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Can triggered electromyography monitoring throughout retraction predict postoperative symptomatic neuropraxia after XLIF? Results from a prospective multicenter trial

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Abstract

Purpose

This multicenter study aims to evaluate the utility of triggered electromyography (t-EMG) recorded throughout psoas retraction during lateral transpsoas interbody fusion to predict postoperative changes in motor function.

Methods

Three hundred and twenty-three patients undergoing L4–5 minimally invasive lateral interbody fusion from 21 sites were enrolled. Intraoperative data collection included initial t-EMG thresholds in response to posterior retractor blade stimulation and subsequent t-EMG threshold values collected every 5 min throughout retraction. Additional data collection included dimensions/duration of retraction as well as pre-and postoperative lower extremity neurologic exams.

Results

Prior to expanding the retractor, the lowestt-EMG threshold was identified posterior to the retractor in 94 % of cases. Postoperatively, 13 (4.5 %) patients had a new motor weakness that was consistent with symptomatic neuropraxia (SN) of lumbar plexus nerves on the approach side. There were no significant differences between patients with or without a corresponding postoperative SN with respect to initial posterior blade reading (p = 0.600), or retraction dimensions (p > 0.05). Retraction time was significantly longer in those patients with SN vs. those without (p = 0.031). Stepwise logistic regression showed a significant positive relationship between the presence of new postoperative SN and total retraction time (p < 0.001), as well as change in t-EMG thresholds over time (p < 0.001), although false positive rates (increased threshold in patients with no new SN) remained high regardless of the absolute increase in threshold used to define an alarm criteria.

Conclusions

Prolonged retraction time and coincident increases in t-EMG thresholds are predictors of declining nerve integrity. Increasing t-EMG thresholds, while predictive of injury, were also observed in a large number of patients without iatrogenic injury, with a greater predictive value in cases with extended duration. In addition to a careful approach with minimal muscle retraction and consistent lumbar plexus directional retraction, the incidence of postoperative motor neuropraxia may be reduced by limiting retraction time and utilizing t-EMG throughout retraction, while understanding that the specificity of this monitoring technique is low during initial retraction and increases with longer retraction duration.

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References

  1. Rodgers WB, Gerber EJ, Rodgers JA (2010) Lumbar fusion in octogenarians: the promise of minimally invasive surgery. Spine (Phila Pa 1976) 35:S355–S360

    Article  Google Scholar 

  2. Lucio JC, VanConia RB, Deluzio KJ, Lehmen JA, Rodgers JA, Rodgers WB (2012) Economics of less invasive spinal surgery: an analysis of hospital cost differences between open and minimally invasive instrumented spinal fusion procedures during the perioperative period. Risk Manag Healthc Policy 5:65

    PubMed Central  PubMed  Google Scholar 

  3. Smith WD, Christian G, Serrano S, Malone KT (2012) A comparison of perioperative charges and outcome between open and mini-open approaches for anterior lumbar discectomy and fusion. J Clin Neurosci 19:673–680

    Article  PubMed  Google Scholar 

  4. Benglis DM, Vanni S, Levi AD (2009) An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine 10:139–144

    Article  PubMed  Google Scholar 

  5. Uribe JS, Arredondo N, Dakwar E, Vale FL (2010) Defining the safe working zones using the minimally invasive lateral retroperitoneal transpsoas approach: an anatomical study. J Neurosurg Spine 13:260–266

    Article  PubMed  Google Scholar 

  6. Moro T, Kikuchi S, Konno S, Yaginuma H (2003) An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine 28:423–428

    PubMed  Google Scholar 

  7. Tohmeh AG, Rodgers WB, Peterson MD (2011) Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine 14:31–37

    Article  PubMed  Google Scholar 

  8. Taylor W, O’Brien R, Cornwall G et al (2013) The role of integrated neurophysiologic monitoring in XLIF. In: Goodrich JA, Volcan IJ (eds) eXtreme lateral interbody fusion (XLIF®), 2nd edn. Quality Medical Publishing, St. Louis, pp 45–57

    Google Scholar 

  9. Berjano P, Lamartina C (2011) Minimally invasive lateral transpsoas approach with advanced neurophysiologic monitoring for lumbar interbody fusion. Eur Spine J 20:1584–1586

    Article  PubMed  Google Scholar 

  10. Cornefjord M, Olmarker K, Farley DB, Weinstein JN, Rydevik B (1995) Neuropeptide changes in compressed spinal nerve roots. Spine 20:670–673

    Article  CAS  PubMed  Google Scholar 

  11. Cornefjord M, Sato K, Olmarker K, Rydevik B, Nordborg C (1997) A model for chronic nerve root compression studies. Presentation of a porcine model for controlled, slow-onset compression with analyses of anatomic aspects, compression onset rate, and morphologic and neurophysiologic effects. Spine (Phila Pa 1976) 22:946–957

    Article  CAS  Google Scholar 

  12. Dezawa A, Unno K, Yamane T, Miki H (2002) Changes in the microhemodynamics of nerve root retraction in patients with lumbar spinal canal stenosis. Spine (Phila Pa 1976) 27:2844–2849

    Article  Google Scholar 

  13. Olmarker K, Holm S, Rydevik B (1990) Importance of compression onset rate for the degree of impairment of impulse propagation in experimental compression injury of the porcine cauda equina. Spine (Phila Pa 1976) 15:416–419

    Article  CAS  Google Scholar 

  14. Pedowitz RA, Garfin SR, Massie JB et al (1992) Effects of magnitude and duration of compression on spinal nerve root conduction. Spine (Phila Pa 1976) 17:194–199

    Article  CAS  Google Scholar 

  15. Matsui H, Kitagawa H, Kawaguchi Y, Tsuji H (1995) Physiologic changes of nerve root during posterior lumbar discectomy. Spine (Phila Pa 1976) 20:654–659

    Article  CAS  Google Scholar 

  16. Valone F III, Lyon R, Lieberman J, Burch S (2014) Efficacy of transcranial motor evoked potentials, mechanically elicited electromyography, and evoked electromyography to assess nerve root function during sustained compression in a porcine model. Spine (Phila Pa 1976) 39:E989–E993

    Article  Google Scholar 

  17. Ozgur BM, Aryan HE, Pimenta L, Taylor WR (2006) Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:435–443

    Article  PubMed  Google Scholar 

  18. Peterson M, Youssef J (2013) eXtreme Lateral Interbody Fusion (XLIF): Lumbar Surgical Technique. In: Goodrich JA, Volcan IJ (eds) eXtreme lateral interbody fusion (XLIF®), 2nd edn. Quality Medical Publishing, St. Louis, pp 159–178

    Google Scholar 

  19. Sharma AK, Kepler CK, Girardi FP, Cammisa FP, Huang RC, Sama AA (2011) Lateral lumbar interbody fusion: clinical and radiographic outcomes at 1 year: a preliminary report. J Spinal Disord Tech 24:242–250

    Article  PubMed  Google Scholar 

  20. Moller DJ, Slimack NP, Acosta FL Jr, Koski TR, Fessler RG, Liu JC (2011) Minimally invasive lateral lumbar interbody fusion and transpsoas approach-related morbidity. Neurosurg Focus 31:E4

    Article  PubMed  Google Scholar 

  21. Berjano P, Balsano M, Buric J, Petruzzi M, Lamartina C (2012) Direct lateral access lumbar and thoracolumbar fusion: preliminary results. Eur Spine J 21(Suppl 1):S37–S42

    Article  PubMed  Google Scholar 

  22. Rodgers WB, Cox CS, Gerber EJ (2009) Minimally invasive treatment (XLIF) of adjacent segment disease after prior lumbar fusions. Internet J Minim Invasive Spinal Tech 3

  23. Tormenti MJ, Maserati MB, Bonfield CM, Okonkwo DO, Kanter AS (2010) Complications and radiographic correction in adult scoliosis following combined transpsoas extreme lateral interbody fusion and posterior pedicle screw instrumentation. Neurosurg Focus 28:E7

    Article  PubMed  Google Scholar 

  24. Formica M, Berjano P, Cavagnaro L, Zanirato A, Piazzolla A, Formica C (2014) Extreme lateral approach to the spine in degenerative and post traumatic lumbar diseases: selection process, results and complications. Eur Spine J 23(Suppl 6):684–692

    Article  PubMed  Google Scholar 

  25. Davis TT, Bae HW, Mok JM, Rasouli A, Delamarter RB (2011) Lumbar plexus anatomy within the psoas muscle: implications for the transpsoas lateral approach to the L4–L5 disc. J Bone Joint Surg Am 93:1482–1487

    PubMed  Google Scholar 

  26. Le TV, Burkett CJ, Deukmedjian AR, Uribe JS (2013) Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976) 38:E13–E20

    Article  Google Scholar 

  27. Bendersky M, Sola C, Muntadas J et al (2015) Monitoring lumbar plexus integrity in extreme lateral transpsoas approaches to the lumbar spine: a new protocol with anatomical bases. Eur Spine J

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Acknowledgments

This study was funded by NuVasive, Inc.

Conflict of interest

Authors JSU, REI, JAY, KK, ASK, FAK, and MDP are consultants to NuVasive. JSU, REI, JAY, KK, and MDP receive research support from NuVasive. JSU and MDP hold shares of NuVasive stock, JSU, REI, JAY, and MDP receive royalties from NuVasive, FAK has been reimbursed for travel on behalf of NuVasive, and MDP is a member of a surgeon advisory board for NuVasive. Author JRB has no conflicts to report.

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Correspondence to Juan S. Uribe.

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Uribe, J.S., Isaacs, R.E., Youssef, J.A. et al. Can triggered electromyography monitoring throughout retraction predict postoperative symptomatic neuropraxia after XLIF? Results from a prospective multicenter trial. Eur Spine J 24 (Suppl 3), 378–385 (2015). https://doi.org/10.1007/s00586-015-3871-8

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  • DOI: https://doi.org/10.1007/s00586-015-3871-8

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