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      Is Open Access

      The Use of Intraoperative Neurophysiological Monitoring in Spine Surgery

      research-article
      , MD 1 , 2 , 3 , , MD, FRCSC 1 , 4 , , BMBCh, FRCS 1 , 4 , , MD 1 , 4 , , MD 5 , , MD, PhD, FRCSC, FACS 1 , 4
      Global Spine Journal
      SAGE Publications
      MEP, SSEP, EMG, monitoring, spine surgery

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          Abstract

          Study Design:

          Narrative review.

          Objective:

          To summarize relevant studies regarding the utilization of intraoperative neurophysiological monitoring (IONM) techniques in spine surgery implemented in recent years.

          Methods:

          A literature search of the Medline database was performed. Relevant studies from all evidence levels have been included. Titles, abstracts, and reference lists of key articles were included.

          Results:

          Multimodal intraoperative neurophysiological monitoring (MIONM) has the advantage of compensating for the limitations of each individual technique and seems to be effective and accurate for detecting perioperative neurological injury during spine surgery.

          Conclusion:

          Although there are no prospective studies validating the efficacy of IONM, there is a growing body of evidence supporting its use during spinal surgery. However, the lack of validated protocols to manage intraoperative alerts highlights a critical knowledge gap. Future investigation should focus on developing treatment methodology, validating practice protocols, and synthesizing clinical guidelines.

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          Most cited references73

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          Stimulation of the cerebral cortex in the intact human subject.

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            The role of cost-effectiveness analysis in health and medicine. Panel on Cost-Effectiveness in Health and Medicine.

            To develop consensus-based recommendations guiding the conduct of cost-effectiveness analysis (CEA) to improve the comparability and quality of studies. The recommendations apply to analyses intended to inform the allocation of health care resources across a broad range of conditions and interventions. This article, first in a 3-part series, discusses how this goal affects the conduct and use of analyses. The remaining articles will outline methodological and reporting recommendations, respectively. The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). The panel reviewed the theoretical foundations of CEA, current practices, and alternative procedures for measuring and assigning values to resource use and health outcomes. The panel met 11 times during 2 1/2 years with PHS staff and methodologists from federal agencies. Working groups brought issues and preliminary recommendations to the full panel for discussion. Draft recommendations were circulated to outside experts and the federal agencies prior to finalization. The panel's recommendations define a "reference case" cost-effectiveness analysis, a standard set of methods to serve as a point of comparison across studies. The reference case analysis is conducted from the societal perspective and accounts for benefits, harms, and costs to all parties. Although CEA does not reflect every element of importance in health care decisions, the information it provides is critical to informing decisions about the allocation of health care resources.
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              Motor evoked potential monitoring improves outcome after surgery for intramedullary spinal cord tumors: a historical control study.

              The value of intraoperative neurophysiological monitoring (INM) during intramedullary spinal cord tumor surgery remains debated. This historical control study tests the hypothesis that INM monitoring improves neurological outcome. In 50 patients operated on after September 2000, we monitored somatosensory evoked potentials and transcranially elicited epidural (D-wave) and muscle motor evoked potentials (INM group). The historical control group consisted of 50 patients selected from among 301 patients who underwent intramedullary spinal cord tumor surgery, previously operated on by the same team without INM. Matching by preoperative neurological status (McCormick scale), histological findings, tumor location, and extent of removal were blind to outcome. A more than 50% somatosensory evoked potential amplitude decrement influenced only myelotomy. Muscle motor evoked potential disappearance modified surgery, but more than 50% D-wave amplitude decrement was the major indication to stop surgery. The postoperative to preoperative McCormick grade variation at discharge and at a follow-up of at least 3 months was compared between the two groups (Student's t tests). Follow-up McCormick grade variation in the INM group (mean, +0.28) was significantly better (P = 0.0016) than that of the historical control group (mean, -0.16). At discharge, there was a trend (P = 0.1224) toward better McCormick grade variation in the INM group (mean, -0.26) than in the historical control group (mean, -0.5). The applied motor evoked potential methods seem to improve long-term motor outcome significantly. Early motor outcome is similar because of transient motor deficits in the INM group, which can be predicted at the end of surgery by the neurophysiological profile of patients.
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                Author and article information

                Journal
                Global Spine J
                Global Spine J
                GSJ
                spgsj
                Global Spine Journal
                SAGE Publications (Sage CA: Los Angeles, CA )
                2192-5682
                2192-5690
                6 January 2020
                January 2020
                : 10
                : 1 Suppl , Special Issue: Quality Improvement and Spine Surgery
                : 104S-114S
                Affiliations
                [1 ]Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
                [2 ]Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
                [3 ]Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
                [4 ]University of Toronto, Toronto, Ontario, Canada
                [5 ]University of Utah, Salt Lake City, UT, USA
                Author notes
                [*]Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst St, Toronto, Ontario M5T2S8, Canada. Email: Michael.Fehlings@ 123456uhn.ca
                Author information
                https://orcid.org/0000-0002-7673-0267
                https://orcid.org/0000-0002-3488-7506
                https://orcid.org/0000-0002-5722-6364
                Article
                10.1177_2192568219859314
                10.1177/2192568219859314
                6947672
                31934514
                6f78e0f2-960f-470b-97ad-350b12291af7
                © The Author(s) 2020

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License ( https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Categories
                Quality in the Present and in the Future
                Custom metadata
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                mep,ssep,emg,monitoring,spine surgery
                mep, ssep, emg, monitoring, spine surgery

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