Journal of pediatric orthopedics · 2026
Are We Getting What We Ask For: Few Patients Meet Mean Arterial Pressure (MAP) Goals After Intraoperative Neuromonitoring (IONM) Changes During Pediatric Spine Surgery.
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O'Connor Michaela J, Brown Michael W, Elfilali Mehdi M, Park Alexander M, Bomback Miles J, Williams Erik D, Choi Joshua, Coury Josephine R, Lenke Lawrence G, Roye Benjamin D, Vitale Michael G
Аннотация
BACKGROUND: Hypotension is a critical, modifiable risk factor for neurological deficit in spine surgery. Patients with intraoperative neurophysiological monitoring (IONM) changes are particularly vulnerable, as their spinal cord has already demonstrated sensitivity to correction, and hypotension may exacerbate areas of inadequate perfusion. These patients are admitted postoperatively to the ICU for close neurological and hemodynamic monitoring. This study evaluated adherence to patient-specific mean arterial pressure (MAP) goals in the first 24 hours following IONM changes.
METHODS: A retrospective review of patients undergoing spinal surgery with IONM changes between 2023 and 2025 at a single institution was conducted. Demographic and radiographic data were documented. Individual 24-hour postoperative "Target MAP" goals were established. Arterial line MAP values were collected. Hypotension was defined as MAP <5th percentile for age-based norms.
RESULTS: Twenty-one patients [12 female, 9 male; mean age 14.3±2.6 y (range: 7.7 to 19.0)] with IONM changes during pediatric deformity surgery were included. Etiologies included 8 idiopathic, 6 neuromuscular, 5 congenital, and 2 syndromic patients. Of those with major coronal deformities (n=19), mean preoperative and postoperative major curves were 79±22 degrees (range: 40 to 120 degrees) and 38±16 degrees (range: 18 to 75 degrees), respectively, with an average correction of 56%±11% (range: 41% to 71%) in completed cases. Four surgeries were aborted. Six patients (29%) had persistent neurological deficits beyond the first postoperative day. The median MAP goal was >80 mm Hg (range: >60 to >100). Twenty patients (95%) did not continuously meet their MAP goal, defined as ≥1 instance of MAP beneath target. Seven patients' (33%) 24-hour average MAPs were below target. On average, patients spent 27% of the time (6.4 h) beneath their target MAP. Four patients (19%) had a documented period of hypotension.
CONCLUSIONS: Despite ICU-level care and established MAP goals in critical patients with prior IONM loss or within warning criteria, postoperative blood pressure management often failed to meet MAP goals. This is the first study to highlight this crucial gap between management goals and postoperative hemodynamic adherence.
LEVELS OF EVIDENCE: Level IV.
METHODS: A retrospective review of patients undergoing spinal surgery with IONM changes between 2023 and 2025 at a single institution was conducted. Demographic and radiographic data were documented. Individual 24-hour postoperative "Target MAP" goals were established. Arterial line MAP values were collected. Hypotension was defined as MAP <5th percentile for age-based norms.
RESULTS: Twenty-one patients [12 female, 9 male; mean age 14.3±2.6 y (range: 7.7 to 19.0)] with IONM changes during pediatric deformity surgery were included. Etiologies included 8 idiopathic, 6 neuromuscular, 5 congenital, and 2 syndromic patients. Of those with major coronal deformities (n=19), mean preoperative and postoperative major curves were 79±22 degrees (range: 40 to 120 degrees) and 38±16 degrees (range: 18 to 75 degrees), respectively, with an average correction of 56%±11% (range: 41% to 71%) in completed cases. Four surgeries were aborted. Six patients (29%) had persistent neurological deficits beyond the first postoperative day. The median MAP goal was >80 mm Hg (range: >60 to >100). Twenty patients (95%) did not continuously meet their MAP goal, defined as ≥1 instance of MAP beneath target. Seven patients' (33%) 24-hour average MAPs were below target. On average, patients spent 27% of the time (6.4 h) beneath their target MAP. Four patients (19%) had a documented period of hypotension.
CONCLUSIONS: Despite ICU-level care and established MAP goals in critical patients with prior IONM loss or within warning criteria, postoperative blood pressure management often failed to meet MAP goals. This is the first study to highlight this crucial gap between management goals and postoperative hemodynamic adherence.
LEVELS OF EVIDENCE: Level IV.