Case SeriesInfluence of Intraoperative Neuromonitoring on the Outcomes of Surgeries for Pediatric Scoliosis in the United States
Introduction
Surgical correction of scoliosis and other pediatric spinal deformities involves substantial manipulation of the vertebral column and the associated neural structures [1], [2], [3]. Although a number of complications can occur after such complex spinal deformity surgeries, neurologic complications are among the most feared [1], [3]. Neurologic injury can result from excessive stretching of spinal cord or the nerve roots, hypoperfusion, direct injury during implant placement, or from patient positioning [2] Historically, the rates of neurologic complications were reported to be 3% to 4% [4], [5]. However, more recent studies report an incidence between 0.5% and 2% [1], [3], [6], [7]. This decline in complication rates over the last few decades is, at least in part, due to the availability of intraoperative neuromonitoring (IONM) [2], [8].
IONM can detect impending neurologic injury intraoperatively, allowing the surgeon to take action to prevent long-lasting neurologic deficits [2]. IONM is becoming more common in pediatric spinal deformity surgeries and is available in most of the United States [2], [3]. Despite increased use, very few studies have compared the outcomes of operations with and without IONM [8], [9], [10]. Although IONM is proven to be useful in detecting early neurologic insult, there is little evidence to support that IONM decreases the incidence of neurologic complications [8], [11]. Moreover, given the rising health care costs, there are also concerns about the utility of IONM in less complex spinal surgeries [9], [10], [12]. As the frequency of IONM increases in pediatric spinal deformity surgeries performed in the United States, it is important to study the effects of IONM on the outcomes of such surgeries at a national level.
Therefore, the present study used the Nationwide Inpatient Sample (NIS), a nationally representative database, to compare 1) the length of stay (LOS), discharge disposition, and hospital charges and 2) in-hospital complications (including neurologic complications) between pediatric fusion surgeries for scoliosis with and without IONM.
Section snippets
Data source
This study used the NIS database from 2009 to 2012. The NIS database is a part of the Healthcare Cost and Utilization Project managed by the Agency for Healthcare Research and Quality (AHRQ) and is the largest all-payer database in the United States containing information about inpatient admissions [13]. The NIS is a stratified sample of 20% of all the hospitalizations in the United States and contains an array of information including demographics, International Classification of Disease,
Results
Majority of the patients in both the groups were discharged to home (monitoring group [MG] = 5,355 [93.8%], nonmonitoring group [NMG] = 24,309 [91.4%]) (Table 3). MG was more likely to be discharged to home after adjusting for baseline characteristics (AOR = 1.25 [95% CI: 1.10–1.41], p<.001) (Table 4). The mean LOS in the MG versus NMG were 5.8±5.1 and 6.2±6.1 days, respectively. On multivariate analysis, there was no difference in LOS between the groups (adjusted coefficient = –0.31 [–0.68 to
Discussion
Neuromonitoring is frequently used during pediatric spinal surgeries to detect impending neurologic damage. Although many studies have validated the effectiveness of IONM in assessing neurologic integrity, the effect of IONM on outcomes of pediatric spinal deformity surgeries has not been studied at a national level. Using the NIS database, this study found that IONM use was reported in 18% of the surgeries, which is lower than expected. This study also found that IONM was associated with
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Author disclosures: JG (none), SD (none), ACE (none), RCC (none), TEK (none), RCG (none).
The authors declare no conflicts of interest.
No funding was obtained for this study.
The study was exempt from IRB approval as it used a publicly available database.