Cervical decompression and reconstruction without intraoperative neurophysiological monitoring.
ABSTRACT The primary goal of this study was to review the immediate postoperative neurological function in patients surgically treated for symptomatic cervical spine disease without intraoperative neurophysiological monitoring. The secondary goal was to assess the economic impact of intraoperative monitoring (IOM) in this patient population.
This study is a retrospective review of 720 consecutively treated patients who underwent cervical spine procedures. The patients were identified and the data were collected by individuals who were not involved in their care.
A total of 1534 cervical spine levels were treated in 720 patients using anterior, posterior, and combined (360°) approaches. Myelopathy was present preoperatively in 308 patients. There were 185 patients with increased signal intensity within the spinal cord on preoperative T2-weighted MR images, of whom 43 patients had no clinical evidence of myelopathy. Three patients (0.4%) exhibited a new neurological deficit postoperatively. Of these patients, 1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy. The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment. The Current Procedural Terminology (CPT) codes for IOM during cervical decompression include 95925 and 95926 for somatosensory evoked potential monitoring of the upper and lower extremities, respectively, as well as 95928 and 95929 for motor evoked potential monitoring of the upper and lower extremities. In addition to the charge for the baseline [monitoring] study, patients are charged hourly for ongoing electrophysiology testing and monitoring using the CPT code 95920. Based on these codes and assuming an average of 4 hours of monitoring time per surgical case, the savings realized in this group of patients was estimated to be $1,024,754.
With the continuing increase in health care costs, it is our responsibility as providers to minimize expenses when possible. This should be accomplished without compromising the quality of care to patients. This study demonstrates that decompression and reconstruction for symptomatic cervical spine disease without IOM may reduce the cost of treatment without adversely impacting patient safety.
- [show abstract] [hide abstract]
ABSTRACT: Despite the growing use of multimodal intraoperative monitoring (IOM) in cervical spinal surgery, limited data exist regarding the sensitivity, specificity, and predictive values of such a technique in detecting new neurological deficits in this setting. The authors sought to define the incidence of significant intraoperative electrophysiological changes and new postoperative neurological deficits in a cohort of patients undergoing cervical surgery. The authors conducted a prospective analysis of a consecutive series of patients who had undergone cervical surgery during a 5-year period at a university-based neurosurgical unit, in which multimodal IOM was recorded. Sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) were determined using standard Bayesian techniques. The study population included 1055 patients (614 male and 441 female) with a mean age of 55 years. The IOM modalities performed included somatosensory evoked potential (SSEP) recording in 1055 patients, motor evoked potential (MEP) recording in 26, and electromyography (EMG) in 427. Twenty-six patients (2.5%) had significant SSEP changes. Electromyographic activity was transient in 212 patients (49.6%), and 115 patients (26.9%) had sustained burst or train activity. New postoperative neurological deficits occurred in 34 patients (3.2%): 6 had combined sensory and motor deficits, 7 had new sensory deficits, 9 had increased motor weakness, and 12 had new root deficits. Of these 34 patients, 12 had spinal tumors, of which 7 were intramedullary. Overall, of the 34 new postoperative deficits, 21 completely resolved, 9 partially resolved, and 4 had no improvement. The deficits that completely resolved did so on average 3.3 months after surgery. Patients with deficits that did not fully resolve (partial or no improvement) were followed up for an average of 1.8 years after surgery. Somatosensory evoked potentials had a sensitivity of 52%, a specificity of 100%, a PPV of 100%, and an NPV of 97%. Motor evoked potential sensitivity was 100%, specificity 96%, PPV 96%, and NPV 100%. Electromyography had a sensitivity of 46%, specificity of 73%, PPV of 3%, and an NPV of 97%. Combined neurophysiological IOM with EMG and SSEP recording and the selective use of MEPs is helpful for predicting and possibly preventing neurological injury during cervical spine surgery.Journal of Neurosurgery Spine 04/2008; 8(3):215-21. · 1.98 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Somatosensory evoked potentials (SSEPs) monitor global spinal cord function, and the interpretation of motor loss is based on inferred rather than direct measurements. Therefore, SSEPs may not be useful for identifying motor function deficits caused by anterior spinal column injury or nerve root injury during decompression or placement of instrumentation. For these reasons, adjunctive methods for monitoring may be especially useful during cervical spine surgery. To evaluate the effectiveness of SSEP and transcranial electrical motor evoked potential (tceMEP) monitoring of spinal cord function during anterior fusion of the cervical spine. Retrospective review. Consecutive instrumented, anterior cervical spine surgeries performed by the same surgeon at a single institution for 119 patients. Record of neurophysiological alerts during surgery and record of postoperative neurological deficits not present before surgery. Spinal cord function was monitored intraoperatively with recordings of ulnar and posterior tibial nerve SSEPs and tceMEPs. Six neurophysiologic alerts occurred that prompted surgeon and/or anesthesiologist intervention. Three patients developed new motor weakness after surgery. One patient had temporary right-leg weakness that was predicted accurately by the disappearance of the right lower extremity tceMEPs. One patient had additional temporary postoperative compromise of the right C5-C6 spinal nerve roots that could not be detected intraoperatively because of absent baseline tceMEPs from the affected muscles. For one patient who developed quadriparesis postoperatively, tceMEP monitoring was precluded by the excessive use of neuromuscular blockade during the procedure. The results illustrate the potential utility of intraoperative SSEPs and the tceMEPs for detection of changes in spinal cord function related to patient positioning and hemodynamic effects during anterior cervical fusion.The Spine Journal 01/2004; 4(2):202-7. · 3.36 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: In scoliosis surgery, intraoperative somatosensory-evoked potentials (SEPs) are affected by physiological parameters, which also have a complicated interaction with each other. Previous studies have reported on how these parameters individually affect SEPs. However, there has been no systematic analysis of these effects. The purpose of this study was to investigate the relationships between variations in intraoperative SEPs and various physiological parameters. Seventy scoliosis patients who underwent intraoperative SEP monitoring were enrolled in this retrospective study. Variations in latency and amplitude were analyzed to evaluate their relationships to blood pressure, heart rate, temperature, and partial pressure of alveolar carbon dioxide (PaCO2) using gray correlation degree analysis. Variations in latency and amplitude correlated most closely with variations in temperature, PaCO2, and heart rate, followed by variations in diastolic and then systolic blood pressure. Variations in different physiological parameters are related to variations in intraoperative SEPs to different degrees. Monitoring specialists should take this into consideration when making decisions based on abnormal SEPs.Medical science monitor: international medical journal of experimental and clinical research 05/2009; 15(5):CR226-30. · 1.36 Impact Factor