Spine - 2026-03-10 - Journal Article
Analysis of 5317 Consecutive Pediatric Spinal Deformity Intraoperative Neuromonitoring (IONM) Alerts: Importance of Normotension at Correction and IONM Recovery.
Bozorgmehr CK, Rakers L, Kelly B, Luhmann SJ
Topics
Key Takeaway
In 5,317 consecutive pediatric spinal deformity cases, IONM alerts occurred in 4.2% and systematic corrective actions—most commonly hypotension correction—reduced permanent neurologic deficit to 0.15% at final follow-up.
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Summary
This single-center retrospective review of an institutional IONM database (1992–2024) characterized alert chronology, corrective maneuvers, and neurologic outcomes in 223 pediatric spinal deformity patients with at least one IONM alert out of 5,317 consecutive cases. Hypotension correction was the most common intervention (91/348 corrective actions), followed by adjustment of deformity correction (63/348). Neurologic decline at final follow-up occurred in 0.15% of all cases (8/5,312) and 3.7% of alert cases (8/218), with full recovery in 21 of 29 patients with documented final status.
Key Limitation
Retrospective single-center design spanning 32 years introduces heterogeneity in IONM technology, alert thresholds, anesthetic protocols, and surgeon experience that cannot be controlled, limiting generalizability of specific corrective action efficacy.
Original Abstract
STUDY DESIGN
Case Series.
OBJECTIVE
The study's objective is to detail the chronology of intraoperative neuromonitoring (IONM) alerts during pediatric spinal deformity surgery, the corrective maneuvers taken, and the immediate and final neurologic outcomes.
SUMMARY OF BACKGROUND DATA
IONM reduces the risk of spinal cord dysfunction during pediatric spinal deformity surgery by enabling timely intraoperative intervention. However, limited data exists regarding the chronology of alerts and the effectiveness of specific corrective actions.
METHODS
An institutional neuromonitoring database was reviewed (1992-2024) to identify all consecutive patients (0-18 y) who underwent pediatric spine deformity surgery with at least one IONM alert.
RESULTS
A total of 223 patients (4.2%) were identified out of 5,317 consecutive cases, of which 156 had data recovery intraoperatively, and 67 did not. Diagnoses were kyphosis (n=66), idiopathic (n=63), neuromuscular (n=43), congenital (n=24), syndromic (n=11), and other (n=16). There were 348 corrective actions for 237 alerts, most commonly correction of hypotension (n=91) and adjustment of deformity correction (n=63). Postoperatively, 34 patients with IONM alerts had neurological change from baseline. 29 patients had documented final neurological status; 21 had full recovery to baseline, 5 had partial recovery, 3 had no recovery. Among patients available for final follow-up, neurologic decline occurred in 0.15% (8/5,312) and in 3.7% (8/218) of those with intraoperative IONM alerts.
CONCLUSION
IONM alerts occurred in 4.2% of cases, most frequently at correction/following correction. Corrective actions, most commonly correction of hypotension, theoretically reduced spinal cord dysfunction from 4.2% intraoperatively, to 0.5% (29/5,312) at wake-up and 0.15% (8/5,312) at final exam. This largest single-center experience with IONM in pediatric spinal deformity surgery supports the use of a multimodal IONM, systematic alert response protocol and allows for better preoperative shared-decision making.