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Intraoperative Multimodal Monitoring in Pedicle Subtraction Osteotomies of the Lumbar Spine

A Narrative Literature Review

Shao, Jianning BA*,†; Lee, Bryan S. MD; Pelle, Dominic MD§; Lee, Maxwell Y. BS*,†; Savage, Jason MD§; Tanenbaum, Joseph E. BA, PhD; Mroz, Thomas E. MD§; Steinmetz, Michael P. MD‡,§

doi: 10.1097/BSD.0000000000000740

The use of intraoperative multimodal monitoring (IOM) in spinal deformity surgeries is well documented. In particular, pedicle subtraction osteotomy (PSO), a corrective procedure for sagittal deformity of the spine, often involves IOM usage. By providing immediate feedback to the operating surgeon, IOM has the potential to eliminate or at least minimize the risk of iatrogenic neurological injury. However, despite the widespread usage of IOM, there is currently no standardization of IOM usage in complex spine surgeries, including lumbar PSOs, and decisions concerning IOM utilization are often driven by surgeon experience and preference. This creates a state of clinical equipoise, which is further complicated by the varying degrees of benefit that IOM has on patient outcomes depending on the operation and spinal levels involved. For instance, while IOM use in thoracic PSOs has been shown to be effective, there is no established consensus on the net impact of IOM use in PSOs of the lumbar spine. Although IOM has the potential to mitigate neurological damage, it also increases operation time and cost; thus, it should only be used in operations where it will have a net positive impact on patient outcomes. The question thus becomes whether PSO of the lumbar spine is one such operation. To address this, we examine the most frequently used IOM modalities and evaluate their current usage and efficacy in lumbar PSOs. Furthermore, we will also examine the utility of IOM for other surgeries of the lumbar spine, including corrective procedures for idiopathic scoliosis and degenerative scoliosis, and routine lumbar procedures, such as discectomies and decompression surgeries for foraminal and canal stenosis.

*Cleveland Clinic Lerner College of Medicine

Case Western School of Medicine, Case Western Reserve University

Department of Neurosurgery

§Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, OH

M.P.S.: royalties—Elsevier, Zimmer Biomet; consulting—Globus Medical, Intellirod; honorarium—Globus Medical, Stryker; research support—Globus Medical. T.E.M.: consulting—Globus Medical. J.S.: clinical spine surgery—editorial or governing board; consultant—Stryker. The remaining authors declare no conflict of interest.

Reprints: Jianning Shao, BA, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9980 Carnegie Ave., Cleveland, OH 44195 (e-mail:

Received November 30, 2017

Accepted October 1, 2018

© 2019 by Lippincott Williams & Wilkins, Inc.