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An Invitation to Washington D.C.
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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, December 18, 2008
IBIA-Brain Injury Conference?
Saturday, December 6, 2008
Transient Loss of TcMEP during L5-S1 posterior fusion?
In the following case report, a posterior lower lumbar surgical procedure done on a Spondylolisthesis (L5/S1) patient resulted in a transient loss of motor evoked potentials despite the patient had no neurological injury?. The motor loss was occurred after epidural injection of 2.4mg of morphine?. The authors believe it could be due to the pressure caused by the injection would have compressed cauda equina?.
A 7-year-old girl having posterior spinal fusion for Grade 3 anterior spondylolisthesis at the L5/S1 level was administered 2.5 mg of morphine in 10 ml saline via the caudal epidural route before surgery.Motor-evoked responses were markedly diminished in her lower limbs for 1 h following this but returned spontaneously. She suffered no neurological injury. The cause for this is postulated to be transient cauda equina compression from the volume of injectate. This complication of caudal injection has not been reported before. The possible mechanisms for this are discussed. We believe that significant L5/S1 spondylolisthesis should be considered a contraindication to the use of caudal epidural injections.
Monday, December 1, 2008
Wave P300 (ERP) & Temporal Lobe Epilepsey
Attention impairment in temporal lobe epilepsy: A neurophysiological approach via analysis of the P300 wave.Bocquillon P, Dujardin K, Betrouni N, Phalempin V, Houdayer E, Bourriez JL, Derambure P, Szurhaj W.
Department of Clinical Neurophysiology, Lille University Medical Center, Lille, France.
Purpose:
Attention is often impaired in temporal lobe epilepsy (TLE). The P300 wave (an endogenous, event-related potential) is a correlate of attention which is usually recorded during an "oddball paradigm," where the subject is instructed to detect an infrequent target stimulus presented amongst frequent, standard stimuli.Modifications of the P300 wave's latency and amplitude in TLE have been suggested, but it is still not known whether the source regions also differ. Our hypothesis was that temporal lobe dysfunction would modify the P3 source regions in TLE patients. Methods: A comparative, high density, 128-channel electroencephalographic analysis of the characteristics of P300 (P3b latency and amplitude) was performed in 10 TLE patients and 10 healthy controls during auditory and visual oddball paradigms. The P3b sources were localized on individual 3D MR images using the LORETA method and intergroup statistical comparisons were performed using SPM2(R) software. Results: Our main results (in both individual analyses and intergroup comparisons) revealed a reduction in temporal (and more particularly mesiotemporal) sources and, to a lesser extent, frontal sources in TLE patients, compared with controls. Discussion: This reduction may reflect direct, local cortical dysfunction caused by the epileptic focus or more complex interference between epileptic networks and normal attentional pathways. Hum Brain Mapp, 2009. (c) 2008 Wiley-Liss, Inc.
PMID: 19034898 [PubMed - as supplied by publisher]
Tuesday, November 18, 2008
BMP in Back surgery?:- What and Who?
Bone Morphogenic protein (BMP) is used in certain surgical procedures that involves lower lumbar surgery, but not in other procedures why?. Is BMP good compared to patients own bone transplantation or bone marrow substitute?. Right now it seems lime the FDA has approved BMP to be used only in lower lumbar cases such as L5-S1 procedures?. But, if BMP has anything to do with neurophysiological signals, not sure if there are any reports?.
Brain writes in this column about BMP, it's present usages and more...!. The full article can be read from his original site spine universe, click the topic for the link.
BMP: The What and the Who
Sunday, November 16, 2008
ABRET changes the Eligibility Requirement for All Exams?
The new requirements for CNIM exam is the candidate should undergo prior EEG credentialing???
For someone with a graduate degree or PhD or MD, if they wanted to be neuromonitoring specialist, they must undergo EEG or EP credentialing through ABRET?, does this makes any sense to those advanced degree holders?. It simply sounds to be ridiculous that ABRET is bent on making such changes as this would drive the PhDs and other advanced degree holders, there are already lots of shortage in neuromonitoring, it is difficult for companies to hire graduates with specialization in neurophysiology or neuroscience, with this new requirements, it is going to get worst to find someone with a credentialing in EEG or EP.
As of January 1, 2010 the following eligibility requirements will be in effect for the CNIM Examination
The Certification Examination in Neurophysiologic Intraoperative Monitoring is designed and written for the advanced level electroneurodiagnostic professional who is currently practicing in an intraoperative environment.
All candidates must meet the following requirements by the application deadline. There are no alternative routes.
- An electroneurodiagnostic credential; R. EEG T. or R. EP T. or Canadian equivalent. A copy of current registration must accompany the Application.
Monday, November 3, 2008
Disposable Surgical Face Masks: A Systematic Review
Here is an review on Surgical Masks, a careful review on Masks that looks at all the studies done so far and compares the various usage and it's safety.
Disposable Surgical Face Masks:
A Systematic Review
DISPOSABLE SURGICAL FACE MASKS: A SYSTEMATIC REVIEW
Authors: Allyson Lipp RN DipN RNT MA MSc, Principal Lecturer, School of Care
Sciences, University of Glamorgan, UK.
Peggy Edwards RN Dip Operating
Practice BSc Professional Practice, Welsh Risk Pool Assessor, Pontypridd,
UK
Acknowledgements: Cochrane Collaboration Wounds Group and the Theatre
Nursing Trust Fund. Extracts of systematic review reproduced by kind permission
of: Update Software, Oxford.
ABSTRACT
Surgical face masks were originally developed to contain andHowever, there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound. Surgical face masks have recently been advocated as a protective barrier between the surgical team and the patient, but the role of the surgical face mask as an effective measure in preventing surgical wound infections is questionable.
filter droplets of microorganisms expelled from the mouth and nasopharynx of
healthcare workers during surgery, thereby providing protection for the
patient.
The aim of the systematic review is to identify and review all randomised controlled trials evaluating disposable surgical face masks worn by the surgical team during clean surgery to prevent postoperative surgical wound infection.
Thursday, October 23, 2008
First Spinal Cord Endoscope Surgery Conducted in Iran
Iran News
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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.
My NCBI | |||||
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U.S. National Library of Medicine | |||||
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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.