Corey T Walker1, Han Jo Kim2, Paul Park3, Lawrence G Lenke4, Mark A Weller5, Justin S Smith6, Edward C Nemergut7, Daniel M Sciubba8, Michael Y Wang9, Christopher Shaffrey10, Vedat Deviren11, Praveen V Mummaneni12, Joyce M Chang13, Valli P Mummaneni13, Khoi D Than14, Pedro Berjano15, Robert K Eastlack16, Gregory M Mundis16, Adam S Kanter17, David O Okonkwo17, John H Shin18, Jason M Lewis19, Tyler Koski20, Daniel J Hoh21, Steven D Glassman22, Susan B Vinci23, Alan H Daniels24, Claudia F Clavijo25, Jay D Turner1, Marc McLawhorn26, Juan S Uribe1. 1. Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ. 2. Department of Orthopedics, Hospital for Special Surgery, New York, NY. 3. Department of Neurosurgery, University of Michigan, Ann Arbor, MI. 4. Department of Orthopedics, Columbia University, New York, NY. 5. Department of Anesthesiology, Columbia University, New York, NY. 6. Department of Neurosurgery, University of Virginia, Charlottesville, VA. 7. Department of Anesthesiology, University of Virginia, Charlottesville, VA. 8. Department of Neurosurgery, Johns Hopkins University, Baltimore, MD. 9. Department of Neurosurgery, University of Miami, Miami, FL. 10. Department of Neurosurgery, Duke University, Durham, NC. 11. Department of Orthopedics, University of California-San Francisco, San Francisco, CA. 12. Department of Neurosurgery, University of California-San Francisco, San Francisco, CA. 13. Department of Anesthesiology, University of California-San Francisco, San Francisco, CA. 14. Department of Neurosurgery, Oregon Health and Sciences University, Portland, Oregon. 15. Department of Orthopedics, Istituto Ortopedico Galeazzi, Milan, Italy. 16. Department of Orthopedics, Scripps Clinic, San Diego, CA. 17. Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA. 18. Department of Neurosurgery, Massachusetts General Hospital, Boston, MA. 19. Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts. 20. Department of Neurosurgery, Northwestern University, Chicago, IL. 21. Department of Neurosurgery, University of Florida, Gainesville, FL. 22. Department of Orthopedics, University of Louisville, Louisville, KY. 23. Northstar Anesthesia, Louisville, KY. 24. Department of Orthopedics, Brown University, Providence, Rhode Island. 25. Department of Anesthesiology, University of Colorado-Denver, Denver, CO. 26. Valley Anesthesiology Consultants, Phoenix, AZ.
Abstract
STUDY DESIGN: Expert opinion-modified Delphi study. OBJECTIVE: We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals. SUMMARY OF BACKGROUND DATA: Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice. METHODS: We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus." RESULTS: Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals. CONCLUSION: Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices. LEVEL OF EVIDENCE: 5.
STUDY DESIGN: Expert opinion-modified Delphi study. OBJECTIVE: We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals. SUMMARY OF BACKGROUND DATA: Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice. METHODS: We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus." RESULTS: Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals. CONCLUSION: Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices. LEVEL OF EVIDENCE: 5.
Authors: Minyu Jian; Bo Ma; Haiyang Liu; Chengwei Wang; Fa Liang; Yang Zhou; Hui Qiao; Ruquan Han Journal: BMJ Open Date: 2022-05-02 Impact factor: 3.006