Intraoperative neurophysiological monitoring in surgery of lumbar spinal stenosis

Background. Lumbar spinal stenosis is a pathological constriction of the central spinal canal, lateral pocket or intervertebral foramen. The complication rate of lumbar spinal stenosis surgery ranges from 10 to 24 %. In order to reduce the number of intraoperative and early postoperative complications accompanied by the development of neurological deficit, various techniques of intraoperative neurophysiological monitoring are used.

Aim. Study of informativity of the use of intraoperative neurophysiological monitoring during surgical treatment of degenerative lumbar spinal stenosis based on the experience of the neurosurgical department of the Republican Clinical Hospital (Yoshkar‑Ola, Mari El Republic).

Materials and methods. Thus, 69 decompressive‑stabilizing surgical interventions for degenerative lumbar spinal stenosis at the L3–L5 level, performed with intraoperative neurophysiological monitoring (free‑run electromyography, transcranial motor evoked potentials, somatosensory evoked potentials, triggered electromyography were included in the retrospective study).

Results. During intraoperative neurophysiological monitoring transcranial motor evoked potentials from the legs was registered in all cases. Normal somatosensory evoked potentials were recorded in most cases, in 12 cases (17.4 %) baseline somatosensory evoked potentials were not registered due to preoperative neurological deficits and the presence of concomitant somatic pathology. 308 inserted pedicular screws were examined using the triggered electromyography. Muscle responses were registered in 31 (45 %) operations, 45 (14 %) screws. True negatives were registered with 29 (64.4 %), true positives were registered with 12 (26.7 %), and false positives were registered with 4 (8.9 %) screws. In the postoperative period no increase in motor and sensory neurological deficits was observed in all patients; no neurological signs of screw malpositioning were revealed.

Conclusion. The use of multimodal intraoperative neurophysiological monitoring during surgical treatment of lumbar spinal stenosis reduces the risk of postoperative neurological complications.

1. Issack P.S., Cunningham M.E., Pumberger M. et al. Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad Orthop Surg 2012;20(8):527–35. DOI: 10.5435/JAAOS-20-08-527

2. Steurer J., Roner S., Gnannt R., Hodler J; LumbSten Research Collaboration. Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review. BMC Musculoskelet Disord 2011;12:175. DOI: 10.1186/1471-2474-12-175

3. Otani K., Kikuchi S., Yabuki S. et al. Lumbar spinal stenosis has a negative impact on quality of life compared with other comorbidities: an epidemiological cross-sectional study of 1862 community-dwelling individuals. Scientific World Journal 2013;2013:590652. DOI: 10.1155/2013/590652

4. Verbiest H. Stenosis of the lumbar vertebral canal and sciatica. Neurosurg Rev 1980;3(1):75–89. DOI: 10.1007/BF01644422

5. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br 1954; 36-B(2):230–7. DOI: 10.1302/0301-620X.36B2.230

6. Arnoldi C.C., Brodsky A.E., Cauchoix J. et al. Lumbar spinal stenosis and nerve root entrapment syndromes. Definition and classification. Clin Orthop Relat Res 1976;(115):4–5.

7. Zaina F., Tomkins-Lane C., Carragee E., Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev 2016;2016(1):CD010264. DOI: 10.1002/14651858.CD010264.pub2

8. Knop C., Bastian L., Lange U. et al. Complications in surgical treatment of thoracolumbar injuries. Eur Spine J 2002 Jun; 11(3):214–26. DOI: 10.1007/s00586-001-0382-6

9. Voulgaris S., Karagiorgiadis D., Alexiou G.A. et al. Continuous intraoperative electromyographic and transcranial motor evoked potential recordings in spinal stenosis surgery. J Clin Neurosci 2010;17(2):274–6. DOI: 10.1016/j.jocn.2009.04.013

10. Deletis V., Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol 2008;119(2):248–64. DOI: 10.1016/j.clinph.2007.09.135

11. Kaliya-Perumal A.K., Charng J.R., Niu C.C. et al. Intraoperative electromyographic monitoring to optimize safe lumbar pedicle screw placement – a retrospective analysis. BMC Musculoskelet Disord 2017;18(1):229. DOI: 10.1186/s12891-017-1594-1

12. Mikula A.L., Williams S.K., Anderson P.A. The use of intraoperative triggered electromyography to detect misplaced pedicle screws: a systematic review and meta-analysis. J Neurosurg Spine 2016;24(4):624–38. DOI: 10.3171/2015.6.SPINE141323

13. Sutter M., Eggspuehler A., Jeszenszky D. et al. The impact and value of uni- and multimodal intraoperative neurophysiological monitoring (IONM) on neurological complications during spine surgery: a prospective study of 2728 patients. Eur Spine J 2019; 28(3):599–610. DOI: 10.1007/s00586-018-5861-0

14. Isley M.R., Zhang X.F., Balzer J.R., Leppanen R.E. Current trends in pedicle screw stimulation techniques: lumbosacral, thoracic, and cervical levels. Neurodiagn J 2012;52(2):100–75.

15. Guzey F.K., Emel E., Hakan Seyithanoglu M. et al. Accuracy of pedicle screw placement for upper and middle thoracic pathologies without coronal plane spinal deformity using conventional methods. J Spinal Disord Tech 2006;19(6):436–41. DOI: 10.1097/00024720-200608000-00011