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26-08-2023 | Motor Evoked Potential | Review Article

Utility of transcranial motor-evoked potential changes in predicting postoperative deficit in lumbar decompression and fusion surgery: a systematic review and meta-analysis

Authors: Rajiv P. Reddy, Vamsi K. Gorijala, Varun R. Kaithi, Varun Shandal, Katherine M. Anetakis, Jeffrey R. Balzer, Donald J. Crammond, Jeremy D. Shaw, Joon Y. Lee, Parthasarathy D. Thirumala

Published in: European Spine Journal | Issue 10/2023

Abstract

Purpose

The primary aim of this study was to evaluate whether TcMEP alarms can predict the occurrence of postoperative neurological deficit in patients undergoing lumbar spine surgery. The secondary aim was to determine whether the various types of TcMEP alarms including transient and persistent changes portend varying degrees of injury risk.

Methods

This was a systematic review and meta-analysis of the literature from PubMed, Web of Science, and Embase regarding outcomes of transcranial motor-evoked potential (TcMEP) monitoring during lumbar decompression and fusion surgery. The sensitivity, specificity, and diagnostic odds ratio (DOR) of TcMEP alarms for predicting postoperative deficit were calculated and presented with forest plots and a summary receiver operating characteristic curve.

Results

Eight studies were included, consisting of 4923 patients. The incidence of postoperative neurological deficit was 0.73% (36/4923). The incidence of deficits in patients with significant TcMEP changes was 11.79% (27/229), while the incidence in those without changes was 0.19% (9/4694). All TcMEP alarms had a pooled sensitivity and specificity of 63 and 95% with a DOR of 34.92 (95% CI 7.95–153.42). Transient and persistent changes had sensitivities of 29% and 47%, specificities of 96% and 98%, and DORs of 8.04 and 66.06, respectively.

Conclusion

TcMEP monitoring has high specificity but low sensitivity for predicting postoperative neurological deficit in lumbar decompression and fusion surgery. Patients who awoke with new postoperative deficits were 35 times more likely to have experienced TcMEP changes intraoperatively, with persistent changes indicating higher risk of deficit than transient changes.

Level of Evidence II

Diagnostic Systematic Review.

Available only for authorised users

Weinstein JN, Tosteson TD, Lurie JD et al (2008) Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 358:794–810. https://doi.org/10.1056/NEJMOA0707136CrossRefPubMedPubMedCentral

Ghogawala Z, Dziura J, Butler WE et al (2016) Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 374:1424–1434. https://doi.org/10.1056/NEJMOA1508788/SUPPL_FILE/NEJMOA1508788_DISCLOSURES.PDFCrossRefPubMed

Ghobrial GM, Williams KA, Arnold P et al (2015) Iatrogenic neurologic deficit after lumbar spine surgery: a review. Clin Neurol Neurosurg 139:76–80. https://doi.org/10.1016/J.CLINEURO.2015.08.022CrossRefPubMed

Melachuri SR, Stopera C, Melachuri MK et al (2020) The efficacy of somatosensory evoked potentials in evaluating new neurological deficits after spinal thoracic fusion and decompression. J Neurosurg Spine. https://doi.org/10.3171/2019.12.SPINE191157CrossRefPubMed

Sharma H, Lee SWJ, Cole AA (2012) The management of weakness caused by lumbar and lumbosacral nerve root compression. J Bone Joint Surg Br 94:1442–1447. https://doi.org/10.1302/0301-620X.94B11.29148CrossRefPubMed

Lall RR, Hauptman JS, Munoz C et al (2012) Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist. Neurosurg Focus 33:E10. https://doi.org/10.3171/2012.9.FOCUS12235CrossRefPubMed

Charalampidis A, Jiang F, Wilson JRF et al (2020) The use of intraoperative neurophysiological monitoring in spine surgery. Glob Spine J. https://doi.org/10.1177/2192568219859314CrossRef

Chang R, Reddy RP, Coutinho DV et al (2021) Diagnostic accuracy of SSEP changes during lumbar spine surgery for predicting postoperative neurological deficit: a systematic review and meta-analysis. Spine (Phila Pa 1976) 46:E1343–E1352. https://doi.org/10.1097/BRS.0000000000004099CrossRefPubMed

Thirumala PD, Huang J, Thiagarajan K et al (2016) Diagnostic accuracy of combined multimodality somatosensory evoked potential and transcranial motor evoked potential intraoperative monitoring in patients with idiopathic scoliosis. Spine (Phila Pa 1976) 41:E1177–E1184. https://doi.org/10.1097/BRS.0000000000001678CrossRefPubMed

10.

Thirumala PD, Crammond DJ, Loke YK et al (2017) Diagnostic accuracy of motor evoked potentials to detect neurological deficit during idiopathic scoliosis correction: a systematic review. J Neurosurg Spine 26:374–383. https://doi.org/10.3171/2015.7.SPINE15466CrossRefPubMed

11.

Reddy RP, Chang R, Rosario BP et al (2021) What is the predictive value of intraoperative somatosensory evoked potential monitoring for postoperative neurological deficit in cervical spine surgery?-a meta-analysis. Spine J 21:555–570. https://doi.org/10.1016/J.SPINEE.2021.01.010CrossRefPubMed

12.

Sharan A, Groff MW, Dailey AT et al (2014) Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine. https://doi.org/10.3171/2014.4.SPINE14324CrossRefPubMed

13.

Resnick DK, Choudhri TF, Dailey AT et al (2005) Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine. https://doi.org/10.3171/spi.2005.2.6.0725CrossRefPubMed

14.

Wilent WB, Tesdahl EA, Harrop JS et al (2020) Utility of motor evoked potentials to diagnose and reduce lower extremity motor nerve root injuries during 4386 extradural posterior lumbosacral spine procedures. Spine J. https://doi.org/10.1016/j.spinee.2019.08.013CrossRefPubMed

15.

Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. https://doi.org/10.1136/BMJ.N71CrossRefPubMedPubMedCentral

16.

Whiting PF, Rutjes AWS, Westwood ME et al (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155:529–536. https://doi.org/10.7326/0003-4819-155-8-201110180-00009CrossRefPubMed

17.

Deeks JJ, Macaskill P, Irwig L (2005) The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 58:882–893. https://doi.org/10.1016/J.JCLINEPI.2005.01.016CrossRefPubMed

18.

Alemo S, Sayadipour A (2010) Role of intraoperative neurophysiologic monitoring in lumbosacral spine fusion and instrumentation: a retrospective study. World Neurosurg 73:72–76. https://doi.org/10.1016/J.SURNEU.2009.04.024CrossRefPubMed

19.

Berends HI, Journée HL, Rácz I et al (2016) Multimodality intraoperative neuromonitoring in extreme lateral interbody fusion. Transcranial electrical stimulation as indispensable rearview. Eur Spine J 25:1581–1586. https://doi.org/10.1007/S00586-015-4182-9CrossRefPubMed

20.

Chen Y, Luo C, Wang J et al (2021) Roles of multimodal intra-operative neurophysiological monitoring (IONM) in percutaneous endoscopic transforaminal lumbar interbody fusion: a case series of 113 patients. BMC Musculoskelet Disord 22:1–11. https://doi.org/10.1186/S12891-021-04824-2/TABLES/3CrossRefPubMedPubMedCentral

21.

Cousiño JPC, Luna F, Torche M et al (2020) Anterolateral S1 screw malposition detected with intraoperative neurophysiological monitoring during posterior lumbosacral fusion. Surg Neurol Int. https://doi.org/10.25259/SNI_4_2020CrossRefPubMedPubMedCentral

22.

Kim JH, Lenina S, Mosley G et al (2019) The efficacy of intraoperative neurophysiological monitoring to detect postoperative neurological deficits in transforaminal lumbar interbody fusion surgery. Oper Neurosurg 16:71–78. https://doi.org/10.1093/ONS/OPY061CrossRef

23.

Malham GM, Hamer RP, Biddau DT, Munday NR (2022) Do evoked potentials matter? Pre-pathologic signal change and clinical outcomes with expandable cages in lateral lumbar interbody fusion surgery. J Clin Neurosci 98:248–253. https://doi.org/10.1016/J.JOCN.2022.02.023CrossRefPubMed

24.

Wilent WB, Tesdahl EA, Harrop JS et al (2020) Utility of motor evoked potentials to diagnose and reduce lower extremity motor nerve root injuries during 4386 extradural posterior lumbosacral spine procedures. Spine J 20:191–198. https://doi.org/10.1016/J.SPINEE.2019.08.013CrossRefPubMed

25.

Yaylali I, Ju H, Yoo J et al (2014) Intraoperative neurophysiological monitoring in anterior lumbar interbody fusion surgery. J Clin Neurophysiol 31:352–355. https://doi.org/10.1097/WNP.0000000000000073CrossRefPubMed

26.

Doyal A, Schoenherr JW, Flynn DN (2022) Motor Evoked Potential. StatPearls

27.

Deletis V, Sala F (2008) Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol 119:248–264. https://doi.org/10.1016/J.CLINPH.2007.09.135CrossRefPubMed

28.

Mok JM, Lyon R, Lieberman JA et al (2008) Monitoring of nerve root injury using transcranial motor-evoked potentials in a pig model. Spine (Phila Pa 1976). https://doi.org/10.1097/BRS.0B013E318178E67FCrossRefPubMed

29.

Ushirozako H, Yoshida G, Kobayashi S et al (2018) Transcranial motor evoked potential monitoring for the detection of nerve root injury during adult spinal deformity surgery. Asian Spine J 12:639. https://doi.org/10.31616/ASJ.2018.12.4.639CrossRefPubMedPubMedCentral

30.

Tamkus A, Rice KS, Hoffman G (2018) Transcranial motor evoked potential alarm criteria to predict foot drop injury during lumbosacral surgery. Spine (Phila Pa 1976) 43:E227–E233. https://doi.org/10.1097/BRS.0000000000002288CrossRefPubMed

31.

Gonzalez AA, Jeyanandarajan D, Hansen C et al (2009) Intraoperative neurophysiological monitoring during spine surgery: a review. Neurosurg Focus. https://doi.org/10.3171/2009.8.FOCUS09150CrossRefPubMed

32.

Vitale MG, Skaggs DL, Pace GI et al (2014) Best practices in intraoperative neuromonitoring in spine deformity surgery: development of an intraoperative checklist to optimize response. Spine Deform. https://doi.org/10.1016/j.jspd.2014.05.003CrossRefPubMed

33.

Laratta JL, Ha A, Shillingford JN et al (2018) Neuromonitoring in spinal deformity surgery: a multimodality approach. Glob spine J 8:68–77. https://doi.org/10.1177/2192568217706970CrossRef

34.

Hadley MN, Shank CD, Rozzelle CJ, Walters BC (2017) Guidelines for the use of electrophysiological monitoring for surgery of the human spinal column and spinal cord. Clin Neurosurg 81(5):713–732CrossRef

35.

Schirmer CM, Shils JL, Arle JE et al (2011) Heuristic map of myotomal innervation in humans using direct intraoperative nerve root stimulation. J Neurosurg Spine 15:64–70. https://doi.org/10.3171/2011.2.SPINE1068CrossRefPubMed

36.

Lieberman JA, Lyon R, Feiner J et al (2008) The efficacy of motor evoked potentials in fixed sagittal imbalance deformity correction surgery. Spine (Phila Pa 1976). https://doi.org/10.1097/BRS.0B013E318175C292CrossRefPubMed

37.

Hilibrand AS, Schwartz DM, Sethuraman V et al (2004) Comparison of transcranial electric motor and somatosensory evoked potential monitoring during cervical spine surgery. J Bone Joint Surg Am 86:1248–1253. https://doi.org/10.2106/00004623-200406000-00018CrossRefPubMed

38.

Riley MR, Doan AT, Vogel RW et al (2018) Use of motor evoked potentials during lateral lumbar interbody fusion reduces postoperative deficits. Spine J 18:1763–1778. https://doi.org/10.1016/J.SPINEE.2018.02.024CrossRefPubMed

Title: Utility of transcranial motor-evoked potential changes in predicting postoperative deficit in lumbar decompression and fusion surgery: a systematic review and meta-analysis
Authors: Rajiv P. Reddy
Vamsi K. Gorijala
Varun R. Kaithi
Varun Shandal
Katherine M. Anetakis
Jeffrey R. Balzer
Donald J. Crammond
Jeremy D. Shaw
Joon Y. Lee
Parthasarathy D. Thirumala
Publication date: 26-08-2023
Publisher: Springer Berlin Heidelberg
Keywords: Motor Evoked Potential
Motor Evoked Potential
Published in: European Spine Journal / Issue 10/2023
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-023-07879-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Utility of transcranial motor-evoked potential changes in predicting postoperative deficit in lumbar decompression and fusion surgery: a systematic review and meta-analysis

Abstract

Purpose

Methods

Results

Conclusion

Level of Evidence II

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Level of Evidence II

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