Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study.
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2020-07
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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
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Walker, Corey T, Han Jo Kim, Paul Park, Lawrence G Lenke, Mark A Weller, Justin S Smith, Edward C Nemergut, Daniel M Sciubba, et al. (2020). Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study. Spine, 45(13). pp. 911–920. 10.1097/brs.0000000000003433 Retrieved from https://hdl.handle.net/10161/28143.
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Scholars@Duke
Khoi Duc Than
I chose to pursue neurosurgery as a career because of my fascination with the human nervous system. In medical school, I developed a keen interest in the diseases that afflict the brain and spine and gravitated towards the only field where I could help treat these diseases with my own hands. I focus on disorders of the spine where my first goal is to help patients avoid surgery if at all possible. If surgery is needed, I treat patients using the most advanced minimally invasive techniques available in order to minimize pain, blood loss, and hospital stay, while maximizing recovery, neurologic function, and quality of life. In my free time, I enjoy spending time with my family and friends. I am an avid sports fan and love to eat. I try to stay physically fit by going to the gym and playing ice hockey.
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