Responding to Intraoperative Neuromonitoring Changes During Pediatric Coronal Spinal Deformity Surgery

Stephen J. Lewis, Ian H.Y. Wong, Samuel Strantzas, Laura M. Holmes, Ian Vreugdenhil, Hailey Bensky, Christopher J. Nielsen, Reinhard Zeller, David E. Lebel, Marinus de Kleuver, Niccole Germscheid, Ahmet Alanay, Sigurd Berven, Kenneth M.C. Cheung, Manabu Ito, David W. Polly, Christopher I. Shaffrey, Yong Qiu, Lawrence G. Lenke

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Study Design: Retrospective case study on prospectively collected data. Objectives: The purpose of this explorative study was: 1) to determine if patterns of spinal cord injury could be detected through intra-operative neuromonitoring (IONM) changes in pediatric patients undergoing spinal deformity corrections, 2) to identify if perfusion based or direct trauma causes of IONM changes could be distinguished, 3) to observe the effects of the interventions performed in response to these events, and 4) to attempt to identify different treatment algorithms for the different causes of IONM alerts. Methods: Prospectively collected neuromonitoring data in pre-established forms on consecutive pediatric patients undergoing coronal spinal deformity surgery at a single center was reviewed. Real-time data was collected on IONM alerts with >50% loss in signal. Patients with alerts were divided into 2 groups: unilateral changes (direct cord trauma), and bilateral MEP changes (cord perfusion deficits). Results: A total of 97 pediatric patients involving 71 females and 26 males with a mean age of 14.9 (11-18) years were included in this study. There were 39 alerts in 27 patients (27.8% overall incidence). All bilateral changes responded to a combination of transfusion, increasing blood pressure, and rod removal. Unilateral changes as a result of direct trauma, mainly during laminotomies for osteotomies, improved with removal of the causative agent. Following corrective actions in response to the alerts, all cases were completed as planned. Signal returned to near baseline in 20/27 patients at closure, with no new neurological deficits in this series. Conclusion: A high incidence of alerts occurred in this series of cases. Dividing IONM changes into perfusion-based vs direct trauma directed treatment to the offending cause, allowing for safe corrections of the deformities. Patients did not need to recover IONM signal to baseline to have a normal neurological examination.

Original languageEnglish (US)
Pages (from-to)15S-21S
JournalGlobal Spine Journal
Issue number1_suppl
StatePublished - May 1 2019

Bibliographical note

Funding Information:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was organized and funded by AOSpine International through the AOSpine Knowledge Forum Deformity, a focused group of international spine deformity experts acting on behalf of AOSpine. Study support was provided directly through the AOSpine Research Department.

Publisher Copyright:
© The Author(s) 2019.


  • Brown-Sequard syndrome
  • anemia
  • anterior cord syndrome
  • incomplete spinal cord injuries
  • motor evoked potentials
  • neuromonitoring
  • pediatric
  • perfusion
  • scoliosis
  • transfusion


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