Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET The Neurodiagnostic Society.

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time.

Usefulness of the H-Reflex for Intraoperative Monitoring of Thoracoabdominal Aneurysms.

PURPOSE: Intraoperative neurophysiologic monitoring in thoracoabdominal aneurysms (TAAA) is essential to avoid intraoperative spinal cord injury). Motor and somatosensory evoked potentials may be considered intraoperative tools for detecting spinal cord injury. H-reflex is a well-known neurophysiologic technique to evaluate L5-S1 root. Current evidence supports the observation that H-reflex changes may occur with spinal cord damage as high as the cervical level. This study aimed to evaluate the usefulness of the H-reflex in these surgeries. METHODS: The use of intraoperative H-reflex in TAAA monitoring was evaluated in 12 patients undergoing open or endovascular repair of TAAA for a period of four years (2016-2020) using somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) and bilateral H-reflex. RESULTS: Six neurophysiologic alarms were recorded in five of the 12 patients. Summarizing the neurophysiologic changes of our series, we considered a peripheral change when we detected a unilateral loss of SSEPs, TcMEPs, and H-reflex. Instead, we assumed a central change when we detected a unilateral or bilateral loss of TcMEPs and H-reflex with normal SSEPs, which we considered a sign of spinal cord ischemia. Interestingly H-reflex always changed significantly in combination with TcMEPs in the same fashion. CONCLUSIONS: According to our series, H-reflex can detect intraoperative changes with the same sensitivity as TcMEPs in TAAA surgeries. With the support of other techniques, it can be useful to localize the origin of the lesion (peripheral or central spinal cord), to help in surgical decision-making to avoid postoperative neurologic damage. Based on our results, we recommend the systematic use of H-reflex in TAAA surgeries.

Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET - The Neurodiagnostic Society.

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET - The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These Societies recognize that Neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting Neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in Neurodiagnostics. It represents recommendations of these Societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. As Neurodiagnostics is a growing and dynamic field, we fully intend this document to change over time.

Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society.

SUMMARY: The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET-The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time.

The effect of intraoperative lidocaine administration in a disrupted erector spinae fascial plane on intercostal transcranial motor evoked potentials.

STUDY OBJECTIVE: Erector spinae plane (ESP) blocks have been recently described for postoperative pain management following spine surgery but their effects on intraoperative neuromonitoring are unknown. DESIGN: Retrospective cohort study. SETTING: Pediatric patients at a tertiary care center. PATIENTS: 26 pediatric patients who received bilateral surgically-placed ESP catheters for single-stage posterior spine fusion (PSF) from August 2020 to June 2021. INTERVENTIONS: Patients in this study did not receive any special interventions as part of this observational retrospective study. MEASUREMENTS: This retrospective study investigated the effects of local anesthesia administration through bilateral surgically-placed ESP catheters on intraoperative intercostal transcranial motor evoked potentials (tcMEPs) in the setting of a disrupted erector spinae fascial plane in pediatric patients undergoing single-stage posterior spine fusion. MAIN RESULTS: Of the 26 patients that received bilateral surgically-placed ESP catheters for pediatric posterior spine fusion surgery, none exhibited any changes in intercostal tcMEPs attributable to intraoperative lidocaine administration through the ESP catheters. CONCLUSIONS: The administration of a local anesthetic into a disrupted erector spinae fascial plane does not appear to interfere with intraoperative neuromonitoring of posterior spine fusion surgeries.

Monitoring surgery around the cranial nerves.

Intraoperative neurophysiologic monitoring (IONM) of cranial nerve (CN) function is an essential component in multimodality monitoring of surgical procedures where CNs are at risk for injury. In most cases, IONM consists of localizing and mapping CNs and their pathways, and monitoring of CN motor function during surgery. However, CN VIII, which has no motor function, and is at risk for injury in many surgical procedures, can be easily and accurately monitored using brainstem auditory evoked potentials. For motor CNs, the literature is clear that function can be safely and adequately performed using basic electromyographic (EMG) techniques, such as recording of continuous EMG activity and electrically evoked compound muscle actions potentials. Newer techniques, such as corticobulbar motor evoked potentials and reflex studies, show good potential for a greater degree of functional assessment but require further study to determine their clinical utility. EMG remains the basic clinical neurophysiologic technique with the greatest clinical research supporting its utility in IONM of motor CN function and should be used as part of a comprehensive multimodality IONM protocol. Understanding the physiologic basis of EMG and the changes associated with altered motor function will allow the practitioner to alter surgical course to prevent injury and improve patient safety.

Sharps Injuries Related to Subdermal Needles in the Orbicularis Oris During Intraoperative Neurophysiologic Monitoring.

PURPOSE: Little is known about the incidence and nature of sharps injuries caused by subdermal intraoperative neurophysiologic monitoring (IONM) needle electrodes. In their institution, the authors observed a series of sharps injuries attributed to placement of needles in the orbicularis oris (OO). METHODS: One large academic institution's sharps injury monitoring database was queried for all reported events over 3 years. The de-identified list was filtered for sharps events occurring in the operating room, and the descriptions of the sharps injuries were individually evaluated. Interventions were performed to attempt to decrease the number of sharps injuries from IONM needles, particularly those placed in OO. Similar data were then collected for 3 months post-intervention. RESULTS: Pre-intervention, 327 sharps injuries were reported over the span of 3 years, of which 13 (4.0%) were attributed to IONM needles not in OO and 5 (1.5%) were attributed to IONM needles in OO. Post-intervention, 41 sharps injuries were reported in 3 months, of which 5 (12.2%) were attributed to IONM needles not in OO and 1 (2.4%) was attributed to needles in OO. CONCLUSIONS: The placement of subdermal needles in the OO presents a disproportionately high risk of sharps injury. Interventions were performed to attempt to decrease the rate of sharps injuries from needles in OO; the post-intervention increase in events was likely skewed by small sample sizes. The implementation of these changes and the ongoing surveillance of injury cases may be important data to help decrease the number of sharps injuries attributed to IONM needles.

Clinical Neurophysiology Fellowship Program Directors Survey on a Standardized Fellowship Match Process: A Call for Action.

PURPOSE: To survey US Clinical Neurophysiology (CNP) fellowship program directors on the nature of CNP and related training programs, current recruitment cycle, and views for a standardized process. METHODS: A 23-question electronic survey was sent to all 93 US Accreditation Council for Graduate Medical Education-accredited CNP fellowship program directors from December 2020 to January 2021. RESULTS: The response rate was 60%. There was great variability in the number of CNP positions and CNP tracks offered. The following tracks were identified: 48% EEG dominant, 26% EMG dominant, 22% split equally between EEG and EMG, and 2% and 1% were neurophysiologic intraoperative monitoring and autonomic dominant, respectively. Of the responding institutions, 43% offered a second year of training options to CNP fellows, mainly in conjunction with Epilepsy fellowship, which was pursued by 25% of CNP fellows. Many programs indicated flexibility in their design between different CNP tracks or between CNP and other related training programs based on the available candidates. The median percentage of CNP fellowship positions filled over the last 5 years was 80%, and there was great variation in the recruitment timeline across institutions. Overall, 86% of program directors favored a universal timeline and 71% favored a formal match for CNP. The respondents were split between an independent CNP match (39%) and joining the initiatives of affiliate societies on a standardized process (61%). CONCLUSIONS: There is significant heterogeneity in the makeup of the CNP fellowship programs and the recruitment process. The majority of CNP program directors are in favor of standardization of the recruitment process.

Intraoperative Transcranial Motor-evoked Potential Stimulation Does Not Seem to Cause Seizures.

BACKGROUND: Intraoperative neurophysiological monitoring is of critical importance in evaluating the functional integrity of the central nervous system during surgery of the central or peripheral nervous system. In a large recent study, transcranial motor-evoked potentials (TcMEPs) were found to be associated with a 0.7% risk of inducing a seizure as diagnosed by clinical observation and electromyography in patients having general anesthesia with intravenous anesthetics. The gold standard for seizure diagnosis, however, is electroencephalography (EEG). The aim of this single-institution retrospective study is to ascertain the risk of intraoperative seizures detected using EEG during surgeries in adult patients undergoing intraoperative monitoring with TcMEPs. METHODS: The authors retrospectively reviewed the intraoperative EEG records of 1175 patients anesthetized with a variety of anesthetic agents, including volatile and intravenous anesthetics, to ascertain the rate of EEG-diagnosed seizures attributable to TcMEPs. RESULT: Our analysis did not reveal a single seizure event attributable to TcMEPs in 1175 patients. CONCLUSION: The intraoperative use of TcMEPs does not seem to cause seizures.

Plasma nitrite as an indicator of cerebral ischemia during extracranial/intracranial bypass surgery in moyamoya patients.

BACKGROUND AND PURPOSE: Nitric oxide (NO) plays a key role in ischemia and shows potential as a biomarker for ischemia. We measured mixed venous nitrite (NO2-) as a proxy for NO, during controlled cerebral ischemia in patients with moyamoya disease (MMD) during direct extracranial/intracranial (EC/IC) bypass surgery with temporary occlusion of the M4 branch of the middle cerebral artery (MCA) to permit anastomosis with the superficial temporal artery (STA). This small, focal ischemic event is not reliably detected using cerebral oximetry, somatosensory evoked potentials (SSEPs) or electroencephalography (EEG). METHODS: We enrolled nine adult MMD patients (n=8 female, n=1 male) undergoing direct EC/IC bypass surgery. Nitrite was measured at least one hour prior to MCA occlusion, and before, during and after anastomosis. Cortical function was monitored using either multi-lead EEG and SSEPs, or frontal EEG activity. RESULTS: Mixed venous NO2- was significantly elevated (p<0.05) within 12 min following arterial occlusion vs. baseline. An M4 branch of the MCA was cross clamped for a median duration of 18 (IQR = 5) minutes during anastomosis. One patient with elevated NO2- showed a transient neurologic deficit that resolved 3 days post-operatively. CONCLUSIONS: Mixed venous NO2- was significantly elevated shortly following cerebral artery occlusion vs. baseline in a majority of the study subjects, suggesting that NO2- is a potential biomarker for ischemia. Since all patients received identical burst suppression anesthesia and vasopressors, the fact that NO2- was not elevated during cross-clamp in all patients supports the conclusion that the NO2- elevation is likely due to ischemia.

Novel Mapping Method for the Intraoperative Neurophysiologic Monitoring of Sexual Function During Prostate Surgery.

PURPOSE: The occurrence of urinary incontinence and erectile dysfunction after surgical treatment for prostate cancer is a significant and lingering problem. The aim of this study is to revise and improve older techniques of intraoperative cavernous nerve mapping already in use to improve accuracy and reliability. METHODS: We prospectively studied this technique in 12 patients suffering from prostate cancer. Inhalation or intravenous anesthetic regimen was used with nondepolarizing muscle relaxants. Stimulation protocol was 30 Hz, 0.2 ms, 10 to 20 mA intensity and a maximum duration of 30 seconds. Recording was performed with a system for measuring pressure changes using a stainless steel needle electrode inside the cavernous bodies. Stimulation was systematically performed at three distinct moments during the surgery at various points. An increase or decrease in pressure of 4 cm of H20 in the cavernous bodies was considered a positive result and negative response when no changes occurred after 30 seconds of continuous stimulation. RESULTS: Of patients, 91.6% had positive responses to initial stimulation. The anesthetic regimen did not appear to significantly influence the responses in our series. CONCLUSIONS: In light of the results of this study, the stimulation of the cavernous nerves may be a viable technique in the right context, which includes good patient selection (young patients with a localized tumor and with preserved potency). The major limitation is that mapping techniques are useful to localize functional nerves, but not to monitor function in a continuous manner.

Intraoperative neurophysiologic monitoring (IONM) changes associated with a case of delayed thalamic infarct: Implications for postoperative management.

Treatment of cerebral aneurysms poses a risk of cerebral hemorrhage and/or ischemia; these potential sequelae are usually associated with changes in intraoperative neurophysiologic monitoring (IONM) modalities. Our case demonstrates a patient with significant changes in IONM during the treatment of a right posterior cerebral artery aneurysm who did not develop neurologic deficits until three days postoperatively. IONM changes can represent a guide in postoperative patient management and may pose grounds for closer monitoring of patients with IONM changes that do not develop immediate postoperative deficits.

Intraoperative Tonic-Clonic Seizure Under General Anesthesia Captured by Electroencephalography: A Case Report.

We present the case of a 34-year-old man undergoing craniotomy for arteriovenous malformation resection under general anesthesia who suffered a tonic-clonic seizure captured by intraoperative electroencephalograph. The seizure was extinguished with a propofol bolus. This patient had no previous history of seizures, and no precipitating cause was identified. Intraoperative electroencephalographic seizures under general anesthesia have been recorded previously in the literature, but our observation is the first to demonstrate this with overt motor manifestations. We also discuss the differential diagnosis of an intraoperative seizure under general anesthesia and provide guidance to the anesthesiologist who encounters this event.

Large Amplitude Cortical Evoked Potentials in Nonepileptic Patients. Reviving an Old Neurophysiologic Tool to Help Detect CNS Pathology.

PURPOSE: Although large amplitude evoked potentials (EPs) are typically associated with progressive myoclonic epilepsy patients, giant EPs imply central nervous system (CNS) hyperexcitability and can be seen in various nonepileptic disorders. METHODS: We performed a retrospective chart review including history, physical examination, imaging and diagnostic studies of nonepileptic patients with large amplitude somatosensory evoked potentials (SSEPs) and visual evoked potentials (VEPs) during 2007 to 2013. Large amplitude EPs were defined as follows: VEPs (N75-P100) >18 µV; and SSEPs (N20-P25) >6.4 µV. Recording montage for VEPs was Oz-Cz and SSEPs C3'/C4'-Fz. RESULTS: Fifty-two patients (33 females, 19 males; age range, 9-90 years) were identified. No CNS pathology was detected in 7 patients. All remaining patients were diagnosed with new CNS disorders including: vascular (37%); myelopathies (13%); demyelinating (11%); space occupying lesions (8.7%); syringomyelia (8.7%); hydrocephalus (6.5%); Vitamin B-12 deficiency (4.3%); multiple system atrophy (4.3%); and toxins (2.2%). CONCLUSIONS: This study supports the notion that large amplitude EP implies CNS hyperexcitability and CNS disease. These results confirm the utility of EP studies in patients with suspected CNS pathology.

Characteristics of youth sexual and reproductive health and risky behaviors in two rural provinces of Cambodia.

BACKGROUND: The global number of youths has risen with a majority living in Southeast Asia. In Cambodia, rural youths often face difficult barriers to health, which include lack of sexual and reproductive health knowledge, information, and services. Risky behaviors are a threat to the health of many young people in Cambodia. METHODS: We studied a sample of 300 youths to describe sexual and reproductive health characteristics and risky behaviors in two rural provinces of Cambodia. Using a multi-staged sampling method, 30 villages were selected for interviewing. A peer-to-peer interviewing criterion was used that matched interviewer to interviewee based upon sex. Logistic regression models were used to compare risk between sexes and assess for associations between reproductive health variables, gender, youth attitudes, and risky youth social behaviors. RESULTS: A majority (90%) stated that a boy or girl should defer sex till marriage. A majority of youths (92%) also reported that they may or definitely will seek sexual and reproductive health services in the future. About 5.4% of youth had a prior sexual experience. Only 6.7% of youth reported having they traveled to a local health center, hospital or clinic to seek healthcare for a reproductive health problem. Overall, 27% reported alcohol use in prior 30 days. Relative to girls, boys were more likely to report alcohol use, going out late at night with friends, gambling, pornography use, gambling, and practicing risky behaviors with peers. Living with both parents and current school enrollment, had limited impact on rural youth's individual and social behaviors. CONCLUSION: Although there are favorable findings compatible with traditional Cambodian values and beliefs, the youth in this study are challenged with alcohol use, practicing risky behaviors with peers, and low condom use. Findings have implications for practice and policy to prevent substance abuse and improve outcomes for substance use, sexual and reproductive health.

Six Degree-of-Freedom Measurements of Human Mild Traumatic Brain Injury.

This preliminary study investigated whether direct measurement of head rotation improves prediction of mild traumatic brain injury (mTBI). Although many studies have implicated rotation as a primary cause of mTBI, regulatory safety standards use 3 degree-of-freedom (3DOF) translation-only kinematic criteria to predict injury. Direct 6DOF measurements of human head rotation (3DOF) and translation (3DOF) have not been previously available to examine whether additional DOFs improve injury prediction. We measured head impacts in American football, boxing, and mixed martial arts using 6DOF instrumented mouthguards, and predicted clinician-diagnosed injury using 12 existing kinematic criteria and 6 existing brain finite element (FE) criteria. Among 513 measured impacts were the first two 6DOF measurements of clinically diagnosed mTBI. For this dataset, 6DOF criteria were the most predictive of injury, more than 3DOF translation-only and 3DOF rotation-only criteria. Peak principal strain in the corpus callosum, a 6DOF FE criteria, was the strongest predictor, followed by two criteria that included rotation measurements, peak rotational acceleration magnitude and Head Impact Power (HIP). These results suggest head rotation measurements may improve injury prediction. However, more 6DOF data is needed to confirm this evaluation of existing injury criteria, and to develop new criteria that considers directional sensitivity to injury.