1Scripps Health, San Diego, California.
2San Diego Spine Foundation, San Diego, California.
J Neurosurg Spine. 2023 Nov 17;40(2):162-168. doi: 10.3171/2023.9.SPINE23263. Print 2024 Feb 1.
Intraoperative neuromonitoring (IONM) has become commonplace in assessing neurological integrity during lateral approaches to lumbar interbody fusion surgeries. Neuromonitoring is designed to aid surgeons in identifying the potential for intraoperative nerve injury and reducing associated postoperative complications. However, standardized protocols for neuromonitoring have not been provided, and outcomes are not well described. The purpose of this study was to provide a standardized protocol for IONM, and to describe clinical outcomes in a cohort of individuals who underwent lateral lumbar interbody fusion (LLIF) surgery.
A retrospective review of 169 consecutive patients who underwent LLIF surgery at a single institution from October 2014 to October 2016 was performed. Patient characteristics, intraoperative details, clinical outcomes, and postoperative deficits (PODs) were compared between patients who did and did not trigger IONM alerts, and between patients who did and did not demonstrate a POD. A protocol for IONM decision-making was generated based on these observations.
Most patients (91.7%) underwent surgery for a degenerative spine condition. Twenty-three patients (13.6%) triggered neuromonitoring alerts, and 16 patients (9.5%) demonstrated a POD. Leg pain, back pain, and disability improved significantly (p < 0.045), and 2 patients had both motor and sensory deficits at the 12-week postoperative time point. Patients with a POD demonstrated greater operating room time (p = 0.034) and a greater number of interbody fusion levels (p = 0.015) but were less likely to have triggered a neuromonitoring alert (p = 0.04). There was no association between retractor time and POD (p = 0.98). When an IONM protocol was followed, individuals who experienced a POD were less likely to trigger an alert than those who did not experience a POD (p = 0.04).
This study provides a protocol algorithm for IONM alert responses in patients undergoing LLIF surgery. PODs are most associated with multilevel fusion, and patients with alerts had a low rate of persistent deficit. Future research is needed to validate these findings using a more rigorous comparative study design.
术中神经监测（IONM）已成为评估侧方入路腰椎椎间融合术期间神经完整性的常用方法。神经监测旨在帮助外科医生识别术中神经损伤的可能性，并降低相关的术后并发症。然而，尚未提供标准化的神经监测协议，并且结果描述也不充分。本研究的目的是提供 IONM 的标准化协议，并描述在接受侧方腰椎椎间融合（LLIF）手术的患者队列中的临床结果。
对 2014 年 10 月至 2016 年 10 月在一家机构接受 LLIF 手术的 169 例连续患者进行了回顾性分析。比较了触发 IONM 警报的患者和未触发 IONM 警报的患者、以及出现术后缺陷（POD）的患者和未出现 POD 的患者之间的患者特征、术中细节、临床结果和术后缺陷。根据这些观察结果生成了 IONM 决策的协议。
大多数患者（91.7%）因退行性脊柱疾病接受手术。23 例（13.6%）患者触发了神经监测警报，16 例（9.5%）患者出现 POD。腿部疼痛、背部疼痛和残疾显著改善（p < 0.045），2 例患者在术后 12 周时同时出现运动和感觉缺陷。出现 POD 的患者手术时间更长（p = 0.034），融合节段更多（p = 0.015），但触发神经监测警报的可能性较小（p = 0.04）。牵开器时间与 POD 之间无相关性（p = 0.98）。当遵循 IONM 协议时，出现 POD 的患者比未出现 POD 的患者更不可能触发警报（p = 0.04）。
本研究提供了用于接受 LLIF 手术患者的 IONM 警报反应的协议算法。POD 与多节段融合最相关，而有警报的患者持续缺陷的发生率较低。需要进一步的研究来使用更严格的对照研究设计验证这些发现。
