Analysis of 5317 Consecutive Pediatric Spinal Deformity Intraoperative Neuromonitoring (IONM) Alerts

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.