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Intraoperative neuromonitoring predicts postoperative deficits in severe pediatric spinal deformity patients

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Abstract

Purpose

To evaluate intraoperative monitoring (IOM) alerts and neurologic deficits during severe pediatric spinal deformity surgery.

Methods

Patients with a minimum Cobb angle of 100° in any plane or a scheduled vertebral column resection (VCR) with minimum 2-year follow-up were prospectively evaluated (n = 243). Preoperative, immediate postoperative, and 2-year postoperative neurologic status were reported. Radiographic data included preoperative and 2-year postoperative coronal and sagittal Cobb angles and deformity angular ratios (DAR). IOM alert type and triggering event were recorded. SRS-22r scores were collected preoperatively and 2-years postoperatively.

Results

IOM alerts occurred in 37% of procedures with three-column osteotomy (n = 36) and correction maneuver (n = 32) as most common triggering events. Patients with IOM alerts had greater maximum kyphosis (101.4° vs. 87.5°) and sagittal DAR (16.8 vs. 12.7) (p < 0.01). Multivariate regression demonstrated that sagittal DAR independently predicted IOM alerts (OR 1.05, 95% CI 1.02–1.08) with moderate sensitivity (60.2%) and specificity (64.8%) using a threshold value of 14.3 (p < 0.01). IOM alerts occurred more frequently in procedures with new postoperative neurologic deficits (17/24), and alerts with both SSEP and TCeMEP signals were associated with new postoperative deficits (p < 0.01). Most patients with new deficits experienced resolution at 2 years (16/20) and had equivalent postoperative SRS-22r scores. However, patients with persistent deficits had worse SRS-22r total score (3.8 vs. 4.2), self-image subscore (3.5 vs. 4.1), and function subscore (3.8 vs. 4.3) (p ≤ 0.04).

Conclusion

Multimodal IOM alerts are associated with sagittal kyphosis, and predict postoperative neurologic deficits. Most patients with new deficits experience resolution of their symptoms and have equivalent 2-year outcomes.

Level of evidence

II.

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Data availability

Data is available upon reasonable request.

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Acknowledgements

Jichao Ye MD and Members of the Fox Pediatric Spinal Deformity Study Group: Jahangir K. Asghar MD, Patrick J. Cahill MD, Sumeet Garg MD, David B. Bumpass MD, Richard E. McCarthy MD, Burt Yaszay MD, and Joshua M. Pahys MD are acknowledged.

Funding

This study was supported by Fox Family Foundation.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, Saint Louis, MO, 63110, USA

    Munish C. Gupta & Michael P. Kelly

  2. Department of Orthopaedic Surgery, Columbia University Medical Center New York, New York, USA

    Lawrence G. Lenke

  3. Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA

    Sachin Gupta & Ali S. Farooqi

  4. FOCOS Orthopedic Hospital Accra, Accra, Ghana

    Oheneba Boachie-Adjei

  5. Department of Orthopaedic Surgery, Children’s Hospital Colorado, Aurora, USA

    Mark A. Erickson

  6. Department of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, USA

    Peter O. Newton

  7. Department of Orthopaedic Surgery, Shriners Hospitals for Children Philadelphia, Philadelphia, USA

    Amer F. Samdani

  8. Department of Orthopaedic Surgery, Nemours/Alfred I duPont Hospital for Children, Wilmington, USA

    Suken A. Shah

  9. Department of Orthopaedic Surgery, Paley Orthopedic and Spine Institute at St. Mary’s Medical Center, West Palm Beach, USA

    Harry L. Shufflebarger

  10. Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, USA

    Paul D. Sponseller

  11. Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, USA

    Daniel J. Sucato

Authors
  1. Munish C. Gupta
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  2. Lawrence G. Lenke
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  3. Sachin Gupta
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  4. Ali S. Farooqi
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  5. Oheneba Boachie-Adjei
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  8. Amer F. Samdani
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  9. Suken A. Shah
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  10. Harry L. Shufflebarger
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  11. Paul D. Sponseller
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  12. Daniel J. Sucato
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  13. Michael P. Kelly
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Consortia

The Fox Pediatric Spinal Deformity Study Group

Contributions

MCG: conceptualization, methodology, resources, writing—review and editing, supervision, project administration, data acquisition, statistics, approved final version, agreed to be accountable for all aspects of the work. LGL: conceptualization, methodology, resources, writing—review and editing, supervision, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. SG: investigation, writing—original draft, writing—review and editing, data curation and interpretation, approved final version, agreed to be accountable for all aspects of the work. ASF: investigation, writing—original draft, writing—review and editing, data curation and interpretation, approved final version, agreed to be accountable for all aspects of the work. OBA: methodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. MAE: methodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. PON: methodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. AFS: mmethodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. SAS: methodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. HLS: methodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. PDS: methodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. DJS: methodology, resources, writing—review and editing, project administration, agreed to be accountable for all aspects of the work. MPK: methodology, resources, writing—review and editing, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work. The Fox Pediatric Spinal Deformity Study Group: International Study Group involved in conceptualization, methodology, investigation, provision of resources, project administration, data acquisition, approved final version, agreed to be accountable for all aspects of the work.

Corresponding author

Correspondence to Munish C. Gupta.

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The authors have no competing interests to declare that are relevant to the content of this article.

IRB approval

This multi-center study was approved by the Institutional Review Board at each site.

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Gupta, M.C., Lenke, L.G., Gupta, S. et al. Intraoperative neuromonitoring predicts postoperative deficits in severe pediatric spinal deformity patients. Spine Deform 12, 109–118 (2024). https://doi.org/10.1007/s43390-023-00745-3

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  • DOI: https://doi.org/10.1007/s43390-023-00745-3

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