Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring.

The American Society of Neurophysiological Monitoring (ASNM) was founded in 1989 as the American Society of Evoked Potential Monitoring. From the beginning, the Society has been made up of physicians, doctoral degree holders, Technologists, and all those interested in furthering the profession. The Society changed its name to the ASNM and held its first Annual Meeting in 1990. It remains the largest worldwide organization dedicated solely to the scientifically-based advancement of intraoperative neurophysiology. The primary goal of the ASNM is to assure the quality of patient care during procedures monitoring the nervous system. This goal is accomplished primarily through programs in education, advocacy of basic and clinical research, and publication of guidelines, among other endeavors. The ASNM is committed to the development of medically sound and clinically relevant guidelines for the performance of intraoperative neurophysiology. Guidelines are formulated based on exhaustive literature review, recruitment of expert opinion, and broad consensus among ASNM membership. Input is likewise sought from sister societies and related constituencies. Adherence to a literature-based, formalized process characterizes the construction of all ASNM guidelines. The guidelines covering the Professional Practice of intraoperative neurophysiological monitoring were initially published January 24th, 2013, and subsequently that document has undergone review and revision to accommodate broad inter- and intra-societal feedback. This current version of the ASNM Professional Practice Guideline was fully approved for publication according to ASNM bylaws on February 22nd, 2018, and thus overwrites and supersedes the initial guideline.

Neurophysiological monitoring under anesthesia to position a child with extreme lumbar spine flexion for MRI and CT scan.

A novel application of neurophysiological monitoring enabled us safely to anesthetize and position a child with severe lumbosacral spine flexion for diagnostic MRI and CT scan. We conducted a propofol-based anesthetic to optimize somatosensory (SSEP) and transcranial electric motor (tceMEP) evoked potential amplitudes, thereby facilitating dynamic neurological monitoring while fully extending the patient supine. In cases outside the operating room involving extraordinary changes in patient position, anesthesia providers may consider utilizing neurophysiological monitoring.

Pedicle screws with high electrical resistance: a potential source of error with stimulus-evoked EMG.

STUDY DESIGN: Clinically relevant aspects of pedicle screws were subjected to electrical resistance testing. OBJECTIVES: To catalog commonly used pedicle screws in terms of electrical resistance, and to determine whether polyaxial-type pedicle screws have the potential to create a high-resistance circuit during stimulus-evoked electromyographic testing. SUMMARY OF BACKGROUND DATA: Although stimulus-evoked electromyography is commonly used to confirm the accuracy of pedicle screw placement, no studies have documented the electrical resistance of commonly used pedicle screws. METHODS: Resistance measurements were obtained from eight pedicle screw varieties (5 screws of each type) across the screw shank and between the shank and regions of the screw that would be clinically accessible to stimulus-evoked electromyographic testing with a screw implanted in a pedicle. To determine measurement variability, resistance was measured three times at each site and with the crown of the polyaxial-type screw in three random positions. RESULTS: Resistance across the screw shank ranged from 0 to 36.4 ohms, whereas resistance across the length of the monoaxial-type screws ranged from 0.1 to 31.8 ohms. Resistance between the hexagonal port and shank of polyaxial-type screws ranged from 0 to 25 ohms. In contrast, resistance between the mobile crown and shank of polyaxial-type screws varied widely, ranging from 0.1 ohms to an open circuit (no electrical conduction). Polyaxial-type screws demonstrated an open circuit in 28 of 75 measurements (37%) and a high-resistance circuit (exceeding 1000 ohms) in 5 of 75 measurements (7%). CONCLUSIONS: Polyaxial-type pedicle screws have the potential for high electrical resistance between the mobile crown and shank, and therefore may fail to demonstrate an electromyographic response during stimulus-evoked electromyographic testing in the setting of a pedicle breech. To avoid false-negative stimulus-evoked electromyographic testing, the cathode stimulator probe should be applied to the hexagonal port or directly to the screw shank, and not to the mobile crown.

Neurophysiologic monitoring of spinal nerve root function during instrumented posterior lumbar spine surgery.

STUDY DESIGN: Retrospective review of 61 consecutive patients. OBJECTIVES: To determine the effectiveness of combining intraoperative monitoring of both spontaneous electromyographic activity and compound muscle action potential response to stimulation for detecting a perforation of the pedicle cortex irritation of nerve root during lumbar spine fusion surgery. SUMMARY OF BACKGROUND DATA: The complication rate from instrumentation used with lumbar spine fusion varies from 1 to 33%. To prevent neurologic complications, several monitoring techniques have been used to alert surgeons to possible neurologic damage being introduced during nerve decompression or placement of instrumentation with spine procedures. Because of different sensitivities, one monitoring technique may not be as effective for preventing complications as a combination of techniques. METHODS: Sixty-one consecutive patients who underwent instrumented posterior lumbar fusions received continuous electromyographic monitoring and stimulus-evoked electromyographic monitoring. A significant neurophysiologic event was signaled by sustained neurotonic electromyographic activity, prompting an alert and a pause in the surgical manipulations that precipitated the activity. After insertion of the transpedicular screws, the integrity of the pedicle cortex was tested by stimulating each screw head and recording compound muscle action potentials. In the presence of a pedicle breach, stimulus intensities below 7 mA were sufficient to evoke compound muscle action potentials from the muscle group innervated by the adjacent spinal nerve root, prompting a surgical alert and subsequent repositioning of the screw. RESULTS: Fourteen significant neurophysiologic events occurred in 13 of 61 patients (21%). Sustained neurotonic electromyographic discharges occurred in 5 of 40 patients during placement of interbody fusion cages, in 2 patients during placement of transpedicular screws, and in 1 patient during tightening of rods. On pedicle screw stimulation, breaches of the pedicle cortex were detected in 6 patients. After surgery, no new neurologic deficits were found in 60 of the 61 patients. One patient who experienced temporary paraparesis had sustained neurotonic electromyographic discharges during retraction of the thecal sac and distraction of the disc space before placement of the cage. CONCLUSION: These results suggest that intraoperative electromyographic monitoring provides a real-time measure of impending spinal nerve root injury during instrumented posterior lumbar fusion, allowing for timely intervention and minimization of negative postoperative sequela.