Mirza BİSCEVİC, Aida SEHİC, Sejla BİSCEVİC, Ismet GAVRANKAPETANOVİC, Barbara SMRKE, Damir VUKOMANOVİC, Ferid KRUPİC

Kyphosis e A risk factor for positioning brachial plexopathy during spinal surgeries

Objective: The aim of this study was to evaluate the differences in transcranial electric motor-evoked potentials e TceMEP on upper limbs and the incidences of postoperative brachial plexopathy between patients with kyphotic and scoliotic trunk shapes. Methods: In the period of January 2011eJanuary 2017, 61 consecutive patients (mean age: 18.4 years ± 4.4 years (range: 10e32)) with pediatric spinal deformity underwent surgery in our Department. Eight of them had a kyphotic trunk deformity (Scheuermann kyphosis, neuroﬁbromatosis, posterior thoracic hemivertebra), and the restof the 53 patients had a scoliotic trunk deformity (mostlyadolescent idiopathic scoliosis e AIS, lateral hemivertebra). The TceMEP recordings in all four limbs were analyzed every 30 min, or upon the surgeon's command. Upper limb TceMEP recordings were used as a control of systemic and anesthetic related changes, and as the indicator of positioning brachial plexopathy. Results: Four out of 8 patients (50.0%) from the kyphotic group experienced noteworthy decreases in TceMEP amplitude (65%) in one or both arms, and only 2 out of 53 patients (3.8%) from the scoliotic group, conﬁrming signiﬁcant statistical difference (Chi-square 16.75, p < 0.05). Two out of 8 patients with decreases in TceMEP amplitude suffered from transitory postoperative brachial plexopathy, and both of them were from the kyphotic group. Conclusion: It seems that kyphotic trunks have a higher risk for positioning-related brachial plexopathy, probably due to distribution of trunk's weight onto only four points (two iliac bones and two shoulders), compared to the scoliotic trunks that have wider weight-bearing areas. We emphasize the importance of proper patient positioning and close intraoperative neuro-monitoring of all four limbs in more than one channel per limb.

___

Salkind EM. A novel approach to improving the safety of patients undergoing lumbar laminectomy. AANA J. 2013;81(5):389e393.

Hazarika A, Rath GP. Modiﬁed prone positioning for dorsal spine surgery in a patient with postural deformity due to spasticity of lower limbs. J Clin Anesth. 2014;26(7):582e584.

Kamel I, Barnette R. Positioning patients for spine surgery: avoiding uncommon position-related complications. World J Orthop. 2014;5(4):425e443.

Biscevic M, Biscevic S, Ljuca F, et al. Motor evoked potentials in 43 high risk spine deformities. Med Arh. 2014;68(5):345e349.

Calancie B. Intraoperative neuromonitoring and alarm criteria for judging MEP responses to transcranial electric stimulation: the threshold-level method. J Clin Neurophysiol. 2017;34(1):12e21.

Langeloo DD, Lelivelt A, Louis Journee H, et al. Transcranial electrical motorevoked potential monitoring during surgery for spinal deformity: a study of 145 patients. Spine. 2003;28(10):1043e1050.

Berends HI, Journee HL. Inﬂuence of the montage of stimulation electrodes for intraoperative neuromonitoring during orthopedic spine surgery. J Clin Neurophysiol. 2018;35(5):419e425.

Vialle LR. The incidence and management of acute neurologic complications following complex adult spinal deformity surgery. In: AO Spine Masters Series e Adult Spinal Deformities. vol. 4. New York: Thieme Medical Publishers; 2015: 68e77.

Qiu Y, Wang S, Wang B, et al. Incidence and risk factors of neurological deﬁcits of surgical correction for scoliosis: analysis of 1373 cases at one Chinese institution. Spine. 2008;33(5):519e526.

MacEwen GD, Bunnell WP, Sriram K. Acute neurological complications in the treatment of scoliosis. A report of the Scoliosis Research Society. J Bone Joint Surg Am. 1975;57(3):404e408.

Labrom RD, Hoskins M, Reilly CW, et al. Clinical usefulness of somatosensory evoked potentials for detection of brachial plexopathy secondary to malpositioning in scoliosis surgery. Spine. 2005;30(18):2089e2093.

Schwartz DM, Drummond DS, Hahn M, et al. Prevention of positional brachial plexopathy during surgical correction of scoliosis. J Spinal Disord. 2000;13(2): 178e182.

Chung I, Glow JA, Dimopoulos V, et al. Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury. Spine J. 2009;9(4):287e295.

Uribe JS, Kolla J, Omar H, et al. Brachial plexus injury following spinal surgery. J Neurosurg Spine. 2010;13(4):552e558.

Duffy BJ, Tubog TD. The prevention and recognition of ulnar nerve and brachial plexus injuries. J Perianesth Nurs. 2017;32(6):636e649.

Ying T, Wang X, Sun H, et al. Clinical usefulness of somatosensory evoked potentials for detection of peripheral nerve and brachial plexus injury secondary to malpositioning in microvascular decompression. J Clin Neurophysiol. 2015;32(6):512e517.

Bjerke BT, Zuchelli DM, Nemani MV, et al. Prognosis of signiﬁcant intraoperative neurophysiologic monitoring events in severe spinal deformity surgery. Spine Deform. 2017;5(2):117e123.