Elsevier

Spine Deformity

Volume 7, Issue 1, January 2019, Pages 27-32
Spine Deformity

Case Series
Influence of Intraoperative Neuromonitoring on the Outcomes of Surgeries for Pediatric Scoliosis in the United States

https://doi.org/10.1016/j.jspd.2018.05.013Get rights and content

Abstract

Background

Intraoperative neuromonitoring (IONM) is used to detect impending neurologic damage during complex spinal surgeries. Although IONM is increasingly used during pediatric scoliosis surgeries in the United States, the effect of IONM on the outcomes of such surgeries at a national level is unclear.

Methods

Using National Inpatient Sample (NIS) from 2009 to 2012, 32,305 spinal fusions performed in children 18 years old or younger of age with scoliosis were identified using ICD-9 procedure and diagnosis codes. IONM was identified using the ICD-9 procedure code 00.94. The effects of IONM use on length of stay (LOS), discharge disposition, hospital charges, and in-hospital complications were assessed using multivariate regression analysis adjusting for patient and hospital characteristics.

Results

IONM was used in 5,706 (18%) of the surgeries. IONM was associated with increased home discharge (adjusted odds ratio [AOR] = 1.25 [95% confidence interval 1.10-1.40], p = .001). There was no difference in LOS (p = .096) and hospital charges (p = .750). Neurologic complications were noted in 52 (0.9%) surgeries using IONM and 368 (1.4%) surgeries without IONM (p = .005). Although IONM use trended toward lower risk of neurologic complications in multivariate analysis, it failed to achieve statistical significance (AOR = 0.77 [0.57-1.04], p = .084).

Conclusions

Reported use of IONM in this database was significantly less compared with other databases, suggesting that IONM might be underreported in the NIS database. Nevertheless, in this database, IONM was significantly associated with increased home discharge. Hospital charges and LOS were not affected by IONM. There was a trend toward lower risk of neurologic complications with IONM use, though this finding was not statistically significant.

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

References (23)

  • J. George et al.

    Administrative databases can yield false conclusions—an example of obesity in total joint arthroplasty

    J Arthroplasty

    (2017)
  • J.D. Coe et al.

    Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium. A report of the Scoliosis Research Society Morbidity and Mortality Committee

    Spine (Phila Pa 1976)

    (2006)
  • V.J. Devlin et al.

    Intraoperative neurophysiologic monitoring during spinal surgery

    J Am Acad Orthop Surg

    (2007)
  • D.L. Reames et al.

    Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database

    Spine (Phila Pa 1976)

    (2011)
  • G.H. Thompson et al.

    Segmental spinal instrumentation in idiopathic scoliosis. A preliminary report

    Spine (Phila Pa 1976)

    (1985)
  • R.G. Wilber et al.

    Postoperative neurological deficits in segmental spinal instrumentation. A study using spinal cord monitoring

    J Bone Joint Surg Am

    (1984)
  • T. Cole et al.

    Intraoperative neuromonitoring in single-level spinal procedures: a retrospective propensity score-matched analysis in a national longitudinal database

    Spine (Phila Pa 1976)

    (2014)
  • K.-M.G. Fu et al.

    Morbidity and mortality associated with spinal surgery in children: a review of the Scoliosis Research Society morbidity and mortality database

    J Neurosurg Pediatr

    (2011)
  • D.M. Schwartz et al.

    Neurophysiological detection of impending spinal cord injury during scoliosis surgery

    J Bone Joint Surg Am

    (2007)
  • W.N. Sankar et al.

    Neurologic risk in growing rod spine surgery in early onset scoliosis: is neuromonitoring necessary for all cases?

    Spine (Phila Pa 1976)

    (2009)
  • J.P. Ney et al.

    Does intraoperative neurophysiologic monitoring matter in noncomplex spine surgeries?

    Neurology

    (2015)
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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.

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