Elsevier

World Neurosurgery

Volume 81, Issues 3–4, March–April 2014, Pages 617-623
World Neurosurgery

Peer-Review Report
Practice Trends in the Utilization of Intraoperative Neurophysiological Monitoring in Pediatric Neurosurgery as a Function of Complication Rate, and Patient-, Surgeon-, and Procedure-Related Factors

https://doi.org/10.1016/j.wneu.2013.11.010Get rights and content

Objective

Higher benchmarks in safety for patients undergoing neurosurgery have been introduced. With these principles, new tools and techniques were established, including intraoperative neurophysiological monitoring (IONM). Current trends as a function of patient-, surgeon-, and procedure-related factors and complication rates in the utilization of IONM as an adjunct to the practice of pediatric neurosurgery have not been investigated previously.

Methods

Between 2008 and 2011, 4467 neurosurgical procedures were performed on 2352 patients at Texas Children's Hospital. A retrospective chart review was performed in which surgeon, procedure, and patient characteristics, as well as perioperative complications, were recorded for IONM and non-IONM cases.

Results

Neurosurgical procedures performed with IONM steadily increased. Surgeon-related factors associated with IONM use included surgeons with <10 years of practice (P < .0001), and subspecialty interest in spine (P < .0001) and oncology (P = .0048). Procedure-related factors associated with IONM use included operations involving the spinal cord (P < .0001). Patient-related factors associated with IONM use included children older than 3 years of age and with increased American Society of Anesthesiologists score (P < .0001). The neurological complication rate in the IONM cohort (range 3.4% to 11.3%; mean 6.4%) was significantly higher compared to the non-IONM cohort (range 1.1% to 1.8%; mean 1.5%) (P < .0001).

Conclusions

The percent of procedures performed with IONM increased. However, these trends do not seem governed by improvement to patient outcomes because the complication rates were higher in the IONM cohort than the non-IONM cohort.

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

References (21)

  • G.M. Galloway et al.

    Neurophysiologic intraoperative monitoring in pediatrics

    Pediatr Neurol

    (2011)
  • M.S. Berger et al.

    Correlation of motor cortex brain mapping data with magnetic resonance imaging

    J Neurosurg

    (1990)
  • X. Chen et al.

    Success rate of motor evoked potentials for intraoperative neurophysiologic monitoring: effects of age, lesion location, and preoperative neurologic deficits

    J Clin Neurophysiol

    (2007)
  • S. DiCindio et al.

    Multimodality monitoring of transcranial electric motor and somatosensory-evoked potentials during surgical correction of spinal deformity in patients with cerebral palsy and other neuromuscular disorders

    Spine (Phila Pa 1976)

    (2003)
  • K.A. Elliott et al.

    Respiration and glycolysis of focal epileptogenic human brain tissue

    J Neurophysiol

    (1948)
  • T.O. Erb et al.

    Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child

    Anesth Analg

    (2005)
  • J. Fandino et al.

    Intraoperative validation of functional magnetic resonance imaging and cortical reorganization patterns in patients with brain tumors involving the primary motor cortex

    J Neurosurg

    (1999)
  • F.J. Frei et al.

    Intraoperative monitoring of motor-evoked potentials in children undergoing spinal surgery

    Spine (Phila Pa 1976)

    (2007)
  • D.H. Fulkerson et al.

    Intraoperative monitoring of motor evoked potentials in very young children

    J Neurosurg Pediatr

    (2011)
  • O. Ganslandt et al.

    Magnetic source imaging combined with image-guided frameless stereotaxy: a new method in surgery around the motor strip

    Neurosurgery

    (1997)
There are more references available in the full text version of this article.

Cited by (17)

  • Intraoperative neurophysiology in intramedullary spinal cord tumor surgery

    2022, Handbook of Clinical Neurology
    Citation Excerpt :

    Overall, there is robust Class I–II evidence that IONM is a valid diagnostic test to predict spinal cord injury, but only Class II–III evidence that IONM can prevent such an injury (Fehlings et al., 2010; Nuwer, 2016; Hadley et al., 2018). A radical interpretation of evidence-based medicine (EBM), suggesting that every treatment that is not supported by Class I–II evidence cannot be recommended as standard of care, has been proposed also with regard to spinal cord IONM (Vadivelu et al., 2014; Hadley et al., 2018), but heavily criticized (Sala et al., 2018; Vogel et al., 2018; Nasi et al., 2019). A few systematic reviews and meta-analyses have specifically addressed the role of IONM in ISCT.

  • Effect of Intra- and Extraoperative Factors on the Efficacy of Intraoperative Neuromonitoring During Cervical Spine Surgery

    2019, World Neurosurgery
    Citation Excerpt :

    Although commonly used, the efficacy of intraoperative neuromonitoring (IONM) during anterior cervical decompression and fusion has remained controversial. One report showed a reduction of the neurological complications with anterior cervical decompression and fusion procedures with the use of IONM,1 but other studies did not find any reduction in neurological complications.2-4 One possible explanation for the conflicting results is the differences in the extent of surgery (single vs. multilevel procedure).

  • Intraoperative neurophysiology monitoring in scoliosis surgery in children

    2019, Clinical Neurophysiology Practice
    Citation Excerpt :

    Fisher Exact Test was significant (two tailed p = 0.032) for predicting a new postoperative deficit if there is an alert and no recovery of MEPs after corrective action. Intraoperative neuromonitoring is now considered “standard of care” during paediatric spine surgery (Nuwer et al., 2012a; Ney et al., 2015; Vadivelu et al., 2014; Ferguson et al., 2014). It is not a perfect test and its effectiveness is still being debated.

  • Subcortical Mapping Using an Electrified Cavitron UltraSonic Aspirator in Pediatric Supratentorial Surgery

    2017, World Neurosurgery
    Citation Excerpt :

    The surgeon may decide to pause CUSA use during the dcMEP session, especially if the delivered CUSA current had been low (to test for close proximity only), or the surgeon may decide to continue with uninterrupted CUSA use if it is believed that the distance from the CST is still far. The implications of this technique in pediatric neurosurgery are wide.15-17 Pathologies abutting the CST may include tumors, epileptic zones, and vascular lesions.

View all citing articles on Scopus

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.

View full text