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Title: Patients Without Intraoperative Neuromonitoring (IONM) Alerts During VEPTR Implantation Did Not Sustain Neurological Injury During Subsequent Routine Expansions: A Retrospective Multicenter Cohort Study

Authors: LaGreca J, Flynn T, Cahill PJ, Samdani A, Vitale MG, El-Hawary R, Smith JT, Phillips JH, Flynn JM, Glotzbecker M, Children’s Spine Study Group and Garg S

Journal: Journal of Pediatric Orthopaedics

Date: December 01, 2017

Excerpt: Although the VEPTR device has become an established treatment for the management of severe chest wall and spinal deformities in the growing pediatric patient, there is limited evidence describing the utility of intraoperative neuromonitoring (IONM) during the course of VEPTR treatment. More specifically, the utility of IONM during expansion procedures in patients with no prior history of neurological injury or IONM alert.

Keywords: Surgery, Risks, Neurological Injury, VEPTR, EOS

Summary:

What is the purpose of this study?

Neuromonitoring or observation of regular neurological signals may be used during Vertical Expandable Prosthetic Titanium Rib (VEPTR) implant surgery for scoliosis. The purpose of this study is to determine the necessity of neuromonitoring during routine VEPTR expansions by reviewing the number of alerts or loss of neurological signals given during VEPTR implantations. This is important for the prevention of neurologic injury during VEPTR procedures.

Results

-  This study retrospectively reviewed 352 patients that received VEPTR implantation between 2005-2011.

-  2355 VEPTR procedures were reviewed including implant expansion, revision, etc. 539 procedures used neuromonitoring observation (IONM) and had records available for review.

-  An initial neurologic injury occurred in 3/2355 reviewed VEPTR procedures, all being initial implant surgeries. 1 of these injuries had an IONM alert.  All injuries occurred in patients with congenital scoliosis, fused ribs, and had transient neurological deficits. None occurred in other diagnoses.

-  Alerts occurred in 9 out of 539 procedures (7 of 352 patients). 1 expansion procedure had an IONM alert without prior history of IONM signal changes.  This occurred during closure in presence of infection and high blood pressure.

Important Discussion Points

-  Neurologic injury is rare in treatment of thoracic insufficiency syndrome (TIS) and early onset scoliosis EOS in growth friendly surgery.

-  This study shows limited evidence that neuromonitoring should be conducted during routine VEPTR expansion procedures, especially in patients with no history of neurologic injury.