Matthew R.

Eager, MD
Adam L. Shimer, MD
Faisal Jahangiri, MD
Francis H. Shen, MD
Vincent Arlet, MD

Department of Orthopaedic Surgery

Division of Spine Surgery
Charlottesville, Virginia, USA
 Intraoperative Neuromonitoring – V Arlet

´ Intraoperative neuromonitoring is being employed for an

increasing number of spinal surgeries
« Deformity correction

« Instrumentation

´ Question: How has multimodality intraoperative

neuromonitoring affected our ability to avoid potential
neurologic injury during spine surgery?
 Intraoperative Neuromonitoring – V Arlet

´ All neuromonitored spine cases at UVA

´ 2006-2010
´ Total 2095 cases
´ Possible intraoperative event documented by
neurophysiologist
´ 32 cases with possible intraoperative events
´ Retrospective analysis
« Intraoperative and postoperative clinical findings

´ IRB approved study

 Intraoperative Neuromonitoring – V Arlet

´ 32 cases
« 17 intraoperative “saves” (true event)
« Intraoperative neuromonitoring caused an
intervention during the surgery
² Hypotention (5)
² Patient positioning/external force (4)
² Deformity correction (7)
² Screw malposition, low triggered EMG, repositioned
(1)
« No postoperative deficits
 Intraoperative Neuromonitoring – V Arlet

´ Neuromonitoring changes during a deformity correction case

´ Decreased MEPs of the left foot of 80 % amplitude, tibialis
anterior has dropped 30 % after convex rod insertion
´ Right side remained normal
´ Correction was decreased and left LE MEPs returned to
baseline.
 Intraoperative Neuromonitoring – V Arlet

´ 32 cases
« Controls (4)

² Intradural cord biopsies or tumor resections

² Neuromonitoring changes seen intraoperatively

² Expected postoperative deficits in all cases

« False-positives (4)

² Needle position, SSEP changes / incongruities

² No postoperative deficits

« Improved signals (4)

² SSEPs improved during surgery after neural decompression

¹ 3 cervical corpectomies, 1 thoracic discectomy
 Intraoperative Neuromonitoring – V Arlet

´ 32 cases
« False-negatives (3)
² Posterior lumbar instrumentation
² Passive EMGs quiet during surgery, no
triggered EMGs performed
² Postoperative radiculopathy / motor
weakness
 Intraoperative Neuromonitoring – V Arlet

´ Did we learn any lessons?

« 1.5% incidence of possible intraoperative events
² Did we capture every case?

² Data recorded dependent on neurophysiologist

« Majority of the 32 cases were “saves” (53%)

² What would happen without intervention?

« Passive vs. triggered EMGs

² Could have prevented a second surgery in 3 cases

« Cost?
² Neuromonitoring cost per case?

² Cost of revision surgery

² Cost of poor patient outcome with postoperative deficit

 Intraoperative Neuromonitoring – V Arlet

´ Weaknesses of the study

« Did we capture every possible case with an
intraoperative event?
« The true incidence of false-negative findings is
not able to be elucidated with this database
« Relatively low numbers, single center
 Intraoperative Neuromonitoring – V Arlet

´ Further work to be done

« Can these cases be stratified to predict the need
for neuromonitoring?
² Lookat the relative risks of an intraoperative event
occurring based on the type of surgery
¹ Deformity correction
¹ Instrumentation

¹ Decompression

¹ Location: Cord level, cauda equina level

 Intraoperative Neuromonitoring – V Arlet

´ Overall, this review reinforces the importance

of multimodality neuromonitoring for spinal
surgery.
´ Two major questions remain unanswered:
« 1. When is intraoperative neuromonitoring
necessary for spine surgery? (risks vs. cost)
« 2. What are the true false-positive and false-
negative rates?
 Intraoperative Neuromonitoring – V Arlet

Disclosure: None of the authors of this study

has identified any conflicts of interest

Thank you: for your attention