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Analysis of 5317 Consecutive Pediatric Spinal Deformity Intraoperative Neuromonitoring (IONM) Alerts: Importance of
Christopher K Bozorgmehr1, Leah Rakers2, Brian Kelly3
1Washington University School of Medicine, St. Louis, MO, USA, Barnes-Jewish Hospital, St. Louis, MO, 63110, USA.
Insights
Intraoperative neuromonitoring (IONM) alerts in pediatric spinal deformity surgery occurred in 4.2% of cases, often during correction. Prompt interventions, like managing hypotension, significantly reduced the risk of neurological decline.
Area of Science:
- Neurosurgery
- Orthopedic Surgery
- Spinal Cord Monitoring
Background:
- Intraoperative neuromonitoring (IONM) is crucial for preventing spinal cord dysfunction during pediatric spinal deformity surgery.
- Limited data exists on the timing of IONM alerts and the efficacy of specific interventions.
Purpose of the Study:
- To analyze the sequence of IONM alerts during pediatric spinal deformity operations.
- To document corrective actions taken in response to alerts.
- To evaluate immediate and final neurological outcomes following IONM alerts.
Main Methods:
- A case series review of an institutional neuromonitoring database from 1992 to 2024.
- Inclusion criteria: pediatric patients (0-18 years) undergoing spinal deformity surgery with at least one IONM alert.
- Data collected included alert chronology, corrective maneuvers, and neurological status.
Main Results:
- IONM alerts were identified in 4.2% (223/5,317) of cases, most frequently during or after deformity correction.
- The most common corrective actions involved managing hypotension (91 instances) and adjusting deformity correction (63 instances).
- Neurological decline occurred in 3.7% of patients with alerts, decreasing to 0.15% at final examination.
Conclusions:
- IONM alerts are relatively infrequent but critical in pediatric spinal deformity surgery.
- A systematic protocol for responding to alerts, particularly for hypotension, is effective in mitigating neurological injury.
- This study supports multimodal IONM and systematic alert response for improved patient outcomes and shared decision-making.
Study Design:
Case Series.
Objective:
The study's objective is to detail the chronology of intraoperative neuromonitoring (IONM) alerts during pediatric spinal deformity surgery, the corrective maneuvers taken, and the immediate and final neurologic outcomes.
Summary Of Background Data:
IONM reduces the risk of spinal cord dysfunction during pediatric spinal deformity surgery by enabling timely intraoperative intervention. However, limited data exists regarding the chronology of alerts and the effectiveness of specific corrective actions.
Methods:
An institutional neuromonitoring database was reviewed (1992-2024) to identify all consecutive patients (0-18 y) who underwent pediatric spine deformity surgery with at least one IONM alert.
Results:
A total of 223 patients (4.2%) were identified out of 5,317 consecutive cases, of which 156 had data recovery intraoperatively, and 67 did not. Diagnoses were kyphosis (n=66), idiopathic (n=63), neuromuscular (n=43), congenital (n=24), syndromic (n=11), and other (n=16). There were 348 corrective actions for 237 alerts, most commonly correction of hypotension (n=91) and adjustment of deformity correction (n=63). Postoperatively, 34 patients with IONM alerts had neurological change from baseline. 29 patients had documented final neurological status; 21 had full recovery to baseline, 5 had partial recovery, 3 had no recovery. Among patients available for final follow-up, neurologic decline occurred in 0.15% (8/5,312) and in 3.7% (8/218) of those with intraoperative IONM alerts.
Conclusion:
IONM alerts occurred in 4.2% of cases, most frequently at correction/following correction. Corrective actions, most commonly correction of hypotension, theoretically reduced spinal cord dysfunction from 4.2% intraoperatively, to 0.5% (29/5,312) at wake-up and 0.15% (8/5,312) at final exam. This largest single-center experience with IONM in pediatric spinal deformity surgery supports the use of a multimodal IONM, systematic alert response protocol and allows for better preoperative shared-decision making.
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