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February 21, 2012; 78 (8) Special Article

Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials

Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Clinical Neurophysiology Society

M.R. Nuwer, R.G. Emerson, G. Galloway, A.D. Legatt, J. Lopez, R. Minahan, T. Yamada, D.S. Goodin, C. Armon, V. Chaudhry, G.S. Gronseth, C.L. Harden
First published February 20, 2012, DOI: https://doi.org/10.1212/WNL.0b013e318247fa0e
M.R. Nuwer
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R.G. Emerson
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G. Galloway
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A.D. Legatt
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J. Lopez
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R. Minahan
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T. Yamada
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D.S. Goodin
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C. Armon
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V. Chaudhry
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G.S. Gronseth
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C.L. Harden
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Citation
Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials
Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Clinical Neurophysiology Society
M.R. Nuwer, R.G. Emerson, G. Galloway, A.D. Legatt, J. Lopez, R. Minahan, T. Yamada, D.S. Goodin, C. Armon, V. Chaudhry, G.S. Gronseth, C.L. Harden
Neurology Feb 2012, 78 (8) 585-589; DOI: 10.1212/WNL.0b013e318247fa0e

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Abstract

Objective: To evaluate whether spinal cord intraoperative monitoring (IOM) with somatosensory and transcranial electrical motor evoked potentials (EPs) predicts adverse surgical outcomes.

Methods: A panel of experts reviewed the results of a comprehensive literature search and identified published studies relevant to the clinical question. These studies were classified according to the evidence-based methodology of the American Academy of Neurology. Objective outcomes of postoperative onset of paraparesis, paraplegia, and quadriplegia were used because no randomized or masked studies were available.

Results and Recommendations: Four Class I and 8 Class II studies met inclusion criteria for analysis. The 4 Class I studies and 7 of the 8 Class II studies reached significance in showing that paraparesis, paraplegia, and quadriplegia occurred in the IOM patients with EP changes compared with the IOM group without EP changes. All studies were consistent in showing all occurrences of paraparesis, paraplegia, and quadriplegia in the IOM patients with EP changes, with no occurrences of paraparesis, paraplegia, and quadriplegia in patients without EP changes. In the Class I studies, 16%–40% of the IOM patients with EP changes developed postoperative-onset paraparesis, paraplegia, or quadriplegia. IOM is established as effective to predict an increased risk of the adverse outcomes of paraparesis, paraplegia, and quadriplegia in spinal surgery (4 Class I and 7 Class II studies). Surgeons and other members of the operating team should be alerted to the increased risk of severe adverse neurologic outcomes in patients with important IOM changes (Level A).

GLOSSARY

AAN=
American Academy of Neurology;
ACNS=
American Clinical Neurophysiology Society;
EP=
evoked potential;
IOM=
intraoperative monitoring;
MEP=
motor evoked potential;
SEP=
somatosensory evoked potential;
tce=
transcranial electrical.

Footnotes

  • Study funding: This evidence-based guideline was funded by the American Academy of Neurology and the American Clinical Neurophysiology Society. No author received honoraria or financial support to develop this document.

  • Supplemental data at www.neurology.org

  • Approved by the AAN Therapeutics and Technology Assessment Subcommittee on February 19, 2011; by the AAN Practice Committee on May 19, 2011; by the AAN Board of Directors on October 14, 2011; and by the ACNS Council on June 11, 2011.

  • Endorsed by the American Association of Neuromuscular and Electrodiagnostic Medicine on January 3, 2012.

  • Received June 17, 2011.
  • Accepted October 7, 2011.
  • Copyright © 2012 by AAN Enterprises, Inc.
View Full Text

Disputes & Debates: Rapid online correspondence

  • IONM: The standard of evidence must be both credible and ethical.
    • Stanley A. Skinner, Neurologist/Neurophysiologist, Abbott Northwestern Hospitaldrskinnermd@yahoo.com
    • Stan Skinner, Minneapolis, MN; David Rippe, Minneapolis, MN
    Submitted April 10, 2012
  • Intraoperative neurophysiologic monitoring and parachutes
    • Gary S. Gronseth, Professor, University of Kansasggronseth@kumc.edu
    Submitted April 06, 2012
  • Re:Re:Intraoperative Neurophysiologic Monitoring: Reply to Ney and van der Goes
    • Ronald G. Emerson, Physician, Hospital for Special Surgeryemersonr@hss.edu
    • Ronald Emerson, New York, NY
    Submitted March 23, 2012
  • Intraoperative Spinal Cord Monitoring Does Improve Outcomes
    • Marc R Nuwer, professor, UCLA Dept Neurologymrn@ucla.edu
    • Marc R Nuwer, Los Angeles, CA
    Submitted March 23, 2012
  • Re:Intraoperative Neurophysiologic Monitoring: Reply to Ney and van der Goes
    • John P. Ney, Neurologist, University of Washingtonneyj@u.washington.edu
    • John Ney, Seattle, Washington; David van der Goes, Seattle, WA
    Submitted March 19, 2012
  • Updated Practice Guidelines for IOM - an important step in the right direction
    • Eva K. Ritzl, Director of IOM, Johns Hopkins Universityeritzl1@jhmi.edu
    • Eva K. Ritzl, Baltimore, MD
    Submitted March 19, 2012
  • Re:Updated Practice Guidelines for IOM Fall Short
    • Anup D. Patel, Assistant Professor, The Ohio State University College of Medicineanup.patel@nationwidechildrens.org
    Submitted March 15, 2012
  • Intraoperative Neurophysiologic Monitoring: Reply to Ney and van der Goes
    • Marc R Nuwer, Professor, UCLA Dept NeurologyMRN@UCLA.edu
    • Marc Nuwer, Los Angeles, CA; Ronald Emerson, New York, NY; Robert Minahan, Washington DC; Alan Legatt, New York, NY; Gloria Galloway, Columbus, OH, Jamie Lopez, Stanford, CA and Thoru Yamada, Iowa City, IA
    Submitted March 13, 2012
  • Updated Practice Guidelines for IOM Fall Short
    • John P. Ney, Instructor, Neurology, University of Washington, Comparative Effectiveness and Cost Outcomes Research Centerneyj@uw.edu
    • David N. van der Goes
    Submitted March 06, 2012
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