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Intra-Operative Neuromonitoring (IONM): Is There a Role in Metastatic Spine Tumour Surgery?
Spine 2018 July 24
STUDY DESIGN: Retrospective OBJECTIVE.: We aim to report our experience with multimodal Intraoperative neuromonitoring (IONM) in Metastatic Spine Tumour Surgery (MSTS).
SUMMARY OF BACKGROUND DATA: IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS.
METHODS: A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute were studied retrospectively. After excluding 7 with no baseline signals, 128 patients were analysed. The data collected comprised of demographics, pre and post-operative ASIA grades & neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEP), transcranial electric motor-evoked potentials (tcMEP) and free running electromyography (EMG).
RESULTS: The 128 patients included 61 males&67 females with mean age of 61 years. 116 underwent posterior procedures; 9 anterior and 3 both. The frequency of preoperative ASIA Grades were A = 0,B = 0,C = 10,D = 44 and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain and 8 for intractable pain.Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, 1 false negative and no false positives. Among the 13 true positives, 4 (30%) underwent minimally invasive and 9 (70%) open procedures. 8 (69.2%) patients had posterior approach. 7 (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression; while 5 (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation; and 1 (8.3%) during lateral approach which reversed after changing the plane of dissection. Of the 7 patients without baseline, 5 were ASIA-A, 2 were ASIA-C. The sensitivity, specificity, positive&negative predictive values were 99.1%, 100%, 100%&92.9% respectively.
CONCLUSIONS: Multimodal IONM in MSTS helped in preventing post-operative neurological deficit in 9.4% of patients. It's high sensitivity and specificity to detect intraoperative neurological events envisages its use in ASIA-grade D/E patients requiring instrumented decompression.
LEVEL OF EVIDENCE: 3.
SUMMARY OF BACKGROUND DATA: IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS.
METHODS: A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute were studied retrospectively. After excluding 7 with no baseline signals, 128 patients were analysed. The data collected comprised of demographics, pre and post-operative ASIA grades & neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEP), transcranial electric motor-evoked potentials (tcMEP) and free running electromyography (EMG).
RESULTS: The 128 patients included 61 males&67 females with mean age of 61 years. 116 underwent posterior procedures; 9 anterior and 3 both. The frequency of preoperative ASIA Grades were A = 0,B = 0,C = 10,D = 44 and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain and 8 for intractable pain.Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, 1 false negative and no false positives. Among the 13 true positives, 4 (30%) underwent minimally invasive and 9 (70%) open procedures. 8 (69.2%) patients had posterior approach. 7 (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression; while 5 (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation; and 1 (8.3%) during lateral approach which reversed after changing the plane of dissection. Of the 7 patients without baseline, 5 were ASIA-A, 2 were ASIA-C. The sensitivity, specificity, positive&negative predictive values were 99.1%, 100%, 100%&92.9% respectively.
CONCLUSIONS: Multimodal IONM in MSTS helped in preventing post-operative neurological deficit in 9.4% of patients. It's high sensitivity and specificity to detect intraoperative neurological events envisages its use in ASIA-grade D/E patients requiring instrumented decompression.
LEVEL OF EVIDENCE: 3.
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