title: Loss of spinal cord monitoring signals in children during thoracic kyphosis correction with spinal osteotomy: why does it occur and what should you do?
abstract: METHODS
  A retrospective review of pediatric kyphosis patients undergoing a spinal cord-level osteotomy for correction.
  
  
  OBJECTIVE
  To evaluate the prevalence, etiology, timing, and intervention related to loss of spinal cord monitoring data during surgical correction of pediatric kyphosis in the spinal cord region.
  
  
  BACKGROUND
  Although much has been written regarding the risks inherent to scoliosis surgery, there is less literature available regarding the neurologic outcomes of pediatric kyphosis surgery. As more surgeons contemplate posterior-only kyphosis correction with spinal cord-level osteotomies, the importance of maintaining spinal cord neurologic function is paramount.
  
  
  METHODS
  Forty-two patients with pediatric kyphosis undergoing a posterior-only spinal reconstruction with a spinal cord level osteotomy or posterior-based vertebral column resection performed were reviewed. Patients were categorized by diagnosis, type and incidence of osteotomies, and loss of neurogenic mixed-evoked potential (NMEP) data. Interventions required to regain data and postoperative neurologic outcomes were also reviewed.
  
  
  RESULTS
  Of the 42 patients, 9 (21.4%) demonstrated a complete loss of NMEP data sometime during surgery while concomitant somatosensory sensory-evoked potentials (SSEP) remained within acceptable limits of baseline values. All 9 patients had intraoperative intervention including: blood pressure elevation (n = 1), release of corrective forces (n = 2), blood pressure elevation and correction release (n = 3), malalignment/subluxation adjustment (n = 1), further bony decompression (n = 1), or restoration of anterior column height via a titanium cage along with further posterior decompression (n = 1). In all cases, SSEPs were unchanged and NMEPs returned varying from 8 to 20 minutes after loss, with all patients having a normal wake-up test intraoperatively and a normal neurologic examination after surgery.
  
  
  CONCLUSIONS
  Intraoperative multimodality monitoring with some form of motor tract assessment is a fundamental component of kyphosis correction surgery in the spinal cord region in order to create a safer, optimal environment and to minimize neurologic deficit. The surgeon must be able to trust the information monitoring provides and act on it accordingly.
authors.affiliation: Wooridul Spine Hospital, St. Louis, MO, USA.
authors.forename: Gene
authors.initials: G
authors.lastname: Cheh
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
authors.forename: Anne M
authors.initials: AM
authors.lastname: Padberg
authors.forename: Yongjung J
authors.initials: YJ
authors.lastname: Kim
authors.forename: Michael D
authors.initials: MD
authors.lastname: Daubs
authors.forename: Craig
authors.initials: C
authors.lastname: Kuhns
authors.forename: Georgia
authors.initials: G
authors.lastname: Stobbs
authors.forename: Marsha
authors.initials: M
authors.lastname: Hensley
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004558:Electric Stimulation; D019054:Evoked Potentials, Motor; D005073:Evoked Potentials, Somatosensory; D006801:Humans; D007738:Kyphosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016343:Monitoring, Intraoperative / Q000379:methods; D010027:Osteotomy / Q000009:adverse effects*; D011237:Predictive Value of Tests; D011859:Radiography; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013116:Spinal Cord / Q000503:physiopathology*; D013119:Spinal Cord Injuries / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome