Patients without intraoperative neuromonitoring IONM alerts during implantation

Introduction • Skaggs JBJS 2009 • 1736 rib based growing surgery procedures – 0.

Study Questions • If a patient has no neuromonitoring (IONM) alerts during implant of

Hypothesis • Monitoring does not identify new neurologic injury during expansion of rib based

Methods • Multicenter Retrospective Review rib based growing surgery treatment from 20052011 • All

Total Procedures 2, 355 Confirmed IONM 539 Cases of IONM Alert 9 • Rate

IONM Expansion Alerts • 1/3 was in a child without prior neurologic injury or

• Rate of Neurologic Injury 0. 1% for All Procedures (3/2, 355) Implant

Conclusions • IONM did not identify new neurologic injuries during rib based growing surgery

Significance • IONM may not be necessary in patients undergoing rib based growing surgery

References • • • 1. Campbell RM, Smith MD, Mayes TC, et al. The

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Patients without intraoperative neuromonitoring (IONM) alerts during implantation of rib based growing constructs did not sustain neurologic injury during subsequent routine expansions • • • Jaren La. Greca, BA Tara Flynn, BA Patrick J. Cahill, MD Amer Samdani, MD Michael G. Vitale, MD, MPH Ron El-Hawary, MD, MSc, FRCS(C) John T. Smith, MD Jonathan H. Phillips, MD John M. Flynn, MD Michael Glotzbecker, MD Sumeet Garg, MD Sumeet. garg@childrenscolorado. org

Introduction • Skaggs JBJS 2009 • 1736 rib based growing surgery procedures – 0. 5% overall neurologic injury rate – 0% (1185 procedures) – expansions • Neuromonitoring – 1 alert during expansion • Child with history of alert at implant

Study Questions • If a patient has no neuromonitoring (IONM) alerts during implant of rib based growing construct, is monitoring necessary during expansion procedures? • Describe the rate of IONM alerts and neurologic injury

Hypothesis • Monitoring does not identify new neurologic injury during expansion of rib based growing constructs in children without monitoring alerts during initial implantation

Methods • Multicenter Retrospective Review rib based growing surgery treatment from 20052011 • All available IONM reports were reviewed • Cases with IONM alerts or neurologic injury had additional chart review

Participating Sites

Total Procedures 2, 355 Confirmed IONM 539 Cases of IONM Alert 9 • Rate of IONM alert 1. 7% (9/539) No / Unconfirmed IONM 1, 816

IONM Expansion Alerts • 1/3 was in a child without prior neurologic injury or IONM alert • 2/3 alerts were in a child with prior history of IONM alert

• Rate of Neurologic Injury 0. 1% for All Procedures (3/2, 355) Implant Neurologic Injury 3 Expansion Revision Removal

Conclusions • IONM did not identify new neurologic injuries during rib based growing surgery expansion procedures in patients without a history of IONM alert or neurologic injury • The highest rate of neurologic injury was during implant procedures • There were no instances of neurologic injury during expansion, revision, or removal procedures

Significance • IONM may not be necessary in patients undergoing rib based growing surgery expansion procedures who have not previously had IONM alerts or neurologic injury

References • • • 1. Campbell RM, Smith MD, Mayes TC, et al. The effect of opening wedge thoracostomy on thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am. Aug 2004; 86 -A(8): 1659 -1674. 2. Hell AK, Campbell RM, Hefti F. The vertical expandable prosthetic titanium rib implant for the treatment of thoracic insufficiency syndrome associated with congenital and neuromuscular scoliosis in young children. J Pediatr Orthop B. Jul 2005; 14(4): 287 -293. 3. Joiner ER, Andras LM, Skaggs DL. Mechanisms and risk factors of brachial plexus injury in the treatment of early-onset scoliosis with distraction-based growing implants. J Bone Joint Surg Am. Nov 2013; 95(21): e 161. 4. Devlin VJ, Schwartz DM. Intraoperative neurophysiologic monitoring during spinal surgery. J Am Acad Orthop Surg. Sep 2007; 15(9): 549 -560. 5. Schwartz DM, Auerbach JD, Dormans JP, et al. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am. Nov 2007; 89(11): 2440 -2449. 6. Skaggs DL, Choi PD, Rice C, et al. Efficacy of intraoperative neurologic monitoring in surgery involving a vertical expandable prosthetic titanium rib for early-onset spinal deformity. J Bone Joint Surg Am. Jul 2009; 91(7): 1657 -1663. 7. Sankar WN, Skaggs DL, Emans JB, et al. Neurologic risk in growing rod spine surgery in early onset scoliosis: is neuromonitoring necessary for all cases? Spine (Phila Pa 1976). Aug 2009; 34(18): 1952 -1955. 8. Seyal M, Mull B. Mechanisms of signal change during intraoperative somatosensory evoked potential monitoring of the spinal cord. J Clin Neurophysiol. Oct 2002; 19(5): 409 -415. 9. Smith JT, Hung M. Is Neuromonitoring necessary for VEPTR expansion and implant exchanges in Early Onset Scoliosis? . ICEOS 2013. Proceedings of the 7 th International Congress on Early Onset Scoliosis and Growing Spine. San Diego, CA 2013. 10. Cole T, Veeravagu A, Zhang M, Li A, Ratliff JK. Intraoperative neuromonitoring in single-level spinal procedures: a retrospective propensity score-matched analysis in a national longitudinal database. Spine (Phila Pa 1976). Nov 2014; 39(23): 1950 -1959. 11. Ayoub C, Zreik T, Sawaya R, Domloj N, Sabbagh A, Skaf G. Significance and cost-effectiveness of somatosensory evoked potential monitoring in cervical spine surgery. Neurol India. 2010 May-Jun 2010; 58(3): 424 -428.