Peer-Review ReportPractice Trends in the Utilization of Intraoperative Neurophysiological Monitoring in Pediatric Neurosurgery as a Function of Complication Rate, and Patient-, Surgeon-, and Procedure-Related Factors
Introduction
Children, like adults, are at risk of neurological deterioration during various neurosurgical procedures and may benefit from intraoperative neurophysiological monitoring (IONM). Some neurophysiological techniques commonly used and established in neurosurgical procedures for adults have not reached to widespread use in children. The first use of an intraoperative electroencephalogram was by Foerster and Alternberger in 1935. In the late 1930s through the 1950s, Drs. Herbert Jasper and Wilder Penfield further developed this technique, using electrocorticography for localization and surgical treatment of epilepsy (16). Dawson recorded the first somatosensory evoked potential in 1947 (4). Understanding and establishing techniques to record other evoked potentials, including those produced by motor activity and by visual and auditory stimulation, followed. In 1978, the first intraoperative use of brainstem auditory evoked potentials was reported. Despite the long history between IONM and neurosurgery, controversy about indications for and the usefulness and techniques of IONM in children still exist (19).
Over the past 2 to 3 decades, among other concepts in the neurosciences, the establishment of new techniques and tools such as neuronavigation, functional neuroimaging, and robotics to make neurosurgical procedures safer for the patient emerged. For IONM, the advent of new electrophysiological stimulation techniques and the development of more refined anesthetic strategies have improved and optimized recording of reliable neurophysiological signals in the surgical setting, especially in young patients 5, 8. The frequency of publications devoted to intraoperative neurophysiological techniques has increased significantly over the past few years 1, 6, 10, 11, 12, 14, 17, 18, 19, 20. This evolving and expanding interest in intraoperative neurophysiology likely stems from lofty goals for safe and low-risk surgery and a desire for improved neurological outcomes after surgery on the part of patients, as well as their families and surgeons. A firm rationale for the increased popularity of this adjunct to neurosurgery has not been established. To the best of our knowledge, we present the first study focusing on the practice trends of IONM utilization in pediatric neurosurgery. We suggest that patient-, surgeon-, and procedure-related factors, but not lower neurological complication rates, shape IONM use today.
Section snippets
Chart Review
We retrospectively reviewed the records of consecutive neurosurgical procedures performed between 2008 and 2011 at Texas Children's Hospital. All patients who underwent procedures with or without IONM were included in the analysis. Surgeon-related factors such as years in practice and subspecialty interest within pediatric neurosurgery were recorded. Patient-related factors such as age and comorbidities and procedure-related factors such as the type of cranial, spinal, or peripheral nerve
Results
A total of 4467 neurosurgical procedures with or without IONM were performed from 2008 to 2011. Significant trends were observed during the 4-year period. A steady increase of IONM use was observed (Table 1).
Discussion
Since its initial description more than 75 years ago, IONM has slowly gained acceptance among pediatric neurosurgeons. Decreased rates of neurological deterioration after cranial and spinal surgery have been suggested as a benefit of IONM 1, 2, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, but this remains controversial.
IONM involves the use of multiple monitoring modalities, including evoked potentials such as somatosensory, brainstem auditory, and visual evoked potentials, as well
Conclusions
In the last 4 years, the proportion of operative neurosurgical cases managed with IONM increased substantially in our practice. This trend is likely a direct correlation with increasing surgeon experience and comfort with IONM. From our study, a younger surgeon performing a spine or posterior fossa surgery in an older child with significant comorbidities was more likely to use IONM. The neurological complication rate in cases with IONM was unexpectedly high, and does not seem a logical
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.