February 28, 2012 8:00 — 1 Comment

New Guideline Recommends Intraoperative Monitoring During Spinal and Chest Surgeries

The American Academy of Neurology has issued an updated guideline that recommends monitoring the spinal cord during spinal surgery and certain chest surgeries to help prevent paralysis, or loss of muscle function, related to the surgeries. The guideline, which was developed with the American Clinical Neurophysiology Society, appears in the Feb. 21, 2012, print issue of Neurology ­— the medical journal of the American Academy of Neurology — as well as the Journal of Clinical Neurophysiology.

The guideline states that strong evidence shows monitoring the spinal cord during spinal surgery and certain chest surgeries, such as those performed to repair narrowing of the walls of the aorta, can help prevent paralysis that can be related to the surgery. This also is known as intraoperative monitoring. The procedure can alert the surgeon in time to find and address the problem before damage occurs. For more information, click here to read the full release.

One Comment

  1. Laszlo Tamas says:

    A better link, if you want to download the actual pdf version of the Guidelines, is this:
    http://www.neurology.org/content/78/8/585.full.pdf

    And if you want the table the Guidelines are based on (MSWord), you have to skip to:
    http://www.neurology.org/content/78/8/585/suppl/DC1

    These guidelines really trouble me.

    So let me get this straight – we should always do monitoring because if EPs change, there is a “1 – 100%” chance of post-operative deficit (the range in the studies they reviewed)? Shouldn’t numbers like that make us seriously question the nature and comparability of the studies?

    And if one were to put the results of the studies they reviewed another way (doing the math using the numbers in their own Table e-1):
    - if EPs change, there was a 90% chance that no post-op deficit occurred
    - counting their studies with > 100 subjects, the false positive rate rises to 94%
    - looking at studies in that group which involved neurosurgery, the rate is 95%

    Put in this way, it sounds less impressive.

    The 1% rate of post-op spinal cord deficit in the series as a whole (obviously with monitoring) is not much different from what has been reported in the neurosurgical literature over decades without EP monitoring (e.g. J Spinal Disord. 1993 Jun;6(3):245-50. Cervical laminectomy and foraminotomy as surgical treatment of cervical spondylosis. Snow RB, Weiner H). I bet many of my colleagues out there who don’t use EP monitoring for basic cervical spine surgery have rates of post-op deficit as low.

    But these Guidelines are highly misleading in another, more important way.

    Right from the start, in the first paragraph, they link EP changes (“used to warn”) with function-sparing intervention (“can modify surgery”). Yet this review has not shown in any way that surgery with EP monitoring actually affects outcomes. In fact, you have to go to the last page of text (p. 5) to read that “No studies in humans have directly measured the efficacy of such interventions.”

    Did you know that over 90% of bank robbers ate bread within 24 hours before robbing a bank? Should we therefore ban the sale of sliced bread? This misuse of the concepts of “correlation” and “causality” is understandable in the lay press, but is sad to see in a professional journal.

    Having said that, most of us do use EPs in certain types of spinal surgeries (e.g. tumors in or around the cord). But their wholesale use in every spine case (and I do know a surgeon who uses it even for lumbar discectomies!) is in my opinion completely unwarranted, not least because of the high incidence of false-postives that lengthen surgery times (and shorten our lives!).

    And we wonder why 18% of GDP goes to health care …

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