title: Lateral mass screw stimulation thresholds in posterior cervical instrumentation surgery: a predictor of medial deviation.
abstract: OBJECTIVE Normative data exists for stimulus-evoked pedicle screw electromyography (EMG) current thresholds in the lumbar spine, and is routinely referenced during spine surgeries to detect a screw breach, prevent injury of neural elements, and ensure the most biomechanically sound instrumentation construct. To date, similar normative data for cervical lateral mass screws is limited, thus the utility of lateral mass screw testing remains unclear. To address this disparity, in this study the authors describe cumulative lateral mass screw stimulation threshold data in patients undergoing posterior cervical instrumentation with lateral mass screws. These data are correlated with screw placement on postoperative imaging, and a novel correlation is discovered with direct clinical implications. METHODS Using a ball-tip probe, 154 lateral mass screws in 21 patients were electrically tested intraoperatively. In each case, for each screw, the lowest (or threshold) current at which the first polyphasic stimulus-evoked EMG response was reproducibly observed by a neurophysiologist was recorded. All patients underwent postoperative CT. Screw position within the lateral mass was first measured in the axial and sagittal planes for each lateral mass screw using the CT images. Screw placement was also evaluated by 2 independent physicians, blinded to current threshold data, on a binary scale of acceptability. The predictive capacity of screw EMG threshold data was evaluated via multivariable regression analyses and receiver operating characteristic (ROC) analyses. Predictive capacity was examined with respect to screw position within the lateral mass, as well as screw acceptability. RESULTS Lateral mass screw EMG thresholds did not appear to differ significantly for screws considered "acceptable" versus "unacceptable" according to the radiographic criteria. Accordingly, ROC analysis confirmed that EMG current threshold data were of minimal utility in predicting screw radiographic acceptability. However, EMG threshold was significantly predictive of screw medial distance from the spinal canal. A screw stimulating below 7.5 mA correctly identified a screw as being within 2 mm of the spinal canal with 75% sensitivity and 92% specificity (positive predictive value 20%, negative predictive value 99.3%), independent of its distance relative to other lateral mass landmarks. EMG current threshold was not significantly predictive of screw deviation in the superior or inferior directions, and was inversely predictive of screw deviations in the lateral direction. CONCLUSIONS In the context of uncertainty regarding the utility of cervical lateral mass EMG current threshold data, this study found that EMG current thresholds correspond significantly, and exclusively, with screw distance from the spinal canal. This association appears independent of other criteria for screw misplacement. As such, the authors recommend that EMG current thresholds be referenced in the case of a suspected medial breach as an effective means to rule out screw placement too medial to the spinal canal.
authors.affiliation: School of Medicine.
authors.forename: Bayard
authors.initials: B
authors.lastname: Wilson
authors.affiliation: Department of Neurosurgery.
authors.forename: Erik
authors.initials: E
authors.lastname: Curtis
authors.affiliation: Department of Neurosurgery.
authors.forename: Brian
authors.initials: B
authors.lastname: Hirshman
authors.affiliation: Department of Neurosurgery.
authors.forename: Ahmet
authors.initials: A
authors.lastname: Oygar
authors.affiliation: Department of Radiology.
authors.forename: Karen
authors.initials: K
authors.lastname: Chen
authors.affiliation: Department of Neurosurgery.
authors.forename: Brandon C
authors.initials: BC
authors.lastname: Gabel
authors.affiliation: Department of Family Medicine and Public Health, Division of Biostatistics and Bio-informatics, and.
authors.forename: Florin
authors.initials: F
authors.lastname: Vaida
authors.affiliation: Department of Interventional Neurophysiology, University of California, San Diego, California.
authors.forename: David W
authors.initials: DW
authors.lastname: Allison
authors.affiliation: Department of Neurosurgery.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Ciacci
mesh_terms: D000328:Adult; D000368:Aged; D001863:Bone Screws; D004558:Electric Stimulation / Q000379:methods; D004576:Electromyography / Q000379:methods; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D011184:Postoperative Period; D013123:Spinal Fusion / Q000379:methods; D013904:Thoracic Vertebrae / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: AUC = area under the curve; CI = confidence interval; EEG = electroencephalography; EMG = electromyography; ROC = receiver operating characteristic; TIVA = total intravenous anesthesia; TcMEP = transcranial motor-evoked potential; cervical; electromyography; intraoperative; lateral mass; medial breach