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Patient, Hospital and Geographic Factors Associated With Intraoperative Neuromonitoring for Cervical Spine Surgery: A
Christopher S Lozano1,2,3, Vishwathsen Karthikeyan1,2,3, Husain Shakil1,2,3
1Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.
Study Design:
Retrospective, multi-center cohort study using a nationally representative U.S. inpatient database.
Objective:
To assess national trends in intraoperative neuromonitoring (IONM) use during cervical spine surgery for degenerative cervical myelopathy (DCM) and examine patient-, procedural-, and hospital-level factors associated with its use, focusing on socioeconomic and regional variation.
Summary Of Background Data:
Intraoperative neuromonitoring (IONM) is widely used to detect impending neurologic injury during cervical spine surgery, but evidence supporting its routine use remains inconclusive. Patterns of utilization may be shaped not only by clinical considerations but also by systemic, institutional, and financial factors.
Methods:
We analyzed 2016-2022 National Inpatient Sample data for adults (≥18 y) undergoing cervical decompression and/or fusion for DCM, excluding trauma, infection, or neoplasm. The primary outcome was IONM use. We fit a survey-weighted multivariable logistic regression model to characterize patient, treatment and hospital-level factors associated with IONM use. A separate multilevel model with hospital-specific random intercept was used to generate a median odds ratio to characterize between-hospital variability. U.S. Census Divisions were also included to examine regional variation.
Results:
Among 144,769 admissions for DCM surgery, IONM was used in 29% of cases, increasing from 23% in 2016 to 34% in 2022. Independent associations included private insurance, higher income, fusion procedures, posterior and anterior plus posterior approaches, and treatment at urban and private-investor hospitals (all P<0.05). IONM was more likely in the Pacific, Middle-Atlantic, West-South-Central, and Mountain divisions and less likely in the West-North-Central and East-South-Central regions. The median OR of 3.04 indicated substantial hospital-level variation.
Conclusion:
Although IONM use for DCM has increased over time, substantial heterogeneity persists. This variation is partly explained by measured clinical, sociodemographic, and hospital factors, but likely also reflects unmeasured differences in case mix. Future work integrating richer clinical and qualitative data is needed to clarify these drivers.
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