Research background: The importance of neuromonitoring during spine surgery
Though patients rarely experience neurologic complications during spine deformity surgery, when they occur they can be catastrophic. Providers can use neuromonitoring during surgery to better detect changes in a patient's spinal cord to intervene and reverse neurological deficits if they arise.
Risk factors for changes in intraoperative neuromonitoring include:
- The presence of a large degree or sharp angular spinal deformity
- Cardiopulmonary comorbidities
- Labile intraoperative mean arterial pressures
Twenty-one spine surgeons created a consensus-based checklist and best practice guide for neuromonitoring during spine deformity surgery. The team, which included Mark Erickson, MD, Medical Director of the Spine Program at Children's Hospital Colorado, aims to improve outcomes for patients who undergo spine deformity surgery.
The providers created a consensus-based surgical checklist to guide surgeon responses to intraoperative neuromonitoring changes in spinal deformity surgery patients with a stable spine. The group also developed a consensus-based guide for intraoperative neuromonitoring best practice in the U.S.
The group chose to pursue the creation of the surgical checklist and best practice guide for several reasons:
- Studies show that surgical checklists enhance surgical team response to crisis situations and improve patient outcomes.
- Surgeon performance suffers under stress and time pressure, and checklists can be valuable aids.
- Checklist use resulted in a six-fold reduction in failure of adherence to critical steps in management, according to a recent study.
- There were no widely accepted guidelines for the response to intraoperative neuromonitoring changes in spine deformity surgery.
- Evidence has shown that skilled orthopedic spine surgical teams perform significantly better than teams with less monitoring experience.
- A survey found that the least experienced neuromonitoring team had a neurologic deficit rate that is twice as high as the rate of the most experienced team.
Research methods: Creating consensus for the stable spine surgical checklist
After an extensive literature review of risk factors and recommendations for responding to intraoperative neuromonitoring changes, the research authors administered four surveys to 21 orthopedic spine surgeons and one neurologist experienced in intraoperative neuromonitoring.
The team used the Delphi method to develop and modify the final surgical checklist, which was completed in 12 months. After the group established a balance of opinion, they used a nominal group process to determine which items should be included in the surgical checklist.
Then, the authors reevaluated and modified the checklist during three in-person meetings. Consensus was defined as 80% agreement. After the third meeting and a formal vote on adoption of the checklist by all consensus group participants, the group unanimously agreed to surgeon adoption of the stable spine surgical checklist.
The stable spine surgical checklist and best practice guide
Surgical checklist for the response to intraoperative neuromonitoring changes in patients with a stable spine
Consensus-based guide for intraoperative neuromonitoring best practices in the U.S.
- Intraoperative neuromonitoring is best performed with a team approach: surgeon, anesthesiologist and qualified neuromonitoring personnel should all be involved in the identification and communication of neuromonitoring changes.
- Somatosensory evoked potentials (SSEPs) should be used in all spine deformity cases.
- Transcranial motor evoked potentials (TcMEPs) and/or descending neurogenic evoked potentials (DNEPs) should be used in all spine deformity cases.
- A 50% degradation in SSEP signal amplitude from baseline, and/or a sustained decrease in TcMEP signal amplitude, and/or a decrease in DNEP signal of >60% constitute "significant warning criteria" in spine deformity surgery.
Research discussion: Improving quality and safety in spine surgery
With the increased focus on quality and patient safety in healthcare, providers need to implement highly reliable systems and processes to manage the irregularity of human behavior and decision making.
Spine deformity surgery continues to increase in complexity and sophistication. Just as techniques have evolved to better address greater degrees of deformity, so have the methods for detecting imminent neurologic change through intraoperative neuromonitoring.
Limitations of research:
- The surgical checklist and guide are primarily consensus-based, since the lack of literature in this area limited the authors' ability to make evidence-based recommendations.
- The surgical checklist focuses on patients with a stable spine intraoperatively, since patients with a destabilized spine require a modified checklist designed for the specific needs of that population.
- The checklist is not meant to replace clinical judgment or experience, and responses should be considered on a case-by-case basis.
Research conclusions: Implementing the spine surgery checklist and guide
The final checklist and best practice guide represent the consensus of a group of expert spine surgeons. The checklist includes the most important items to consider when responding to intraoperative neuromonitoring changes in patients with a stable spine.
The intraoperative neuromonitoring guide represents the group consensus on items that should be considered best practices among intraoperative neuromonitoring teams with the appropriate resources. Widespread and successful implementation of the products could improve surgical outcomes and patient safety.