Patients Without Intraoperative Neuromonitoring (IONM) Alerts During VEPTR Implantation Did Not Sustain Neurological Injury During Subsequent Routine Expansions: A Retrospective Multicenter Cohort Study.
BACKGROUND
The purpose of this study was to determine the rate of intraoperative neurological monitoring (IONM) alerts and neurological injury during vertical expandable prosthetic titanium rib (VEPTR) treatment and evaluate the utility of IONM during VEPTR expansion procedures in patients who have not previously had neurological injury or IONM alerts.


METHODS
After institutional review board approval, VEPTR procedures and IONM records were reviewed at 17 institutions for patients treated with VEPTR from 2005 to 2011. All consecutive cases in patients with minimum 2-year follow-up were included. Patients with prior history of growing rods or other invasive spine-based surgical treatment were excluded. Surgeries were categorized into implant, revision, expansion, and removal procedures. Cases with IONM alerts or neurological injury had additional detailed review. Descriptive statistics were used for data analysis.


RESULTS
In total, 2355 consecutive VEPTR procedures (352 patients) consisting of 299 implant, 377 revision, 1587 expansion, and 92 removal procedures were included. In total, 620 VEPTR procedures had IONM, and 539 of those had IONM records available for review. IONM alerts occurred in 9/539 procedures (1.7%): 3/192 implants (1.6%), 3/58 revisions (5.2%), and 3/258 expansions (1.2%). New neurological injury occurred in 3/2355 procedures (0.1%), 3/352 patients (0.9%). All 3 injuries were in implant procedures, only 1 had an IONM alert. All 3 had upper extremity motor deficits (1 had sensory deficit also). All had full recovery at 17, 30, and 124 days postinjury. One patient without prior neurological injury or IONM alert had an IONM alert during expansion that resolved after an increase in blood pressure. The remaining IONM alerts during expansions were all in children with prior IONM alerts during implant, revision, or exchange procedures.


CONCLUSIONS
The highest rate of neurological injury in VEPTR surgery was found for implant procedures. There were no instances of neurological injury during VEPTR expansion, revision, or removal procedures. IONM did not identify new neurological injuries in patients undergoing VEPTR expansion who did not previously have a history of IONM signal change or neurologic injury.


METHODS
Level IV-diagnostic study.
*University of Colorado School of Medicine, Aurora, CO †Children's Spine Foundation, Valley Forge ‡The Children's Hospital of Philadelphia §Shriners Hospital for Children in Philadelphia, Philadelphia, PA ∥Morgan Stanley Children's Hospital New York-Presbyterian, New York, NY ¶IWK Health Centre, Halifax, Nova Scotia, Canada #Primary Children's Medical Center, Salt Lake City, UT **Orlando Health, Orlando, FL ††Children's Hospital Boston, Boston, MA ‡‡Children's Hospital Colorado, Orthopedics Institute, University of Colorado, Aurora, CO.
Jaren
J
LaGreca
Tara
T
Flynn
Patrick J
PJ
Cahill
Amer
A
Samdani
Michael G
MG
Vitale
Ron
R
El-Hawary
John T
JT
Smith
Jonathan H
JH
Phillips
John M
JM
Flynn
Michael
M
Glotzbecker
Sumeet
S
Garg
D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring; D008297:Male; D009989:Orthotic Devices; D019736:Prostheses and Implants; D012189:Retrospective Studies; D012272:Ribs / Q000601:surgery*; D012600:Scoliosis / Q000601:surgery*; D013119:Spinal Cord Injuries / Q000175:diagnosis* / Q000517:prevention & control; D013131:Spine / Q000601:surgery*; D014025:Titanium
D014025:Titanium