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Wednesday, March 4, 2009

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 results69,70.
The Journal of Bone and Joint Surgery (American). 2009;91:743-751.doi:10.2106/JBJS.H.01689

Monday, February 16, 2009

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.
Current Treatment Options in NeurologyCurrent Treatment Options in Neurology
Curr Treat Options Neurol. 2009 Mar;11(2):137-49.
Seder DBJarrah 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 BFudickar AScholz 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".
British Journal of Surgery 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 MKonturek ACichoń 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. 

"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?)
The Laryngoscope 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 WBMurry TDhiman SAviv JLifante 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"

Friday, February 13, 2009

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:

Saturday, January 24, 2009

Neurophysiology Recitation of Texts Only: 1824-1889?

Today, we have the most sophisticated tools to study and learn science and medical subjects. Most of the ground breaking scientific and medical findings came out of a laboratory research that involves animal research or human research, without practical research, can't imagine the fate of our medical and scientific achievements. If that is true for general science and medical field, the progress we made in neuroscience in general and clinical neuroscience like Neurophysiology and Intraoperative neuromonitoring is an amazing break through of our learning using modern tools. What were they during just 200 years ago in physiology and neurophysiology?. Not much.......... Physiology was studied and taught by only reciting the texts like some of those Jabber's of religious scriptures in temples, really?. 

it seems during early to late 1800's the Physiology was taught by reciting the texts. For the very first time live animal demonstration in anesthetized animals was introduced in America by Dalton.
NeurologyNeurology 2000;55:859-864
© 2000 American Academy of Neurology 

Historical Neurology

John Call Dalton, Jr., MD

America’s first neurophysiologist

Edward J. Fine, MDTara Manteghi, BASidney H. Sobel, MD and Linda A. Lohr, MA

From the Department of Veterans’ Affairs Medical Center and Department of Neurology (Dr. Fine and Ms. Manteghi), State University of New York at Buffalo; Finger Lakes Radiation Oncology (Dr. Sobel), Clifton Springs, NY; and the Robert L. Brown, MD, History of Medicine Collection (Ms. Lohr), State University at Buffalo, NY.

Address correspondence and reprint requests to Dr. Edward J. Fine, Neurology Service, Department of Veterans’ Affairs Medical Center, 3495 Bailey Avenue, Buffalo, NY 14215.

Before the discoveries of John Call Dalton, Jr., MD (1824–1889), innervation of laryngeal muscles, long-term effects of cerebellar lesions, and consequences of raised intracranial pressure were poorly understood. Dalton discovered that the posterior cricoarytenoid muscles adducted the vocal cords during inspiration. He confirmed Flourens’ observations that acute ablation of the cerebellum of pigeons caused loss of coordination. Dalton observed that properly cared for pigeons gradually recovered "coordinating power." Dalton observed that prolonged raised intracranial pressure caused tachycardia and then fatal bradycardia in dogs. Before Dalton published his photographic atlas of the human brain, neuroanatomy atlases were sketched by Europeans and imported into the United States. Dalton’s atlas of the human brain contained precise photographs of vertical and horizontal sections that equal modern works. Before Dalton introduced live demonstrations of animals, physiology was taught by recitation of texts only. Dalton was the first American-born professor to teach physiology employing demonstrations of live animals operated on under ether anesthesia. He wrote an essay advocating experimentation on animals as the proper method of acquiring knowledge of function and that humane animal experimentation would ultimately improve the health of man and animals. His eloquent advocacy for humane experimental physiology quelled attacks by contemporaneous antivivisectionists. Dalton was America’s first experimental neurophysiologist.

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...?

Benton County Daily Record

Northwest Medical Center added to malpractice suit

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.

Sunday, January 4, 2009

Dexmedetomidine- A New Short Term Sedative?

Interesting Review on "Dexmedetomidine", the most recent sedative approved by the FDA.

pmc logo image
Logo of bumcproc
Dexmedetomidine: a novel sedative-analgesic agent
Ralph Gertler, MD,corresponding author1 H. Cleighton Brown, MD,1 Donald H. Mitchell, MD,1 and Erin N. Silvius, MD1
1From the Department of Anesthesiology and Pain Management, Baylor University Medical Center, Dallas, Texas; and Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center at Dallas.
corresponding authorCorresponding author.
Corresponding author: Ralph Gertler, MD, Department of Anesthesiology and Pain Management, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246 (e-mail: Ralph_Gertler10@excite.com).

Neuromonitoring & Peadiatric Cardiopulmonary bypass surgical procedures?:- Boosts Evidence Based practice & Best Practice?

Usage of intraoperative neurophysiologic monitoring during Peadiatric cardiopulmonary bypass surgical procedures reported in the following research papers, addition of IONM tothe surgical team has helped them to improve the post surgical neurological complications. Two of the following studies one published recently in Sept-Oct 2008 and the other in 2007, both in peer reveiwed journals discuss the importance of IONM usage in terms of reducing neurological risk, patient safety and faster discharge of patients that could be benefitial to both the patients and the hospitals.

The influence of neurophysiologic monitoring on the management of pediatric cardiopulmonary bypass.

ASAIO J. 2008 Sep-Oct;54(5):467-9

Department of Anesthesiology, Penn State College of Medicine, Hershey, Pennsylvania 17033, USA. skimatian@hmc.psu.edu

We describe a process by which we sought to determine how the addition of intraoperative neurophysiologic monitoring (IONM) impacted the management of cardiopulmonary bypass (CPB) during pediatric cardiac surgery.
While maintaining a consistent team of surgeons, anesthesiologists, nurses, and perfusionists, a multi-modal, IONM program was established consisting of Near Infrared Spectroscopy, Transcranial Doppler, and eight channel electroencephalography. A retrospective review of cases from 1 year before the institution of the IONM program was compared with data obtained from cases performed after neurophysiologic monitoring was established as a standard of care for pediatric patients on CPB.
This comparative analysis of CPB management revealed a significant increase in the use of donor blood added to the CPB circuit prime as well as in the maintenance of a higher hematocrit during the bypass period after the implementation of IONM.
These changes in the management of pediatric CPB correlated with recommendations of previous studies that examined postoperative neurophysiologic outcomes, suggesting that these changes were not only consistent with best practices, but that the presence of IONM data facilitated a transition to evidence-based practice.

Benefit of neurophysiologic monitoring for pediatric cardiac surgery.

Department of Surgery, University of Louisville School of Medicine, Ky., USA.

BACKGROUND: Pediatric patients undergoing repair of congenital cardiac abnormalities have a significant risk of an adverse neurologic event. Therefore this retrospective cohort study examined the

potential benefit of interventions based on intraoperative neurophysiologic monitoring in decreasing both postoperative neurologic sequelae and length of hospital stay as a cost proxy.
METHODS: With informed parental consent approved by the institutional review board,

electroencephalography, transcranial Doppler ultrasonic measurement of middle cerebral artery blood flow velocity, and transcranial near-infrared cerebral oximetry were monitored in 250 patients.
An interventional algorithm was used to detect and correct specific deficiencies in cerebral perfusion or oxygenation or to increase cerebral tolerance to ischemia or hypoxia. RESULTS: Noteworthy changes in brain perfusion or metabolism were observed in 176 of 250 (70%) patients. Intervention that altered patient management was initially deemed appropriate in 130 of 176 (74%) patients with neurophysiologic changes.
Obvious neurologic sequelae (i.e., seizure, movement, vision or speech disorder) occurred in five of 74 (7%) patients without noteworthy change, seven of 130 (6%) patients with intervention, and 12 of 46 (26%) patients without intervention (p = 0.001). Survivors' median length of stay was 6 days in the no-change and intervention groups but 9 days in the no-intervention group. In addition, the percentage of patients in the no-intervention group discharged from the hospital within 1 week (32%) was significantly less than that in either the intervention (51%, p = 0.05) or no-change (58%, p = 0.01) groups.
On the basis of an estimated hospital neurologic complication cost of $1500 per day, break-even analysis justified a hospital expenditure for neurophysiologic monitoring of $2142 per case. CONCLUSIONS:
Interventions based on neurophysiologic monitoring appear to decrease the incidence of postoperative neurologic sequelae and reduce the length of stay. Inasmuch as the break-even cost for neurophysiologic monitoring is more than four times the actual average charge, both patients and hospital may profit from this service.
Because this study was not a truly randomized clinical trial, unintentional statistical bias may have occurred and caution is urged in interpreting the magnitude of apparent intergroup outcome differences.

Tuesday, December 23, 2008

Detached Skull But Intact Spinal Cord: Massive Accident with damages to Nervous System, 9 Y Boy Survives!!!

9 year old boy miraculously survives car crash decapitationPic from The MedGuru.com
Though Neurophysiological Details are not available, no Cranial Nerve restoration details are available in news reports, it is not clear how much of spinal cord functionally spared by the accident, how much motor and sensory functions of the boy was lost and recovered following the procedure is not clear. Despite the details are not out there on the news, surgical team and hospital certainly will have detailed information, the survival of this young Boy is unique, special and a medical achievement. 
A 9 year old boy after a fatal accident who was determined to have only 2% chance of survival is making great recovery after neurosurgical procedures?. 
This is a rare fatal accident almost sounds like a movie story but a real event happened in Hillsboro Texas, it is just amazing to realize a orthopedic decapitation is possible for a surgeon to work and fix the head and nerves back to functioning condition, though details are not available, but even considering this at a news level, it is nothing but Amazing. This is also the medical and surgical achievement of the surgeon and the crew.
Catharine Paddock, PhD writes at the Medical News Today, about a nearly decapitated 9 year old dcapitated boy was operated by Dr Richard Roberts, a pediatric neurosurgeon at the Cook Childrens' Medical Center in Fort Worth, as per the news below, the surgeon was able to fix the head back and the boy is recovering?. It will be interesting to know about how the facial and other Cranial nerves were placed back, if at all?. If all the Cranial nerves have damages or completely severed, how did the surgical team managed to keep the vital functions going?. 
Jordan Taylor, a nine year old boy from Hillsboro, Texas, is making a rare and astonishing recovery from surgery to reattach his head to his neck after suffering an orthopedic decapitation three months ago; the youngster was buckled in the back seat of a car his mother was driving when they were hit by a dump truck that the authorities say ran a stop sign.

'Internal Decapitation': Boy's amazing recovery

Tuesday, December 23, 2008 | 1:42 PM

Surviving an 'Internal Decapitation'

Doctors quickly pointed out that an atlanto-occipital dislocation cannot be called a "decapitation" in the traditional sense. For one thing, even though the skull is disjoined form the spinal column, the head does not technically leave the body. And in Jordan's case, as with others, the spinal cord -- that crucial superhighway of nerve fibers that connects the brain to the rest of the body -- was not severed.

Still, Dr. Phillip Tibbs, chair of neurosurgery at the University of Kentucky, says that in many cases, the end result is much the same.

Health and Wellness News

Texas Boy Survives Orthopedic Decapitation

Atlanta, GA 12/22/2008 05:41 PM GMT (TransWorldNews)

A 9-year-old Hillsboro, Texas boy’s recovery from a near decapitation is being called a miracle. Jordan Taylor only had a 1-2 percent chance to live after suffering an orthopedic decapitation in a car accident 3 months again.

Jordan was riding in the back seat of a car his mother Stacey Perez was driving when a dump truck ran a stop sign and hit the vehicle. The boy’s skull separated from his neck but his spinal cord remained intact.

“The energy basically made his head lift up off his neck, and then move forward. All of the connective tissue that essentially keeps your head connected to your neck was destroyed,” says Dr. Richard Roberts, the pediatric neurosurgeon who operated on Jordan.

Jordan’s skull and neck has been reattached with a metal plate and titanium rods. Dr. Roberts says it’s a miracle that Jordan is able to walk and talk.

Click here for more People News

9 year old boy miraculously survives car crash decapitation

Texas, United States, December 23: A 9 year old boy from Texas was involved in a motor vehicle accident that separated his skull from his vertebrae three months ago, but doctors miraculously reattached his head to his neck and now he’s fully recovered.

According to his mother he’s planning to go back to school after Christmas break.

Neurophysiology News!

Neurophysiolgy & Pudental Nerve Connection:-
Beyond the Abstract - Evaluation of the Safety and Efficacy of ...
UroToday - Berkeley,CA,USA
Neurophysiological studies give invaluable information on the involvement of the parts of the nervous system which are essential in the control of sexual ...
See all stories on this topic
Neuroscience Boot Camp
ScienceBlogs - USA
Laboratory visits will include a trip to an MRI scanner, an EEG/ERP lab, an animal neurophysiologylab, and a transcranial magnetic stimulation lab. ...
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Delmarva Now - Salisbury,MD,USA
She completed a clinical fellowship in neurophysiology at Henry Ford. In addition to her training in general neurology care, including headache and migraine ...
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Medical Acupuncture Gaining Acceptance by the US Air Force
MarketWatch - USA
Based on modern neurophysiological concepts, Niemtzow developed a variation of acupuncture that involves inserting very tiny semi-permanent needles into ...
See all stories on this topic
Novel method of chaotic communication proposed by physicists
eTaiwan News - Taiwan
In addition to use in communications, Hu went on, temporal transfer entropy can also be applied to many different scientific fields, such as neurophysiology ...
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Blackrock can build bigger ICU
Irish Medical Times - Dublin,Ireland
The building to be knocked down contains a pharmacy, neurophysiology services and a prayer room. The current unit will also be revamped as part of the ...
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Get lost ... and get better architecture
... before a single brick is ever laid, said Edelstein, a trained neurophysiologist and a visiting scholar at the University of California at San Diego. ...
See all stories on this topic