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

Spine (Phila Pa 1976). 2012 

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

de Blas G, Barrios C, Regidor I, Montes E, Burgos J, Pizá-Vallespir G, Hevia E.

Source

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

Abstract

STUDY DESIGN:

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

OBJECTIVE:

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.

SUMMARY OF BACKGROUND DATA:

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.  

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

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

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 November 2012

Abstract

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:

Brain Awarness Week- Spread the Word..!

Best Wishes to Brain Awareness Week Program, the people behind and to Sharp Brains, Thanks, DrMuni Muni,      How 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 "A very time-efficient man­ner to get a state of the art update on the lat­est inno­va­tions in assess­ing and pro­mot­ing brain health, and from the com­fort of your own office." - Dr. Keith Wesnes, Prac­tice Leader, Bracket/ United BioSource Corporation A con­ve­nient and sur­pris­ingly com­pelling forum for catch­ing up on applied cog­ni­tive research from lead­ers in the field and for help­ing shape future brain health care." - Dr. Yaakov Stern, Cog­ni­tive Neu­ro­science Divi­sion Leader, Colum­bia University Have a very stimulating Brain Awareness Week! The SharpBrains Team

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!.

inomed Remote Viewer by Netop Supports Neuromonitoring,  February 26, 2013New app enables physicians and clinical staff to remotely monitor real-time data from intraoperative neurophysiological monitoring (IONM) devices via an iPad.

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.

“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.

Full read:

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.