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Impact of Intraoperative Neuromonitoring Alert Resolution on Motor Deficits and Short-Term Outcomes After Spine Fusion.

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Title: Impact of Intraoperative Neuromonitoring Alert Resolution on Motor Deficits and Short-Term Outcomes After Spine Fusion.
Authors: Olson J; From the Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA ., Dalton JF, Martinazzi B, Giakas A, Lee Y, Mathew J, Narayanan R, Tarawneh O, Oris RJ, Herczeg C, Baidya J, Huang R, Ng M, Baek G, Green WA, Eichbaum Y, Hitchner M, Witt L, Hammelef E, Middleton CJ, Patel K, Uvarov E, McCurdy M, Kaye ID, Cha TD, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK
Source: The Journal of the American Academy of Orthopaedic Surgeons [J Am Acad Orthop Surg] 2026 Sep 15; Vol. 34 (18), pp. e2504-e2512. Date of Electronic Publication: 2025 Dec 30.
Publication Type: Journal Article
Language: English
Journal Info: Publisher: Wolters Kluwer Country of Publication: United States NLM ID: 9417468 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1940-5480 (Electronic) Linking ISSN: 1067151X NLM ISO Abbreviation: J Am Acad Orthop Surg Subsets: MEDLINE
Imprint Name(s): Publication: 2016- : Philadelphia : Wolters Kluwer
Original Publication: Rosemont, IL : American Academy of Orthopaedic Surgeons, c1993-
MeSH Terms: Spinal Fusion*/adverse effects , Intraoperative Neurophysiological Monitoring*/methods , Postoperative Complications*/prevention & control , Postoperative Complications*/etiology, Humans ; Female ; Male ; Middle Aged ; Aged ; Retrospective Studies ; Adult ; Treatment Outcome
Abstract: Introduction: Intraoperative neurophysiologic monitoring (IONM) is commonly used during spinal surgery to track nerve function, with alerts indicating reduced nerve output and input. While IONM allows for surgical adjustments to mitigate nerve damage, its precise indications, effectiveness, and interpretation of alerts remain debated. Therefore, this study investigated the effect of IONM alert resolution on postoperative outcomes.
Methods: All adult patients who underwent spinal fusion with IONM and experienced an alert in 2017 at a single tertiary center were included. Patients who experienced mortality or had incomplete physical examination documentation were excluded. Postoperative weakness/deficit was defined as a decrease of ≥1 point on a five-point motor strength scale at either immediate postoperative or 2-week follow-up compared with preoperative strength. Deficits were categorized as immediate only, persistent, or de novo (appearing at 2 weeks). IONM alert resolution was graded as full (return to baseline), partial (improvement but no return to baseline), or no resolution. Statistical analysis used Kruskal-Wallis tests (alpha = 0.05).
Results: Our study included 115 patients, categorized by alert resolution: no resolution (n = 20), partial resolution (n = 22), and full resolution (n = 73). The partial and full resolution groups had higher cervical region involvement (86.4% and 67.1% vs. 25.0%, P < 0.001) compared with the no-resolution group. Otherwise, demographic characteristics were similar across groups. Notably, the degree of alert resolution was not associated with the rate, timing, or eventual resolution of postoperative motor deficits. Complications, length of stay, discharge disposition, and 90-day emergency department visits and readmissions were similar across groups.
Conclusion: Despite its frequent use in spine surgery, our findings suggest that the resolution of an IONM alert may not reliably predict the presence, timing, or reversibility of postoperative motor deficits. This suggests that neurologic injury, once indicated, may be more persistent than intraoperative monitoring alone can convey.
(Copyright © 2025 by the American Academy of Orthopaedic Surgeons.)
References: Kos N, Gradisnik L, Velnar T: A brief review of the degenerative intervertebral disc disease. Med Arch 2019;73:421-424.
Weinstein JN, Tosteson TD, Lurie JD, et al.; SPORT Investigators: Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008;358:794-810.
Zaina F, Tomkins-Lane C, Carragee E, Negrini S: Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev 2016;2016:CD010264.
Youssef JA, Heiner AD, Montgomery JR, et al.: Outcomes of posterior cervical fusion and decompression: A systematic review and meta-analysis. Spine J 2019;19:1714-1729.
Singh M, Balmaceno-Criss M, Anderson G, et al.: Anterior cervical discectomy and fusion versus cervical disc arthroplasty: An epidemiological review of 433,660 surgical patients from 2011 to 2021. Spine J 2024;24:1342-1351.
Gornet MF, Lanman TH, Burkus JK, et al.: Two-level cervical disc arthroplasty versus anterior cervical discectomy and fusion: 10-year outcomes of a prospective, randomized investigational device exemption clinical trial. J Neurosurg Spine 2019;31:508-518.
Hijji FY, Narain AS, Bohl DD, et al.: Lateral lumbar interbody fusion: A systematic review of complication rates. Spine J 2017;17:1412-1419.
Gadjradj PS, Basilious M, Goldberg JL, et al.: Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: A systematic review and meta-analysis. Eur Spine J 2023;32:1054-1067.
Reddy RP, Chang R, Rosario BP, et al.: What is the predictive value of intraoperative somatosensory evoked potential monitoring for postoperative neurological deficit in cervical spine surgery?-a meta-analysis. Spine J 2021;21:555-570.
Lall RR, Lall RR, Hauptman JS, et al.: Intraoperative neurophysiological monitoring in spine surgery: Indications, efficacy, and role of the preoperative checklist. Neurosurg Focus 2012;33:E10.
Wong AK, Shils JL, Sani SB, Byrne RW: Intraoperative neuromonitoring. Neurol Clin 2022;40:375-389.
Skinner S, Guo L: Intraoperative neuromonitoring during surgery for lumbar stenosis. Handb Clin Neurol 2022;186:205-227.
Nuwer MR, Dawson EG, Carlson LG, Kanim LE, Sherman JE: Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: Results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 1995;96:6-11.
Fehlings MG, Brodke DS, Norvell DC, Dettori JR: The evidence for intraoperative neurophysiological monitoring in spine surgery: Does it make a difference? Spine 2010;35:S37-S46.
Gonzalez AA, Jeyanandarajan D, Hansen C, Zada G, Hsieh PC: Intraoperative neurophysiological monitoring during spine surgery: A review. Neurosurg Focus 2009;27:E6.
Mundis GM, Record NC, Shahidi B, et al.: Incidence of postoperative neurological deficit with the use of an intraoperative neuromonitoring protocol for lateral lumbar interbody fusion. J Neurosurg Spine 2024;40:162-168.
Alluri R, Mok JK, Vaishnav A, et al.: Intraoperative neuromonitoring during lateral lumbar interbody fusion. Neurospine 2021;18:430-436.
Farooq J, Pressman E, Elsawaf Y, McBride P, Alikhani P: Prevention of neurological deficit with intraoperative neuromonitoring during anterior lumbar interbody fusion. Clin Spine Surg 2022;35:E351-E355.
Nie JW, Hartman TJ, Zheng E, MacGregor KR, Oyetayo OO, Singh K: Neuromonitoring in lateral approaches for lumbar interbody fusion: A systematic review. World Neurosurg 2022;168:268-277.e1.
Blumenthal SL, Edionwe JI, Courtois EC, Guyer RD, Satin AM, Ohnmeiss DD: Is the use of intraoperative neuromonitoring justified during lumbar anterior approach surgery? Int J Spine Surg 2024;18:217-221.
Daniel JW, Botelho RV, Milano JB, et al.: Intraoperative neurophysiological monitoring in spine surgery: A systematic review and meta-analysis. Spine 2018;43:1154-1160.
Clark AJ, Safaee M, Chou D, et al.: Comparative sensitivity of intraoperative motor evoked potential monitoring in predicting postoperative neurologic deficits: Nondegenerative versus degenerative myelopathy. Glob Spine J 2016;6:452-458.
Bhalodia VM, Schwartz DM, Sestokas AK, et al.: Efficacy of intraoperative monitoring of transcranial electrical stimulation-induced motor evoked potentials and spontaneous electromyography activity to identify acute-versus delayed-onset C-5 nerve root palsy during cervical spine surgery: Clinical article. J Neurosurg Spine 2013;19:395-402.
Alvi MA, Kwon BK, Hejrati N, et al.: Accuracy of intraoperative neuromonitoring in the diagnosis of intraoperative neurological decline in the setting of spinal surgery—A systematic review and meta-analysis. Glob Spine J 2024;14:105S-149S.
Kim DH, Zaremski J, Kwon B, et al.: Risk factors for false positive transcranial motor evoked potential monitoring alerts during surgical treatment of cervical myelopathy. Spine 2007;32:3041-3046.
Lee JY, Hilibrand AS, Lim MR, et al.: Characterization of neurophysiologic alerts during anterior cervical spine surgery. Spine 2006;31:1916-1922.
Skinner S, Holdefer R, McAuliffe JJ, Sala F: Medical error avoidance in intraoperative neurophysiological monitoring: The communication imperative. J Clin Neurophysiol 2017;34:477-483.
Tamkus AA, Rice KS, Kim HL: Differential rates of false-positive findings in transcranial electric motor evoked potential monitoring when using inhalational anesthesia versus total intravenous anesthesia during spine surgeries. Spine J 2014;14:1440-1446.
Nunes RR, Bersot CDA, Garritano JG: Intraoperative neurophysiological monitoring in neuroanesthesia. Curr Opin Anaesthesiol 2018;31:532-538.
Gunter A, Ruskin KJ: Intraoperative neurophysiologic monitoring: Utility and anesthetic implications. Curr Opin Anaesthesiol 2016;29:539-543.
Kobayashi K, Imagama S, Yoshida G, et al.: Efficacy of intraoperative intervention following transcranial motor-evoked potentials alert during posterior decompression and fusion surgery for thoracic ossification of the posterior longitudinal ligament: A prospective multicenter study of the monitoring committee of the Japanese society for spine surgery and related research. Spine 2021;46:268-276.
Zelenty WD, Paek S, Dodo Y, et al.: Utilization trends of intraoperative neuromonitoring for anterior cervical discectomy and fusion in New York State. Spine 2023;48:492-500.
Koffie RM, Morgan CD, Giraldo JP, et al.: Should somatosensory and motor evoked potential monitoring be used routinely in all posterior cervical operations for degenerative conditions of the cervical spine? World Neurosurg 2022;162:e86-e90.
Austerman RJ, Sulhan S, Steele WJ, Sadrameli SS, Holman PJ, Barber SM: The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample. J Spine Surg (Hong Kong) 2021;7:132-140.
Ajiboye RM, Zoller SD, Sharma A, et al.: Intraoperative neuromonitoring for anterior cervical spine surgery: What is the evidence? Spine 2017;42:385-393.
Krause KL, Cheaney Ii B, Obayashi JT, Kawamoto A, Than KD: Intraoperative neuromonitoring for one-level lumbar discectomies is low yield and cost-ineffective. J Clin Neurosci 2020;71:97-100.
Halsey MF, Myung KS, Ghag A, Vitale MG, Newton PO, de Kleuver M: Neurophysiological monitoring of spinal cord function during spinal deformity surgery: 2020 SRS neuromonitoring information statement. Spine Deform 2020;8:591-596.
Bible JE, Goss M: To use or not use intraoperative neuromonitoring: Utilization of neuromonitoring during spine surgeries and associated conflicts of interest, a cross-sectional survey study. J Am Acad Orthop Surg Glob Res Rev 2022;6:e21.00273.
Konopka JA, Grabel ZJ, Segal DN, Rhee JM: Intraoperative neuromonitoring use patterns in degenerative, nondeformity cervical Spine Surgery: A survey of the cervical spine research Society. Clin Spine Surg 2021;34:E160-E165.
Entry Date(s): Date Created: 20260626 Date Completed: 20260904 Latest Revision: 20260904
Update Code: 20260905
DOI: 10.5435/JAAOS-D-25-00907
PMID: 42357864
Database: MEDLINE
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DbLabel: MEDLINE
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  Data: Introduction: Intraoperative neurophysiologic monitoring (IONM) is commonly used during spinal surgery to track nerve function, with alerts indicating reduced nerve output and input. While IONM allows for surgical adjustments to mitigate nerve damage, its precise indications, effectiveness, and interpretation of alerts remain debated. Therefore, this study investigated the effect of IONM alert resolution on postoperative outcomes.&lt;br /&gt;Methods: All adult patients who underwent spinal fusion with IONM and experienced an alert in 2017 at a single tertiary center were included. Patients who experienced mortality or had incomplete physical examination documentation were excluded. Postoperative weakness/deficit was defined as a decrease of ≥1 point on a five-point motor strength scale at either immediate postoperative or 2-week follow-up compared with preoperative strength. Deficits were categorized as immediate only, persistent, or de novo (appearing at 2 weeks). IONM alert resolution was graded as full (return to baseline), partial (improvement but no return to baseline), or no resolution. Statistical analysis used Kruskal-Wallis tests (alpha = 0.05).&lt;br /&gt;Results: Our study included 115 patients, categorized by alert resolution: no resolution (n = 20), partial resolution (n = 22), and full resolution (n = 73). The partial and full resolution groups had higher cervical region involvement (86.4% and 67.1% vs. 25.0%, P &amp;lt; 0.001) compared with the no-resolution group. Otherwise, demographic characteristics were similar across groups. Notably, the degree of alert resolution was not associated with the rate, timing, or eventual resolution of postoperative motor deficits. Complications, length of stay, discharge disposition, and 90-day emergency department visits and readmissions were similar across groups.&lt;br /&gt;Conclusion: Despite its frequent use in spine surgery, our findings suggest that the resolution of an IONM alert may not reliably predict the presence, timing, or reversibility of postoperative motor deficits. This suggests that neurologic injury, once indicated, may be more persistent than intraoperative monitoring alone can convey.&lt;br /&gt; (Copyright &#169; 2025 by the American Academy of Orthopaedic Surgeons.)
– Name: Ref
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  Data: Kos N, Gradisnik L, Velnar T: A brief review of the degenerative intervertebral disc disease. Med Arch 2019;73:421-424.&lt;br /&gt;Weinstein JN, Tosteson TD, Lurie JD, et al.; SPORT Investigators: Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008;358:794-810.&lt;br /&gt;Zaina F, Tomkins-Lane C, Carragee E, Negrini S: Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev 2016;2016:CD010264.&lt;br /&gt;Youssef JA, Heiner AD, Montgomery JR, et al.: Outcomes of posterior cervical fusion and decompression: A systematic review and meta-analysis. Spine J 2019;19:1714-1729.&lt;br /&gt;Singh M, Balmaceno-Criss M, Anderson G, et al.: Anterior cervical discectomy and fusion versus cervical disc arthroplasty: An epidemiological review of 433,660 surgical patients from 2011 to 2021. Spine J 2024;24:1342-1351.&lt;br /&gt;Gornet MF, Lanman TH, Burkus JK, et al.: Two-level cervical disc arthroplasty versus anterior cervical discectomy and fusion: 10-year outcomes of a prospective, randomized investigational device exemption clinical trial. J Neurosurg Spine 2019;31:508-518.&lt;br /&gt;Hijji FY, Narain AS, Bohl DD, et al.: Lateral lumbar interbody fusion: A systematic review of complication rates. Spine J 2017;17:1412-1419.&lt;br /&gt;Gadjradj PS, Basilious M, Goldberg JL, et al.: Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: A systematic review and meta-analysis. Eur Spine J 2023;32:1054-1067.&lt;br /&gt;Reddy RP, Chang R, Rosario BP, et al.: What is the predictive value of intraoperative somatosensory evoked potential monitoring for postoperative neurological deficit in cervical spine surgery?-a meta-analysis. Spine J 2021;21:555-570.&lt;br /&gt;Lall RR, Lall RR, Hauptman JS, et al.: Intraoperative neurophysiological monitoring in spine surgery: Indications, efficacy, and role of the preoperative checklist. Neurosurg Focus 2012;33:E10.&lt;br /&gt;Wong AK, Shils JL, Sani SB, Byrne RW: Intraoperative neuromonitoring. Neurol Clin 2022;40:375-389.&lt;br /&gt;Skinner S, Guo L: Intraoperative neuromonitoring during surgery for lumbar stenosis. Handb Clin Neurol 2022;186:205-227.&lt;br /&gt;Nuwer MR, Dawson EG, Carlson LG, Kanim LE, Sherman JE: Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: Results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 1995;96:6-11.&lt;br /&gt;Fehlings MG, Brodke DS, Norvell DC, Dettori JR: The evidence for intraoperative neurophysiological monitoring in spine surgery: Does it make a difference? Spine 2010;35:S37-S46.&lt;br /&gt;Gonzalez AA, Jeyanandarajan D, Hansen C, Zada G, Hsieh PC: Intraoperative neurophysiological monitoring during spine surgery: A review. Neurosurg Focus 2009;27:E6.&lt;br /&gt;Mundis GM, Record NC, Shahidi B, et al.: Incidence of postoperative neurological deficit with the use of an intraoperative neuromonitoring protocol for lateral lumbar interbody fusion. J Neurosurg Spine 2024;40:162-168.&lt;br /&gt;Alluri R, Mok JK, Vaishnav A, et al.: Intraoperative neuromonitoring during lateral lumbar interbody fusion. Neurospine 2021;18:430-436.&lt;br /&gt;Farooq J, Pressman E, Elsawaf Y, McBride P, Alikhani P: Prevention of neurological deficit with intraoperative neuromonitoring during anterior lumbar interbody fusion. Clin Spine Surg 2022;35:E351-E355.&lt;br /&gt;Nie JW, Hartman TJ, Zheng E, MacGregor KR, Oyetayo OO, Singh K: Neuromonitoring in lateral approaches for lumbar interbody fusion: A systematic review. World Neurosurg 2022;168:268-277.e1.&lt;br /&gt;Blumenthal SL, Edionwe JI, Courtois EC, Guyer RD, Satin AM, Ohnmeiss DD: Is the use of intraoperative neuromonitoring justified during lumbar anterior approach surgery? Int J Spine Surg 2024;18:217-221.&lt;br /&gt;Daniel JW, Botelho RV, Milano JB, et al.: Intraoperative neurophysiological monitoring in spine surgery: A systematic review and meta-analysis. Spine 2018;43:1154-1160.&lt;br /&gt;Clark AJ, Safaee M, Chou D, et al.: Comparative sensitivity of intraoperative motor evoked potential monitoring in predicting postoperative neurologic deficits: Nondegenerative versus degenerative myelopathy. Glob Spine J 2016;6:452-458.&lt;br /&gt;Bhalodia VM, Schwartz DM, Sestokas AK, et al.: Efficacy of intraoperative monitoring of transcranial electrical stimulation-induced motor evoked potentials and spontaneous electromyography activity to identify acute-versus delayed-onset C-5 nerve root palsy during cervical spine surgery: Clinical article. 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              Text: 2026 Sep 15
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