Electroretinogram by Donnell J Creel

Figure Reference: Med.Utah.edu (linked, pl click)

In general, intraopertive neurophysiological monitoring teams do not conduct ERG or EOG in the Operating room set up, it is rather cumbersome and difficult to get a reliable readings combined with the difficulty of placing the recording electrode and risks that are associated with the procedure.  However, Donnell in its Chapter on"The electroretinogram" presents the latest developments that record the status of retinal function using skin electrodes and he also sheds light on the recent advancement in ERG the multifocal retiongram. Whether you are going to conduct this test or not, if you are interested in all the evoked potentials and the basics, this is an excellent reading material. Enjoy.

 The Electroretinogram: Clinical Applications by Donnell J. Creel

Electrophysiological testing of patients with retinal disease began in clinical departments in the late nineteen forties. Under the influence of the Swedish pioneers, Holmgren (1865) and Granit (1933), the electroretinogram was being dissected into component parts and early intraretinal electrode studies were beginning to tell which cells or cell layers gave rise to the various components. A detailed discussion of the electroretinogram, or ERG as it is commonly abbreviated, is found in the accompanying chapter by Ido Perlman. A little after the introduction of the ERG as a test of the state of the patient’s retina, another diagnostic test called the electrooculogram (EOG) was introduced to the clinic (Arden et al., 1962). The EOG had advantages over the ERG in that electrodes did not touch the surface of the eye. The changes in the standing potential across the eyeball were recorded by skin electrodes during simple eye movements and after exposure to periods of light and dark. Over the years ERG recording techniques have become progressively more sophisticated in the clinical setting. With the advent of perimetry, optical coherence tomography (OCT) and pattern ERG techniques, more precise mapping of dysfunctional areas of the retina is now possible. The most recent advance in ERG technology is the multifocal electroretinogram (mfERG). The mfERG provides a detailed assessment of the health of the central retina.

Why Should Anesthesiologists Be More Involved

With Neurophysiologic Monitoring?

Antoun Koht, M.D.

Anesthesiologists should re-evaluate and re-ignite their interest in neurophysiologic monitoring.

Their active involvement could lead to improved neuromonitoring today and allow

for possible supervision in the future.

Currently, neurophysiologic monitoring is conducted by trained technologists capable of

operating the neuromonitoring machine, connecting wires, obtaining reproducible signals,

and identifying signal changes; and they should be able to troubleshoot technical issues contributing to signal changes. However, diagnosis of the etiology of signal changes may be difficult

and outside the realm of their expertise. In order to elucidate signal change etiology, it is necessary to examine all potential causative factors, including rapidly checking monitoring circuit integrity, evaluating patient position, optimizing physiologic status, eliminating pharmacologic contributions, and correlating surgical maneuvers with signal changes.

ABRET's Policy on ABNM/CNIM Exams: Unfriendly and hindering Prospective Specialists?.

I recently received an email from one of our neuromonitoring colleagues with a serious concern about ABRET's policy on ABNM exams, I hope the ABRET officials read this blog article and also listen to practitioners in the field while drafting policies. 

**********************************************************

Date: Tue, 25 May 2010 12:08:58 -0700
Subject: need your advice, thanks
From: yingliu.lin@gmail.com


To: edu@drmuni.com
Dear Dr. Muni
My name is pearl, I am a regular reader for your neuromonitoring blog, which really impressed me. I read your article about the critical comment on ABRET's new policy changes on the CNIM requirement, and I am so happy to see the good outcome.


Now I am bothered by ABNM’s new policy changes on applicant’s eligibility. Beginning Aug, 2010, the new policy requires all applicants to provide a statement from a qualifying, supervising neurophysiologist. The new policy defines “a qualifying supervising neurophysiologist is either and individual with board certification from the American board of neurophysiologic monitoring (I think the number of these people is less than 200 in US) ora licensed physician who is board certified in neurology by the American board of psychiatry and neurology and who has fellowship training in clinical neurophysiology including intraoperative neurophysiological monitoring (I don’t know how many people would be qualified for this criteria, even less?), which means if one is not trained by any of these qualifying neurophysiologists, he or she will not get a statement and lose the opportunity to take the exam. Another potential problem is that the exam itself won’t be the major factor to decide whether or not one is competent to be a certificated neurophysiologist because subjective opinions based on personal motives (something like competition) could block a competent person’s opportunity taking the exam. I personally think this is not like a job hunting situation, in which the references recommendation should play the important role in judging a person’s qualification. This is a testing, as long as a candidate meets all of the objective requirements, such as three years experience in the field of neuromonitoring, completing 300 cases, and Ph.D degree in neurophysiology or neuroscience, shouldn’t the exam itself be the first to talk? With the IOM growing so fast, younger qualified people in this field should be encouraged to become board certificated experts, instead of trying to restrict people taking the exam by adding some crap requirements for whatever reasons or purposes. This new change gives a small number of people privilege to determine whether or not one has chance to take the exam even if he or she meets all objective requirements, which undermines the fair competition.


I think you understand my points about this issue, may I know your thoughts, and what is your suggestion if one can not get a statement from a neurophysiologist for the crap reasons?


Thanks for your time; I am looking forward to hearing from you.


All the best
pearl
**************************************************************

This issue was lingering in my mind for quite sometime, when Pearl wrote to me the above e-mail, I realized it is time to make a point on my blog, like Pearl few of my other colleagues who are veterans in this field of neuromonitoring also told me about these policies are rather callous, my friends on the phone expressed their concern about the shrewd and unfriendly policies of ABRET that is going to keep the qualified PhDs away and deprive the neuromonitoring field with only handful of ABNMs?. 

ABNM Exams policies are redundant and mundane , further appear to make the candidate miserable with too many useless requirements, in addition to those mundane policies, the exam board seems to fail many candidates, some very talented PhDs and MDs have been failed repeatedly, simply reflecting the motive of ABRET board to make more money out of the candidates in fees?, if this continues, I sincerely hope  that ABRET is going to be scrutinized and comes under the  radar of US exams regulatory boards.  This current article I am writing is mostly to talk about how their policies are framed to make the process of exam cumbersome and ridiculous.

Several months ago, ABRET reversed certain policies on CNIM following wide criticism of their CNIM exam requirements , they made it more realistic, appealing and useful to CNIM seekers.

This time, it is about ABNM exams, the number of ABNM certified neurophysiologists/neurologists are very few in US, as of 2008 there were only 128 D-ABNM. And, as per the latest numbers listed on ABNM website, there are only 144 diplomats received the D-ABNM. If the website is not updated in the last two years, it might be another 20-30 candidates in this last two years, adding to be around 175 or 180 diplomats. This is most likely the latest number, this is in all reality is an abysmal count considering the demand and need to have many such highly trained specialists. There is no other country or organization in US or outside to award ABNM, which means that the number quoted above is a global  ABNM, there are no such ABNM outside US. And, not even in UK or Canada is there such ABNM diplomats?.

Isn't this irony that an organization created to support, promote and safeguard the the field of modern patient care is blocking the prospects of so many PhDs. What is disturbing is the requirements from PhD/MDs to appear for exam, as you will notice in the accompanied E-mail message from Pearl,  in order to submit ABNM exam, a highly trained PhD holder with several years of experience in academia or industry, and possibly the PhDs would have had faculty experience, regardless of such high qualification and expertise, like a school student they have to get approval from a board certified Surgeon or a neurophysiologist with a D-ABNM. The application requirement is one of these must sign the application and recommend the candidate, this is ridiculous, ABRETs policy sounds like running  kinder garden school, does not look like a advanced medical care providers certification exam.

Why would someone with a PhD and tremendous experience have to stoop to a fellow neurophysiologist with a DBANM or a surgeon to file exam application, why?. Does this make any sense at all??. I can say that my neurophysiology/neuromonitoring CEO or supervisor is a Jerk and stupid, and may be the surgeon I work with do not have expert knowledge in brain and spine, or nervous system. Even neurologists do not have special and advanced knowledge as much as a Neurophysiologist, what a crap is this that a PhD has to go and get his application approved, this policy has to change.

ABRET and ABNM must realize that there are shortcomings in the number of D-ABNM, but there are also other issues like the ABNM's can't bill or claim cpt codes like an M.D can do?,  this is a terrible policy too!.  How many neurologists can set up a neuromonitoring test, prepare the patient, set up protocol, execute an appropriate test, monitor actively, interpret and analyze the data instantly and warn the surgeon about changes?. How many neurologists and spine surgeons and other surgeons really know or have comprehensive knowledge about neurophysiology, the intricacies of evoked potentials?. The clinical training and knowledge is not going to be of much use inside the OR, unless they were trained by a Neurophysiologist as to how to monitor and interpret the signals in the OR.

Hope the ABRET and ASNM look into these and do not bow down to the Medical Association, the neuromonitoring field is developed by decades of hard work and dedication of many neuroscientists and researchers in the field, after decades of establishing this field and make it to applicable in the clinical set up, the medical association and jobless clinicians want to steal away neuromonitoring field with their crap policies and subjugation of the monitoring professionals in the name of medical regulations deliberately designed to keep the MDs running the show?.

ABRET has to be thoughtful about their policies besides making PhDs in Neurophysiology and PhDs from related neuroscience fields with D-ABNM should be able to bill like an MD, including the medicare policies where an M.D oversight is currently a requirement, will the ABRET wake up and fight on these issues, as well as keep the exam policies user friendly and approachable for PhDs with experience in neuromonitoring?

This modern and growing health care field needs more doctorate level providers, especially those with PhD in Neurophysiology, or PhDs in allied field with extensive training in Neurophysiology.

Intraoperative Neurophysiological Monitoring, by Leon K Liem

eMedicine
Liem's article on "Intraoperative Neurophysiological
monitoring", a good place for starters to know the basics of
neuromonitoring.  Author: Leon K Liem, MD, Assistant Clinical Professor, Division of Neurological Surgery, University of Hawaii, John Burns School of Medicine

Contributor Information and Disclosures

Updated: Feb 11, 2010

Introduction

This article provides an overview of the various neurophysiological monitoring techniques used intraoperatively.
Intraoperative neurophysiological monitoring has been utilized in attempts to minimize neurological morbidity from operative manipulations. The goal of such monitoring is to identify changes in brain, spinal cord, and peripheral nerve function prior to irreversible damage. Intraoperative monitoring also has been effective in localizing anatomical structures, including peripheral nerves and sensorimotor cortex, which helps guide the surgeon during dissection.
Evoked potential monitoring includes somatosensory evoked potentials (SSEP), brainstem auditory evoked potentials (BAEP), motor evoked potentials (MEP), and visual evoked potentials (VEP). Electromyography (EMG) also is used extensively during operative cases. Scalp electroencephalography (EEG) provides data for analysis in SSEP, BAEP, and VEP. Scalp EEG also can be used to monitor cerebral function during carotid or other vascular surgery. In addition, EEG recorded directly from the pial surface, or electrocorticography (ECoG), is used to help determine resection margins for epilepsy surgery, and to monitor for seizures during electrical stimulation of the brain carried out while mapping cortical function. http://emedicine.medscape.com/article/1137763-overview

ABNM- Latest Schedules of Exams

American Board of Neurophysiologic Monitoring

Exam Application Requirements for Application Written Exam Oral Exam Recertification Policy and Procedures Official List of Diplomates Officers and Board

Next Written Exams Certification Examination in Neurophysiologic Monitoring - Part I - Written Application Deadline Examination Date 12/31/2009 2/6/2010 - 2/20/2010 6/28/2010 8/7/2010-8/21/2010 Next Oral Exams Certification Examination in Neurophysiologic Monitoring - Part II - Oral Application Deadline Examination Date Location 4/5/2010 4/25/2010 Nashville, TN only 10/4/2010 10/24/2010 Chicago, IL only For information about registering for these tests please contact the Professional Testing Corporationor email us at info@abnm.info. Check the site: http://www.ptcny.com/clients/ABNM/index.html

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."

Human Atlas:- Video Education of Anatomy?

As the above caption suggests, if you click one of the topics, you can see and listen to a beautiful and quite simple description of different anatomical structure of human Body. 

For someone who is just learning Anatomy or atlas of the Human body,  this is a good place to start......... you can start here. 

Audio and visual learning is more effective than just reading, though nothing can replace a careful and thorough reading habit. Modern tools makes learning much more easier and simpler. 

Here it is, hope you will find it useful.

One of the topic I clicked to see the video was "Anatomy of Spine", quite simple but appropriate information to begin learning the spine anatomy.

This can be a very good tool for someone who might be interested in learning neuroanatomy and neurophysiology. These 3D descriptions can be useful for non-neuroscience as well as neuroscience students, for Neuromonitoring newbies?.. and even for those who know the field, a quick refresher. 

Few Example Video's:

3D: Anatomy of Spine

3D: Lumbar Laminectomy

3D: Spinal Stenosis

Link:http://www.atlantichealth.org/en/atlantic/healthinformation/human+atlas+videos.html

73% of Patients suffered Complications, 11 out of 15 Patient?, What kind of IONM Company serves such a Surgeon?

Today's "Daily Record" carried the following news about a"medical malpractice suit"filed against Northwest Medical Center. In addition to the hospital and the surgeon, the neuromonitoring company known as American Intraoperative  Monitoring LLC? is also in trouble?.

"If" one has to go by this report and the number of surgeries done by the surgeon involved in this suit, 11 out of 15 patients (73%) had complications after spinal corrections (it not clear what kind of surgical procedure done on all the 15 surgical procedures, but the current case that is reported here is an anterior discectomy and fusion simply known as ACDF?). The number of patients suffering from post surgical complications are very significant, going by this report. This amount of surgical complications in the first place is rare, I haven't heard of a 73% complications (unless someone send me some past reports or ref?). 

Nevertheless, for argument I am wondering, what kind of a Neuromonitoring Company will provide neurophyisological monitoring services to a surgeon of this kind reported in this law suit?. Why?. Are you part of a bad practice and demoralized medical ethics, do you know what you are doing inside the OR?.

The report also claims that the Neuromonitoring Staff, seems to be an RN trained in neuromonitoring was aware about abnormalities (?? is this SSEPs loss? or Motor Loss or Spinal cord damage or what?) but did not warn the surgeon while it was happening during the surgery, neither he or she reported this after the surgical procedure?............Immmmmm...?

Northwest Medical Center added to malpractice suit

By Scott F. Davis Northwest Arkansas Times

Posted on Friday, January 23, 2009

Email this story | Printer-friendly version

FAYETTEVILLE - A Bentonville couple amended their malpractice lawsuit Thursday against Dr. Cyril "Tony" Anthony Raben and his clinic, Northwest Arkansas Spine and Orthopedic Associates, adding three new parties as defendants.

Theresa Paulino and her husband, Eddie Paulino, seek damages because she lost the use of her legs following neck surgery by Raben on Dec. 17, 2008, according to the complaint.

The Paulinos added Northwest Medical Center to the lawsuit, claiming "negligent credentialing" after learning that an audit by the Arkansas State Medical Board showed a very high complication rate for Raben's prior surgeries.

Read the full story: click the topic of this news linked to the original news.

Anesthesia and Neuromonitoring by Reza Gorji, MD

Reza Gorji from University of NY writes at the Neuroanesthesia.net about various neuromonitoring methods and the effect of anesthesia, what types of anesthetic agent is advisable for certain types of EPs and EEGs during surgical procedures.

Anesthesia and Neuromonitoring: Electroencephalography and Evoked Potentials Reza Gorji, MD, Department of Anesthesiology, University Hospital, State University of NY, Syracuse, NY

• Anesthesia and Neuromonitoring (EEG & EP) Patients undergoing neurologic/orthopedic procedures involving the peripheral and central nervous system may be at increased risk from hypoxia/ischemia to vital neurologic structures. Intraoperative neuromonitoring may improve patient outcome by:
  

a. Allowing early detection of ischemia/hypoxia before irreversible damageoccurs

b. Indicating the need for operative intervention (shunts placed in carotid surgery) to minimize nerve damage The role of anesthesiology in neuromonitoring is one of understanding the appropriate anesthetic techniques, applying knowledge of medicine, surgery, physiology and pharmacology to get the best possible outcome.

This monograph will discuss the

various clinically important neuromonitors and offer solutions as they apply to clinical anesthesia.

It is divided in 3 broad sections: Electroencephalography, sensory evoked potentials and motor evoked potentials.

Spinal cord tumor removal & Neuromonitoring

Spinal cord tumor resection can pose serious risks of
surgical
induced sensory or motor deficits, intraoperative neuromonitoring
of
combined sensory and motor pathways can be useful to prevent potential
damages. Here are some collective articles related to spinal cord tumor resection.

http://www.doaj.org/doaj?func=abstract&id=198856

Neuromonitoring News!

Biotronics-a neuromonitoring company based in Ann-Arbor acquired another company :American Neuromonitoring of Farmington Hills. Here is the story......

Deal positions Biotronics for growth
"This is historically a very fragmented industry. ... Only in the last few years have (companies) begun to build to serving 20, 40 and, in our case, hundreds of clinicians in the field. Once you get yourself in a larger scale, you're able to provide a better price point to hospitals." - Gene Balzer, Biotronics chief executive officer.

By TINA REEDThe Ann Arbor News
As the practice of monitoring patients' nerve functions during spinal surgeries grows in popularity, an Ann Arbor-based company said it's aggressively trying to grow itself to make the practice more accessible to U.S. hospitals.

Biotronic NeuroNetwork recently acquired American Neuromonitoring of Farmington Hills in a move it hopes will position itself for future acquisitions and increase its monitoring expertise, said Gene Balzer, Biotronics chief executive officer.