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Intraoperative neurophysiological monitoring during complex spinal deformity cases in pediatric patients:
James Drake1, Reinhard Zeller, Abhaya V Kulkarni
1Division of Neurosurgery, Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON, Canada. james.drake@sickkids.ca
Insights
Intraoperative neurophysiological monitoring (IONM) is crucial for pediatric complex spinal deformity surgery, enhancing safety and predicting outcomes. Maintaining IONM provides reassurance, while loss of MEPs indicates potential adverse events.
Area of Science:
- Pediatric neurosurgery
- Spinal deformity correction
- Intraoperative neurophysiological monitoring
Background:
- Complex spinal deformity (CSD) in children presents unique challenges due to spinal cord impingement risks.
- Surgical correction of CSD, including decompression, instrumentation, and fusion, carries significant hazards.
- Intraoperative neurophysiological monitoring (IONM) is increasingly recognized as vital for these complex pediatric cases.
Observation:
- IONM techniques, including MEPs and EMG, were utilized in pediatric CSD cases.
- IONM provided critical real-time information during surgeries, influencing operative decisions.
- Specific anesthetic considerations and expertise are necessary for effective IONM in pediatric spinal surgery.
Findings:
- Loss of motor evoked potentials (MEPs) during IONM is a strong predictor of adverse neurological outcomes.
- Consistent IONM signals offer reassurance of maintained spinal cord function.
- Diminished MEPs may indicate neurological injury with potential for significant recovery.
Implications:
- IONM is an invaluable tool for improving safety and outcomes in pediatric CSD surgery.
- The high utility and detection rate of neurological injury suggest IONM should be standard for all spinal surgeries.
- Further standardization of IONM equipment, techniques, and training is needed.
Introduction:
Complex spinal deformity (CSD) problems in pediatric patients result from a wide variety of congenital, acquired, neoplastic, or traumatic abnormalities that result in a combination of spinal deformity and spinal cord impingement. While these problems are rare, decompression, correction, instrumentation, and fusion are quite hazardous. Intraoperative neurophysiological monitoring (IONM) seems particularly beneficial in these patients.
Methodology:
Somatosensory evoked potentials, transcranial electrical motor evoked potentials (MEPs), direct waves, and electromyography were used in a variety of CSD cases over a period when IONM was routine for most spinal cases. Examples of cases in which IONM provided important intraoperative information and significantly affected the course of the operation are illustrated.
Results:
IONM is a useful tool particularly in CSD cases in pediatric patients but requires special expertise and anesthetic considerations. Loss of MEP appears to have particularly important adverse prognostic information. Conversely, maintenance of IONM provides significant reassurance that the spinal cord function is being maintained. Preserved but persistently diminished MEPs usually predict a neurological injury that will significantly improve and possibly completely recover. Issues concerning training, certification, oversight, standardization of equipment, and technique are partially but incompletely resolved.
Discussion:
IONM is an extremely valuable tool for management of CSD pediatric patients. The utility of IONM is such and the detection of unexpected or unanticipated neurological injury frequent enough that a strong argument that it be used in every spinal surgery case can be made.