400,000 Lumbar/Cervical Procedures in 2008, Expected to go up to 650,000/year by 2015?

News about increasing number of Lumbar and Cervical spine procedures in US is going around all over the net, I am not sure if the
neuromonitoring and apsiring future spine specialists read this story. It is
interesting to note there are about 400,000 surgeries performed during 2008 alone and the number is projected to be about 650,000 by 2015 as the aging population increases in number!.

The data analysis was carried out by a company called Global Markets Direct (Global Data), check the link but be aware that you CANNO'T find or read the news report at their site, as the data is sold for $3500 or so?.

But, there are numerous reports providing information from the original Global markets data?.

Laura Woods article at the research and markets is the best place to start if you
are interested to learn more about this news.

Research and Markets: US Spinal Surgery Devices Market: Increasing Procedures to Drive Growth(http://www.researchandmarkets.com/research/504cb6/us_spinal_surgery) has announced the addition of GlobalData 's new report
"US Spinal Surgery Devices Market: Increasing Procedures
to Drive Growth" to their offering. This new report finds
that the increasing incidence of degenerative disc disease and increasing aging population in the US will provide huge growth and investment opportunities for the Spinal surgery market in the US. "US Spinal Surgery Devices Market: Increasing Procedures to Drive Growth", highlights this growing aging population as one of the key market drivers for the spinal surgery market in the US.

Significant Grant Allows University Of Canterbury To Investigate Prevention Of Hearing Loss

· ear surgery

· hearing impairment

· hearing loss

· surgery

Contributor: Voxy News Engine

Wednesday, 25 November, 2009 - 12:58

The Oticon Foundation in New Zealand has today awarded a research grant of almost $350,000 to the University of Canterbury to investigate the prevention of hearing loss during ear surgery.

"This is a major financial commitment to a substantial research project by the University of Canterbury's Department of Communication Disorders into methods to monitor hearing and reduce hearing loss during otologic surgery - or ear micro-surgery," says Tim Olphert, Chairman to the Trustees, of The Oticon Foundation in New Zealand.

"The Oticon Foundation has reviewed the proposed research headed by Dr Greg O'Beirne( PhD) and Mr Phil Bird, (MBChB, FRACS) and believes it is of such significant importance internationally that it is providing the $340,895.53 needed to fund the three year project."

An International Survey on Neuromonitoring?

Neuromonitoring is quite extensively utilized in US, ask both neurosurgeons and Orthopedic surgeons you work, they will tell you how useful this modern tool to them to complete their surgery safely and comfortably, that is what the surgeons I involve with tell me and they are pretty top notch in their field, so imagine what the surgeons nationwide would think about IONM?.

Internationally, IOM is not that widely practiced, there is no data available to ascertain either on the internet or offline on books that can provide information of IOM outside US. There could be various reasons why it is not that common as in US, may be the cost of using IOM, availability of the technology, trained professionals or experts readily available to employ them and numerous other factors may play a role. I have a list of IOM companies in US as well as a stat (from society websites) on trained professionals in US documented in my Neuromonitoringcompanies Blog. This report published in the latest neurosurgery focus journal is perhaps the first of this kind I have noticed recently, a German group did a survey among neurosurgeons in several countries regarding their usage of IOM services. Though the number of instituitions, number of surgeons and patients surveyed is smaller, the number of countries participated also is very small for this kind of survey, I would not make a conclusion based on this study but this certainly a good idea to conduct a survey and it has to be more comprehensive.

Neurosurg Focus. 2009 Oct;27(4):E2.

Neurophysiological intraoperative monitoring in neurosurgery: aid or handicap? An international survey.

Cabraja M, Stockhammer F, Mularski S, Suess O, Kombos T, Vajkoczy P.

Department of Neurosurgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany. mario.cabraja@charite.de

OBJECT: Neurophysiological intraoperative monitoring (IOM) is regarded as a useful tool to provide information about physiological changes during surgery in eloquent areas of the nervous system, to increase safety and reduce morbidity. Nevertheless, numerous older studies report that very few patients benefit from IOM, and that there are high rates of false-positive and false-negative changes of neurophysiological parameters during surgery. There is an ongoing discussion about the effectiveness of neurophysiological IOM. This questionnaire study was performed to evaluate the attitude of neurosurgeons toward neurophysiological IOM and the availability of this tool. METHODS: One hundred fifty neurosurgeons from 60 institutions in 16 countries were asked to answer anonymously a questionnaire with 11 questions. The questionnaire covered aspects of personal experience, the neurosurgical institution, and availability of neurophysiological IOM as well as asking the surgeon's opinion of the procedure. RESULTS: One hundred nine questionnaires were returned (73%). Seven questionnaires were excluded because of failure to complete the form correctly or completely, leaving 102 respondents from 44 institutions in 16 countries in the study; 79.5% of the included institutions provided neurophysiological IOM. Young neurosurgeons did not put more trust in IOM than experienced neurosurgeons. With growing IOM experience, surgeons seem to allow less influence of the findings on the course of their operation. At large institutions in which > 1500 operations per year are done, IOM is performed by the neurosurgeons themselves in most cases. In institutions with fewer operations, the IOM team consists mostly of nonneurosurgeons. Regardless of the availability of neurophysiological IOM, all surgeons stated that IOM is gaining increasing importance. CONCLUSIONS: Neurophysiological IOM represents an established tool in neurosurgery. Although the importance of IOM is emphasized by the majority of neurosurgeons, the relevance of this tool to the course of the operation changes with increasing neurophysiological IOM experience.

ASNM Society Meeting, ClearWater Beach, Florida!

If you are attending or planning to attend ASNM winter meeting to be held in Clearwater Beach, Florida,
please note the change in dates.
Here is the e-mail from the committee.

Subject: ASNM IMPORTANT DATE CHANGE--- Winter 2010 Symposium From: "ASNM Registration" Date: Thu, October 29, 2009 7:05 am To: Priority: Normal Options: View Full Header View Printable Version Download this as a file View as plain text

Dear ASNM Members,

Please make NOTE: the dates of our 2010 Winter Symposium have been changed. The NEW dates are Friday, March 5th and Saturday, March 6th. We would appreciate it if you could "spread the word" to your colleagues about the change. More information will follow shortly.

We apologize for any inconvenience this may have caused.

---Best Regards,
The Winter Symposium Committee

Check the ASNM site for more information about the winter meeting

ASNM Winter Symposia – Hotel booking

Hotel Registration

ASNM Winter Symposium 2010 Clearwater Beach, FL March 5th-6th Hilton Clearwater Beach Spa and Resort Note: Category 1 AMA CMEs offered.

ASNM Winter Symposia – Vendor Registration

More Information Comming Soon

ASNM Winter Symposium 2010 Clearwater Beach, FL March 5th-6th Hilton Clearwater Beach Spa and Resort Note: Category 1 AMA CMEs offered.

CNIM and ABNM

Exam Archives 

ABRET Exam Schedule Dates

Exam Schedule Dates for 2008 - 2009

From ABRET's Website:-

Written

Examination	Date(s)	Location	Deadline
EEG & CLTM Written Exams	October 4-18, 2008	LaserGrade Sites	08/15/2008
EP & CNIM Written Exams	February 28-March 14, 2009	LaserGrade Sites	01/15/2009
EEG & CLTM Written Exams	May 2-16, 2009	LaserGrade Sites	03/15/2009
EP & CNIM Written Exams	August 1-15, 2009	LaserGrade Sites	06/15/2009
EEG & CLTM Written Exams	October 3-17, 2009	LaserGrade Sites	08/15/2009

Orals

Examination	Date(s)	Location	Deadline
EEG & EP Oral Exams	October 25-26, 2008	Pittsburgh, PA	08/26/2008
EEG & EP Oral Exams	February 21-22, 2009	Atlanta, GA	12/22/2008
EEG & EP Oral Exams	April 18-19, 2009	Milwaukee, WI	02/19/2009
EEG & EP Oral Exams	August 8-9, 2009	Phoenix, AZ	06/09/2009
EEG & EP Oral Exams	October 24 & 25, 2009	Detroit, MI	08/25/2009

ISIN-International Soceity of Intraoperative Neuromonitoring

ISIN has redesigned their website, it looks much better now and there is more information for you now.

NeuroMonitoring Cuts Stroke Risk of Carotid Surgery?

In this Elsevier medical news, Kerri writes about how utilizing neuromonitoring could cut the risks of stroke during carotid surgery, this is not a new report, but for those who missed this news article,
you can read it here.

Neuromonitoring Cuts Stroke Risk Of Carotid Surgery
BY KERRI WACHTER
Elsevier Global Medical News

ORLANDO — Targeted neuromonitoring can dramatically reduce stroke complications during and after carotid endarterectomy, according to one expert speaking at the annual meeting of the American Society of Neuroimaging. “A targeted monitoring strategy— and I stress the word targeted— has virtually eliminated intraoperative stroke and stroke due to postoperative carotid thrombosis in our unit,” said A. Ross Naylor, M.D., professor of vascular surgery at the University of Leicester in England. Carotid endarterectomy (CEA) carries a small but important
risk of stroke for both symptomatic and asymptomatic patients. Although neuromonitoring can be an effective way to minimize the risks associated with carotid endarterectomy,
here is “more to monitoring than deciding who needs a bit of plastic tubing shoved into their artery. You have to ask the right questions, and then you’ll start to get the right answers.” Dr. Naylor reported that his team uses continuous transcranial Doppler (TCD) sonography
and completion angioscopy for intraoperative monitoring. “We ask very limited questions
of transcranial Doppler,” he said. The group tries to maintain a mean middle cerebral artery velocity greater than 15 cm/sec. Hemodynamic failure is usually not the problem. “I have
seen over 1,200-1,500 carotids now in our unit, and I cannot ascribe hemodynamic failure to
any patient.” Technical errors and thrombosis are the more likely culprits. TCD reveals
shunt malfunctions and “is the only method capable of diagnosing on-table thrombosis,” he said.
Dr. Naylor and his team use ....
http://www.vascularweb.org/professionals/vascular_specialist/vol1/number1/pdf/VN_1005.pdf

New on PubMed:

Investigation of the regeneration potential of the recurrent laryngeal nerve (RLN) after compression injury, using neuromonitoring.

Moskalenko V, Hüller M, Gasser M, Demidchik Y, Thiede A, Timm S, Ulrichs K, Hamelmann W.

Department of General and Visceral Surgery, Hospital of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, D-55131, Mainz, Germany. moskalenko@tut.by

INTRODUCTION:

The aim of this study was to investigate the regeneration potential of RLN after the compression of the nerve, without disrupting its continuity, using neuromonitoring.

METHODS: In the first operation, the RLN and nervus vagus of adult Goettingen minipigs were dissected free, and the neuromonitoring parameters (amplitude, threshold and lag time of signal) were measured. Injury of the RLN was induced using a "bulldog" clamp. When the signal was no longer detectable, after the 15 min regeneration phase, the operation was finished. The neuromonitoring studies (see above) were repeated in a second operation 6 months later. RESULTS: (1) After the first operation, acute clamping of the RLN led to a reduction in the amplitude of the neuromonitoring signal; the lag time and the threshold of signal remained. Complete restitution of the signal was observed during the first regeneration phase. Repeated clamping led to complete disappearance of the signal. (2) During the second operation, i.e., after 6 months of regeneration, the neuromonitoring signals of both RLN and nervus vagus were detected in 93% of the GMP. No statistical differences (p = 0.17) were noticed between the amplitude of the RLN before the nerve injury (first operation) and after nerve regeneration (second operation). A significant increase in the lag time (p <>

PMID: 18751999 [PubMed - indexed for MEDLINE]

Nature Magazine and Review on Microscopy?

When I saw this news about "Nature Magazine's recent reviews on Microscopy,
I thought this is a good news for lots of readers and microscopy
specialists. I was thinking of writing about Microscopy and my personal
experiences in using various microscopes, good to know Nature carried out
this in the latest issue.

Out of the plethora of topics that I specialized during my graduation and research years, microscopy and tissue culture was one of them. I have been using microscopes ranging from a very basic compound microscope to dissection microcopes, bright field and phase contrast microscopes to microscopes with convulution set up, fluroscent microscope, TEM-Transmission Electron Microscope and 3D access Confocal Microscope...! I served as the editor of Connecticut Microscopy Society for a year and also helped in editorial for another year or so. This is just a honorary job and no support or financial help given, it is soley a interest in microscope based service to the society. For this service, I received Governors certificate of achievement and service from the Connecticut state Gov Jody Rell, my insterest in microscopy goes way back to school days and it is quite humbling to realize, sustained interest and practice leads to rewards and recognition. I will soon write more about microscopes.

For those who are interested to learn about the microcope and it's great use in
discovery, here is the Nature Journal editorial.

Nature Editorial:
Nature 459, 615 (4 June 2009) Microscopic marvels

Abstract
Microscopes are changing the face of biology. Researchers should innovate and collaborate if they want to be part of the new vision.
Watching molecular-scale events unfold in a living cell can be an inspiring experience. The inner workings of the nucleus, the shuttling of cellular cargo, the passage of messages through a membrane — seeing this tumultuous activity up close can fire the scientific imagination in a way that abstract data from genetic sequences or chemical analyses can never quite equal.

New: What's New in Spine Surgery?

In the following article "What's new in spine surgery, a perspective on latest approaches to treat cervical spinal deformity is discussed by Bridwell, KH et al, this is a very latest compilation of spine related works. At the bottom of this paper, the authors list some interesting recent works under the topic evidence based treatment in Orthopedic surgeries? in addition to their lengthy and useful reference list that will be of great interest to many.

The Journal of Bone and Joint Surgery (American). 2009;91:1822-1834.
doi:10.2106/JBJS.I.00488
© 2009 The Journal of Bone and Joint Surgery, Inc.

What's New in Spine Surgery

Keith H. Bridwell, MD¹, Paul A. Anderson, MD², Scott D. Boden, MD³, Alexander R. Vaccaro, MD⁴ and Jeffrey C. Wang, MD^{5 1} Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, Campus Box 8233, St. Louis, MO 63110. E-mail address: bridwellk@wudosis.wustl.edu

Many controversies still exist with regard to the surgical treatment of cervical spine pathology. The role of allograft, autograft, plate fixation, and bone morphogenetic protein is not entirely clear. There is still debate about the surgical treatment of myelopathy anteriorly as opposed to posteriorly. Clearly, there is substantial anatomic variation in the location of the vertebral artery. Disc arthroplasty for the cervical spine continues to appear to be a viable option for patients with single-level pathology.

Hey, Watch your Back!!!, It is not just Swine Flu (H1N1) but much more dangerous HFMD is spreading in China?

Nature, the reputed UK based science magazine posted the following editorial about virus threat in China, oh wait it is not just about H1N1 which is spreading fast world wide. It is not even the SARS that the magazine is reporting about, but "Hand, Foot and Mouth Disorder (HFMD)?. How dangerous this HFMD.........read further!

Editorial

Nature 459, 751-752 (11 June 2009) | doi:10.1038/459751b; Published online 10 June 2009

Watch your back

Top of page

Abstract

The H1N1 flu epidemic is not the world's only disease threat.

If you are a health official facing two highly contagious diseases — one that is already killing dozens of people, and another that threatens to kill people by the thousands or millions, but hasn't yet done so — how do you allocate your resources? The answer can be a difficult balancing act, as the situation in China is showing

In 2008, more than 500,000 HFMD infections were reported in China, and 200 people died. This year, as the disease moves through its peak season, similar numbers look possible. There is currently no vaccine to prevent it and no drug to cure it. The best safeguard is good hygiene: HFMD transmission is mainly via saliva and faeces. But even Singapore, renowned for its cleanliness, has had 8,896 cases this year, and had had even more by this time last year. There have also been cases this year in Taiwan, Hong Kong and South Korea.

Myelin Removal Beads....?

I received the following e-mail message about a new product related to myelin removal?. If you are looking for a better way to isolate and remove myelin.......'. I have not used this product or this companies antibody, just thought some one might benefit.

Myelin Removal Beads: premium efficiency for neural cell separation and antibody staining Dear Dr. Muni.., The exclusive worldwide release of the Myelin Removal Beads from Miltenyi Biotec is an important step forward in neuroscience research. The interfering presence of myelin within neural cell suspensions can now be rapidly removed from mouse, rat, or human tissue samples and is highly recommended for optimal antibody staining and magnetic cell separation. Request a quotation

Neuromonitoring Companies Blog?

Check the companies list here: Neuromonitoring companies

Median Nerve SSEP:- Is there a relationship between Median Nerve SSEP & Level of Spinal Cord Injury?

This case study was conducted by the American Spinal Cord Injury Association (ASIA) on patients with Quadriplegia. The question asked was is there a relationship between median nerve SSEP changes and level of spinal cord injury?.

The answer is yes, neuromonitoring of median nerve SSEPs conducted on 14 quadriplegic patients and 8 normal individuals. Amplitude and latency analysis of waveforms N9, N13 and N20 was conducted. N9 responses were present in all the patients and normal subjects, both amplitude and latency were similar in both groups.

On the other hand, N13 was absent in Quadriplegia patients?
N20 was absent in C5 patients with Quadriplegia? but it was present in C6-7 patients, though the amplitudes were decreased with normal latency. Did you notice these waveform changes in your recording?.

Read further:

Original Article

Spinal Cord (2009) 47, 372–378; doi:10.1038/sc.2008.147; published online 20 January 2009

Relationship between median nerve somatosensory evoked potentials and spinal cord injury levels in patients with quadriplegia

M I F de Arruda Serra Gaspar¹, A Cliquet Jr^2,3, V M Fernandes Lima⁴ and D C C de Abreu¹

Methods:

Fourteen individuals with quadriplegia and 8 healthy individuals were evaluated. Electrophysiological assessment of the median nerve was performed by evoked potential equipment. The injury level was obtained by ASIA. N₉, N₁₃ and N₂₀ were analyzed based on the presence or absence of responses. The parameters used for analyzing these responses were the latency and the amplitude. Data were analyzed using mixed-effect models.

Neuron News:-

Neuron news is a WebRing site that publishes some cool topics in neuroscience, in this Nov 2008 news note, they talk about EcoG and developments in this neurotechnology?. I do not find anything new in this news as EcoG is already recorded in clinical set up, but the one thing that is interesting in this news is the type of electrode development, something that can sit on the surface of the brain without perturbations of membranes or causing any penetration that would be deleterious, anyways, there are lots of stuff to browse through including a lot on consiousness at neuronews.

Lumbar Fusion & Analgesic related Death?

In one of the latest issue of "Spine" (Spine: 1 April 2009 - Volume 34 - Issue 7 - pp 740-747doi: 10.1097/BRS.0b013e31819b2176Surgery), a study related to lumbar fusion and analgesic death been analyzed and reported. The authors claim that the risk of death was higher in those patients who received instrumentation and especially inter vertebral cage placement when compared to bone only fusion??. Though I have not heard any perioperative death or even serious consequences in huge number of spine cases we did in the recent past, this report is a caution to look into the analgesic effect spine fusion, streamlining the usage of analgesics that are less toxic is extremely important.

Mortality After Lumbar Fusion Surgery
Juratli, Sham Maghout MD, MPH; Mirza, Sohail K. MD, MPH; Fulton-Kehoe, Deborah PhD, MPH; Wickizer, Thomas M. PhD; Franklin, Gary M. MD, MPH

Abstract

Study Design. Retrospective population-based cohort study.

Objective. To describe mortality after lumbar fusion surgery in Washington State workers' compensation claimants in the perioperative period and beyond.

Summary of Background Data. Although lumbar fusion surgery can be associated with serious complications, perioperative mortality is generally considered rare. Population-based mortality estimates have been limited to surgery in older adults.

Methods. We identified all Washington State workers' compensation claimants who underwent fusion between January 1994 and December 2001 (n = 2378) and assessed the frequency, timing, and causes of death. Mortality follow-up was concluded in 2004. Death was ascertained from Washington State vital statistics records and from the workers' compensation claims database. Poisson regression was used to obtain age- and gender-adjusted mortality rates. Years of potential life lost, percent of potential life lost, and mean potential life lost were calculated for the leading 5 causes of death and we calculated the risk of death associated with selected predictors.

Results.

Among the 2378 lumbar fusion subjects in the study cohort, 103 were deceased by 2004. The 3-year cumulative mortality rate was 1.93% (95% confidence interval, 1.41%-2.57%). The 90-day perioperative mortality rate was 0.29% (95% confidence interval, 0.11%-0.60%). The risk of perioperative mortality was positively associated with repeat fusions. The age- and gender-adjusted all-cause mortality rate was 3.1 deaths per 1000 worker-years (95% confidence interval, 0.9-9.8).

Analgesic-related deaths were responsible for 21% of all deaths and 31.4% of all potential life lost.

The risk of analgesic-related death was higher among workers who received instrumentation or intervertebral cage devices compared with recipients of bone-only fusions (1.1% vs. 0.0%; P = 0.03) and among workers with degenerative disc disease (age- and gender-adjusted mortality rate ratio, 2.71) (95% confidence interval, 1.17-6.28).

The burden was especially high among subjects between 45 and 54 years old with degenerative disc disease (rate ratio, 7.45).

Conclusion. Analgesic-related deaths are responsible for more deaths and more potential life lost among workers who underwent lumbar fusion than any other cause. Risk of analgesic-related death was especially high among young and middle-aged workers with degenerative disc disease.

© 2009 Lippincott Williams & Wilkins, Inc.

Neurophysiological Monitoring Symposium!

Coming Up....!

I just came back from Clearwater, FL after two days of intensive and elaborate symposium on Nueorphysiological monitoring organized by the American Society of Neurophysiological Monitoring (ASNM).

It was quite an insightful symposium participated by neuromonitoring specialists from all over US, almost all the speakers of this meeting were the most renowned and well known in this field.

......................can't wait to hear my experience and views on this meeting.......?. Ooooohhh, Clearwater's beach is beautiful, beautiful and the weather was just incredeble last weekend!.

What's New in Pediatric Orthopaedics???- Review by Kim and Noonan

In the latest issue of the journal JB and JS,  authours Young-Jo Kim, MD, PhD¹ 

and Kenneth J. Noonan, MD published their reviews on"Pediatric Orthopaedics". 

They discuss about the recent advancements in the field of Pediatric Orthopadics 

with emphasis on various spine deformity, neurological disorders in childrens with 

appropirate surgical methods used. They have done an excellent review of the literature, 

the 82 references listed can be useful for those in the Pediatric Ortho as well as for 

Neurophysiologists. There is a section on basic science applications and in another 

section on spine, they talk about effectiveness of Intraoperative monitoring 

using motor evoked potentials.

The effectiveness of spinal cord monitoring during spinal deformity surgery was recently reported in two large studies (involving >1000 patients), with the incidence of spinal cord injury approaching 1%^66,67. Transcranial motor-evoked potentials are exquisitely sensitive to threatened spinal cord function, andtheir use together with traditional somatosensory evoked potentials improves the accuracy of spinal cord monitoring. Somatosensory evoked potentials may not detect all problems and may not detect problems as rapidly as transcranial motor-evoked potentials do⁶⁷, and the sensitivity of transcranial motor-evoked potentials has led some centers to abandon somatosensory evoked potentials in favor of motor monitoring alone. For instance, Hsu et al.⁶⁸ reported 100% sensitivity for the detection of a clinically important neurological event in a consecutive series of 144 patients. The authors defined a neurological event as either a new postoperative deficit or a 50% decrease in the monitoring potential over a one-minute period. The rapidity with which motor monitoring detects spinal cord compromise makes it a valuable tool for sagittal plane correction, and prompt detection of a problem can lead to its resolution before a permanent deficit results^69,70.

The Journal of Bone and Joint Surgery (American). 2009;91:743-751.doi:10.2106/JBJS.H.01689

Neuromonitoring:- a Review on PubMed Publications

We do not get much time to go read all the published papers on Neuromonitoring, unlike during the Laboratory research days, my visit to PubMed is less frequent, but yet I do not give up on my practice to go here and spend some time in catching up with the latest papers.  In my recent visit to the PubMed, I found the following ongoing research activities in the field of neuromonitoring. 

This is a very brief review, will help re-route the interested readers or visitors to the PubMed original article. Right now, I have access to only the abstracts, so just by going through the abstracts of recently published article I thought to list the recent papers here. 

PubMed Search "Neuromonitoring" check the links direct to the articles.

1.Therapeutic hypothermia for cardiac arrest: a practical approach.

Curr Treat Options Neurol. 2009 Mar;11(2):137-49.

Seder DB, Jarrah S argues that though Therapeutic Hypothermia (TH) is the most immediate and well known technique to review patients suffering from cardiac arrest (known as Encephalopathic survivors), a combined approach that involves various emerging tools such as critical care or Neuromonitoring can yield better outcome of patients, usage of neuromonitoring is critical during decooling phase...!

In the same journal of Curr Treat Options Neurol, another article emphasize the knowledge and usage of multimodality neuromonitoring for better outcome of patients aneurysmal subarachnoid hemorrhage (SAH)

a non traumatic hemmorrhage caused by either a tumor,infection or vascular malformation. 

2.Critical care management of subarachnoid hemorrhage."This article reviews the natural history of aneurysmal SAH and

strategies for disease management in the acute setting, including available tools for monitoring brain function.

Intensive care management of patients with SAH focuses on prevention of further neurologic injury. Aneurysmal rebleeding, hydrocephalus, seizures, and delayed ischemic injury represent major threats"

In vascular surgeries like carotid endarterectomy and when the internal carotid artery (ICA) is clamped the neuromonitoring playes an important role in giving early warning of Ischemia or embolism, especially the Sensory evoked potential and EEG monitoring.  Some of the techniques used are Transcranial Doppler (TCD) to measure the mean blood flow velocity, and Near-infrared Spectroscopy (NIRS) to assess the dynamics of "haemoglobine", but these techniques according to Bein B, Fudickar A, Scholz J. the practicability of using TCD and NIRS posses problems in about 20% patients?. Bein et all suggests the "Gold Standard" for better outcome and patient safety is to use intraoperative monitoring of SSEP?.

 3. [Anesthesia in vascular surgery--monitoring of cerebral function].

"Use of somatosensory evoked potentials (SEP) is the most widespread cerebral neuromonitoring during vascular surgery due to its high reliability and simple application. Sensitivity and specifity for ischemic lesions are 100% and 94%-99%, respectively. SEP are regarded as the gold standard for cerebral neuromonitoring in anaesthetized patients".

 Br J of Surg , In this British Journal of Surgery Publication,

4. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy.  Barczyński M, Konturek A, Cichoń S discuss about testing the hypothesis "Neuromonitoring of Recurrent Layrngeal nerves during Thyroidectomy?.  Unlike Barczyriski et al., who concluded the that the neuromonitoring in their surgical procedures

"Nerve monitoring decreased the incidence of transient but not permanent RLN paresis compared with visualization alone, particularly in high-risk patients".

These Italian surgery team in  video-assisted thyroidectomy (VAT) a same day surgical procedure, they found Intraoperative monitoring of reccurrent laryngeal monitoring helped prevent permanent damages to laryngeal nerves. 

5. Video-assisted thyroidectomy performed in a one-day surgery setting.

"Intraoperative neuromonitoring (IONM) was used for RLN identification. Intact parathyroid hormone (iPTH) levels were determined early postoperatively at +6-h. Postoperative complications, conversion rate were analyzed. RESULTS: No cases required conversion to open surgery or ordinary recovery (i.e. >24h). Incidence of temporary hypoparathyroidism was 11.6% (5/43) with no case of symptomatic hypocalcemia. Incidence of temporary RLN injury was 2.3% (1 patient) with no case of permanent or bilateral RLN injury. All patients were satisfied with the type of recovery. CONCLUSIONS: This preliminary report is an example of the safe incorporation between new technologies (IONM, early iPTH measurement) with improvement of the quality and safety of VAT performed in a one-day surgery setting. (this is a Dec 2008 article, not 2009?)

 6. In this latest issue of Laryngoscope, risks of VOICE alterations? (vocal cord damage due to laryngeal nerve injury) has been discussed. The Columbia University surgical team presents their data in this interesting finding and the authors conclude that there was 100% preservation of vocal cords during this minimally invasive, local anesthesia induced thyroidectomy.  The authors 

"Inabnet WB, Murry T, Dhiman S, Aviv J, Lifante JC discuss that the dentification and preservation of the external branch of the superior laryngeal nerve (EBSLN) is paramount for normal vocal function preservation after thyroidectomy. 

Thyroidectomy was successfully completed under local anesthesia in all cases. The recurrent laryngeal nerve(s) was identified and preserved in each patient as demonstrated by normal perioperative transnasal flexible laryngoscopy.

A total of 15 EBSLNs were at risk, but only 8 EBSLNs (53%) were definitively identified.

 Neuromonitoringdemonstrated preservation of the EBSLN in 100% of cases.

The analysis of the results of the VHI-10 questionnaire before and 3 weeks after surgery indicated no significant change in patients' perception of voice severity. CONCLUSION:: Monitoring of the EBSLN during thyroidectomy under local anesthesia is a feasible alternative to conventional nerve monitoring under general anesthesia. This technique may be useful for the preservation of voice quality during a minimally invasive thyroidectomy under local anesthesia"