title: Intraoperative neurophysiologic monitoring in spine surgery. Developments and state of the art in France in 2011.
abstract: Intraoperative spinal cord monitoring consists in a subcontinuous evaluation of spinal cord sensory-motor functions and allows the reduction the incidence of neurological complications resulting from spinal surgery. A combination of techniques is used: somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), neurogenic motor evoked potentials (NMEP), D waves, and pedicular screw testing. In absence of intraoperative neurophysiological testing, the intraoperative wake-up test is a true form of monitoring even if its latency long and its precision variable. A 2011 survey of 117 French spinal surgeons showed that only 36% had neurophysiological monitoring available (public healthcare facilities, 42%; private facilities, 27%). Monitoring can be performed by a neurophysiologist in the operating room, remotely using a network, or directly by the surgeon. Intraoperative alerts allow real-time diagnosis of impending neurological injury. Use of spinal electrodes, moved along the medullary canal, can determine the lesion level (NMEP, D waves). The response to a monitoring alert should take into account the phase of the surgical intervention and does not systematically lead to interruption of the intervention. Multimodal intraoperative monitoring, in presence of a neurophysiologist, in collaboration with the anesthesiologist, is the most reliable technique available. However, no monitoring technique can predict a delayed-onset paraplegia that appears after the end of surgery. In cases of preexisting neurological deficit, monitoring contributes little. Monitoring of the L1-L4 spinal roots also shows low reliability. Therefore, monitoring has no indication in discal and degenerative surgery of the spinal surgery. However, testing pedicular screws can be useful. All in all, thoracic and thoracolumbar vertebral deviations, with normal preoperative neurological examination are currently the essential indication for spinal cord monitoring. Its absence in this indication is a lost opportunity for the patient. If neurophysiological means are not available, intraoperative wake-up test is a minimal obligation.
authors: Service de neurophysiologie clinique, hôpital de la Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
authors: M
authors: M
authors: Gavaret
authors: J L
authors: JL
authors: Jouve
authors: Y
authors: Y
authors: Péréon
authors: F
authors: F
authors: Accadbled
authors: N
authors: N
authors: André-Obadia
authors: E
authors: E
authors: Azabou
authors: B
authors: B
authors: Blondel
authors: G
authors: G
authors: Bollini
authors: J
authors: J
authors: Delécrin
authors: J-P
authors: JP
authors: Farcy
authors: J
authors: J
authors: Fournet-Fayard
authors: C
authors: C
authors: Garin
authors: P
authors: P
authors: Henry
authors: V
authors: V
authors: Manel
authors: V
authors: V
authors: Mutschler
authors: G
authors: G
authors: Perrin
authors: J
authors: J
authors: Sales de Gauzy
mesh_terms: D005602:France; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D015203:Reproducibility of Results; D013116:Spinal Cord / Q000503:physiopathology* / Q000601:surgery; D013118:Spinal Cord Diseases / Q000503:physiopathology / Q000601:surgery*
keywords: Kyphosis; Motor evoked potentials; Multimodal spinal cord monitoring; Neurogenic motor evoked potentials; Scoliosis; Somatosensory evoked potentials