Intraoperative Neurophysiologic Monitoring: Reply to Ney and van der Goes
Marc RNuwer, 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
Intraoperative neurophysiologic monitoring (IOM) raises warnings early enough to allow for interventions during spinal cord surgery. We believe clinical experience and animal experiments establish unequivocally that IOM warns of spinal cord injury, and interventions reverse impairment and prevent paraplegia. Our assessment [1] discussed this rationale and cited literature.
The assessment process was constrained narrowly so that only the "prediction" question could be asked. That answer is clear and crucial: IOM accurately warns of neural insults intraoperatively. Spinal cord injury produces irreversible deficits within minutes. The absence of randomized human outcome studies is no accident; in light of overwhelming animal data, it is our opinion that human experiment would be unconscionable.
We emphatically reject Drs. Ney and van der Goes' suggestion [2] that post-operative assessment of paraplegia is an adequate alternative outcome measure because by that time the damage is irreversible.
Regarding cost effectiveness, assume that spinal cord IOM saves adverse outcome in 0.5% of surgeries.[3] For a young person who is devastated by preventable paraplegia, costs include diminished quality of life, lifelong medical care, lost opportunity, and social services. The expense of IOM to spare each incidence of paraplegia is not only cost effective but an overall cost savings.
The best way to treat paraplegia is to prevent it in the first place.
1. Nuwer MR, Emerson RG, Galloway G, et al. Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials. Neurology 2012;78:585-589.
2. Ney JP, van der Goes D. Updated Practice Guidelines for IOM Fall Short. Neurology http://www.neurology.org/content/78/8/585/reply#neurology_el_45846. Letter. Accessed March 3, 2011.
3. Nuwer MR, Dawson EG, Carlson LG, Kanim LEA, Sherman JE. Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 1995;96:6-11.
For disclosures, contact the editorial office at journal@neurology.org.
Intraoperative neurophysiologic monitoring (IOM) raises warnings early enough to allow for interventions during spinal cord surgery. We believe clinical experience and animal experiments establish unequivocally that IOM warns of spinal cord injury, and interventions reverse impairment and prevent paraplegia. Our assessment [1] discussed this rationale and cited literature.
The assessment process was constrained narrowly so that only the "prediction" question could be asked. That answer is clear and crucial: IOM accurately warns of neural insults intraoperatively. Spinal cord injury produces irreversible deficits within minutes. The absence of randomized human outcome studies is no accident; in light of overwhelming animal data, it is our opinion that human experiment would be unconscionable.
We emphatically reject Drs. Ney and van der Goes' suggestion [2] that post-operative assessment of paraplegia is an adequate alternative outcome measure because by that time the damage is irreversible.
Regarding cost effectiveness, assume that spinal cord IOM saves adverse outcome in 0.5% of surgeries.[3] For a young person who is devastated by preventable paraplegia, costs include diminished quality of life, lifelong medical care, lost opportunity, and social services. The expense of IOM to spare each incidence of paraplegia is not only cost effective but an overall cost savings.
The best way to treat paraplegia is to prevent it in the first place.
1. Nuwer MR, Emerson RG, Galloway G, et al. Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials. Neurology 2012;78:585-589.
2. Ney JP, van der Goes D. Updated Practice Guidelines for IOM Fall Short. Neurology http://www.neurology.org/content/78/8/585/reply#neurology_el_45846. Letter. Accessed March 3, 2011.
3. Nuwer MR, Dawson EG, Carlson LG, Kanim LEA, Sherman JE. Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 1995;96:6-11.
For disclosures, contact the editorial office at journal@neurology.org.