Is the Use of Intraoperative Neuromonitoring Justified During Lumbar Anterior Approach Surgery?

IF 1.7 Q2 SURGERY International Journal of Spine Surgery Pub Date : 2024-05-06 DOI:10.14444/8589

Scott L Blumenthal, Joel I Edionwe, Emily C Courtois, Richard D Guyer, Alexander M Satin, Donna D Ohnmeiss

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Abstract

Background: Intraoperative neuromonitoring (IONM) became widely used in spine surgery to reduce the risk of iatrogenic nerve injury. However, the proliferation of IONM has fallen into question based on effectiveness and costs, with a lack of evidence supporting its benefit for specific spine surgery procedures. The purpose of this study was to evaluate the use of IONM and the rate of neurological injury associated with anterior lumbar spinal surgery.

Methods: This was a retrospective study on a consecutive series of 359 patients undergoing lumbar anterior approach surgery for anterior lumbar interbody fusion (ALIF), total disc replacement (TDR), or hybrid (ALIF with TDR) for the treatment of symptomatic disc degeneration. Patients undergoing any posterior spine surgery were excluded. Operative notes were reviewed to identify any changes in IONM and the surgeon's response. Clinic notes were reviewed up to 3 months postoperatively for indications of iatrogenic nerve injury.

Results: There were 3 aberrant results with respect to IONM. Changes in IONM of a lower extremity occurred for 1 patient (0.3%). The surgeon evaluated the situation and there was no observable reason for the IONM change. Upon waking, the patient was found to have no neurological deficit. There were 2 cases of neurologic deficits in this population, which were classified as false-negatives of IONM (0.56%, 95% CI: 0.1% to 1.8%). In both cases, the patients were found to have a foot drop after the anterior approach surgery.

Conclusion: In this study, there was 1 false-positive and 2 false-negative results of IONM. These data suggest that IONM is not beneficial in this population. However, many surgeons may feel obligated to use IONM for medicolegal reasons. There is a need for future studies to delineate cases in which IONM is beneficial and the type of monitoring to use, if any, for specific spine surgery types.

Clinical relevance: This study questions the routine use of IONM in anterior lumbar approach surgery for the treatment of symptomatic disc degeneration. This has significant implications related to the cost of this practice.

Level of evidence: 4:

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在腰椎前路手术中使用术中神经监测是否合理？

背景：术中神经监测（IONM）已广泛应用于脊柱手术，以降低先天性神经损伤的风险。然而，基于有效性和成本的考虑，术中神经监测仪的普及受到质疑，缺乏证据支持其对特定脊柱手术的益处。本研究的目的是评估 IONM 的使用情况以及与腰椎前路手术相关的神经损伤率：本研究是一项回顾性研究，对359名接受腰椎前路手术的患者进行了观察，这些患者接受了腰椎椎间融合术（ALIF）、全椎间盘置换术（TDR）或混合手术（ALIF与TDR），以治疗有症状的椎间盘退变。接受任何脊柱后路手术的患者均被排除在外。对手术记录进行审查，以确定 IONM 的任何变化和外科医生的反应。对术后3个月的门诊记录进行复查，以寻找先天性神经损伤的迹象：在 IONM 方面有 3 个异常结果。1名患者（0.3%）的下肢IONM发生了变化。外科医生对情况进行了评估，没有发现 IONM 发生变化的原因。醒来后发现患者没有神经功能缺损。该人群中有两例神经功能缺损，被归类为 IONM 假阴性（0.56%，95% CI：0.1% 至 1.8%）。这两例患者都是在前路手术后出现足下垂：结论：在这项研究中，IONM结果有1例假阳性和2例假阴性。这些数据表明，IONM 对这一人群并无益处。然而，许多外科医生可能出于医疗法律原因而不得不使用 IONM。今后有必要开展研究，以确定在哪些情况下使用 IONM 是有益的，以及在特定脊柱手术类型中应使用哪种类型的监测（如果有的话）：这项研究对在治疗有症状的椎间盘退变的腰椎前路手术中常规使用 IONM 提出了质疑。这对这一做法的成本有重大影响：4:

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来源期刊

International Journal of Spine Surgery Medicine-Surgery

CiteScore

3.10

自引率

0.00%

发文量

162

期刊介绍： The International Journal of Spine Surgery is the official scientific journal of ISASS, the International Intradiscal Therapy Society, the Pittsburgh Spine Summit, and the Büttner-Janz Spinefoundation, and is an official partner of the Southern Neurosurgical Society. The goal of the International Journal of Spine Surgery is to promote and disseminate online the most up-to-date scientific and clinical research into innovations in motion preservation and new spinal surgery technology, including basic science, biologics, and tissue engineering. The Journal is dedicated to educating spine surgeons worldwide by reporting on the scientific basis, indications, surgical techniques, complications, outcomes, and follow-up data for promising spinal procedures.