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Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response

Abstract

Study Design

Consensus-based creation of a checklist and guideline.

Objective

To develop a consensus-based checklist to guide surgeon responses to intraoperative neuromonitoring (IONM) changes in patients with a stable spine and to develop a consensus-based best practice guideline for IONM practice in the United States.

Summary of Background Data

Studies show that checklists enhance surgical team responses to crisis situations and improve patient outcomes. Currently, no widely accepted guidelines exist for the response to IONM changes in spine deformity surgery.

Methods

After a literature review of risk factors and recommendations for responding to IONM changes, 4 surveys were administered to 21 experienced spine surgeons and 1 neurologist experienced in IONM. Areas of equipoise were identified and the nominal group process was used to determine items to be included in the checklist. The authors reevaluated and modified the checklist at 3 face-to-face meetings over 12 months, including a period of clinical validation using a modified Delphi process. The group was also surveyed on current IONM practices at their institutions. This information and existing IONM position statements were used to create the IONM best practice guideline.

Results

Consensus was reached for the creation of 5 checklist headings containing 26 items to consider in the response to IONM changes. Consensus was reached on 5 statements for inclusion in the best practice guideline; the final guideline promotes a team approach and makes recommendations aimed at decreasing variability in neuromonitoring practices.

Conclusions

The final products represent the consensus of a group of expert spine surgeons. The checklist includes the most important and high-yield items to consider when responding to IONM changes in patients with a stable spine, whereas the IONM guideline represents the group consensus on items that should be considered best practice among IONM teams with the appropriate resources.

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Author information

Correspondence to Hiroko Matsumoto MA.

Additional information

Author disclosures: MGV (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from SRS, POSNA, Chest Wall and Spine Deformity Research Foundation, other from Biomet, outside the submitted work); DKS (Biomet, DePuy Synthes, Stryker, Medtronic, during the conduct of the study; grants from POSNA & SRS, personal fees from Biomet; Medtronic, nonfinancial support from Growing Spine Study Group, Scoliosis Research Society, Growing Spine Foundation Medtronic Strategic Advisory Board, personal fees from expert testimony, from Stryker, and from Wolters Kluwer HealtheLippincott Williams & Wilkins; Biomet Spine, other from Medtronic, other from Stryker; Biomet, Medtronic, outside the submitted work; in addition, Dr. Skaggs has a patent Medtronic issued); GIP (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); MLW (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); HM (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from SRS, POSNA, Children’s Spine Foundation (Grant no.: CWSD005, CWSD0004, CWSD0022, CWSD0026, CWSD0049), Cerebral Palsy International Research Foundation, outside the submitted work); RCEL (none); DLB (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); JPD (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; other from Elsevier, other from Veritas Health, Shriner’s International, outside the submitted work); JBE (none); MAE (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; and POSNA Board of Directors); JMF (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; other from Biomet, other from LWW, outside the submitted work); MPG (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); KNI (DePuy Synthes, other from SpineCraft, outside the submitted work); SJL (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; personal fees and other from Medtronic, personal fees and other from Stryker, personal fees and other from AO spine, outside the submitted work); SJL (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; personal fees from Medtronic, personal fees from Stryker, personal fees from Orthofix, personal fees from DePuy Synthes, personal fees from Lippincott, from Globus, outside the submitted work); AM (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); SR(none); JOS (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from CWSDSG Foundation, personal fees from DePuy, outside the submitted work); SAS (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants and other from Setting Scoliosis Straight Foundation, grants and personal fees from DePuy Synthes Spine, outside the submitted work); JTS (Depuy Synthes, other from Spineguard, other from Ellipse Technologies, outside the submitted work); KMS (none); PDS (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants and personal fees from DePuy Synthes Spine, personal fees from Globus, personal fees from JBJS, personal fees from Oakstone Medical Publishing, outside the submitted work); DJS (Grants from Pediatric Orthopaedic Society of North America, personal fees from AAOS YOC, grants from Orthopaedic Research and Education Foundation, other from Scoliosis Research Society Board Membership, grants from Department of Defense, grants from DePuy Spine, grants from University of Washington St. Louis, outside the submitted work); DPR (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from SRS, POSNA, Children’s Spine Foundation (Grant no.: CWSD005, CWSD0004, CWSD0022, CWSD0026, CWSD0049), OREF, CPIRF (Grant no.: R-808-12), other from OMeGA, Biomet, outside the submitted work); LGL (none).

This study was supported by an unrestricted educational grant from Medtronic Somafor Danek, Stryker Spine, DePuy Synthes Spine, Biomet Spine, and the ST. GILES FOUNDATION.

A work product of the combined SRS/POSNA task force on quality and safety in scoliosis care, and endorsed by the Pediatric Orthopaedic Society of North America and the Scoliosis Research Society.

For an electronic version of the checklist please contact Michael G. Vitale, MD, MPH at mgv1@columbia.edu.

Author disclosures: MGV (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from SRS, POSNA, Chest Wall and Spine Deformity Research Foundation, other from Biomet, outside the submitted work); DKS (Biomet, DePuy Synthes, Stryker, Medtronic, during the conduct of the study; grants from POSNA & SRS, personal fees from Biomet; Medtronic, nonfinancial support from Growing Spine Study Group, Scoliosis Research Society, Growing Spine Foundation Medtronic Strategic Advisory Board, personal fees from expert testimony, from Stryker, and from Wolters Kluwer HealtheLippincott Williams & Wilkins; Biomet Spine, other from Medtronic, other from Stryker; Biomet, Medtronic, outside the submitted work; in addition, Dr. Skaggs has a patent Medtronic issued); GIP (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); MLW (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); HM (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from SRS, POSNA, Children’s Spine Foundation (Grant no.: CWSD005, CWSD0004, CWSD0022, CWSD0026, CWSD0049), Cerebral Palsy International Research Foundation, outside the submitted work); RCEL (none); DLB (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); JPD (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; other from Elsevier, other from Veritas Health, Shriner’s International, outside the submitted work); JBE (none); MAE (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; and POSNA Board of Directors); JMF (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; other from Biomet, other from LWW, outside the submitted work); MPG (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); KNI (DePuy Synthes, other from SpineCraft, outside the submitted work); SJL (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; personal fees and other from Medtronic, personal fees and other from Stryker, personal fees and other from AO spine, outside the submitted work); SJL (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; personal fees from Medtronic, personal fees from Stryker, personal fees from Orthofix, personal fees from DePuy Synthes, personal fees from Lippincott, from Globus, outside the submitted work); AM (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study); SR(none); JOS (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from CWSDSG Foundation, personal fees from DePuy, outside the submitted work); SAS (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants and other from Setting Scoliosis Straight Foundation, grants and personal fees from DePuy Synthes Spine, outside the submitted work); JTS (Depuy Synthes, other from Spineguard, other from Ellipse Technologies, outside the submitted work); KMS (none); PDS (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants and personal fees from DePuy Synthes Spine, personal fees from Globus, personal fees from JBJS, personal fees from Oakstone Medical Publishing, outside the submitted work); DJS (Grants from Pediatric Orthopaedic Society of North America, personal fees from AAOS YOC, grants from Orthopaedic Research and Education Foundation, other from Scoliosis Research Society Board Membership, grants from Department of Defense, grants from DePuy Spine, grants from University of Washington St. Louis, outside the submitted work); DPR (Biomet, Medtronic, DePuy Synthes, Stryker, during the conduct of the study; grants from SRS, POSNA, Children’s Spine Foundation (Grant no.: CWSD005, CWSD0004, CWSD0022, CWSD0026, CWSD0049), OREF, CPIRF (Grant no.: R-808-12), other from OMeGA, Biomet, outside the submitted work); LGL (none).

This study was supported by an unrestricted educational grant from Medtronic Somafor Danek, Stryker Spine, DePuy Synthes Spine, Biomet Spine, and the ST. GILES FOUNDATION.

A work product of the combined SRS/POSNA task force on quality and safety in scoliosis care, and endorsed by the Pediatric Orthopaedic Society of North America and the Scoliosis Research Society.

For an electronic version of the checklist please contact Michael G. Vitale, MD, MPH at mgv1@columbia.edu.

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Vitale, M.G., Skaggs, D.L., Pace, G.I. et al. Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response. Spine Deform 2, 333–339 (2014). https://doi.org/10.1016/j.jspd.2014.05.003

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Level of Evidence

  • V

Keywords

  • Neuromonitoring
  • Spine deformity surgery
  • Surgical checklist