Aims. Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury which enables early intervention resulting in a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon-directed intraoperative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon-directed TcMEP is presented in terms of viability, safety, and efficacy. Methods. We carried out a retrospective review of a single surgeon’s prospectively maintained database of cases in which TcMEP monitoring had been used between 2010 and 2017. The upper limbs were used as the control. A true alert was recorded when there was a 50% or more loss of amplitude from the lower limbs with maintained upper limb signals. Patients with true alerts were identified and their case history analyzed. Results. Of the 299 cases reviewed, 279 (93.3%) had acceptable traces throughout and awoke with normal clinical neurological function. No patient with normal traces had a postoperative clinical neurological deficit. True alerts occurred in 20 cases (6.7%). The diagnoses of the alert group included nine cases of adolescent idiopathic scoliosis (AIS) (45%) and six of congenital scoliosis (30%). The incidence of deterioration based on diagnosis was 9/153 (6%) for AIS, 6/30 (20%) for congenital scoliosis, and 2/16 (12.5%) for spinal tuberculosis. Deterioration was much more common in congenital scoliosis than in AIS (p = 0.020). Overall, 65% of alerts occurred during rod instrumentation: 15% occurred during decompression of the internal apex in vertebral column resection surgery. Four alert cases (20%) awoke with clinically detectable neurological compromise. Conclusion. Surgeon-directed TcMEP monitoring has a 100% negative predictive value and allows early identification of physiological cord distress, thereby enabling immediate intervention. In resource constrained environments, surgeon-directed TcMEP is a viable and effective method of intraoperative spinal cord monitoring. Level of evidence: III. Cite this article: Bone Joint J 2021;103-B(3):547–552

Introduction Transcranial motor evoked potentials are routinely used at The Children’s Hospital at Westmead to monitor the spinal cord in spinal surgery. This study is a prospective review of all spinal cord monitoring procedures from 1999 to 2004 in patients undergoing elective spinal deformity correction surgery at The Children’s Hospital at Westmead and Westmead Hospital. Spinal cord monitoring with Somatosensory Evoked Potentials (SSEP) and MEP has been widely used in combination during spinal surgery with good sensitivity and specificity. The use of CMAP as the only modality has not been widely used and its efficacy has not been fully elucidated. Using MEP and CMAP only may increase the sensitivity of spinal cord monitoring compared with combined SSEP and MEP monitoring. Methods The intra-operative monitoring outcomes were compared with patient’s post-operative clinical outcomes. The sensitivity and specificity were calculated and determined for our monitoring protocol. Results Transcranial MEPs were measured in 146 patients in 175 procedures. In 2 patients (2 procedures) we were unable to record any CMAPS. There were 15 intra-operative monitoring changes (8.7%). There were no new post-operative neurological deficits. Our results compare favourably to the literature with respect to the false-negative rate or new neurological events. Discussion Using our anaesthetic protocol and spinal monitoring criteria, we were able to successfully monitor patients undergoing elective spinal deformity correction surgery for a variety of diagnoses. The monitoring criteria are sufficiently strict to achieve a sensitivity of 1.0 (95%CI = 0.66–1.00) and a specificity of 0.97 (95%CI = 0.83–0.99). Monitoring of CMAPs alone has been adequate to avoid clinical neurological deficits

Aims

The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years.

A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.