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Monday, June 3, 2013

Spine Journal: Article on Safe Thoracic Pedicle screw placedment

Thoracic pedicle screw placements especially the upper thoracic levels do not have specific  muscle innervation making it difficult to test pedicle screws, in other words it is not as discrete as you can do a test on for example Deltoid (Cervical) or Tibialis anterior (lumbar). The following article though

Safe pedicle screw placement in thoracic scoliotic curves using t-EMG: stimulation threshold variability at concavity and convexity in apex segments.


Department of Clinical Neurophysiology, Hospital Ramón y Cajal, Madrid, Spain.



A cross-sectional study of nonconsecutive cases (level III evidence).


In a series of young patients with thoracic scoliosis who were treated with pedicle screw constructs, data obtained from triggered electromyography (t-EMG) screw stimulation and postoperative computed tomographic scans were matched to find different threshold limits for the safe placement of pedicle screws at the concavity (CC) and convexity (CV) of the scoliotic curves. The influence of the distance from the medial pedicle cortex to the spinal cord on t-EMG threshold intensity was also investigated at the apex segment.


Whether the t-EMG stimulation threshold depends on pedicle bony integrity or on the distance to neural tissue remains elusive. Studying pedicle screws at the CC and CV at the apex segments of scoliotic curves is a good model to address this issue because the spinal cord is displaced to the CC in these patients.
Mar 15;37(6):E387-95. doi: 10.1097/BRS.0b013e31823b077b.

IONM news

Some updates:  http://drmunisneuromonitoring.blogspot.com/

Benefit of Intraoperative IONM and Expenses?...

The risks are minimal but they are real, and when you are not using the advanced technology and knowledge available to assess and safeguard the patients from risks of nerve damage or paralysis, your care is flawed and pretty dangerous, if you can spent 25 thousands for surgery and do not use Neuromonitoring that might cost another thousand or two, and you think that is cost effective, then something wrong with such ideas. Bringing safety inside OR must be the top priority of an operating surgeon (performing surgeon). There are several vascular or neurological complications happen during spine surgical procedures that may not be identified timely if you do not use neuromonitoring techniques, and when you find out after the surgery, it is too late.  

Wednesday, March 13, 2013

How to be a Better Surgeon, apart from Surgereries what else can play important role to be the best surgeon?.

Professor Steve Bogdewic talks about Surgeons and how to be a better surgeon!...

Watch the video:  Link

Dr. George W. Copeland Professor of Family Medicine

[Alliance of Distinguished and Titled 
Professors]Indiana University, Indianapolis
Dr. Stephen P. Bogdewic is the Dr. George W. Copeland Professor of Family Medicine and the Executive Associate Dean for Faculty Affairs and Professional Development at Indiana University School of Medicine. Dr. Bogdewic received his Ph.D. in Adult Education and Organizational Development from the University of North Carolina. Dr. Bogdewic has served as President of the Society of Teachers of Family Medicine (STFM) and was the recipient of the Society’s highest teaching award, the Excellence in Education Award.
Dr. Bogdewic’s scholarly interests include faculty development, leadership development, and qualitative research methodologies. Office: (317) 278-5461; E-mail: bogdewic@iupui.edu

Saturday, March 9, 2013

Electrocautery and Spinal Cord damage- loss of motor activities..!

Nerve damages or spinal cord damage during brain and spine surgical procedures depends upon various myraids of factors, one of them is mechanical. However, how many of you even thought of an electrocautery can produce spinal cord damage resulting EMGs and motor activity loss?. This report published in an porcine model discusses a case. I have not read a human case yet, but it is a real possibility, it can happen during surgery.  If anyone knows a human case or clinical scenario's, please post a comment below.
Spinal cord injury from electrocautery: observations in a porcine model using electromyography and motor evoked potentials. Stanley A. Skinner, et al  Journal of Clinical Monitoring and Computing


We have previously investigated electromyographic (EMG) and transcranial motor evoked potential (MEP) abnormalities after mechanical spinal cord injury. We now report thermally generated porcine spinal cord injury, characterized by spinal cord generated hindlimb EMG injury activity and spinal cord motor conduction block (MEP loss). Electrocautery (EC) was delivered to thoracic level dural root sleeves within 6–8 mm of the spinal cord (n = 6). Temperature recordings were made near the spinal cord. EMG and MEP were recorded by multiple gluteobiceps intramuscular electrodes before, during, and after EC. Duration of EC was titrated to an end-point of spinal motor conduction block (MEP loss). In 5/6 roots, ipsilateral EMG injury activity was induced by EC. In 4/5 roots, EMG injury activity was identified before MEP loss. In all roots, a minimum of 20 s EC and a temperature maximum of at least 57 °C at the dural root sleeve were required to induce MEP loss. Unexpectedly, conduction block was preceded by an enhanced MEP in 4/6 trials. EMG injury activity, preceding MEP loss, can be seen during near spinal cord EC. Depolarization and facilitation of lumbar motor neurons by thermally excited descending spinal tracts likely explains both hindlimb EMG and an enhanced MEP signal (seen before conduction block) respectively. A thermal mechanism may play a role in some unexplained MEP losses during intraoperative monitoring. EMG recordings might help to detect abnormal discharges and forewarn the monitorist during both mechanical and thermal injury to the spinal cord.

Full PDF: click on the top right corner of the journal for pdf article. Link:

Thursday, March 7, 2013

Brain Awarness Week- Spread the Word..!

SharpBrains Logo
BAWBest Wishes to Brain Awareness Week Program, the people behind and to Sharp Brains, Thanks, DrMuni

BAW offerHow will you be cel­e­brat­ing Brain Aware­ness Week next week (March 11th-17th , 2013)?

Here's a sug­ges­tion: you can start watching, at a spe­cial 95% pric­ing dis­count, more than 25 hours of exclu­sive pre­sen­ta­tions from over 40 lead­ing minds as they discuss the latest on applied neu­ro­plas­tic­ity and brain health. These pre­sen­ta­tions, which took place dur­ing the 2012 Sharp­Brains Vir­tual Sum­mit, shed light on some of the most impor­tant ques­tions about the cur­rent and future state of brain health and wellness:
  • How can the health indus­try bet­ter incor­po­rate the body's most vital organ -- the brain?
  • How are con­sumer beliefs and behav­iors towards brain health and brain train­ing evolving?
  • Which pro­fes­sional groups are ide­ally posi­tioned to become "brain fit­ness coaches"?
  • How can neu­ro­science inform spe­cial education?
  • How can Big Data and global inter­net access trans­form brain health practices?  
-> You can ORDER A $15 PASS NOW (reg­u­lar price is $295). Pass hold­ers receive two-month log-in access to the online pre­sen­ta­tions begin­ning on March 11th. 

What Speak­ers and Par­tic­i­pants say about the 2012 Sharp­Brains Summit:
  • "The Sharp­Brains Sum­mit is a rare vehi­cle for get­ting mul­ti­ple expert per­spec­tives on cur­rent devel­op­ments in improv­ing brain func­tion in a con­cise and clear way."  -  Dr. Michael Pos­ner, Pro­fes­sor Emer­i­tus, Uni­ver­sity of Oregon
  • "Great exam­ple of how bring­ing sci­en­tific lead­ers and inno­va­tors together can spur thought­ful dis­cus­sion about our most vital organ - the brain." - Dr. San­dra Bond Chap­man, Direc­tor, Cen­ter for Brain­Health at The Uni­ver­sity of Texas at Dallas
  • "The Sharp­Brains Sum­mit pro­vides com­mon ground for prac­ti­tion­ers, sci­en­tists and indus­try lead­ers to work towards the com­mon goal of dri­ving brain health and fit­ness for­ward with a thought­ful, ana­lyt­i­cal and prac­ti­cal approach." - Kate Sul­li­van, Direc­tor of the Brain Fit­ness Cen­ter at Wal­ter Reed National Mil­i­tary Med­ical Center
  • An impres­sive vir­tual con­vo­ca­tion of lead­ing sci­en­tists and devel­op­ers and adopters of cog­ni­tive enhance­ment tech­nol­ogy." - Dr. Robert Bilder, Chief of Med­ical Psychology-Neuropsychology, UCLA Semel Insti­tute for Neuroscience
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Have a very stimulating Brain Awareness Week!

The SharpBrains Team

Tuesday, March 5, 2013

App for remote Neurominotoring (IONM)?

 APP for biking track, app for walking, app for finding what song it is and now an App for remote neuromontioring?, interesting!.

COPENHAGEN – inomed, a leading medical technology provider based in Germany, has announced the availability of an app that enables hospital staff to remotely monitor the signals of a patient’s intraoperative nerve activity during surgery. The app, Remote Viewer, was developed for inomed by Netop and is based on their remote access application, Netop Remote Control Mobile for iOS. With inomed Remote Viewer, doctors and hospital personnel can securely and remotely track neuromonitoring signals - recorded on an inomed IONM device - in real-time.
inomed Remote Viewer“We’re pleased to be working with inomed on the Remote Viewer,” said Kurt Bager, CEO, Netop. “This is not only an example of how our remote access solutions can be leveraged across industry verticals to serve the evoling needs of our customers and partners, but also how our solutions perform in critical environments where reliability is an absolute necessity.”
With Netop’s remote access software solution now preinstalled on all inomed neuromonitoring devices, the app allows inomed to expand its product offerings and provide its customers with additional service levels. To activate the functionality users will need to purchase an inomed license for the company’s neuromonitoring device, but the Remote Viewer app is free and available for iOS devices at the App Store.

Wednesday, January 30, 2013

Vascular Complications During Thoracic Pedicle Screw Placement: What?. Is this even Possible, yes!.

Surgery insight: During surgical performance or surgical procedures and providing patient care, there is nothing like oh you mean that?, well that is very simple or take for granted in a casual way, one must show at most attention and care in every small to big steps, so do the neuromonitoring and anesthesia professionals, you can be of great help to surgeon when you detect changes or unusual activity that can get surgeons attention right away. Ofcourse for surgeons, there is no room for error but absolutely there is no room for Oh I have done 1000s of surgery, pricking a nerve or artery during my pedicle screw insertion is not going to happen, oh well, it did. The following paper describes a case and death of a patient two weeks after the surgery, so be diligent.
While reading this article :Thoracic pedicle screw placement: Free-hand technique  by Yongjung J. Kim, Lawrence G. Lenke regarding Scoliosis and thoraci pedicle screw placement, I came across the two back reference that startled me, an important and interesting reference about how vascular complications can occur by careless pedicle screw placement?..
Vascular complications 
22.Heini P, Scholl E, Wyler D, Eggli S. Fatal cardiac tamponade associated with posterior 
spinal instrumentation. A case report. Spine 1998;23:2226–30.  
Heini et al[22] described a case of fatal cardiac tamponade that
was due to a prick injury of the right coronary artery by a Kirschner
Neurology India | December 2005 | Vol 53 | Issue 4
CMYK517 517 Kim et al: Thoracic pedicle screw placement
wire. The injury was confirmed by autopsy after the patient died
12 days after surgery.
14. Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixation in 
spinal deformities: are they really safe? Spine 2001;26:2049–57.   
Suk et al [14] described a case of an over­penetrated screw causing irritation of the thoracic aorta resulting in severe chest pain.
 25. Minor ME, Morrissey NJ, Peress R, Carroccio A, Ellozy S, Agarwal G, et al. 
Endovascular treatment of an iatrogenic thoracic aortic injury after spinal 
instrumentation: case report. J Vasc Surg 2004;39:893–6
 Recently Minor et al [25] reported endovascular  treatment of an iatrogenic aortic injury by misplaced thoracic pedicle screw at T5. 
I have not yet read all these three papers, I will comment further after I go through them all.

What is O-Arm, is the X-Ray imaging finally getting a Facelift in tech?

Interesting tech developments seems to be happening in X-Ray imaging, came across news about O-Arm today and also noticed the fluoroscopic ultra-imaging developments and check those below, as well as the link to Hologic?...This area or technology can be quite useful to surgeons and hospitals, this is something they better look at for efficient surgical procedures and precision detection.
Here is the O-Arm, will this help surgeon view different angles, depth and positioning of pedicle screws and so on?.
Gene writes about O-Arm Imaging system- Link:

O-arm™ Imaging System

by  on  • 11:54 am
multi2D lr O arm™ Imaging System
Have you seen the O-arm™ Imaging System before? We haven’t. Until today, that is. We learned about it this morning when a company’s rep left O-arm™ brochures (and no food) in our physicians’ lounge. The device byBreakaway Imaging, LLC, of Littleton, MA, was FDA-cleared last year and is now distributed by Medtronic.
So here’s the scoop about the device that has a robotics-assisted positioning system:

Also note the following C-Arm Mini, interesting:

The Next Generation in Mini C-arm Imaging with Flat Detector Technology

New and Innovative Flat Detector Mini C-arm Design
  • Ergonomic flat detector design with ease of positioning for patient/surgeon access
  • Greatest range of motion in a new innovative mini C-arm design
  • Forward tube source design now offers greater C-arm depth
  • Flat detector technology with 75 micron array and 2k x 1.5k resolution

And, finally, the following Dorsal Column Stabilization Outflow: 

Artis zeego, dorsal spinal stabilization workflow

Thursday, July 26, 2012

Current Trends in Pedicle Screw Stimulation techniques

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

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

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

PMID: Neurodiagn J. 2012 Jun;52(2):100-75.
[PubMed - in process]

Tuesday, June 19, 2012

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

 Emerson RG's article published in the latest issue of Journal of Clinical Neurophysiology must be an eye opener for Naysayer neurologists and to those skeptic spine specialists out there who is impetuously discredit the predictability values and reliability of intraoperative neurophysiological monitoring. My own personal IONM experience provided to more than 1500 surgical procedures reveal even more than 99.6% accuracy of detection, wherein about 4-5 spine patients lives been saved (four lumbar and cervical fusion spine cases, and one scoliosis procedure) because of the timely warning from the IONM results during the surgical procedures, the timely warning enabled surgeon to take immediate intervention measures to reverse the risk of permanent damage thereby saved the patient from paralysis.
               The number of years accounted in this study, and the number of patients who underwent surgical procedures used for this analysis of Dr.Emerson's study is compelling and producing an authoritative findings. It is a must have clinical paper for all those who work in IONM field and a great reference source to be given to those naysayers.
J Clin Neurophysiol. 2012 Apr;29(2):149-50.

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

Emerson RG. Abstract

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

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

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

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

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

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

Review of Neuromonitoring field 32 Years Ago?.

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

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


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

Friday, April 27, 2012

KFC Chicken Twister & Salmonella, watch out!

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

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

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

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