Evolving Compartment Syndrome detected by SSEPs/TcMEPs neuromonitoring during Cervical Spine surgery

Case Report

Evolving Compartment Syndrome Detected by Loss of Somatosensory- and Motor-evoked Potential Signals During Cervical Spine Surgery

Check the details under case reviews. in this blog.!.

Current Trends in Pedicle Screw Stimulation techniques

PubMed Research Publications:

Latest review from Isley etal,  here is the most recent review article on Pedicle screw stimulation and evaluation using EMG monitoring techniques. It might be a good read to refresh the knowledge about the literature on pedicle screw tests.

Current trends in pedicle screw stimulation techniques: lumbosacral, thoracic, and cervical levels.

Abstract: Unequivocally, pedicle screw instrumentation has evolved as a primary construct for the treatment of both common and complex spinal disorders. However an inevitable and potentially major complication associated with this type of surgery is misplacement of a pedicle screw(s) which may result in neural and vascular complications, as well as impair the biomechanical stability of the spinal instrumentation resulting in loss of fixation. In light of these potential surgical complications, critical reviews of outcome data for treatment of chronic, low-back pain using pedicle screw instrumentation concluded that "pedicle screw fixation improves radiographically demonstrated fusion rates;" however the expense and complication rates for such constructs are considerable in light of the clinical benefit (Resnick et al. 2005a). Currently, neuromonitoring using free-run and evoked (triggered) electromyography (EMG) is widely used and advocated for safer and more accurate placement of pedicle screws during open instrumentation procedures, and more recently, guiding percutaneous placement (minimally invasive) where the pedicle cannot be easily inspected visually. The latter technique, evoked or triggered EMG when applied to pedicle screw instrumentation surgeries, has been referred to as the pedicle screw stimulation technique. As concluded in the Position Statement by the American Society of Neurophysiological Monitoring (ASNM), multimodality neuromonitoring using free-run EMG and the pedicle screw stimulation technique was considered a practice option and not yet a standard of care (Leppanen 2005). Subsequently, the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Disorders of the Spine and Peripheral Nerves published their "Guidelines for the Performance of Fusion Procedures for Degenerative Disease of the Lumbar Spine" (Heary 2005, Resnick et al. 2005a, Resnick et al. 2005b). It was concluded that the "primary justification" of intraoperative neuromonitoring"... is the perception that the safety and efficacy of pedicle screw fixation are enhanced..." (Resnick et al. 2005b). However in summarizing a massive (over 1000 papers taken from the National Library of Medicine), contemporary, literature review spanning nearly a decade (1996 to 2003), this invited panel (Resnick et al. 2005b) recognized that the evidence-based documents contributing to the parts related to pedicle screw fixation and neuromonitoring were "... full of potential sources of error ..." and lacked appropriate, randomized, prospective studies for formulating rigid standards and guidelines. Nevertheless, current trends support the routine use and clinical utility of these neuromonitoring techniques. In particular free-run and triggered EMG have been well recognized in numerous publications for improving both the accuracy and safety of pedicle screw implantation. Currently, treatment with pedicle screw instrumentation routinely involves all levels of the spine - lumbosacral, thoracic, and cervical. Significant historical events, various neuromonitoring modalities, intraoperative alarm criteria, clinical efficacy, current trends, and caveats related to pedicle screw stimulation along the entire vertebral column will be reviewed.

PMID: Neurodiagn J. 2012 Jun;52(2):100-75.

22808751

[PubMed - in process]

The Essence of Neuromonitoring: 23 Year Retrospective Study of 3436 Spinal Deformity Surgeries, Staggering 99.6% Accuracy/Detection of Permanent damage!

 Emerson RG's article published in the latest issue of Journal of Clinical Neurophysiology must be an eye opener for Naysayer neurologists and to those skeptic spine specialists out there who is impetuously discredit the predictability values and reliability of intraoperative neurophysiological monitoring. My own personal IONM experience provided to more than 1500 surgical procedures reveal even more than 99.6% accuracy of detection, wherein about 4-5 spine patients lives been saved (four lumbar and cervical fusion spine cases, and one scoliosis procedure) because of the timely warning from the IONM results during the surgical procedures, the timely warning enabled surgeon to take immediate intervention measures to reverse the risk of permanent damage thereby saved the patient from paralysis.

               The number of years accounted in this study, and the number of patients who underwent surgical procedures used for this analysis of Dr.Emerson's study is compelling and producing an authoritative findings. It is a must have clinical paper for all those who work in IONM field and a great reference source to be given to those naysayers.

J Clin Neurophysiol. 2012 Apr;29(2):149-50.

NIOM for spinal deformity surgery: there's more than one way to skin a cat.

Emerson RG. Abstract

STUDY DESIGN: This was a 23-year retrospective study of 3436 consecutive pediatric orthopedic spinal surgery patients between 1995 and 2008.

OBJECTIVE: To demonstrate the effectiveness of multimodality electrophysiologic monitoring in reducing the incidence of iatrogenic neurologic deficit in a pediatric spinal surgery population.

SUMMARY OF BACKGROUND DATA: The elective nature of many pediatric spinal surgery procedures continues to drive the need for minimizing risk to each individual patient. Electrophysiologic monitoring has been proposed as an effective means of decreasing permanent neurologic injury in this population.

METHODS: A total of 3436 consecutive monitored pediatric spinal procedures at a single institution between January 1985 and September 2008 were reviewed. Monitoring included somatosensory evoked potentials, descending neurogenic evoked potentials, transcranial electric motor evoked potentials, and various nerve root monitoring techniques. Patients were divided into 10 diagnostic categories. True-positive and false-negative monitoring outcomes were analyzed for each category. Neurologic deficits were classified as transient or permanent.

RESULTS: Seven of 10 diagnostic groups demonstrated true-positive findings resulting in surgical intervention. Seventy-four (2.2%) potential neurologic deficits were identified in 3436 pediatric surgical cases. Seven patients (0.2%) had false-negative monitoring outcomes. These patients awoke with neurologic deficits undetected by neuromonitoring. Intervention reduced permanent neurologic deficits to 6 (0.17%) patients. Monitoring data were able to detect permanent neurologic status in 99.6% of this population. The ratio of intraoperative events to total monitored cases was 1 event every 42 surgical cases and 1 permanent neurologic deficit every 573 cases.

CONCLUSIONS: The combined use of somatosensory evoked potentials, transcranial electric motor evoked potentials, descending neurogenic evoked potentials, and electromyography monitoring allowed accurate detection of permanent neurologic status in 99.6% of 3436 patients and reduced the total number of permanent neurologic injuries to 6.

Review of Neuromonitoring field 32 Years Ago?.

The utilization and importance of Neuromonitoring in hospital or intensive care set up was reviewed elaborately 32 years ago during 1985. Did anything change or how much change has took place in this field is quite interesting, while basic principles and intraoperative modalities discussed remain pretty much same today as 32 years ago, IONM field did make lots of progress ever since, better tests, analysis and interpretation of results got savvy and reliable upto 96-99% accuracy than it was during1985. Advancements in terms of application in various surgical procedure and combinatorial tests to yield better results, some newer techniques, and the entire hardware/machine technology certainly been upgraded to fit the Operating Room environment.

W.Hacks, the author of this review from the then FRG (West Germany, no longer the case after 90s unified Germany) made a remarkable attempt to provide insights 32 years ago. The review has been published in "Journal of Neurology (interestingly, the very first issue of this journal was published way back in the year 1891 that continued till today with the same name Journal of Neurology Volume 1 / 1891 - Volume 259 / 2012), quite an respectable journal in the field of neurology, it is still exist with the same name with a significant impact factor score of 3.85, ranked 33 among 185 clinical neurology journals [The top five Neurology journals are rated as follows:  (Neurology, Brain, Annals of Neurology, Journal of Neurotrauma, and Stroke, for an interesting review of these top journals, click here LINK).

Here is the link to the partial or one page review available at the bottom of this abstract, it is a pay per view article, only one page is viewable for non subscribers.

Abstract

Neuromonitoring—the continuous or intermittent observation of nervous system functions—has become a field of interdisciplinary interest. Basically there are two major applications of neuromonitoring: in the operating theatre and the neurological or neurosurgical intensive care unit. Evoked potential recording, intracranial pressure measurement, serial EEG recording, cerebral blood flow measurement and ultrasound techniques have all been used as monitoring methods. The application of these techniques for operations, intensive care and the evaluation of brain death will be described.

Key words  Neuromonitoring - Intraoperative monitoring - Evoked potential monitoring - Spinal cord monitoring - Brain death

http://resources.metapress.com/pdf-preview.axd?code=kpj1622557hv431x&size=largest

KFC Chicken Twister & Salmonella, watch out!

Brain damage after eating KFC's contaminated chicken twister?, Ouch..! are you still going to KFC?. I have to say that it has been years since I even had a glimpse of  the KFC building, let alone go inside to buy some meal, it is simply a disgusting food place, no wonder why the Australian court ordered KFC to pay $8Million to a 7 year old girl who suffered Salmonella infection after eating KFC food.
That is a one disgusting place to go for food?.

KFC ordered to pay $8m  to brain-damaged girl Paul Bibby, April 27, 2012 - 3:36PM  Read more: http://www.smh.com.au/nsw/kfc-ordered-to-pay-8m-to-braindamaged-girl-20120427-1xpkc.html#ixzz1tHQSfBEP

KFC ordered to pay $8 million to girl left brain damaged after eating meal. Monika Samaan ... her family has been awarded $8 million. Photo: Picture courtesy of NBN NewsRead more: http://www.smh.com.au/nsw/kfc-ordered-to-pay-8m-to-braindamaged-girl-20120427-1xpkc.html#ixzz1tHQrHQC8

Samaan, then seven, was in a coma for six months and was left with spastic quadriplegia with severe brain damage.

Bis- Is it Reliable?, what do the Anesthesiologists & Surgeons must know about Bis?.

New England Journal of Medicine is one of the Most respected and trustable medical journals out there, personally I place NEJM on top of some of even the well known American medical journals without a slightest doubts. 

And, this time it is the NEJM that has published some important results on BIS monitor usage by anesthesiologists inside the Operating Rooms.. The question many of the medical professionals must raise about this little tool is, is it a valuable technique to be used about patient's awareness or sleep/awake status during surgical procedures??. Now we know for sure from this study that the actual "validity" of BIS is seriously flawed and questionable?, further lead to a massive Re-call of FDA approved Bis monitors by the manufacturer Covidien, "Covidien PLC (COV) unveiled an expanded recall of its BIS Bilateral sensors" (Wall Street Journal)

Here is the RESULT of a study published in NEJM:

RESULTS
A total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, who were interviewed postoperatively had definite intraoperative awareness (a difference of 0.17 percentage points; 95% confidence interval [CI], −0.03 to 0.38; P=0.98). Thus, the superiority of the BIS protocol was not demonstrated. A total of 19 cases of definite or possible intraoperative awareness (0.66%) occurred in the BIS group, as compared with 8 (0.28%) in the ETAC group (a difference of 0.38 percentage points; 95% CI, 0.03 to 0.74; P=0.99), with the superiority of the BIS protocol again not demonstrated. There was no difference between the groups with respect to the amount of anesthesia administered or the rate of major postoperative adverse outcomes.

This topic of whether or not BIS monitor can help the anesthesiologist regarding the level of anesthesiology administered to patient is enough, or deep enough for a surgical incision to be performed by surgeon without perturbing patient memory was under debate among professionals for quite sometime, but this research group headed by Michael S Avidan, the principle investigator along with a big team at Washington University School of Medicine clarified to a some extent and proves the major consensus in the field that bis is unreliable?, the patients may be sleep but not to an extent intended or needed by anesthesiologist, so the patient might still be able to recall some of the ongoing conversations or sounds in the OR, huh?.

It is not just about remembering what is going on in the OR while sleeping on the surgical bed, but beyond that the Pain the patient will be enduring and remembering the pain due to surgical procedure is simply unacceptable and need to be addressed by medical and health care communities immediately. As far as feeling or remembering the pain of a surgical knife cutting though lasts for few seconds to minutes, it still unacceptable medical practice for the patient to go through or endure such pain, we are not in a war zone or some third world where there is no proper medical facility or no other alternative but take a knife and cut in a emergency scenario?.  However, what we are discussing here is about a totally equipped, highly advanced, ethically and medically justified planned surgical set up, and there is no execuse.

Here is the Link to the Full Study:

Study Evaluating Whether the Bispectral Index Prevents Patients at Higher Risk From Being Awake During Surgery and Anesthesia (BAG-RECALL)

This study has been completed.

First Received on May 16, 2008.   Last Updated on January 3, 2011   History of Changes

Sponsor:	Washington University School of Medicine
Collaborators:	Foundation for Anesthesia Education and Research American Society of Anesthesiologists University of Chicago University of Manitoba University of Michigan
Information provided by:	Washington University School of Medicine
ClinicalTrials.gov Identifier:	NCT00682825