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Updated: Jun 12, 2026
Intraoperative Ultrasound in Spinal Surgery
Published on: August 17, 2022
Evolution of multimodal intraoperative neuromonitoring in pediatric spinal deformity surgery over 39 years: are we
Gabrielle A Rogie1, Hilton C Braithwaite1, Chris Bozorgmehr1
1Department of Orthopedic Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
Insights
Multimodal intraoperative neuromonitoring (IONM) in pediatric spinal deformity surgery shows increased alerts but similar false negatives over time. Evolving case complexity, not monitoring performance, likely explains observed differences between eras.
Area of Science:
- Pediatric Orthopedics
- Neurosurgery
- Spinal Surgery
- Neuromonitoring
Background:
- Intraoperative neuromonitoring (IONM) is crucial for pediatric spinal deformity surgery.
- Understanding trends in IONM use and outcomes is essential for improving patient safety.
- Comparing different surgical eras helps identify advancements and persistent challenges.
Purpose of the Study:
- To compare the incidence and characteristics of multimodal IONM in pediatric spinal deformity surgery.
- To analyze changes in IONM alert rates and neurologic deficit occurrences between two distinct time periods (1985-2008 and 2008-2024).
Main Methods:
- A retrospective review of 3316 pediatric spinal deformity surgeries (2008-2024) was performed.
- Key IONM modalities included somatosensory-evoked potentials (SSEP), transcranial electrical motor-evoked potentials (TCeMEP), and descending neurogenic-evoked potentials (DNEP).
- Descriptive analysis focused on monitoring performance and case complexity shifts over time.
Main Results:
- IONM alert frequency increased from 2.2% (1985-2008) to 4.1% (2008-2024).
- Permanent neurologic deficits rose from 0.17% to 0.48%, with higher rates in kyphosis and revision surgeries.
- False negatives remained similar but became more consequential, leading to permanent deficits in 80% of cases in the modern era.
Conclusions:
- Multimodal IONM is vital in pediatric spinal deformity surgery, with a 4.1% alert rate and 0.48% permanent neurologic deficit rate.
- False negatives, especially nerve root related, continue to be a significant limitation.
- Observed era-specific differences likely stem from increased case complexity and evolving surgical techniques rather than intrinsic monitoring performance changes.
Purpose:
To describe the incidence and characteristics of multimodal intraoperative neuromonitoring (IONM) in pediatric spinal deformity surgery between two eras (1985-2008 vs. 2008-2024).
Methods:
A review was conducted of 3316 consecutive pediatric spinal deformity surgeries (2008-2024) at a single institution. Neuromonitoring modalities included somatosensory-evoked potentials (SSEP), transcranial electrical motor-evoked potentials (TCeMEP), and descending neurogenic-evoked potentials (DNEP). Due to inherent cohort heterogeneity and evolving surgical standards over four decades, a descriptive analysis was prioritized to characterize shifts in monitoring performance and case complexity.
Results:
IONM alerts were more frequent in 2008-2024 at 4.1% (1 in 24) versus 2.2% (1 in 46). Highest alert rates were in kyphosis/kyphoscoliosis (14.8% vs. 9.3%) and revision procedures (9.5% vs. 3.0%). Most alerts occurred during correction/instrumentation (62.2% vs. 47%). Permanent neurologic deficits were more common in the modern cohort: 16 patients (0.48%, 1 in 207) versus 6 (0.17%, 1 in 573). False negatives occurred at similar frequencies (0.15% vs. 0.2%) but were more consequential, with 80% resulting in permanent deficits versus 14% previously. While lower in comparison to the historic era, IONM was associated with a disparity between alert frequent and observed permanent neurologic deficit rates with alerts occurring in 4.1% of cases and permanent deficits in 0.48% (historic era: 2.2 and 0.17%, respectively). However, this coincided with an increase in case complexity as evidenced by higher prevalence of three-column osteotomies and use of traction.
Conclusion:
Multimodal IONM remains a critical adjunct in pediatric spinal deformity surgery, with alert events occurring in 4.1% of cases and an observed permanent neurologic deficit rate of 0.48%. False negatives, particularly nerve root related, remain a key limitation. Observed differences between eras likely reflect evolving case complexity, surgical techniques, and monitoring practices rather than changes in intrinsic monitoring performance.
