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*NEUROMONITORING [IONM] is a common term used to describe an evidence based patient care provided by Neurophysiologists with PhD/ M.D. The most appropriate term used to refer this medical health care field is Intra-Operative Neurophysiological Monitoring(IONM). *For consultancy use the contact/feedback form.
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Thursday, October 23, 2008
First Spinal Cord Endoscope Surgery Conducted in Iran
Neuromonitoring:-Failing to be Assertive to communicate the neurophysiological abnormalities will cost you a Lot?
$11.7 M verdict against bystander doctor
A team of doctors at North Fulton Medical Center worked on Josh Coleman’s back surgery in 2003. Dr. Frank Puhalovich had a minor role: “he was only in the operating room for about 10 minutes making sure a technician properly hooked up a monitor that tracks nerve impulses along the spinal [cord] through electrodes attached to Coleman’s head and feet.” But after Puhalovich left, during surgery, the alarm went off: attorneys blame the surgeons’ failure to respond to the alarm in a timely fashion for Coleman’s paralysis. Coleman sued everyone involved, and all the doctors settled, except Puhalovich. So Coleman proceeded to trial against Puhalovich, blamed him also, and a jury awarded $11.7 million. The press coverage gives no indication what the theory of liability is against Puhalovich.
Joshua Coleman, sitting in a wheelchair next to his attorneys, Bill Stone and David Boone, smiled as the verdict was announced after the two-week civil trial.“Josh is high as a kite right now,” Stone said. “He’s going to have a great weekend.”
(Beth Warren, “Paralyzed man awarded $11.7 million”, Atlanta Journal-Constitution,Mar. 24).
Update: Kevin, MD post with clever title Shotgun yields a jackpot.
Shotgun yields a jackpot
Tuesday, October 21, 2008
Cochlear Microphonics & CNAP recording in Neuromonitoring??
Anatomy of Ear (pic fromHearing and Hair Cells John S. Oghalai, M.D.Baylor College of Medicine ) (human ear pic: Muni's_neuromonitoring1)Jorge Bohorquez et al describes a system in their recent publication listed below, according to their study one can test both outer hair cell and inner hair cell electrical activity during surgical procedures. Though this work is evaluated in aniamal study, it is pretty interesting if this can be moved to the OR in our neuromonitoring procedures. I am not sure if this is already practiced in the OR by any neuromonitoring companies. It is a very common procedure to do auditory brain stem evoked potentials in tumor resection or craniotomy procedure that might put the 8th nerve in risk, nevertheless, this CM, CAP and CNAP will be a very important approach in certain cases where injury to both IHC and OHCs can be avoided?.
Neuromonitoring of cochlea and auditory nerve with multiple extracted parameters during induced hypoxia and nerve manipulation
Jorge Bohórquez et al 2005 J. Neural Eng. 2 1-10 doi: 10.1088/1741-2560/2/2/001electrocochleogram (ECochGm) were recorded at the round window (RW) niche using a specially designed otic probe.The ECochGm was further processed to obtain cochlear microphonics (CM) and compound action potentials (CAP). The amplitude and phase of the CM were used to quantify the activity of outer hair cells (OHC); CAP amplitude and latency were used to describe the auditory nerve and the synaptic activity of the inner hair cells (IHC). In addition, concurrent monitoring with
a second electrophysiological channel was achieved by recording compound nerve action potential (CNAP)obtained directly from the auditory nerve. Stimulation paradigms, instrumentation and signal processing methods were developed to extract and differentiate the activity of the OHC and the IHC in response to three different frequencies. Narrow band acoustical stimuli elicited CM signals indicating mainly nonlinear operation of the mechano-electrical transduction of the OHCs. Special envelope detectors were developed and applied to the ECochGm to extract the CM fundamental component and its harmonics in real time. The system was extensively validated in experimental animal surgeries by performing nerve compressions and manipulations.
Monday, October 20, 2008
Medical & Legal Issues Regarding Brain Injury
What are the medical and legal aspects of Brain Damage or Axonal damage?
what type of knowledge is neccessary to deal with court cases that may require background knowledge and expertise in looking at the area of brain damage and discuss the intricacies of brain damage and axonal damage to the court officials as well as to the lay people in the jury??. This following article appeared in the latest issue of the newsletter of IBIA (International Brain Injury Association) discusses in detail about what health care professionals should know?.
Medical-Legal Illustration: What Health Care Professionals Should Know
By Robert L. Shepherd, MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated
Figure 1: Example of graphics that can aid expert testimony: This particular series of illustrations helps demonstrate one of the most difficult concepts for layperson decision makers to appreciate – that is, how brain injuries (traumatic axonal and shear injury) can occur in an individual with only a minor, or sometimes even no significant blow to the head. The illustrations are also particularly helpful in explaining how an individual can have these injuries, yet the injuries are not evidenced on traditional brain imaging studies such as CT or MRI. Another very effective animation demonstrating this same phenomenon even more convincingly can be seen at the following link: http://medivisuals.com/mildtbi
Thursday, October 9, 2008
Gray's Anatomy
The Bartleby.com edition of Gray’s Anatomy of the Human Body features 1,247 vibrant engravings—many in color—from the classic 1918 publication, as well as a subject index with 13,000 entries ranging from the Antrum of Highmore to the Zonule of Zinn.
Henry Gray (1821–1865).Anatomy of the Human Body. 1918.TWENTIETH EDITION
THOROUGHLY REVISED AND RE-EDITED BY WARREN H. LEWIS
ILLUSTRATED WITH 1247 ENGRAVINGS
NEW YORK: BARTLEBY.COM, 2000
Wednesday, October 1, 2008
NEUROMONITORING RESEARCH Articles -PubMed
A quick search or browsing on the PubMed on the subject neuromonitoring produced these results summarised in My NCBI column here.
This is the summary of publications thus far available in the pubmed search. Because of the way the robotic search is conducted using terms/words we "type in", there is a possiblity of exlusion of some related research papers, or inclusion of unrelated papers in the cumulative numbers. But, to the most part I believe these are the numbers reflecting published works on neuromonitoring.
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for Items 1 - 20 of 312, of Page 16 Next , Review: 72 for of Page 9 Next, |
TcMEP=23 (2 Pages), Reviews: 1
SSEPs (the term SSEP alone does not produce result on somatosensory
but unrelated articles, but SSEPs is the correct term to use)
= 411 (21 Pages), Reviews:18
Intraoperative, Cortical Mapping= 459 (23 Pages), Reviews:69
Carotid Endarctomy, Neuromonitoring= 28 (2 Pages), Reviews=6
Scoliosis= 12 (1 Page), Review:1
Pubmed search of the topic Neuromonitoring using words "neuromonitoring, intraoperative neuromonitoring resulted in about 312 research article, 72 reviews for the term neuromonitoring and 179 research article and 34 reviews for the term intraoperative neuromonitoring respectively.While there are several combination of word search to know the publication lists in this field, the search I posted here pretty much compiles most of them. Some of the other ways to look at the publications in this field using the search words such as "MEP, SSEP, EMG, EEG, Cortical Mapping, Carotid Endarctomy, Scoliosis. Some of the key words required a combination search with the word intraoperative to get specific research articles. In the following section, I will discuss the latest research reports on neuromonitoring comprising works done in 2008.
Wednesday, September 17, 2008
NeuroMonitoring in Epilepsy Related Diseases & Surgeries!?.
In the latest issue of the journal JNS, Scellig S. D. Stone, M.D., and James T. Rutka from The Hospital for Sick Children, and The University of Toronto, Ontario, Canada discuss issues relate to the topic "challenges in Epilepsy related diseases and neurosurgeries in epilepsy patients".
These challenges can provide great opportunities for neuromonitoring, infact, in this very review you will find that the existing brain mapping and EcoG has been a gold standard to conduct successeful neurosurgeries, it has become an important tool for surgeons to identify and map the areas in epilepsy patients who undergo surgeries to get rid of the epileptic loci in the brain.
1.Electrocorticography recording method, using this method one can reliably map the brain areas of interest for surgical removal by directly placing grid electrodes on the surface of brain (invasive), using the method poineered by the Penfield and Jasper[34.Jasper H, Electrocorticography.Penfield W, Jasper H: Epilepsy and the Functional Anatomy of the Human Brain Boston, Little Brown, 1954. 692–738].
2.Depth Electrode Recordings, this method can be combined with the direct mapping of the brain using depth electrode, deep isertion of electrodes into subcortical areas will provide additional information about ictical and interactive epileptic regions, in reality, the DER can be performed outside the OR perioperatively as well as inside the OR intraoperatively, enabling the surgeon to develop a streamlined strategy into the brain area of interest to be lesioned, lesioning brain areas is the surgical procedures carried out to eliminate epileptic activities.
3.Intraoperative EcoG is yet another recording used widely to operate on interactive epileptic patients, the most important use of EcoG seems to be to during extralesional resections or lesionectomy combined with spike-positive tissue resection procedures. EcoG monitoring seems to have helped reduce the rate of second surgical procedure and reduced epileptic activities significantly in those patients. One of the surgical procedure where EcoG was very useful in the removal of the hippocampal area or mesial temporal or gliosis surgical procedures.
4.Direct Cortical Stimulation method, mostly used in surgeries that involve sensory motor or language areas, a direct application of focal cortical pulses of low voltage current using a hand held bipolar electrode.
techniques in combination as a "multi-model" neuromonitoring procedurecan go long way in safegurding better surgical procedures in epilepsy patients. This is a great review any neurophysiologist or neurosurgeon or neurologist or neuromonitoring personnel must read for better understanding of surgical procedures and neuromonitoring in epilepsy patients.
Sunday, September 14, 2008
Ulnar Neuropathy? If the surgery site is lower Lumosacral level, why should you monitor upper limp SSEPs?
This article in the latest Spine Journal (an electronic publication) demonstrates that upper limp SSEP monitoring is quite handy in detecting ulnar nerve neuropathy during lower back surgeries??.
PubMed-NCBI Spine J. 2008 Aug 4. [Epub ahead of print] Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury.
BACKGROUND CONTEXT: Somatosensory evoked potential (SSEP) is used to monitor integrity of the brain, spinal cord, and nerve roots during spinal surgery. It records the electrical potentials from the scalp after electrical stimulation of the peripheral nerves of the upper or lower limbs. The standard monitoring modality in lumbosacral spine surgery includes lower-limb SSEP and electromyography (EMG). Upper-limb SSEP monitoring has also been used to detect and prevent brachial plexopathy and peripheral nerve injury in thoracic and lumbosacral spine surgeries. We routinely monitor lower-limb SSEP and EMG in lumbosacral spine procedures at our institution. However, a few patients experienced postoperative numbness and/or pain in their ulnar distribution with uneventful lower-limb SSEP and EMG.
PubMed-NCBI Spine J. 2008 Aug 4. [Epub ahead of print] Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury.
Friday, September 5, 2008
Neuromonitoring Signal Changes during Spinal Epidural Hematoma?
there are few non-surgically induced damages that might go unnoticed in the absence of intraoperative neuromonitoring such as ischaemia, hematoma, stroke and so on...?.The following work demonstrates the timely detection of epidural hematoma by neurophysiological wave form changes.
the disappearance of evoked potentials and the subsequent appearance of paraplegia in our patient was unlikely to be caused by the epidural LA, but probably by the occurrence of the spinal epidural hematoma as a complication of epidural catheterization.
Acute spinal cord dysfunction was revealed by INM, then elucidated by imaging of the spine. The whole sequence of events led to timely urgent neurosurgical intervention which resulted in complete restoration of motor and sensory functions.
Our patient’s case supports the value of evoked-potential monitoring during spinal surgery.This case and previous work offer arguments that evoked potentials are relatively insensitive to epidural LAs, but nevertheless we suggest that neuraxial LAs better be avoided in cases in which INM is used.
Friday, August 15, 2008
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.
Tuesday, July 29, 2008
Nerve Conduction Study & Needle Electromyography
ADVANCE is a comprehensive platform for the performance of traditional nerve conduction studies and needle electromyography procedures. The technical specifications include a precision electrical stimulator and dual recording channels for acquiring nerve conduction responses. A third channel is available for recording needle electromyography signals. ADVANCE introduces several important technological improvements.Last update: 7:30 a.m. EDT July 29, 2008WALTHAM, Mass., Jul 29, 2008 (BUSINESS WIRE) -- NeuroMetrix, Inc. (NURO:neurometrix inc comNURO 1.39, -0.02, -1.4%) today announced that it has completed the CE technical file for its ADVANCE System ("ADVANCE"). With this regulatory step, NeuroMetrix intends to begin marketing ADVANCE to neurologists, clinical neurophysiologists, hand surgeons, and other specialists in the EU.
NeuroMetrix, Inc.
Jessica Borchetta, 781-314-2725
Administrative Assistant
neurometrix.ir@neurometrix.com
Friday, July 18, 2008
65,000 Peers, Doctors Online Network!
Doctors can join 30,000??? (it is 65,000 now!) peers to comment on stories and initiate discussions.
By AMNews staff. Oct. 15, 2007.
Doctors now can share their views on American Medical News articles with thousands of their colleagues on Sermo, an online community for physicians only.Current and recent articles in the American Medical News online edition -- amednews.com -- carry links that instantly connect readers to the free Sermo site (www.sermo.com). Established Sermo member physicians then need only log in. First-time physician users can access the Sermo community after a simple registration procedure, taking about two minutes, that includes verification of their MD or DO degree.
Thursday, June 12, 2008
Spinal cord tumor removal & Neuromonitoring
http://www.doaj.org/doaj?func=abstract&id=198856Spinal 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.
Spinal Cord integerity risk & Tibial single Trial SSEP?
Single trial Tibial Somatosensory SSEP along with H-reflex can be used to monitor the spinal cord integerity and function during surgical procedures that put the cord in risk. The following article
describes how this combination of a single trial SSEP can be
useful?.
When spinal cord functional integrity is at risk during surgery, intraoperative neuromonitoring is recommended.
Tibial Single Trial Somatosensory Evoked Potentials (SEPs) and H-reflex are here used in a combined neuromonitoring method: both signals monitor the spinal cord status, though involving different nervous pathways.However, SEPs express a trial-to-trial variability that is difficult to track because of the intrinsic low signal-to-noise ratio. For this reason single trial techniques are needed to extract SEPs from the background EEG.
Wednesday, May 21, 2008
4th and 5th Cervical Laminae-Acute Hemiparesis?
Traumatic invagination of the fourth and fifth cervical laminae with acute hemiparesis
U. R. Hähnle, L. Nainkin
From the University of the Witwatersrand, Johannesburg, South Africa
Crutchfield tongs. As the neurological deficit did not recover
during the following week operation was undertaken.
Through a posterior approach, exposing the laminae and
lateral masses from C3 to C6, the invagination of the right
laminae of the C4 and the C5 vertebrae was confirmed. All
other posterior elements such as the facet joints, ligamentum
flavum, interspinous ligaments and spinous processes
were intact. The fracture at C2 was not exposed.
Reduction of the invaginated laminae was achieved by
gentle traction on the spinous processes. Mild flexion of the
neck helped to maintain the reduction. As the neck was
extended there was a tendency for the laminae to reinvaginate.
Transverse wiring of the two involved spinous processes
was undertaken with tension towards the left-sided
lateral masses to maintain the position of the reduced
laminae.
Adequate decompression was confirmed on a postoperative
CT scan (Figs 3a and 3b).
Tuesday, April 15, 2008
How to Calculate Frequency, Duration & Amplitude in EEG?
Calculating Frequency, Duration, Amplitude, and Voltage Using a Legend
By Bill Byrum, MBA, R. EEG/EP T., CNIM
In this article I want to review with you
how simple it is to use a Legend. You will
need a measurement ruler graduated into
one mm segments. It would also be handy
to have a calculator that can be set to divide
to 3 decimal places. If you perform division
by hand, please be sure to carry the results
to 3 decimal places when calculating
waveform duration.
I strongly recommend whenever you
are doing calculation utilizing a Legend
that you use a referential montage and the
reference is not contaminated with EEG
activity. This is because in a bipolar
montage the waveforms are the result of
two inputs active with EEG activity. The
same can be said of a referential montage if
the reference is contaminated. For complete article, click the linked title?.
Wednesday, February 20, 2008
Degenerative Disc Disease- in a Illustrative way?
Sunday, February 17, 2008
NEUROMONITORING COMPANIES IN AMERICA: How Many? & Who are they?
- Neuromonitoring1 ......is the only place on the internet or offline on any books where you will find list of companies that provide Neuromonitoring in America, it is not clear at this moment how many countries health care system applies this approach (there is no data on it, but I am sure there are only handful of nations like USA, Canada, UK, Sweden, Singapore so far known to employ or have companies doing this service, among them the most widely established neuromonitoring practices occur in US.
- This list is by far the comprehensive, though it does not reflect one hundred percent of companies in US but certainly most of them with a webaddress and well known names are listed here.
A list of all these neuromonitoring companies are documented at the bottom of this blog under separate topic: Neuromonitoring Companies!!.You will be able to get more details of those companies such as name brand, directors, office staff, company goals, operating areas and schedules etc., along with the link to each company at the very bottom of this blog under title Neuromonitoring Companies and Centers.
Two of the latest addition are Synapse neuromonitoring and Argos Neuromonitoring, the list will be updated periodically.
Neuromonitoring News!
Deal positions Biotronics for growthBy TINA REEDThe Ann Arbor News
"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.
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.