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Toleikis JR, Pace C, Jahangiri FR, Hemmer LB, Toleikis SC. Intraoperative somatosensory evoked potential (SEP) monitoring: an updated position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2024:10.1007/s10877-024-01201-x. [PMID: 39068294 DOI: 10.1007/s10877-024-01201-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Somatosensory evoked potentials (SEPs) are used to assess the functional status of somatosensory pathways during surgical procedures and can help protect patients' neurological integrity intraoperatively. This is a position statement on intraoperative SEP monitoring from the American Society of Neurophysiological Monitoring (ASNM) and updates prior ASNM position statements on SEPs from the years 2005 and 2010. This position statement is endorsed by ASNM and serves as an educational service to the neurophysiological community on the recommended use of SEPs as a neurophysiological monitoring tool. It presents the rationale for SEP utilization and its clinical applications. It also covers the relevant anatomy, technical methodology for setup and signal acquisition, signal interpretation, anesthesia and physiological considerations, and documentation and credentialing requirements to optimize SEP monitoring to aid in protecting the nervous system during surgery.
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Affiliation(s)
| | | | - Faisal R Jahangiri
- Global Innervation LLC, Dallas, TX, USA
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
| | - Laura B Hemmer
- Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Sahin MC, Ipek EM, Zinnuroglu M, Borcek AO. How did intraoperative neuromonitorization prevent tetraplegia? Childs Nerv Syst 2022; 39:1323-1328. [PMID: 36400977 DOI: 10.1007/s00381-022-05748-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 11/05/2022] [Indexed: 11/19/2022]
Abstract
Patients with mucopolysaccharidosis type IVA (MPS IVA) have many risk factors for myelopathy and paresis. These are spinal cord compression, bone stenosis, and soft tissue thickening with ligament laxity, deformity, odontoid hypoplasia, and atlantoaxial instability. Although most patients with MPS IVA appear generally healthy at birth, patients often show skeletal deformities within a few years. Surgical indications are difficult to determine. Historically, many physicians have used prophylactic decompression and fusion in young, asymptomatic MPS IVA patients to prevent cord compression. Although spinal cord decompression is usually required at the craniocervical junction in patients with MPS IVA, decompression may be required at other spinal cord levels as well. There is a risk of developing neurological damage during surgery. The most common causes are ischemia secondary to cardiac output deteriorated in the prone position or due to artery damage, and local trauma due to neck movements or traction while bringing the patient to the prone position. Neurophysiological monitoring is very important during surgery to reduce the risk of neurological damage in spinal cord surgery. In this case report, a case with loss of lower extremity neuromonitorization motor evoked potential (MEP) responses in the early period of surgery without any intervention to the craniocervical junction after prone positioning will be presented.
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Affiliation(s)
- Mustafa Caglar Sahin
- Faculty of Medicine Department of Neurosurgery, Gazi University, 06560, Ankara, Turkey.
| | - Emine Metin Ipek
- Faculty of Medicine Department of Physical Medicine and Rehabilitation, Gazi University, 06560, Ankara, Turkey
| | - Murat Zinnuroglu
- Faculty of Medicine Department of Physical Medicine and Rehabilitation, Gazi University, 06560, Ankara, Turkey
| | - Alp Ozgun Borcek
- Faculty of Medicine Department of Neurosurgery Division of Pediatric Neurosurgery, Gazi University, 06560, Ankara, Turkey
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Diaz A, Chin C, Burks SS, McCarthy D, Matadial C, Levene HB. A Retrospective Pilot Study for Preoperative Screening to Prevent Iatrogenic Cervical Spinal Cord Injury. Cureus 2021; 13:e12550. [PMID: 33564543 PMCID: PMC7863023 DOI: 10.7759/cureus.12550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
PURPOSE The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series. METHODS Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure. RESULTS There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman's and Spurling's sign, independently, were significantly associated with a positive neck extension exam (p<0.05). Fourteen patients were recommended for cervical decompression prior to planned procedure. CONCLUSIONS Our preoperative cervical spine clearance protocol is safe and may aid in identifying patients susceptible to iatrogenic cervical spine injury.
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Affiliation(s)
- Anthony Diaz
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Christopher Chin
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Stephen S Burks
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - David McCarthy
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Christina Matadial
- Department of Anesthesiology, University of Miami Miller School of Medicine/Miami Veteran Affairs Healthcare System, Miami, USA
| | - Howard B Levene
- Research, Miami Veterans Hospital, Miami, USA.,Neurological Surgery, Levene Neurosurgical Consulting, Inc, Miami, USA
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Gokcen HB, Ozturk C. Ossification of the Ligamentum Flavum at the Thoracic and Lumbar Region in an Achondroplastic Patient. World Neurosurg 2019; 126:461-465. [PMID: 30877011 DOI: 10.1016/j.wneu.2019.03.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Achondroplasia, a genetic disorder of bone growth, produces specific clinical features of the extremities and spine. Spinal stenosis, seen in patients with achondroplasia, is a congenital disorder related to premature fusion of the pedicles to the lamina. It can be caused by ossification of the ligamentum flavum, which is rare in patients with achondroplasia. CASE DESCRIPTION We report a rare congenital spinal stenosis with ossification of the ligamentum flavum and thoracolumbar kyphosis deformity in a 24-year-old man with dwarfism and achondroplasia. He was treated with posterior instrumentation and decompression with a wide laminectomy. CONCLUSIONS Treatment of the deformity and the rare condition of ligamentum flavum in a patient with achondroplasia resulted in improved neurologic status and symptoms. To our knowledge, this is the first case report including treatment for both the deformity and thoracic and lumbar ossified ligamentum flavum lesion in a patient with achondroplasia.
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Affiliation(s)
- H Bahadir Gokcen
- Department of Orthopedics and Traumatology, Istinye University Medical Faculty, Istanbul, Turkey.
| | - Cagatay Ozturk
- Department of Orthopedics and Traumatology, Istinye University Medical Faculty, Istanbul, Turkey
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Graham RB, Cotton M, Koht A, Koski TR. Loss of intraoperative neurological monitoring signals during flexed prone positioning on a hinged open frame during surgery for kyphoscoliosis correction: case report. J Neurosurg Spine 2018; 29:339-343. [DOI: 10.3171/2018.1.spine17811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Various complications of prone positioning in spine surgery have been described in the literature. Patients in the prone position for extended periods are subject to neurological deficits and/or loss of intraoperative signals due to compression neuropathies, but positioning-related spinal deficits are rare in the thoracolumbar deformity population. The authors present a case of severe kyphoscoliotic deformity with critical thoracolumbar stenosis in which, during the use of a hinged open frame in the prone position, complete loss of intraoperative neural monitoring signals occurred while the frame was flexed into kyphosis to facilitate exposure and instrumentation placement. When the frame was reset to a neutral position, evoked potentials returned to baseline and the operation proceeded without complications. This case represents, to the authors’ knowledge, the first report of loss of evoked potentials due to an alteration of prone positioning on a hinged open frame. When positioning patients in such a manner, careful attention should be directed to intraoperative signals in patients with critical stenosis and kyphotic deformity.
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Affiliation(s)
| | - Mathew Cotton
- 2Division of Intraoperative Neurophysiologic Monitoring, Department of Neurology,
| | | | - Tyler R. Koski
- 4Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Ammar A, Zarnegar R, Yassari R, Kinon M. Large central lumbar disc herniation causing acute cauda equina syndrome with loss of evoked potentials during prone positioning for surgery. Surg Neurol Int 2018; 9:66. [PMID: 29629233 PMCID: PMC5875114 DOI: 10.4103/sni.sni_482_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 01/29/2018] [Indexed: 01/14/2023] Open
Abstract
Background: Few studies in the literature discuss operative positioning for lumbar surgery precipitating acute cauda equina syndromes (CES). Case Description: A 56-year-old male with a large L2-3-disc herniation was placed prone on a Jackson table. He immediately lost all motor and sensory evoked potentials. Signals returned to the baseline when surgery was aborted, and he was returned to the supine position. However, potentials were again lost when he was repositioned prone, following which the surgeons proceeded with surgical decompression with a good outcome. Conclusion: This case highlights the risk for patients with large acute lumbar disc herniation/stenosis and CES undergoing prone positioning for lumbar decompression. Here, despite the secondary loss of both sensory and motor evoked potentials, the patient successfully underwent lumbar decompressive surgery/discectomy performed on a Jackson table, resulting in full postoperative neurological recovery.
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Affiliation(s)
- Adam Ammar
- Department of Neurosurgery, Montefiore Medical Center, New York, USA
| | - Reza Zarnegar
- Department of Neurology, Weill Cornell Medical College, New York Presbyterian Queens Hospital, New York, USA
| | - Reza Yassari
- Department of Neurosurgery, Montefiore Medical Center, New York, USA
| | - Merritt Kinon
- Department of Neurosurgery, Montefiore Medical Center, New York, USA
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Abstract
Multimodal intraoperative neurophysiologic monitoring is a reliable tool for detecting intraoperative spine injury and is recommended during surgery for degenerative cervical myopathy (DCM). Somatosensory evoked potential (SEP) can be used to monitor spine and peripheral nerve injury during positioning in surgery for DCM. Compensation technique for transcranial evoked muscle action potentials (tcMEPs) should be adopted in intraoperative monitoring during surgery for DCM. Free-running electromyography is a useful real-time monitoring add-on modality in addition to SEP and tcMEP.
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Efficacy of Head Repositioning in Restoration of Electrophysiological Signals During Cervical Spine Procedures. J Clin Neurophysiol 2017; 34:174-178. [DOI: 10.1097/wnp.0000000000000340] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kim DG, Jo SR, Park YS, Hyun SJ, Kim KJ, Jahng TA, Kim HJ, Park KS. Multi-channel motor evoked potential monitoring during anterior cervical discectomy and fusion. Clin Neurophysiol Pract 2017; 2:48-53. [PMID: 30214970 PMCID: PMC6123893 DOI: 10.1016/j.cnp.2016.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 10/27/2022] Open
Abstract
Objectives Anterior cervical discectomy and fusion (ACDF) surgery is the most common surgical procedure for the cervical spine with low complication rate. Despite the potential prognostic benefit, intraoperative neurophysiological monitoring (IONM), a method for detecting impending neurological compromise, is not routinely used in ACDF surgery. The present study aimed to identify the potential benefits of monitoring multi-channel motor evoked potentials (MEPs) during ACDF surgery. Methods We retrospectively reviewed 200 consecutive patients who received IONM with multi-channel MEPs and somatosensory evoked potentials (SSEPs). On average, 9.2 muscles per patient were evaluated under MEP monitoring. Results The rate of MEP change during surgery in the multi-level ACDF group was significantly higher than the single-level group. Two patients from the single-level ACDF group (1.7%) and four patients from the multi-level ACDF group (4.9%) experienced post-operative motor deficits. Multi-channel MEPs monitoring during single and multi-level ACDF surgery demonstrated higher sensitivity, specificity, positive predictive and negative predictive value than SSEP monitoring. Conclusions Multi-channel MEP monitoring might be beneficial for the detection of segmental injury as well as long tract injury during single- and multi-level ACDF surgery. Significance This is first large scale study to identify the usefulness of multi-channel MEPs in monitoring ACDF surgery.
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Affiliation(s)
- Dong-Gun Kim
- Department of Neurology, Myung Diagnostic Radiology Clinic, Seoul, Republic of Korea
| | - Seong-Rae Jo
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Seop Park
- Department of Neurosurgery, Spine Center, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Gyeongnam, Republic of Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Al Bahri RS, MacDonald DB, Mahmoud AHM. Motor and somatosensory evoked potential spinal cord monitoring during intubation and neck extension for thyroidectomy in a Down syndrome boy with atlantoaxial instability. J Clin Monit Comput 2016; 31:231-233. [PMID: 26820847 DOI: 10.1007/s10877-016-9832-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
Abstract
Intubation or neck extension can compress the spinal cord in patients with craniocervical instability. Protective motor evoked potential (MEP) and somatosensory evoked potential (SEP) monitoring of these maneuvers is an obvious consideration when these patients undergo already-monitored spinal surgery, but might be overlooked when they undergo other normally unmonitored procedures. Here we report monitoring intubation and neck extension for the unusual indication of thyroidectomy in a Down syndrome boy with atlantoaxial instability. Transcranial electric stimulation thenar MEPs and optimized median nerve SEPs were acquired about every minute throughout intubation and neck extension under propofol and remifentanil anesthesia without neuromuscular blockade. Potentials were stable and there was no neurologic deficit. This approach could protect craniocervical instability patients against cord compression when they undergo intubation and neck extension for surgical procedures that would not otherwise indicate spinal cord monitoring.
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Affiliation(s)
- Raiya Saif Al Bahri
- Department of Anesthesia, King Faisal Specialist Hospital and Research Center, MBC 22, PO Box 3354, Riyadh, 11211, Saudi Arabia
| | - David B MacDonald
- Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital and Research Center, MBC 76, PO Box 3354, Riyadh, 11211, Saudi Arabia.
| | - Ahmed Haroun M Mahmoud
- Department of Anesthesia, King Faisal Specialist Hospital and Research Center, MBC 22, PO Box 3354, Riyadh, 11211, Saudi Arabia
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Tong CKW, Chen JCH, Cochrane DD. Spinal cord infarction remote from maximal compression in a patient with Morquio syndrome. J Neurosurg Pediatr 2012; 9:608-12. [PMID: 22656250 DOI: 10.3171/2012.2.peds11522] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Morquio syndrome, or mucopolysaccharidosis type IV, is a rare enzyme deficiency disorder and results in skeletal dysplasia. Odontoid dysplasia is common among affected patients, resulting in atlantoaxial instability and spinal cord compression. Surgical treatments include decompression and prophylactic fusion, during which intraoperative neuromonitoring is important to alert the surgical team to changes in cord function so that they can prevent or mitigate spinal cord injury. This report describes a 16-year-old girl with Morquio syndrome who developed paraplegia due to thoracic spinal cord infarction during foramen magnum and atlantal decompression. This tragic event demonstrates the following: 1) that patients with Morquio syndrome are at risk for ischemic spinal cord injury at levels remote from areas of maximal anatomical compression while under anesthesia in the prone position, possibly due to impaired cardiac output; 2) the significance of absent motor evoked potential responses in the lower limbs with preserved upper-limb responses in an ambulatory patient; 3) the importance of establishing intraoperative neuromonitoring baseline assessments prior to turning patients to the prone position following induction of anesthesia; and 4) the importance of monitoring cardiac output during prone positioning in patients with chest wall deformity.
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Affiliation(s)
- Calvin K W Tong
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Canada
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The prevention of neural complications in the surgical treatment of scoliosis: the role of the neurophysiological intraoperative monitoring. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20 Suppl 1:S105-14. [PMID: 21416379 DOI: 10.1007/s00586-011-1756-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Indexed: 10/18/2022]
Abstract
Iatrogenic spinal cord injury is the most feared complication of scoliosis surgery. The importance of combined somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) monitoring during spine surgery is well known. The current authors retrospectively evaluated the results of neurophysiological intraoperative monitoring (IOM) in a large population of patients who underwent surgical treatment for spinal deformity. Intraoperative monitoring of SEPs and transcranial electrical stimulation MEPs (TES-MEP) was performed in 172 successive patients who underwent surgical treatment of idiopathic (128 pts), congenital (15 pts) or syndromic (29 pts) scoliosis. The first 106 patients (Group 1) underwent only SEP monitoring, while the other 66 patients (Group 2) underwent combined SEP and TES-MEP monitoring, when the technique was introduced in the current authors' institution. Halogenate anaesthesia (Sevoflurane, MAC 0.6-1.2) was performed in Group 1 cases, total intravenous anaesthesia (Propofol infusion, 6-10 mg/kg/h) in Group 2 patients. A neurophysiological "alert" was defined as a reduction in amplitude (unilateral or bilateral) of at least 50% for SEPs and of 65% for TES-MEPs compared with baseline. In Group 1, two patients (1.9%) developed postoperative neurologic deficits following surgical correction of spinal deformity, consisting of permanent paraparesis in one case and transient paraparesis secondary to spinal cord ischaemia in the other. Twelve patients presented intraoperative significant changes of neurophysiological parameters that improved following corrective actions by surgeons and anaesthesiologists, and did not show any postoperative neurologic deficits. In ten cases the alert was apparently unrelated to surgical manoeuvres or to pharmacological interventions and no postoperative neurologic deficits were noted. Considering the patients of Group 2, two patients (3.0%) presented transient postoperative neurologic deficits preceded by significant intraoperative changes in SEPs and TES-MEPs. In five cases a transient reduction in the amplitudes of SEPs (1 patient) and/or TES-MEPs (5 patients) was recorded intraoperatively with no postoperative neurologic deficits. In conclusion, in the current series of 172 patients the overall prevalence of postoperative neurologic deficit was 2.3% (4 patients). When combined SEP and TES-MEP monitoring was performed, the sensitivity and specificity of IOM for sensory-motor impairment was 100 and 98%, respectively. Combined SEP and TES-MEP monitoring must be regarded as the neurophysiological standard for intraoperative detection of emerging spinal cord injury during corrective spinal deformity surgery. Early detection affords the surgical team an opportunity to perform rapid intervention to prevent injury progression or possibly to reverse impending neurologic sequelae.
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Sriganesh K, Ramesh VJ, Veena S, Chandramouli BA. CASE REPORT: Dexmedetomidine for awake fibreoptic intubation and awake self-positioning in a patient with a critically located cervical lesion for surgical removal of infra-tentorial tumour. Anaesthesia 2010; 65:949-51. [DOI: 10.1111/j.1365-2044.2010.06411.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yamamoto N, Kobashi H, Shiba M, Itoh T. Efficacy and limitations of intraoperative spinal cord monitoring using nasopharyngeal tube electrodes. J Neurosurg Spine 2010; 13:200-10. [DOI: 10.3171/2010.3.spine08298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Motor evoked potentials are widely used for intraoperative spinal cord monitoring. However, there are problems with anesthetic constraints and high trial-by-trial variability of compound muscle action potential amplitude in muscle motor evoked potential monitoring. It is difficult to determine when to warn the surgeon of an occurrence of spinal cord risk. A method of estimation for motor function in the spinal cord has not been established. To monitor spinal cord function with reliable evoked potentials, including the upper cervical spinal cord and the ventral spinal cord, the authors developed a nasopharyngeal tube electrode that can be placed in front of the upper and ventral cervical spinal cord. The purpose of this study was to investigate the origins and pathways of descending or ascending spinal cord evoked potentials (SCEPs) elicited with this electrode, and the usefulness and limitations of this method.
Methods
A nasopharyngeal tube electrode was inserted into the nostril. A catheter electrode was placed in the epidural or subarachnoid space at the thoracic spine. Ventral SCEP was recorded from the thoracic spinal cord after transpharyngeal stimulation, and dorsal SCEP was recorded with the nasopharyngeal electrode after thoracic spinal cord stimulation. There was no restriction of anesthetic technique in recording. When the amplitude of either of the SCEPs declined to 80% of the baseline, a warning was provided to the surgeon during the observed operative procedure. At the end of surgery, less than 50% or more than 30% of the baseline amplitude was considered a significant change in both SCEPs. The sensitivity and specificity for both SCEPs to detect neurological deterioration were calculated.
Results
The electrode provided noninvasive access to the ventral cervicomedullary junction. The SCEPs showed stable responses. A response change was only observed in situations involving a risky procedure for the spinal cord. Ventral SCEPs showed high sensitivity (73.1%) for identifying patients with new neurological deficits or an exacerbation of preexisting neurological deficits after surgery, but dorsal SCEPs showed lower sensitivity (46.1%) in the total number of cases. Both SCEPs showed high specificities. The sensitivities of ventral SCEP, dorsal SCEP, and either SCEP were 100.0%, 50.0%, and 100.0% for the upper cervical spinal cord, 33.3%, 0%, and 55.6% for the lower cervical spinal cord, and 77.8%, 64.7%, and 88.2% for the thoracic spinal cord.
Conclusions
Combined recording of both SCEPs estimated the ventral and dorsal white matter function in the spinal cord. Measuring the SCEPs with the nasopharyngeal electrode can be another useful approach for upper cervical and thoracic spinal cord monitoring. Ventral SCEP was more reliable for monitoring postoperative spinal cord function than dorsal SCEP. Ventral SCEP does not estimate the gray matter and spinal root functions in the lower cervical spinal cord.
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Cervical spine motion generated with manual versus jackson table turning methods in a cadaveric c1-c2 global instability model. Spine (Phila Pa 1976) 2009; 34:2912-8. [PMID: 20010399 DOI: 10.1097/brs.0b013e3181b7eddb] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN.: Cadaveric biomechanical study. OBJECTIVE.: To quantify spinal motion created by transfer methods from supine to prone position in a cadaveric C1-C2 global instability model. SUMMARY OF BACKGROUND DATA.: Patients who have sustained a spinal cord injury remain at high risk for further secondary injury until their spine is adequately stabilized. To date, no study has evaluated the effect of patient transfer methods from supine to prone position in the operating room, on atlantoaxial cervical spine motion. METHODS.: A global instability was surgically created at the C1-C2 level in 4 fresh cadavers. Two transfer protocols were tested on each cadaver. The log-roll technique entailed performing a standard 180 degrees log-roll rotation of the supine patient from a stretcher to the prone position onto the operating room Jackson table (OSI, Union City, CA). The "Jackson technique" involved sliding the supine patient to the Jackson table, securing them to the table, and then rotating them into a prone position. An electromagnetic tracking device registered motion between the C1 and C2 vertebral segments. Three different head holding devices (Mayfield, Prone view, and blue foam pillow) were also compared for their ability to restrict C1-C2 motion. Six motion parameters were tracked. Repeated measures statistical analysis was performed to evaluate angular and translational motion. RESULTS.: For 6 of 6 measures of angulation and translation, manual log-roll prone positioning generated significantly more C1-C2 motion than the Jackson table turning technique. Out of 6 motion parameters, 5 were statistically significant (P < 0.001-0.005). There was minimal difference in C1-C2 motion generated when comparing all 3 head holding devices. CONCLUSION.: The data demonstrate that manual log-roll technique generated significantly more C1-C2 motion compared to the Jackson table technique. Choice of headrest has a minimal effect on the amount of motion generated during patient transfer, except that the Mayfield device demonstrates a slight trend toward increased C1-C2 motion.
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Multimodality monitoring of the central nervous system using motor-evoked potentials. Curr Opin Anaesthesiol 2008; 21:560-4. [DOI: 10.1097/aco.0b013e32830f1fbd] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pajewski TN, Arlet V, Phillips LH. Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S115-29. [PMID: 17619913 PMCID: PMC2072895 DOI: 10.1007/s00586-007-0419-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Accepted: 06/27/2007] [Indexed: 01/08/2023]
Abstract
Optimal outcome in spine surgery is dependent of the coordination of efforts by the surgeon, anesthesiologist, and neurophysiologist. This is perhaps best illustrated by the rising use of intraoperative spinal cord monitoring for complex spine surgery. The challenges presented by neurophysiologic monitoring, in particular the use of somatosensory and motor evoked potentials, requires an understanding by each member for the team of the proposed operative procedure as well as an ability to help differentiate clinically important signal changes from false positive changes. Surgical, anesthetic, and monitoring issues need to be addressed when relying on this form of monitoring to reduce the potential of negative outcomes in spine surgery. This article provides a practical overview from the perspective of the neurophysiologist, the anesthesiologist, and the surgeon on the requirements which must be understood by these participants in order to successfully contribute to a positive outcome when a patient is undergoing complex spine surgery.
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Affiliation(s)
- Thomas N. Pajewski
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA USA
| | - Vincent Arlet
- Division of Scoliosis and Spine Surgery, Department of Orthopedic Surgery, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908-0710 USA
| | - Lawrence H. Phillips
- Department of Neurology, University of Virginia Health System, Charlottesville, VA USA
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Eggspuehler A, Sutter MA, Grob D, Jeszenszky D, Porchet F, Dvorak J. Multimodal intraoperative monitoring (MIOM) during cervical spine surgical procedures in 246 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S209-15. [PMID: 17610090 PMCID: PMC2072893 DOI: 10.1007/s00586-007-0424-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/07/2007] [Indexed: 10/23/2022]
Abstract
A prospective study of 246 patients who received multimodal intraoperative monitoring during cervical spine surgery between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during cervical spine surgery. It is appreciated that complication rate of cervical spine surgery is low, however, there is a significant risk of neurological injury. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information and/or alert regarding any neurological changes during the operation to the surgeon. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor-evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 246 consecutive patients with cervical pathologies, majority spinal stenosis due to degenerative changes of cervical spine were monitored by means of MIOM during the surgical procedure. About 232 patients presented true negative while 2 patients false negative responses. About ten patients presented true positive responses where neurological deficit after the operation was predicted and two patients presented false positive findings. The sensitivity of MIOM applied during cervical spine procedure (anterior and/or posterior) was 83.3% and specificity of 99.2%. MIOM is an effective method of monitoring the spinal cord functional integrity during cervical spine surgery and can help to reduce the risk of neurological deficit by alerting the surgeon when monitoring changes are observed.
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Affiliation(s)
- Andreas Eggspuehler
- Department of Neurology/Spine Unit, Schulthess Clinic, Lengghalde 2, 8008, Zurich, Switzerland.
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