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• W2795044412 abstract "RECOMMENDATIONS Diagnostic Level I Multimodality intraoperative monitoring (MIOM), including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) recording, during spinal cord/spinal column surgery is a reliable and valid diagnostic adjunct to assess spinal cord integrity and is recommended if utilized for this purpose. MEP recordings are superior to SSEP recordings during spinal cord/spinal column surgery as diagnostic adjuncts for assessment of spinal cord integrity and are recommended if utilized for this purpose. Level II SSEP recordings during spinal cord/spinal column surgery are reliable and valid diagnostic adjuncts to describe spinal cord integrity and are recommended if utilized for this purpose. Therapeutic (Preventive) Level II MIOM, including SSEPs and MEP recording, during spinal cord/spinal column surgery does not improve gross total tumor resection or improve neurological outcome, when utilized during intramedullary tumor resection procedures (no therapeutic benefit). Level III There is insufficient evidence to suggest a therapeutic relationship between electrophysiological monitoring, including SSEP and MEP recordings, during spinal cord/spinal column surgery, and neurological outcome; its use is not recommended for this purpose. While intraoperative monitoring (IOM) may detect a neurological injury during spinal surgery, its use does not result in improved neurological outcome, even when IOM alerts occur. While IOM may be considered to be integral to the technique for lateral approaches, there is insufficient evidence to support a recommendation for or against its use as a therapeutic adjunct with respect to a reduction in iatrogenic nerve injury and/or improvement in postoperative neurological outcome. Cost Effectiveness Level III At present, there is insufficient evidence to support IOM during spinal surgery as a cost-effective measure. Due to the lack of evidence supporting IOM as an effective therapeutic adjunct, the expense of IOM and its interpretation during spinal column/spinal cord surgery may not justify its use in attempting to prevent iatrogenic spinal cord injury. RATIONALE Electrophysiological monitoring techniques allow the assessment of spinal cord sensory pathways (SSEPs), motor pathways (MEPs), and spinal root function (electromyographic potentials). Recording of these parameters after spinal cord injury or during spinal column or spinal cord operative procedures (IOM) has the potential to evaluate the integrity of the sensory and motor pathways and spinal roots in real-time fashion (diagnostic potential). Theoretically, alterations in established recordings during spinal cord/spinal column surgery implicate an impending spinal cord injury—an injury that could potentially be prevented (risk factors for injury reversed or corrected) to help assure a better outcome following surgery (therapeutic potential). A great deal has been written on the topic of electrophysiological monitoring and spinal cord function. Despite the use of phrases such as “standard of care” by some authors1,2 and professional medical subspecialty organizations,3-5 significant clinical equipoise exists, and the value of IOM during spinal surgery remains controversial. The author group (comprising 2 senior adult spine attending neurosurgeons, 1 pediatric spine attending neurosurgeon, and 1 senior resident neurosurgeon with 5 yr of training in critical appraisal of the medical literature, providing significant collective experience in clinical epidemiology, management of spinal column/spinal cord pathologies, and neurosurgical guidelines development and authorship) posed several research questions as the premise for investigation. These questions fell into 3 broad categories: diagnostic, therapeutic, and cost-effectiveness. Specifically: What is the diagnostic utility of SSEPs, MEPs, or MIOM in the setting of spinal column or spinal cord surgery? Does the use of combined monitoring (SSEPs and MEPs concurrently) offer a diagnostic advantage during spinal cord surgery? Is there a therapeutic role for IOM during spinal cord or spinal column surgery (ie, does IOM use improve patient outcomes)? What is the cost of IOM during spinal surgery, and is its use considered to be cost-effective? This review is intended to examine the medical evidence on these important topics and to generate evidence-based recommendations for the use of IOM during spinal column or spinal cord surgery. METHODOLOGY A National Library of Medicine (PubMed) computerized literature search from 1966 to 2017 was undertaken using combinations of the following keywords: spinal cord injury, spinal cord tumor, spine trauma, spinal fracture, SSEP, MEP, neurophysiological IOM. All primarily pediatric, non-English language citations, duplicate references, commentaries, letters, single-patient case reports and tangentially related articles were excluded. Titles, abstracts, and reference lists of the remaining publications were reviewed and additional citations were extracted. Finally, authors were asked to contribute articles known to them on the subject matter that were not found by other search means. The resulting publication list formed the foundation for this review. Each article's research objective, study design, methodology, results, conclusions, and study limitations were reviewed by each of the author group members. Based on these parameters, each article was classified as diagnostic, therapeutic, both diagnostic and therapeutic, or related to cost-effectiveness. The strength of the scientific evidence presented in each article was graded based on a modified North American Spine Society (NASS) criteria,6 previously used in multiple neurosurgical guidelines, including the 2013 publication “Methodology of the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries”7 (Table 1). Evidentiary tables were created to show a detailed chronology of the existing evidence addressing each of the 3 primary topics (diagnostic potential, therapeutic potential, and cost-effectiveness). The evidence was then synthesized into recommendations of Level I, II, and III, corresponding to the designated classes of evidence. Systematic reviews were included for contextual support. Their evidence was rated, but did not directly contribute to the level of recommendation. TABLE 1. - Rating Scheme for the Strength of the Evidence: Modified NASS Schema5 to Conform to Neurosurgical Criteria as Previously Published and for Ease of Understanding and Implementation: Levels of Evidence for Primary Research Questiona Class Therapeutic studies: investigating the results of treatment Diagnostic studies: investigating a diagnostic test Clinical assessment: studies of reliability and validity of observations, including clinical examination, imaging results, and classifications I High-quality randomized controlled trial with statistically significant difference or no statistically significant difference but narrow confidence intervals Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference “gold” standard) Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a κ statistic ≥ 0.60 or an intraclass correlation coefficient of ≥ 0.70 Systematic reviewb of class I randomized controlled trials (and study results were homogeneousc) Systematic reviewb of class I studies II Lesser quality randomized controlled trial (eg, <80% follow-up, no blinding, or improper randomization) Development of diagnostic criteria on consecutive patients (with universally applied reference “gold” standard) Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a κ statistic of 0.40-0.60 or an intraclass correlation coefficient of 0.50-0.70 Prospectived comparative studye Systemic reviewb of class II studies Systemic reviewb of class II studies or class I studies with inconsistent results Study of nonconsecutive patients; without consistently applied reference “gold” standard Case-control studyf Systemic reviewb of class III studies Retrospectiveg comparative studye Case-control study Systematic reviewb of class II studies III Case seriesh Poor reference standard Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a κ statistic of <0.40 or an intraclass correlation coefficient of <0.50 Expert opinion Expert opinion aA complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.bA combination of results from 2 or more prior studies.cStudies provided consistent results.dStudy was started before the first patient enrolledePatients treated 1 way (eg, halo vest orthosis) compared with a group of patients treated in another way (eg, internal fixation) at the same institution.fPatients identified for the study on the basis of their outcome, called “cases” (eg, failed fusion), are compared with those who did not have outcome, called “controls” (eg, successful fusion).gThe study was started after the first patient was enrolled.hPatients treated 1 way with no comparison group of patients treated in another way.Reprinted from Walters BC. Methodology of the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Neurosurgery, 2013;72(suppl 3):17-21,7 by permission of the Congress of Neurological Surgeons. SCIENTIFIC FOUNDATION The use of electrophysiological monitoring during spinal cord surgery has been advocated as a means of measuring the functional integrity of the spinal cord during spinal cord decompression, spinal column deformity correction, intramedullary tumor resection, and during stabilization of cervical and thoracic spinal column traumatic injury procedures. In this role, electrophysiological monitoring is a potential diagnostic adjunct during spinal surgery. MIOM of the spinal cord has also been touted as a therapeutic tool during spinal surgery to improve neurological outcome in surgically treated patients. The purpose of this evidence-based review is to quantify and evaluate the medical evidence pertaining to electrophysiological monitoring during spinal surgery of all types, both as a diagnostic adjunct and as a therapeutic tool, as well as to assess the reliability of these measures. Monitoring as a Diagnostic Adjunct During Spinal Cord/Spinal Column Surgery In 1995, Nuwer et al8 reported the results of a large survey of Scoliosis Research Society surgeons, 80% of whom reported using SSEP monitoring in 51 263 of 97 586 spine procedures. Surgeons provided outcome data on operated patients and the name of the neurophysiologist who applied and interpreted the SSEPs during the procedures. The response rate from neurophysiologists in the survey was 59%. They provided detailed SSEP technical results on the cases they monitored. In this heterogeneous compilation of self-reported series, the true-negative rate was 97.94%, true-positive rate 0.42%, false-positive rate 1.51%, and false-negative rate 0.13%. Using the raw data provided by the authors, one can calculate sensitivity and specificity of 77% and 98.5%, respectively. The authors reassigned 200 false-positive cases to the true-positive category with the assumption that those cases represented “neurological deficits prevented” by the SSEP alert and subsequent interventions. This accounts for their reported sensitivity and specificity of 92% and 98.9%; positive and negative predictive values (PPV and NPV) of 42% and 99.9%, respectively. Their analysis of survey data provides class II medical evidence for SSEP monitoring to predict acute neurological deficits following spinal surgery.8 May et al9 described the application of SSEP monitoring to 191 patients treated with cervical spinal surgery for a variety of extradural pathological conditions, including 24 patients treated for cervical spinal traumatic injuries. SSEPs were unobtainable in 9 patients with poor neurological function prior to surgery.9 They noted that SSEP changes during surgery in 33 patients. Twenty-four patients had SSEP alterations without a postoperative neurological deterioration (false positives). Nine patients had SSEP alterations during the procedure and new postoperative deficits (true positives). They described a sensitivity of 99% and a specificity of 27% for the use of SSEPs during cervical spinal surgery. False-positive recordings exceeded true-positive recordings nearly 3 to 1. They concluded that SSEP monitoring in this setting is a reliable method to monitor the cervical spinal cord (high sensitivity), but that their role remains open to debate due to low specificity. Despite the low specificity, the appropriate application of Bayesian statistics to this population of patients makes this the initial class I medical evidence study for the use of IOM as a diagnostic adjunct during surgery on the human spinal cord or spinal column. Morota et al10 reported a prospective series of 32 MEP monitored intramedullary spinal cord tumor resections (8 of which were children < 12 yr of age) assessing neurological outcomes on postoperative day 7 in relation to successful MEP monitoring and observed intraoperative deteriorations. MEP monitoring was achieved in only 19 cases (5 of which were pediatric). Successful MEP monitoring in the 14 adults was associated with a good surgical outcome (P < .05), but this did not hold true for the few children monitored. Three patients who had MEP amplitude deterioration that fell below 50% of baseline had markedly decreased motor function after surgery (paraplegia, 1 permanent). None of those whose MEP amplitude remained above 50% of baseline had significant deterioration by postoperative day 7. This report provides class II evidence for MEP monitoring as a diagnostic adjunct. In 1998, Kothbauer et al11 described a retrospective review of 100 consecutive operations performed using muscle and epidural MEP monitoring on 98 patients with intramedullary spinal cord tumors.11 Baseline MEP tracings were obtained in 93 patients, of whom 5 had amplitude decrements and/or D-wave attenuation during surgery that predicted a long-term motor deficit. Those 5 patients were paraplegic immediately after surgery but recovered quickly so were deemed false positives. No patient experienced a permanent or long-term motor deficit so there were no false negatives. Therefore, the sensitivity and specificity of MEP monitoring in this series was 91% and 100%, respectively. This analysis constitutes class II medical evidence that MEP monitoring can predict postoperative neurological function. Pelosi et al12 in 2002 reported their comparison of combined MEPs/SSEPs vs single modality spinal cord monitoring in 126 consecutive orthopedic spinal procedures in 97 patients (79 with spinal deformity; 18 with “miscellaneous spinal disorders”). Combined monitoring was achieved in 104 cases (82%), while 18 patients were monitored by a single modality: 16 with SSEPs alone, and 2 with MEPs alone. Significant changes were observed in 16 patients as defined by at least 50% reduction in amplitude or 10% increase in latency (MEPs = 15/16; SSEPs = 8/16). New neurological deficits were observed in 6 of the 16 patients with significant changes identified using combined monitoring. All patients with normal MEP tracings at the end of the case awoke free of new motor deficits. The authors concluded that combined MEP/SSEP IOM is safe, reliable, and superior to single modality IOM. This series provides class II medical evidence for combined IOM as a diagnostic modality during spinal column surgery. In 2004, Hilibrand et al13 described a retrospective review of 427 patients treated with either anterior (324 procedures), posterior (83 procedures), or combined anterior-posterior spinal surgeries (20 procedures) for a variety of pathologies performed using SSEP and transcranial MEP (TcMEP) monitoring.13 Twelve patients experienced substantial (defined as at least 60% reduction in amplitude) or complete loss of TcMEPs during surgery. The authors defined a true-positive result as either a reverse in potential loss after intraoperative intervention or a persistent loss of potential with a new postoperative neurological deficit. Ten patients had return of their TcMEP recordings to baseline and a normal postoperative neurological exam, while 2 awoke with persistent TcMEP amplitude loss and new postoperative neurological deficits. No patients experienced a new neurological deficit without a persistent loss in TcMEP recording at the end of the case. TcMEPs were considered to be both sensitive (100%) and specific (100%). SSEPs missed 9 of 12 patients defined as true positives. Of the 2 patients with a new postoperative neurological deficit, SSEP recordings were normal in 1. The loss of SSEP amplitude lagged behind the loss in TcMEP amplitude by more than 30 min in the remaining patient. The sensitivity of SSEPs in this series was 25% with a specificity of 100%. Despite a high sensitivity, the authors warn that the delay in the reduction of SSEP amplitude were clinically significant. This study provides class I medical evidence that TcMEP recordings are of value as a diagnostic means to assess cord integrity during surgery and are superior to SSEP recordings in identifying motor tract injury during cervical spinal surgery. The recording methods these authors employed for SSEP recordings eliminated the false-positive alerts previously identified and described by May et al9 (improved specificity).13 Tsirikos et al14 evaluated the efficacy of SSEP recordings during spinal reconstructive procedures following trauma (20 cervical, 8 thoracic, 6 thoracolumbar, and 48 lumbar fracture dislocation injuries). Fifty-nine patients had a depression of wave amplitude of greater than 25% during surgery; 25 had an amplitude depression of greater than 50%, and 7 had a greater than 75% diminution of wave amplitude. Four patients experienced new postoperative neurological deficits. The authors calculated that a drop of SSEP wave amplitude of 60% or greater had a sensitivity of 67% and a specificity of 81% (with 1 false negative), in predicting postoperative function. A 20% increase in SSEP amplitude from the initial baseline was positively correlated with a superior neurological prognosis (class II medical evidence). In 2006, Accadbled et al15 performed a retrospective analysis of prospectively collected IOM data using an epidural bipolar electrode to provide SSEP and neurogenic MEP recordings in 191 consecutive patients treated with surgical correction and stabilization of idiopathic and neuromuscular scoliosis. They could not obtain any recordings from 4 patients (2.1%). A true-positive alert (defined as a return of potentials to baseline after intraoperative intervention or persistent potential loss with a postoperative deficit) was identified in 5 patients. None of these patients had a new postoperative neurological deficit. They reported no false negatives. The authors provide class I medical evidence in support of the safety and validity of combined IOM recording during scoliosis surgery (sensitivity of IOM: 100%, specificity of IOM: 52.7%, PPV: 5.4%, NPV: 100%). This class I medical evidence study on IOM in scoliosis surgery has questionable relevance to patients with cervical spinal cord pathology. Khan et al16 described a retrospective review of a prospectively collected series of SSEP tracings in 508 consecutive cervical corpectomy procedures for patients with degenerative cervical disease, most commonly spondylotic cervical stenosis with myelopathy. SSEP alerts (defined as at least 50% reduction in amplitude or 10% increase in latency) were reported in 27 cases (5.3%) and 12 patients (2.4%) awoke with new motor deficits (11 nerve root injuries and 1 cord injury), corresponding to sensitivity and specificity of 77% and 100%, respectively. Irreversible SSEP changes occurred in 1 patient who awoke quadriplegic, yielding sensitivity and NPV of 100% for spinal cord injury. This series constitutes additional class II medical evidence for the diagnostic utility of SSEP recordings during cervical spinal cord surgery. In 2006, Paradiso et al17 reported their prospective experience with combined SSEP and continuous electromyography (EMG) monitoring of 44 consecutive adult patients undergoing tethered cord release surgery. Two patients had new neurological deficits postoperatively, one of which was detected by SSEPs (alert criteria defined as at least 50% reduction in amplitude). One additional patient had SSEP changes that improved following a change in the surgical strategy and had no new deficit afterwards (SSEP sensitivity = 50%, specificity = 100%). Spontaneous EMG (spEMG) activity was reliably observed in 36 cases (82%) and both patients who experienced new postoperative deficits had activation in the corresponding myotome during surgical manipulation with a sensitivity of 100% and 19% specificity for detecting new deficits. This report constitutes class I medical evidence for SSEP monitoring in tethered cord release surgery, and class II medical evidence for EMG monitoring (the diagnostic criteria for EMG were not clearly defined). In 2007, Sutter et al18 performed MIOM during the surgical treatment of 1017 consecutive patients for lumbar spinal stenosis (n = 409), cervical/thoracic stenosis (n = 282), spinal deformity (n = 217), or tumors (n = 109). MIOM included SSEP, MEP, and EMG monitoring.18 The 1017 study patients represented 9% of the 11 536 spinal surgical procedures performed at the reporting institution during the 5-yr study period. The investigators identified 935 true-negative cases, 8 false negatives, 66 true-positive cases, and 8 false positives. They calculated the sensitivity of MIOM in their experience to be 89%. The calculated specificity was 99%. The authors provide class I medical evidence on the effectiveness and reliability of electrophysiological monitoring during spinal surgery, but provide class II medical evidence on its utility to monitor the functional integrity of the spinal cord. Greater than 40% of the procedures in their series did not involve the spinal cord as the pathology treated was below the level of the conus (lumbosacral pathology). In 2007, Eggspuehler et al19 from the same institution reported the results of a prospective assessment of 246 patients treated with cervical spinal surgery who were monitored with MIOM. The majority of patients had cervical spinal stenosis and represents the cervical stenosis patients from the cohort of 1017 patients described in the prior publication of the same year by the same investigator group (same number of patients collected over same time period). Seven patients in the cervical spinal cohort had fractures/instability. They identified 232 true-negative cases, 2 false negatives, 10 true-positive cases, and 2 false positives. The authors calculated the sensitivity of MIOM for cervical spinal surgery to be 83.3%, with a specificity of 99.2%. This study provides class I medical evidence on the validity and reliability of MIOM to measure the integrity of the spinal cord during cervical spinal surgery. In the same year, MacDonald et al20 described a retrospective case series of 206 consecutive thoracolumbar spinal surgeries in which 4-limb SSEP and TcMEP recording were carried out. The majority of patients (190) were treated for scoliosis; however, an unspecified number of patients were treated for spinal pathology below the level of the conus, including 16 patients with a variety of spinal pathologies (including vertebral tumor, spondylolisthesis, spinal fracture, and iatrogenic spinal instability following laminectomy), which did not include potential spinal cord involvement/compression. They determined the sensitivity of MIOM in their series to be 70% with a specificity of 93%. TcMEP recordings were consistently more sensitive and specific than SSEPs in their study. They noted that MIOM may not accurately identify postoperative new-onset radiculopathy and delayed paraparesis. Their class I medical evidence study on patients with a variety of thoracolumbar pathologies may not be generalizable to patients with cervical spinal or spinal cord pathology. Later in 2007, Sutter et al21 described a 109 patient cohort from their original 1017 patient series who were treated for spinal/spinal cord lesions and tumors, operated upon using MIOM.21 Forty-five patients were treated for tumors of the spinal column (epidural), 41 were operated upon for intradural extramedullary (IDEM) pathology, and 23 were operated upon for intramedullary pathology, including 9 patients with syringomyelia and multiple other patients (number not specified) with lumbar or lumbosacral pathology. They described a sensitivity of 92% and a specificity of 99% for MIOM to predict the functional integrity of the spinal cord during and after surgery in this population subgroup and offer class I medical evidence on the diagnostic ability of MIOM for this purpose. Kim et al22 described a retrospective review of 52 consecutive patients who had been monitored with SSEP and TcMEP recordings during surgical procedures for symptomatic cervical myelopathy. They noted 6 major TcMEP alerts during surgery with greater than 80% loss of amplitude. There were no SSEP alerts in these patients and no patient experienced a new postoperative deficit. An additional patient had a TcMEP alert during surgery and suffered a new postoperative deficit. They determined that TcMEPs had a sensitivity of 100% and a specificity of 90% for a clinically significant spinal cord injury. SSEPs in their series had a sensitivity of 0% and a specificity of 100%. The PPV of TcMEP recording was 17%. They concluded that TcMEP recordings had superior sensitivity compared to SSEP recordings, but that a high false-positive rate existed with TcMEP recordings even in high-risk cervical myelopathy patients. Their study provides class I medical evidence on the superiority of TcMEP recordings (compared to SSEP recordings) for the diagnosis of a postoperative motor deficit following surgery for cervical myelopathy. It offers class II medical evidence on the utility of MIOM as a diagnostic adjunct for patients with cervical spinal pathology, due to the limited number of patients evaluated with a single pathology. In 2008, Kelleher et al23 published a prospective analysis of 1055 consecutive patients treated with cervical spinal surgery for a variety of spinal/spinal cord pathologies in which IOM was used. All patients received SSEP monitoring; 427 had EMG recordings in addition to SSEP monitoring. Only 26 patients were monitored with the combination of SSEP, TcMEP, and EMG recordings. Twenty-six patients had significant SSEP changes. EMG activity was transient in 212 patients and 115 patients had burst or train activity. New postoperative neurological deficits were identified in 34 patients (3.2%). Seven had new sensory deficits, 6 had new motor and sensory deficits, 9 had new/increased motor deficits, and 12 had new root deficits. Nine patients in their series experienced new cord injuries that were not detected by IOM; 3 of these patients with new motor deficits were monitored with TcMEP recordings. The authors calculated the sensitivity, specificity, PPV, and NPV values for SSEPs (52%, 100% 100%, 97%), TcMEPs (100%, 96%, 96%, 100%), and EMG recordings (46%, 73%, 3%, 97%) in their study. The authors23 concluded that IOM with SSEP and EMG recording and the selective use of TcMEPs are helpful for “predicting and possibly preventing neurological injury during cervical spinal surgery.” Their report offers class I medical evidence on the ability of MIOM to measure the functional integrity of the spinal cord and to predict neurological outcome following cervical spinal surgery. Their study provides class II medical evidence on the comparative value of the 3 different monitoring modalities they employed. Less than half of the patients were monitored with combined IOM techniques (n = 427). Only 26 patients, considered high risk by the authors, were monitored with all 3 modalities including TcMEP recordings. The data provided in the above table are “overall” values for each recording modality, not the respective values of each modality when all 3 were used together (n = 26). This form of reporting does not allow a true comparison of SSEP, TcMEP, and EMG monitoring (respectively) and therefore weakens the strength of the medical evidence provided on this issue. The authors provided no evidence on the therapeutic ability of IOM to prevent neurological injury.23 The following year, Quraishi et al24 reported an analysis of 102 prospectively collected adult spinal deformity correction procedures performed with MIOM who were independently evaluated for new postoperative neurological deficits. SSEP recordings were monitored in 101 patients, magnetoencephalography (MEG) in 89 patients, and MEPs in 12 patients. Using the independent postoperative neurological exam as the gold standard, combined MIOM sensitivity and specificity were 100% and 84.3%, respectively (PPV = 13.9%; NPV = 97%). Narrowing the focus to those patients treated with a high-risk procedure (defined as major deformity corrective surgery requiring 1 or more osteotomies; n = 32), the results of MIOM were as follows: sensitivity and specificity 67% and 98%; PPV = 80% and NPV = 96%. This well-designed, controlled study offers class I medical evidence on the reliability of MIOM for the detection of intraoperative spinal cord injury. In 2010, Fehlings et al25 offered a systematic review of the literature on IOM recordings during s" @default.
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• W2795044412 date "2017-09-27" @default.
• W2795044412 modified "2023-10-18" @default.
• W2795044412 title "Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord" @default.
• W2795044412 cites W1516465994 @default.
• W2795044412 cites W1545389719 @default.
• W2795044412 cites W1577209660 @default.
• W2795044412 cites W1593410573 @default.
• W2795044412 cites W1691161514 @default.
• W2795044412 cites W1921896658 @default.
• W2795044412 cites W1925167047 @default.
• W2795044412 cites W1965133455 @default.
• W2795044412 cites W1967670096 @default.
• W2795044412 cites W1968483438 @default.
• W2795044412 cites W1969111342 @default.
• W2795044412 cites W1969764019 @default.
• W2795044412 cites W1971161168 @default.
• W2795044412 cites W1972432357 @default.
• W2795044412 cites W1975020816 @default.
• W2795044412 cites W1975566930 @default.
• W2795044412 cites W1992607106 @default.
• W2795044412 cites W1993775529 @default.
• W2795044412 cites W1995266498 @default.
• W2795044412 cites W1998126328 @default.
• W2795044412 cites W1998431777 @default.
• W2795044412 cites W2006113712 @default.
• W2795044412 cites W2008326124 @default.
• W2795044412 cites W2010927263 @default.
• W2795044412 cites W2020190388 @default.
• W2795044412 cites W2021672445 @default.
• W2795044412 cites W2023637448 @default.
• W2795044412 cites W2023641392 @default.
• W2795044412 cites W2025135473 @default.
• W2795044412 cites W2026622796 @default.
• W2795044412 cites W2027401309 @default.
• W2795044412 cites W2028886154 @default.
• W2795044412 cites W2040636420 @default.
• W2795044412 cites W2042693004 @default.
• W2795044412 cites W2052620766 @default.
• W2795044412 cites W2053789134 @default.
• W2795044412 cites W2055094942 @default.
• W2795044412 cites W2056360153 @default.
• W2795044412 cites W2056942081 @default.
• W2795044412 cites W2057425375 @default.
• W2795044412 cites W2059181291 @default.
• W2795044412 cites W2059277632 @default.
• W2795044412 cites W2060656538 @default.
• W2795044412 cites W2064269328 @default.
• W2795044412 cites W2069215448 @default.
• W2795044412 cites W2069302603 @default.
• W2795044412 cites W2071226587 @default.
• W2795044412 cites W2071274510 @default.
• W2795044412 cites W2072945487 @default.
• W2795044412 cites W2078842442 @default.
• W2795044412 cites W2083391148 @default.
• W2795044412 cites W2084237330 @default.
• W2795044412 cites W2084385880 @default.
• W2795044412 cites W2084544316 @default.
• W2795044412 cites W2089214286 @default.
• W2795044412 cites W2090527761 @default.
• W2795044412 cites W2091215889 @default.
• W2795044412 cites W2092357510 @default.
• W2795044412 cites W2096729080 @default.
• W2795044412 cites W2111235924 @default.
• W2795044412 cites W2111673073 @default.
• W2795044412 cites W2126871121 @default.
• W2795044412 cites W2127723339 @default.
• W2795044412 cites W2156187592 @default.
• W2795044412 cites W2167832240 @default.
• W2795044412 cites W2169497366 @default.
• W2795044412 cites W2171435078 @default.
• W2795044412 cites W2291188318 @default.
• W2795044412 cites W2313297803 @default.
• W2795044412 cites W2313651735 @default.
• W2795044412 cites W2314751695 @default.
• W2795044412 cites W2324365750 @default.
• W2795044412 cites W2326330812 @default.
• W2795044412 cites W2328282525 @default.
• W2795044412 cites W2328755358 @default.
• W2795044412 cites W2334351502 @default.
• W2795044412 cites W2340475313 @default.
• W2795044412 cites W2346135278 @default.
• W2795044412 cites W2462189551 @default.
• W2795044412 cites W2580499768 @default.
• W2795044412 doi "https://doi.org/10.1093/neuros/nyx466" @default.
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