The Journal of Bone and Joint Surgery (American). 2010;92:64-71.
doi:10.2106/JBJS.H.01839
© 2010 The Journal of Bone and Joint Surgery, Inc.
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Risk Factors for Spinal Cord Injury During Surgery for Spinal Deformity

Michael G. Vitale, MD, MPH1, Derek W. Moore, MD2, Hiroko Matsumoto, MA1, Ronald G. Emerson, MD3, Whitney A. Booker, BS1, Jaime A. Gomez, MD4, Edward J. Gallo3, Joshua E. Hyman, MD1 and David P. Roye, Jr., MD1

1 Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, 3959 Broadway, Room 800 North, New York, NY 10032. E-mail address for M.G. Vitale: mgv2{at}columbia.edu
2 Department of Orthopaedic Surgery, The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
3 Department of Neurology, Columbia University, 710 West 168th Street, New York, NY 10032
4 Department of Orthopaedic Surgery, Columbia University, 622 West 168 Street, PH11-Center, New York, NY 10032

Investigation performed at the Columbia University Medical Center, New York, NY

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Background Spinal cord monitoring is now considered standard care during surgery for spinal deformity. Combined somatosensory and motor evoked potential monitoring allows the detection of early spinal cord dysfunction in most patients. The purpose of the current study was to identify clinical factors that increase the risk of intraoperative electrophysical changes and to provide management recommendations.

Methods The records of 162 consecutive patients who underwent surgery for the treatment of spinal deformity at a tertiary referral center were reviewed. Electrophysical monitoring of these patients was considered to have been successful if reproducible signals had been obtained. Relevant electrophysical changes included a reduction, as compared with baseline, of >50% in the amplitude of the somatosensory evoked potentials; an increase, as compared with baseline, of >10% in the latency of the somatosensory evoked potentials; a loss of motor evoked potentials; and an abrupt decrease of >75% in the motor evoked potentials.

Results One hundred and fifty-one (93%) of the 162 patients were monitored successfully. Four of the eleven patients with unsuccessful monitoring had neuromuscular scoliosis. Twelve of the 151 successfully monitored patients had a true electrophysical event, and two of them were found to have new postoperative neurologic deficits that represented a change from the findings of their preoperative neurologic examination. The determined causes of these electrophysical events included curve correction in eight patients, hypotension in two, direct cord trauma in one, and malposition of a pedicle screw in one. The patients with a true electrophysical event had a significantly higher rate of neurologic events than did the patients who did not have a true electrophysical event (p < 0.001). The rate of true electrophysical events was significantly higher in the patients with cardiopulmonary comorbidities than it was in the patients with no comorbidities (p = 0.011).

Conclusions Combined somatosensory and motor evoked potential monitoring effectively prevents neurologic injury in most children undergoing surgery for spinal deformity. Despite the potential for false-positive results, we recommend setting a low threshold for defining relevant electrophysical changes. Rapid intervention can reverse these changes and avoid potentially serious neurologic complications. Patients with cardiopulmonary comorbidities may be at a higher risk for having relevant electrophysical events.

Level of Evidence Diagnostic Level III. See Instructions to Authors for a complete description of levels of evidence.


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