoperative neuromonitoring (IONM) data following data loss results in a reduced risk for new postoperative motor deficit in pediatric and adult spinal deformity surgery.

Methods

A consecutive series of 1106 patients underwent spine surgery from 2015 to 2023 by a single surgeon. Cord alerts were defined by Somatosensory-Evoked Potentials (SSEP; warning criteria: 10% increase in latency or > 50% loss in amplitude) and Motor-Evoked Potentials (MEP; warning criteria: 75% loss in amplitude without return to acceptable limits after stimulation up 100 V above baseline level). Timing of IONM loss and recovery, interventions, and baseline/postoperative day 1 (POD1) lower extremity motor scores were analyzed.

Results

IONM Cord loss was noted in 4.8% (53/11,06) of patients and 34% (18/53) with cord alerts had a POD1 deficit compared to preoperative motor exam. MEP and SSEP loss attributed to 98.1% (52/53) and 39.6% (21/53) of cord alerts, respectively. Abnormal descending neurogenic-evoked potential (DNEP) was seen in 85.7% (12/14) and detected 91.7% (11/12) with POD1 deficit. Abnormal wake-up test (WUT) was seen in 38.5% (5/13) and detected 100% (5/5) with POD1 deficit. Most cord alerts occurred during a three-column osteotomy (N = 23/53, 43%); decompression (N = 12), compression (N = 7), exposure (N = 4), and rod placement (N = 14). Interventions were performed in all 53 patients with cord loss and included removing rods/less correction (N = 11), increasing mean arterial pressure alone (N = 10), and further decompression with three-column osteotomy (N = 9). After intervention, IONM data improved in 45(84.9%) patients (Full improvement: N = 28; Partial improvement: 17). For those with full and partial IONM improvement, the POD1 deficit was 10.7% (3/28) and 41.2% (7/17), respectively. For those without any IONM improvement (15.1%, 8/53), 100% (8/8) had a POD1 deficit, P < 0.001.

Conclusion

A full or partial improvement in IONM data loss after intraoperative intervention was significantly associated with a lower risk for POD1 deficit with an absolute risk reduction of 89.3% and 58.8%, respectively. All patients without IONM improvement had a POD1 neurologic deficit.

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Data availability

Data is not publicly available but available upon request.

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Funding

The authors did not receive support from any organization for the submitted work.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Columbia University Medical Center, The Daniel and Jane Och Spine Hospital at New York-Presbyterian, 5141 Broadway, New York, NY, 10034, USA

    Nathan J. Lee, Lawrence G. Lenke, Michael Fields, Matthew Simhon, Varun Arvind, Anastasia Ferraro, Matthew Cooney, Erik Lewerenz, Justin L. Reyes, Steven Roth, Chun Wai Hung, Justin K. Scheer, Thomas Zervos, Joseph M. Lombardi, Zeeshan M. Sardar, Ronald A. Lehman & Fthimnir M. Hassan

  2. The Och Spine Hospital, New York-Presbyterian, New York, NY, USA

    Nathan J. Lee, Lawrence G. Lenke, Steven Roth, Chun Wai Hung, Justin K. Scheer, Earl D. Thuet, Joseph M. Lombardi, Zeeshan M. Sardar & Ronald A. Lehman

  3. Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA

    Mitchell Yeary, Alexandra Dionne, Chidebelum Nnake & Ted Shi

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Contributions

LGL, JML, ZMS, RAL: contributed to the concept/design of the work, revised the work critically for important intellectual content, approved the final version to be published, and agrees to be accountable for all aspects of the work. MY, CN, MF, MS, MC, EL, JLR, SR, CWH, JKS, TZ, EDT, AF: contributed to the concept/design of the work, acquisition of the data, revised the work critically for important intellectual content, approved the version to be published, and agrees to be accountable for all aspects of the work. NJL, TS, VA, FMH: contributed to the concept/design of the work, drafted the work, acquisition, analysis, and interpretation of the data, approved the version to be published, and agrees to be accountable for all aspects of the work. AD: contributed to the concept/design of the work, drafted the work, acquisition of the data, revised the work critically for important intellectual content, approved the final version to be published, and agrees to be accountable for all aspects of the work.

Corresponding author

Correspondence to Fthimnir M. Hassan.

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Conflict of interest

Fthimnir M. Hassan, Erik Lewerenz, Nathan J. Lee, Mitchell Yeary, Alexandra Dionne, Chidebelum Nnake, Michael Fields, Matthew Simhon, Ted Shi, Varun Arvind, Anastasia Ferraro, Matthew Cooney, Justin L. Reyes, Steven Roth, Chun Wai Hung, Justin K. Scheer, Thomas Zervos, and Earl D. Thuet have no relevant financial or non-financial interests to disclose. Lawrence G. Lenke has received grant support from AO Spine, International Spine Summit Group, Scoliosis Research Society, EOS Technology and Setting Scoliosis Straight Foundation as a study investigator. Ronald A. Lehman has received grant support from the Department of Defense as a study investigator. Joseph M. Lombardi, Zeeshan M. Sardar, Ronald A. Lehman, and Lawrence G. Lenke have received consulting fees from Medtronic. Joseph M. Lombardi has received consulting fees from Stryker. Lawrence G. Lenke has received consulting fees from Acuity Surgical and Abryx. Lawrence G. Lenke has received reimbursements from Broadwater, AO Spine, and Scoliosis Research Society for attending meetings/travel. Ronald A. Lehman and Lawrence G. Lenke have received royalties and are patent holders from Medtronic. Ronald A. Lehman has received royalties and is a patent holder from Stryker.

Ethical approval

AAAU8101.This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Columbia University Irving Medical Center approved this study.

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Informed consent was obtained from all individual participants included in the study.

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Lee, N.J., Lenke, L.G., Yeary, M. et al. Does an improvement in cord-level intraoperative neuromonitoring data lead to a reduced risk for postoperative neurologic deficit in spine deformity surgery?. Spine Deform (2024). https://doi.org/10.1007/s43390-024-00944-6

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