Journal of Pediatric Orthopaedics - 2026-04-10 - Journal Article
Are We Getting What We Ask For: Few Patients Meet Mean Arterial Pressure (MAP) Goals After Intraoperative Neuromonitoring (IONM) Changes During Pediatric Spine Surgery.
O'Connor MJ, Brown MW, Elfilali MM, Park AM, Bomback MJ, Williams ED, Choi J, Coury JR, Lenke LG, Roye BD, Vitale MG
Topics
Key Takeaway
Despite ICU admission and individualized MAP goals after intraoperative neuromonitoring changes, 95% of pediatric spine patients failed to continuously meet their MAP target, spending an average of 27% of the first 24 postoperative hours (6.4 hours) below goal.
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Summary
This study asked whether ICU-level postoperative MAP goals are actually achieved in pediatric spine patients who experienced IONM changes intraoperatively. Twenty-one patients with a median MAP goal >80 mmHg were monitored via arterial line for 24 hours postoperatively. Ninety-five percent had at least one MAP excursion below target, 33% had a 24-hour average MAP below target, and 29% had persistent neurological deficits beyond postoperative day one.
Key Limitation
The single-institution retrospective design with only 21 patients, four aborted surgeries, and heterogeneous MAP targets prevents determination of whether MAP non-adherence causally contributed to the 29% rate of persistent neurological deficits.
Original Abstract
BACKGROUND
Hypotension is a critical, modifiable risk factor for neurological deficit in spine surgery. Patients with intraoperative neurophysiological monitoring (IONM) changes are particularly vulnerable, as their spinal cord has already demonstrated sensitivity to correction, and hypotension may exacerbate areas of inadequate perfusion. These patients are admitted postoperatively to the ICU for close neurological and hemodynamic monitoring. This study evaluated adherence to patient-specific mean arterial pressure (MAP) goals in the first 24 hours following IONM changes.
METHODS
A retrospective review of patients undergoing spinal surgery with IONM changes between 2023 and 2025 at a single institution was conducted. Demographic and radiographic data were documented. Individual 24-hour postoperative "Target MAP" goals were established. Arterial line MAP values were collected. Hypotension was defined as MAP <5th percentile for age-based norms.
RESULTS
Twenty-one patients [12 female, 9 male; mean age 14.3±2.6 y (range: 7.7 to 19.0)] with IONM changes during pediatric deformity surgery were included. Etiologies included 8 idiopathic, 6 neuromuscular, 5 congenital, and 2 syndromic patients. Of those with major coronal deformities (n=19), mean preoperative and postoperative major curves were 79±22 degrees (range: 40 to 120 degrees) and 38±16 degrees (range: 18 to 75 degrees), respectively, with an average correction of 56%±11% (range: 41% to 71%) in completed cases. Four surgeries were aborted. Six patients (29%) had persistent neurological deficits beyond the first postoperative day. The median MAP goal was >80 mm Hg (range: >60 to >100). Twenty patients (95%) did not continuously meet their MAP goal, defined as ≥1 instance of MAP beneath target. Seven patients' (33%) 24-hour average MAPs were below target. On average, patients spent 27% of the time (6.4 h) beneath their target MAP. Four patients (19%) had a documented period of hypotension.
CONCLUSIONS
Despite ICU-level care and established MAP goals in critical patients with prior IONM loss or within warning criteria, postoperative blood pressure management often failed to meet MAP goals. This is the first study to highlight this crucial gap between management goals and postoperative hemodynamic adherence.
LEVELS OF EVIDENCE
Level IV.