Efficacy and safety for combination of t-EMG with O-arm assisted pedicle screw placement in neurofibromatosis type I scoliosis surgery

Due to the characteristics of neurofibromatosis type I (NF-1) scoliosis, the precise placement of pedicle screws still remains to be a challenge. Triggered screw electromyography (t-EMG) has been proved to exhibit high sensitivity to identify mal-positioned pedicle screws, but no previous study assessed the combination of t-EMG with O-arm-assisted pedicle screw placement in NF-1 scoliosis surgery. To evaluate efficacy and safety for combination of t-EMG with O-arm-assisted pedicle screw placement in NF-1 scoliosis surgery. From March 2018 to April 2020, sixty-five NF-1 scoliosis patients underwent t-EMG and O-arm-assisted pedicle screw fixation were retrospectively reviewed. The channel classification system was applied to classify the pedicle morphology based on pedicle width measurement by preoperative computed tomography scans. The minimal t-EMG threshold for screw path inspection was used as 8 mA, and operative screw redirection was also recorded. All pedicle screws were verified using a second intraoperative O-arm scan. The correlation between demographic and clinical data with amplitude of t-EMG were also analyzed. A total of 652 pedicle screws (T10-S1) in 65 patients were analyzed. The incidence of an absent pedicle (channel classification type C or D morphology) was 150 (23%). Overall, abnormal t-EMG threshold was identified in 26 patients with 48 screws (7.4%), while 16 out of the 48 screws were classified as G0, 14 out of the 48 screws were classified as G1, and 18 out of the 48 screws were classified as G2. The screw redirection rate was 2.8% (18/652). It showed that t-EMG stimulation detected 3 unacceptable mal-positioned screws in 2 patients (G2) which were missed by O-arm scan. No screw-related neurological or vascular complications were observed. Combination of t-EMG with O-arm-assisted pedicle screw placement was demonstrated to be a safe and effective method in NF-1 scoliosis surgery. The t-EMG could contribute to detecting the rupture of the medial wall which might be missed by O-arm scan. Combination of t-EMG with O-arm could be recommended for routine use of screw insertion in NF-1 scoliosis surgery.