The assessment of complications after spine surgery: time for a paradigm shift?

BACKGROUND CONTEXT: Recent years have witnessed a shift in the assessment of spine surgical outcomes with a greater focus on the patient's perspective. However, this approach has not been widely extended to the assessment of complications. PURPOSE: The present study sought to quantify the patient-rated impact/severity of complications of spine surgery and directly compare the incidences of surgeon-rated and patient-reported complications. STUDY DESIGN: Prospective study of patients undergoing surgery for painful degenerative lumbar disorders, being operated in the Spine Center of an orthopedic hospital. PATIENT SAMPLE: A total of 2,303 patients (mean [standard deviation] age, 61.9 [15.1] years; 1,136 [49.3%] women and 1,167 [50.7%] men). PATIENTS: Core Outcome Measures Index, self-rated complications, bothersomeness of complications, global treatment outcome, and satisfaction. Surgeons: Spine Tango surgery and follow-up documentation forms registering surgical details and complications. METHODS: PATIENTS completed questionnaires before and 3 months after surgery. Surgeons documented complications before discharge and at the first postoperative follow-up, 6 to 12 weeks after surgery. RESULTS: In total, 615 out of 2,303 (27%) patients reported complications, with "bothersomeness" ratings of 1%, not at all; 22%, slightly; 26%, moderately; 34%, very; and 17%, extremely bothersome. PATIENTS most commonly reported sensory disturbances (35% of those reporting a complication) or ongoing/new pain (27%) followed by wound healing problems (11%) and motor disturbances (8%). The surgeons documented complications in 19% of patients. There was a minimal overlap regarding the presence or absence of complications in any given patient. CONCLUSIONS: Most complications reported by the patient are perceived to be at least moderately bothersome and are, hence, not inconsequential. Surgeons reported lower complication rates than the patients did, and there was only moderate agreement between the ratings of the two. As with treatment outcome, complications and their severity should be assessed from both the patient's and the surgeon's perspectives.

Lumbar facet joint effusion in MRI: a sign of instability in degenerative spondylolisthesis?

PURPOSE: The term "segmental instability" of the lumbar spine is not clearly defined, especially as it relates to degenerative spondylolisthesis (DS) and rotational translation (RT). We investigated whether facet joint effusion on conventional supine MRI indicated increased abnormal motion in DS and RT. METHODS: 160 patients (119 female, 41 male, mean age 68.8 years, range 38.8-89.3 years) who had undergone decompression only or decompression with instrumented fusion for degenerative spondylolisthesis with different degrees of narrowing of the spinal canal were identified retrospectively from our spine surgery database. All had preoperative upright X-rays in AP and lateral views as well as supine MRI. The imaging studies were assessed for the following parameters: percent of slippage, absolute value of facet joint effusion, facet angles, degree of facet degeneration and spinal canal central narrowing, disc height, presence of facet cysts and the presence of rotational translation in the AP X-ray. RESULTS: 40/160 patients showed no facet joint effusion, and in these the difference in the values for the % slip on upright X-ray and % slip on supine MRI was ≤3%. A further 12 patients also showed a difference ≤3%, but had some fluid in the joints (0.44 ± 0.38 mm). In 108 patients, the difference in the % slip measured on X-ray and on MRI was >3% (mean 10.6%, range 4-29%) and was associated with a mean facet effusion size of 2.15 ± 0.85 mm. The extent of effusion correlated significantly with the relative slippage difference between standing and supine positions (r = 0.64, p < 0.001), and the extent of the left/right difference in effusion was associated with the presence of rotational translation (RT 1.31 ± 0.8 mm vs. no-RT 0.23 ± 0.17 mm, p < 0.0001). CONCLUSIONS: Facet joint effusion is clearly correlated with spontaneous reduction of the extent of slippage in the supine position compared to the upright position. Also, the greater the difference in right and left facet effusion, the higher the likelihood of having a RT. Future studies should assess whether analysis of facet joint effusion measured on routine MRI can help in decision-making regarding the optimal surgical treatment to be applied (decompression alone or combined with fusion).

An observational study of patient-rated outcome after atlantoaxial fusion in patients with rheumatoid arthritis and osteoarthritis.

BACKGROUND: Fusion is used to address several types of abnormality of the atlantoaxial segment. Traditionally, outcome has been assessed by achieving solid bony union. Recently, however, patient-rated outcome instruments have been increasingly used, although these may be influenced by concomitant comorbidity. QUESTIONS/PURPOSES: We therefore asked whether patients with rheumatoid arthritis (RA), with its associated comorbidity, had worse self-rated outcomes after C1-2 fusion than patients with osteoarthritis (OA). PATIENTS AND METHODS: We retrospectively reviewed all 30 (23 OA and seven RA) prospectively followed patients in our local Spine Registry (part of the Spine Society of Europe Spine Tango Registry) who had undergone C1-2 fusion. Before surgery and 3 and 12 months later, patients completed the multidimensional Core Outcome Measures Index (COMI) questionnaire. Global outcome and satisfaction with treatment were also assessed. RESULTS: We found no group differences for duration of operation, blood loss, or perioperative surgical or general complications. Compared with the OA group, the RA group showed a better baseline COMI score and less improvement in the COMI from preoperatively to 12 months followup. However, the proportion of "good" global scores at 12 months followup was similarly high in both groups (87% OA and 86% RA) as was satisfaction (96% for OA versus 86% for RA). CONCLUSIONS: Symptoms and impairment were less severe in the RA group at baseline and showed less improvement after surgery, but the proportion of "good global outcomes" was similar in both groups, and the great majority of patients in both groups were satisfied with their treatment. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Comparison of patient and surgeon ratings of outcome 12 months after spine surgery: presented at the 2009 Joint Spine Section Meeting.

OBJECT: The contemporary assessment of spine surgical outcome primarily relies on patient-centered reports of symptoms and function. Such measures are considered to reduce bias compared with traditional surgeon-based outcome ratings. This study examined the agreement between patients' and surgeons' ratings of outcome 1 year after spine surgery. METHODS: The study involved 404 patients (mean age 56.6 +/- 16.4 years; 259 women, 145 men) and their treating surgeons. At baseline and 12 months postoperatively patients completed the Core Outcome Measures Index (COMI) rating pain, function, quality of life, and disability. At 12 months postoperatively, they also rated the global outcome of surgery and their satisfaction with treatment. The surgeon, blinded to the patient's evaluation, rated the global outcome of surgery as excellent, good, fair, or poor. RESULTS: Seventy-six percent of the patients who were considered by the surgeon to have an excellent or good outcome achieved the minimum clinically important difference (MCID) of a 2.2-point reduction on the COMI; 24% achieved less than the MCID. There was a significant correlation between the surgeons' and patients' global outcome ratings (Spearman rho = 0.56; p < 0.0001). The degree of absolute agreement between them was significantly influenced by surgeon seniority: senior surgeons "overrated" the outcome in 24.5% of cases (compared with patients' ratings) and "underrated" it in 17.5% of cases. Junior surgeons overrated in 7.8% of cases and underrated in 43.8% of cases (p < 0.0001). Surgeon overrating occurred significantly more frequently for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment). In a multivariate model, the independent variables "senior surgeon" and "patient dissatisfaction with care" were the most significant unique predictors of surgeon overrating of the global outcome (p < 0.0001; adjusted R(2) for the model = 0.16). CONCLUSIONS: Overall, agreement between surgeon and patient was reasonably good. The majority of patients who were rated as excellent/good by the surgeons had achieved the MCID in the prospectively measured COMI score. Discrepancies in outcome ratings were influenced by surgeon seniority and patient satisfaction. For a balanced view of the surgical result, outcomes should be assessed from the perspectives of both the patient and the surgeon.

A comparison of outcomes of cervical disc arthroplasty and fusion in everyday clinical practice: surgical and methodological aspects.

Randomised controlled trials (RCTs) of cervical disc arthroplasty vs fusion generally show slightly more favourable results for arthroplasty. However, RCTs in surgery often have limited external validity, since they involve a select group of patients who fit very rigid admission criteria and who are prepared to subject themselves to randomisation. The aim of this study was to examine whether the findings of RCTs are verified by observational data recorded in our Spine Center in association with the Spine Society of Europe Spine Tango surgical registry. Patients undergoing fusion/stabilisation or disc arthroplasty for degenerative cervical spinal disease were selected for inclusion. They completed a questionnaire pre-operatively and at 12 and 24 months follow-up (FU). The questionnaire comprised the multidimensional Core Outcome Measures Index (COMI; 0-10 scale) and, at FU, questions on global outcome and satisfaction with treatment (5-point scales, dichotomised to "good" and "poor"), re-operation and patient-rated complications. The surgeon completed a Spine Tango Surgery form. The outcome data from 266 (208 fusion, 58 arthroplasty) out of 284 eligible patients who had reached 12 months FU, and 169 (139 fusion, 30 arthroplasty) out of 178 who had reached 24 months FU, were included. Patients with cervical disc arthroplasty were younger [46 (SD 8) years vs 56 (SD 11) years for fusion; P < 0.05], had less comorbidity (P < 0.05), more often had only mono-segmental pathology (69% arthroplasty, 47% fusion) and only one type of degenerative pathology (69% arthroplasty, 46% fusion). Surgical complication rates were similar in each group (arthroplasty, 1.5%; fusion, 2.6%). The reduction in the COMI score was significantly greater in the arthroplasty group (at 12 months, 4.8 (SD 3.0) vs 3.7 (SD 2.9) points for fusion, and at 24 months 5.1 (SD 2.8) vs 3.8 (SD 2.9) points; each P < 0.05). In the arthroplasty group, a "good" global outcome was recorded in 90% patients (at 12 months) and 93% (at 24 months); in the fusion group the figures were 80 and 82%, respectively (group differences at each timepoint, P > 0.09). Satisfaction with treatment was similar in both groups (89-93%), at each timepoint. In multiple regression analysis, treatment group was of borderline significance as a unique predictor of the change in COMI at FU (P = 0.059 at 12 months, P = 0.055 at 24 months) in a model in which known confounders (age, comorbidity, number of affected levels) were controlled for. Being in the arthroplasty group was associated with an approximately 1-point greater reduction in the COMI score at FU. The results of this observational study appear to support those of the RCTs and suggest that, in patients with degenerative pathology of the cervical spine, disc arthroplasty is associated with a slightly better outcome than fusion. However, given the small size of the difference, its clinical relevance is questionable, especially in view of the a priori more favourable outcome expected in the arthroplasty group due to the more rigorous selection of patients.

Great expectations: really the novel predictor of outcome after spinal surgery?

STUDY DESIGN: Prospective study. OBJECTIVE: The present study compared different theories on the role of expectations in a group of patients undergoing lumbar decompression surgery. SUMMARY OF BACKGROUND DATA: Patients' expectations of treatment are a potentially important predictor of self-rated outcome after surgery. Some studies suggest that high baseline expectations per se yield better outcomes, others maintain that the fulfillment of prior expectations is paramount, and still others assert that it is the actual improvement in symptom status that governs outcome, regardless of prior expectations. METHODS: Hundred patients took part (33 F, 67 M; mean [SD] age, 65 [11] yrs). Before surgery, they completed a booklet containing the Roland-Morris (RM) disability questionnaire, 0-10 pain graphic rating scales (back and leg separately), and Likert-scales about the degree of improvement expected in various domains. Two and 12 months after surgery, questions were answered regarding the perceived improvement for each of these domains, the RM and pain scales were completed again, and the patients rated the global outcome on a 5-point Likert-scale. RESULTS: Compared with the actual improvement recorded at 12 months, prior expectations had been overly optimistic in about 40% patients for the domains leg pain, back pain, walking capacity, social life, mental well-being, and independence, and in 50% patients for everyday activities and sport. There was no significant relationship between baseline expectations and follow-up scores for back pain, leg pain, RM-disability (corrected for baseline values), or global outcome. Hierarchical multiple regression analysis revealed that "expectations being fulfilled" was the most significant predictor of global outcome. CONCLUSION: In this patient group, expectations of surgery were overly optimistic. Having one's expectations fulfilled was most important for a good outcome. The results emphasize the importance of assessing patient-orientated outcome in routine practice, and the factors that might influence it, such that realistic expectations can be established for patients before surgery.

Translaminar screw fixation of the lumbar spine: long-term outcome.

STUDY DESIGN: Retrospective clinical cohort study. OBJECTIVES: To evaluate the long-term results after translaminar screw fixation of the lumbar spine in a large group of patients and to identify predictors of a good outcome. SUMMARY OF BACKGROUND DATA: Translaminar screw fixation represents an alternative operative technique to transpedicular fixation systems for short-segment lumbar fusion. The strategy behind this technique is to block the facet joints with perforating screws. Although the method has been in use for more than 20 years, few studies reporting the long-term outcome in large groups of patients are to be found in the literature. METHODS: The Core Outcome Measures Index, a multidimensional outcome questionnaire, was sent to 643 consecutive patients who had undergone lumbar fusion with translaminar screws between 1987 and 2004, for various degenerative conditions of the lumbar spine. Patients also rated the global outcome and their satisfaction with treatment. Disc height was measured from preoperative radiographs using the distortion compensated roentgen analysis method. 476 patients (74%) completed and returned the questionnaire. Multiple logistic regression analysis was used to identify factors associated with a good outcome. RESULTS: After an average follow-up period of 10 years (range: 2-20 years) 352 of 476 patients (74%) reported that the operation had either "helped a lot" or "helped" (good outcome); 124 of 476 patients (26%) declared that it "helped only little," "didn't help," or "made things worse" (poor outcome). Controlling for potential confounders, a preoperative disc height <80% of that reported for a normal population was the most significant unique predictor of a good outcome (OR = 14.86, 95% CI: 6.77-32.61, P < 0.0001). CONCLUSION: Translaminar screw fixation is a straightforward and effective technique for short-segment fusion in the lumbar spine. For patients with a strict indication for spondylodesis, intact posterior elements (lamina and facets) and a low preoperative disc height, translaminar screw fixation represents a successful fixation technique in the lumbar spine with good long-term results.

Ratings of global outcome at the first post-operative assessment after spinal surgery: how often do the surgeon and patient agree?

Patient-orientated questionnaires are becoming increasingly popular in the assessment of outcome and are considered to provide a less biased assessment of the surgical result than traditional surgeon-based ratings. The present study sought to quantify the level of agreement between patients' and doctors' global outcome ratings after spine surgery. 1,113 German-speaking patients (59.0 +/- 16.6 years; 643 F, 470 M) who had undergone spine surgery rated the global outcome of the operation 3 months later, using a 5-point scale: operation helped a lot, helped, helped only little, didn't help, made things worse. They also rated pain, function, quality-of-life and disability, using the Core Outcome Measures Index (COMI), and their satisfaction with treatment (5-point scale). The surgeon completed a SSE Spine Tango Follow-up form, blind to the patient's evaluation, rating the outcome with the McNab criteria as excellent, good, fair, and poor. The data were compared, in terms of (1) the correlation between surgeons' and patients' ratings and (2) the proportions of identical ratings, where the doctor's "excellent" was considered equivalent to the patient's "operation helped a lot", "good" to "operation helped", "fair" to "operation helped only little" and "poor" to "operation didn't help/made things worse". There was a significant correlation (Spearman Rho = 0.57, p < 0.0001) between the surgeons' and patients' ratings. Their ratings were identical in 51.2% of the cases; the surgeon gave better ratings than the patient ("overrated") in 25.6% cases and worse ratings ("underrated") in 23.2% cases. There were significant differences between the six surgeons in the degree to which their ratings matched those of the patients, with senior surgeons "overrating" significantly more often than junior surgeons (p < 0.001). "Overrating" was significantly more prevalent for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment; each p < 0.001). In a multivariate model controlling for age and gender, "low satisfaction with treatment" and "being a senior surgeon" were the most significant unique predictors of surgeon "overrating" (p < 0.0001; adjusted R (2) = 0.21). Factors with no unique significant influence included comorbidity (ASA score), first time versus repeat surgery, one-level versus multilevel surgery. In conclusion, approximately half of the patient's perceptions of outcome after spine surgery were identical to those of the surgeon. Generally, where discrepancies arose, there was a tendency for the surgeon to be slightly more optimistic than the patient, and more so in relation to patients who themselves declared a poor outcome. This highlights the potential bias in outcome studies that rely solely on surgeon ratings of outcome and indicates the importance of collecting data from both the patient and the surgeon, in order to provide a balanced view of the outcome of spine surgery.

The influence of preoperative back pain on the outcome of lumbar decompression surgery.

STUDY DESIGN: Prospective study with 12-month follow-up. OBJECTIVE: To examine how the relative severity of low back pain (LBP) to leg/buttock pain (LP) influences the outcome of decompression surgery for spinal stenosis. SUMMARY OF BACKGROUND DATA: Decompression surgery is a common treatment for lumbar spinal canal stenosis, with generally good outcome. However, concomitant LBP at presentation can make it difficult to decide whether decompression alone will result in a good overall outcome. METHODS: The Spine Society of Europe Spine Tango system was used to acquire the data from 221 patients. Inclusion criteria were lumbar degenerative spinal stenosis, first-time surgery, maximum 3 affected levels, and decompression as the only procedure. Before and 12 months after surgery, patients completed the multidimensional Core Outcome Measures Index (COMI; includes 0-10 LP and LBP scales); at 12 months, global outcome was rated on a Likert-scale and dichotomized into "good" and "poor" groups. RESULTS: There was a low but significant positive correlation between baseline LP-minus-LBP scores and both improvement in the multidimensional COMI score after 12 months (r = 0.21, P = 0.003) and the score on the 12-month global outcome scale (r = 0.19, P = 0.007). In the good outcome group, mean baseline LP was 2.3 (+/-3.7) points higher than LBP; in the poor group, the corresponding value was 0.8 (+/-3.4) (P = 0.01 between groups). In multivariate regression analyses (controlling for age, gender, comorbidity), baseline LBP intensity was the most significant predictor of the 12-month COMI score, and preoperative LP-minus-LBP score of the global outcome (each P < 0.05). CONCLUSION: Overall, greater back pain relative to LP at baseline was associated with a significantly worse outcome after decompression. This finding seems intuitive, but has rarely been quantified in the many predictor studies conducted to date. Consideration of relative LBP and LP scores may assist in clinical decision-making and in establishing realistic patient expectations.

The patient's perspective on complications after spine surgery.

Recent years have witnessed a paradigm shift in relation to the assessment of outcome in spine surgery: multidimensional patient-centred questionnaires have superseded traditional surgeon-based ratings of outcome, and surgical registries have been developed to capitalise on the principle of "strength in numbers." However, the assessment of complications has not enjoyed this same enlightened patient-centred approach. The present study investigated post-surgical complications from the patient's perspective. All German-speaking patients undergoing surgery within our Spine Center in 2005 were asked to complete the patient-orientated Core Measures Outcome Index of the SSE Spine Tango Spine Surgery Registry before and 12 months after surgery; the surgeon completed a Spine Tango surgery form. In the 12-month questionnaire, the patient was asked, "did any complications arise as a consequence of your operation 1 year ago (e.g. problems with wound healing, paralysis, sensory disturbances, etc.)? If so, give details." Patients were also asked about their satisfaction with the operation and the global outcome of surgery. 1,035 patients were sent a 12-month questionnaire; 972 (94%) returned the completed questionnaire. 29% patients answered "yes" to the question about complications. The incidence of patient-rated complications was significantly associated with outcome/satisfaction (P < 0.05), suggesting these complications were not trivial to the patient. The results indicate that, just like outcome, "complications" should be assessed from both the patient's and the surgeon's perspectives, not least to better understand the reasons accounting for dissatisfaction and a poor patient-rated outcome.

The international spine registry SPINE TANGO: status quo and first results.

With an official life time of over 5 years, Spine Tango can meanwhile be considered the first international spine registry. In this paper we present an overview of frequency statistics of Spine Tango for demonstrating the genesis of questionnaire development and the constantly increasing activity in the registry. Results from two exemplar studies serve for showing concepts of data analysis applied to a spine registry. Between 2002 and 2006, about 6,000 datasets were submitted by 25 centres. Descriptive analyses were performed for demographic, surgical and follow-up data of three generations of the Spine Tango surgery and follow-up forms. The two exemplar studies used multiple linear regression models to identify potential predictor variables for the occurrence of dura lesions in posterior spinal fusion, and to evaluate which covariates influenced the length of hospital stay. Over the study period there was a rise in median patient age from 52.3 to 58.6 years in the Spine Tango data pool and an increasing percentage of degenerative diseases as main pathology from 59.9 to 71.4%. Posterior decompression was the most frequent surgical measure. About one-third of all patients had documented follow-ups. The complication rate remained below 10%. The exemplar studies identified "centre of intervention" and "number of segments of fusion" as predictors of the occurrence of dura lesions in posterior spinal fusion surgery. Length of hospital stay among patients with posterior fusion was significantly influenced by "centre of intervention", "surgeon credentials", "number of segments of fusion", "age group" and "sex". Data analysis from Spine Tango is possible but complicated by the incompatibility of questionnaire generations 1 and 2 with the more recent generation 3. Although descriptive and also analytic studies at evidence level 2++ can be performed, findings cannot yet be generalised to any specific country or patient population. Current limitations of Spine Tango include the low number and short duration of follow-ups and the lack of sufficiently detailed patient data on subgroup levels. Although the number of participants is steadily growing, no country is yet represented with a sufficient number of hospitals. Nevertheless, the benefits of the project for the whole spine community become increasingly visible.

The Neck Pain and Disability Scale: cross-cultural adaptation into German and evaluation of its psychometric properties in chronic neck pain and C1-2 fusion patients.

STUDY DESIGN: Cross-cultural adaptation of an outcome questionnaire. OBJECTIVE: The aim of the study was to cross-culturally adapt the Neck Pain and Disability Scale (NPAD) for the German language, and to assess its psychometric qualities. SUMMARY OF BACKGROUND DATA: Neck pain and its associated disability represent an extremely common musculoskeletal problem. Reliable and valid questionnaires for its assessment are available in English, but no German versions of these exist. METHODS: The English version of the NPAD was translated into German (NPAD-D) and back-translated according to established guidelines. Twenty-three patients with chronic neck pain completed the NPAD-D twice over 1 to 2 weeks, to assess its test-retest reliability. A further 80 patients [40% male, mean (SD) 54 (18) years] completed the questionnaire and underwent a clinical follow-up examination, 1 to 14 years after C1-C2 fusion. These patients also documented their satisfaction with the surgery. RESULTS: Cronbach's alpha values (internal consistency) for the NPAD-D whole scale and for the NPAD-D subscales pain, disability, and neck-specific function were 0.97, 0.95, 0.97, and 0.87, respectively. The ICC for the test-retest reliability of the NPAD-D was excellent (0.97) and the SEM was relatively low (3.8), giving a "minimal detectable difference" for the scale of 10.5 (scale range is 0-100). The range of motion in rotation, assessed during the clinical examination, correlated significantly with the scores on NPAD-D item 16 (stiffness of neck) (Rho = -0.52, P < 0.0001) and item 17 (trouble turning neck) (Rho = -0.59, P < 0.0001). Range of motion in flexion-extension correlated significantly with the scores on item 18 (trouble looking up and down) (Rho = -0.60, P < 0.0001) and item 19 (trouble working overhead) (Rho = -0.45, P < 0.0001). The NPAD-D scores differed significantly between patients who were satisfied with the result of their operation and those who were not [mean values 36.4 (SD 24.3) and 58.1 (SD 27.4), respectively; P = 0.008]. CONCLUSION: The NPAD-D is a reliable and valid patient-orientated instrument for use in future studies of neck pain and disability in German speaking patients.

Multimodal intraoperative monitoring (MIOM) during 409 lumbosacral surgical procedures in 409 patients.

A prospective study on 409 patients who received multimodel intraoperative monitoring (MIOM) during lumbosacral surgical procedures between March 2000 and December 2005 was carried out. The objective of this study was to determine the sensitivity and specificity of MIOM techniques used to monitor conus medullaris, cauda equina and nerve root function during lumbosacral decompression surgery. MIOM has increasingly become important to monitor ascending and descending pathways, giving immediate feedback information regarding any neurological deficit during the decompression and stabilisation procedure in the lumbosacral region. Intraoperative spinal- and cortical-evoked potentials, combined with continuous EMG- and motor-evoked potentials of the muscles, were evaluated and compared with postoperative clinical neurological changes. A total of 409 consecutive patients with lumbosacral spinal stenosis with or without instability were monitored by MIOM during the entire surgical procedure. A total of 388 patients presented true-negative findings while two patients presented false negative and 1 patient false-positive findings. Eighteen patients presented true-positive findings where neurological deficit after the operation was intraoperatively predicted. Of the 18 true-positive findings, 12 patients recovered completely; however, 6 patients recovered only partially. The sensitivity of MIOM applied during decompression and fusion surgery of the lumbosacral region was calculated as 90%, and the specificity was calculated as 99.7%. On the basis of the results of this study, MIOM is an effective method of monitoring the conus medullaris, cauda equina and nerve root function during surgery at the lumbosacral junctions and might reduce postoperative surgical-related complications and therefore improve the long-term results.

The diagnostic value of multimodal intraoperative monitoring (MIOM) during spine surgery: a prospective study of 1,017 patients.

A prospective study of 1,017 patients who received MIOM during spine surgery procedures between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve roots function during spine surgery. MIOM has become a widely used method of monitoring neural function during spine surgery. Several techniques only monitor either ascending or descending pathways and thus may not provide sensitive or specific results. MIOM aims to monitor both ascending and descending pathways therefore giving immediate feedback information regarding any neurological deficits during the operation. Intraoperative sensory spinal and cortical evoked potentials, combined with monitoring of EMG and motor evoked potentials recorded from the spinal cord and muscles elicited by electrical motor cortex, spinal cord, cauda equina and nerve root stimulation, was evaluated and compared with post-operative clinical neurological changes. One thousand and seventeen consecutive patients underwent a total of 4,731 h of MIOM to evaluate any neural deficits that may have occurred during spine surgery. Of these, 935 were true negative cases, 8 were false negative cases, 66 were true positive cases and 8 were false positive cases, resulting in a sensitivity of 89% and a specificity of 99%. Based on the results of this study, MIOM is an effective method of monitoring the spinal cord functional integrity during spine surgery and therefore can lead to reduction of neurological deficit and consequently improve postoperative results.

Multimodal intraoperative monitoring during surgery of spinal deformities in 217 patients.

A prospective study was performed on 217 patients who received MIOM during corrective surgery of spinal deformities between March 2000 and December 2005. Aim is to determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during corrective spine surgery. MIOM is becoming an increasingly used method of monitoring function during corrective spine surgery. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information regarding any neurological deficits during the operation. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 217 consecutive patients with spinal deformities of different aetiologies were monitored by means of MIOM during the surgical procedure. Out of which 201 patients presented true negative findings while one patient presented false negative and three patients presented false positive findings. Twelve patients presented true positive findings where neurological deficit after the operation was predicted. All neurological deficits in those 12 patients recovered completely. The sensitivity of MIOM applied during surgery of spinal deformities has been calculated of 92.3% and the specificity 98.5%. Based upon the results of this study MIOM is an effective method of monitoring the spinal cord and nerve root function during corrective surgery of spinal deformities and consequently improves postoperative results. The Wake-up test for surgical procedure of spinal deformities became obsolete in our institution.