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Intraoperative neuromonitoring predicts postoperative deficits in severe pediatric spinal deformity patients
Munish C Gupta1, Lawrence G Lenke2, Sachin Gupta3
1Department of Orthopedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, Saint Louis, MO, 63110, USA. guptam@wudosis.wustl.edu.
Insights
Intraoperative monitoring (IOM) alerts during severe pediatric spinal deformity surgery are linked to greater spinal curvature and predict new neurologic deficits. Most deficits resolve within two years, with similar patient-reported outcomes.
Area of Science:
- Spine Surgery
- Neuromonitoring
- Pediatric Orthopedics
Background:
- Severe pediatric spinal deformities require complex surgical correction.
- Intraoperative monitoring (IOM) is crucial for detecting potential neurologic injury during these procedures.
- Understanding IOM alerts and their correlation with neurologic deficits is essential for improving patient safety.
Purpose of the Study:
- To evaluate the incidence and significance of intraoperative monitoring (IOM) alerts in severe pediatric spinal deformity surgery.
- To determine the association between IOM alerts and postoperative neurologic deficits.
- To assess the long-term functional outcomes in patients experiencing neurologic deficits.
Main Methods:
- Prospective evaluation of 243 pediatric patients with severe spinal deformities (Cobb angle ≥100° or VCR).
- Recording of preoperative, immediate postoperative, and 2-year postoperative neurologic status.
- Analysis of radiographic data, IOM alert types, triggering events, and SRS-22r scores.
Main Results:
- IOM alerts occurred in 37% of procedures, often triggered by osteotomy or correction maneuvers.
- Increased sagittal deformity angular ratio (DAR) independently predicted IOM alerts.
- Alerts, especially multimodal (SSEP and TCeMEP), were associated with new postoperative neurologic deficits, though most resolved by 2 years.
Conclusions:
- Multimodal IOM alerts in severe pediatric spinal deformity surgery correlate with sagittal spinal parameters and predict postoperative neurologic deficits.
- While new deficits can occur, most patients experience symptom resolution and achieve comparable 2-year functional outcomes.
- Persistent deficits were associated with lower SRS-22r scores.
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.
