1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and.
2Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
J Neurosurg Spine. 2019 Mar 29;31(1):76-86. doi: 10.3171/2019.1.SPINE181110. Print 2019 Jul 1.
Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF.
This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score-matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars).
A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score-matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges.
The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).
术中神经生理监测（IONM）是脊柱手术中的一种有用辅助手段，已被证明可改善脊柱侧凸矫正手术的效果。然而，其在颈椎前路椎间盘切除融合术（ACDF）中的应用效果尚不清楚，因为很少有研究比较使用和不使用 IONM 的 ACDF 结果。作者旨在评估 IONM 对 ACDF 安全性和成本的影响。
这是一项回顾性分析，数据来自 2009 年至 2013 年医疗保健成本和利用项目的国家（全国）住院患者样本。确定了主要手术编码为 ACDF 的患者，并搜索诊断编码以确定术后发生神经并发症的病例。作者使用 IONM 作为独立变量，对术后神经并发症进行单变量和多变量逻辑回归分析；其他协变量包括年龄、性别、手术指征、多节段融合、Charlson 合并症指数（CCI）评分和入院类型。他们还使用 IONM 作为治疗指标，并使用上述变量作为协变量，进行了 1:1 比例的倾向评分匹配（最近邻法）。在倾向评分匹配队列中，他们比较了神经并发症、住院时间（LOS）和医院费用（以美元计）。
共确定了 141007 例 ACDF 手术。IONM 用于 9540 例（6.8%）。单变量分析（OR 0.80，p = 0.39）或多变量回归（OR 0.82，p = 0.45）均未发现神经并发症与 IONM 使用之间存在显著关联。相比之下，年龄≥65 岁、多节段融合、CCI 评分>0 和非择期入院与神经并发症发生率增加相关。倾向评分匹配队列包括 18760 例接受 ACDF 手术的患者，其中 9380 例（IONM 组）和 9380 例（非 IONM 组）接受了 IONM 监测。IONM 组和非 IONM 组的神经并发症发生率相似（0.17%比 0.22%，p = 0.41）。IONM 组和非 IONM 组 LOS≥2 天的患者比例相似（19%比 18%，p = 0.15）。IONM 的使用与医院费用增加 6843 美元（p < 0.01）有关。
在 ACDF 后，IONM 的使用与神经并发症发生率的降低无关。数据来源的局限性使得无法对 IONM 在预防更复杂病理（即后纵韧带骨化或颈椎畸形）患者神经并发症方面的有效性进行具体评估。
