title: Intraoperative neurophysiological monitoring during complex spinal deformity cases in pediatric patients: methodology, utility, prognostication, and outcome.
abstract: BACKGROUND
  Complex spinal deformity (CSD) problems in pediatric patients result from a wide variety of congenital, acquired, neoplastic, or traumatic abnormalities that result in a combination of spinal deformity and spinal cord impingement. While these problems are rare, decompression, correction, instrumentation, and fusion are quite hazardous. Intraoperative neurophysiological monitoring (IONM) seems particularly beneficial in these patients.
  
  
  METHODS
  Somatosensory evoked potentials, transcranial electrical motor evoked potentials (MEPs), direct waves, and electromyography were used in a variety of CSD cases over a period when IONM was routine for most spinal cases. Examples of cases in which IONM provided important intraoperative information and significantly affected the course of the operation are illustrated.
  
  
  RESULTS
  IONM is a useful tool particularly in CSD cases in pediatric patients but requires special expertise and anesthetic considerations. Loss of MEP appears to have particularly important adverse prognostic information. Conversely, maintenance of IONM provides significant reassurance that the spinal cord function is being maintained. Preserved but persistently diminished MEPs usually predict a neurological injury that will significantly improve and possibly completely recover. Issues concerning training, certification, oversight, standardization of equipment, and technique are partially but incompletely resolved.
  
  
  CONCLUSIONS
  IONM is an extremely valuable tool for management of CSD pediatric patients. The utility of IONM is such and the detection of unexpected or unanticipated neurological injury frequent enough that a strong argument that it be used in every spinal surgery case can be made.
authors.affiliation: Division of Neurosurgery, Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON, Canada. james.drake@sickkids.ca
authors.forename: James
authors.initials: J
authors.lastname: Drake
authors.forename: Reinhard
authors.initials: R
authors.lastname: Zeller
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
authors.forename: Samuel
authors.initials: S
authors.lastname: Strantzas
authors.forename: Laura
authors.initials: L
authors.lastname: Holmes
mesh_terms: D000293:Adolescent; D005071:Evoked Potentials; D005260:Female; D050815:Fractures, Compression / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D005729:Ganglioneuroma / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D006053:Goldenhar Syndrome / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods*; D009085:Mucopolysaccharidosis IV / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D018482:Muscle, Skeletal / Q000503:physiopathology; D009482:Neurophysiology / Q000379:methods*; D011379:Prognosis; D012680:Sensitivity and Specificity; D013122:Spinal Diseases / Q000175:diagnosis / Q000503:physiopathology* / Q000601:surgery*; D013125:Spinal Neoplasms / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D013131:Spine / Q000002:abnormalities / Q000503:physiopathology / Q000601:surgery; D016896:Treatment Outcome