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1.
World Neurosurg ; 127: e1044-e1050, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30980975

RESUMO

OBJECTIVE: Corkscrew (CS) electrodes are usually used for transcranial electrical stimulation (TES) in the intraoperative monitoring of motor evoked potentials (MEP). Direct cranial stimulation with peg-screw (PS) electrodes can elicit MEP. The present study investigated the difference in the initial threshold between PS and CS electrodes for intraoperative MEP monitoring. METHODS: We retrospectively analyzed TES-MEP monitoring for supratentorial surgery in 72 patients. Of these 72 patients, 44 were monitored with PS and CS electrodes (PS/CS group) and 28 were monitored with CS and CS electrodes (CS/CS group). TES was used to deliver electrical stimulation by a train of 4-pulse anodal constant current stimulation. The initial threshold in each electrode was checked and analyzed. RESULTS: In the PS/CS group, the initial threshold with the PS electrode was 38.3 ± 15.1 mA (mean ± standard deviation) on the affected side, and the initial threshold with the CS electrode was 51.4 ± 13.9 mA on the unaffected side. The initial threshold with the PS electrode was significantly lower than that with the CS electrode (P = 0.0001). In the CS/CS group, the initial threshold was 56.2 ± 16.5 mA on the affected side and 62.1 ± 18.6 mA on the unaffected side, with no statistically significant difference (P = 0.23). CONCLUSION: The initial threshold to elicit MEP was significantly lower with the PS electrode than with the CS electrode. A PS electrode can be used as a feasible stimulation electrode for TES-MEP.


Assuntos
Parafusos Ósseos , Eletrodos Implantados , Potencial Evocado Motor/fisiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Crânio/cirurgia , Estimulação Transcraniana por Corrente Contínua/métodos , Adolescente , Adulto , Idoso , Parafusos Ósseos/normas , Encéfalo/fisiologia , Encéfalo/cirurgia , Criança , Eletrodos Implantados/normas , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/instrumentação , Monitorização Neurofisiológica Intraoperatória/normas , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estimulação Transcraniana por Corrente Contínua/instrumentação , Estimulação Transcraniana por Corrente Contínua/normas , Adulto Jovem
2.
Neuromodulation ; 22(4): 472-477, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30629330

RESUMO

INTRODUCTION: Clinical response to deep brain stimulation (DBS) strongly depends on the appropriate placement of the electrode in the targeted structure. Postoperative MRI is recognized as the gold standard to verify the DBS-electrode position in relation to the intended anatomical target. However, intraoperative computed tomography (iCT) might be a feasible alternative to MRI. MATERIALS AND METHODS: In this prospective noninferiority study, we compared iCT with postoperative MRI (24-72 hours after surgery) in 29 consecutive patients undergoing placement of 58 DBS electrodes. The primary outcome was defined as the difference in Euclidean distance between lead tip coordinates as determined on both imaging modalities, using the lead tip depicted on MRI as reference. Secondary outcomes were difference in radial error and depth, as well as difference in accuracy relative to target. RESULTS: The mean difference between the lead tips was 0.98 ± 0.49 mm (0.97 ± 0.47 mm for the left-sided electrodes and 1.00 ± 0.53 mm for the right-sided electrodes). The upper confidence interval (95% CI, 0.851 to 1.112) did not exceed the noninferiority margin established. The average radial error between lead tips was 0.74 ± 0.48 mm and the average depth error was determined to be 0.53 ± 0.40 mm. The linear Deming regression indicated a good agreement between both imaging modalities regarding accuracy relative to target. CONCLUSIONS: Intraoperative CT is noninferior to MRI for the verification of the DBS-electrode position. CT and MRI have their specific benefits, but both should be considered equally suitable for assessing accuracy.


Assuntos
Encéfalo/diagnóstico por imagem , Estimulação Encefálica Profunda/normas , Monitorização Neurofisiológica Intraoperatória/normas , Imagem por Ressonância Magnética/normas , Tomografia Computadorizada por Raios X/normas , Adolescente , Adulto , Idoso , Encéfalo/cirurgia , Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tomografia Computadorizada por Raios X/métodos , Adulto Jovem
3.
Clin Neurophysiol ; 130(1): 161-179, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30470625

RESUMO

Intraoperative somatosensory evoked potentials (SEPs) provide dorsal somatosensory system functional and localizing information, and complement motor evoked potentials. Correct application and interpretation require in-depth knowledge of relevant anatomy, electrophysiology, and techniques. It is advisable to facilitate cortical SEPs with total intravenous propofol-opioid or similarly favorable anesthesia. Moreover, SEP optimization is recommended to enhance surgical feedback speed and accuracy by maximizing signal-to-noise ratio (SNR); it consists of selecting highest-SNR peripheral and cortical derivations while omitting low-SNR channels. Confounding factors causing non-surgical SEP reduction should be excluded before issuing a warning. It is advisable to facilitate their identification with peripheral SEP controls and cortical SEP systemic controls whenever possible. Warning criteria should adjust for baseline drift and reproducibility. The recommended adaptive warning criterion is visually obvious amplitude reduction from recent pre-change values and clearly exceeding trial-to-trial variability, particularly when abrupt and focal. Acquisition and interpretation should be done by qualified technical and professional level personnel. Indications for SEP monitoring include intracranial, posterior fossa, and spinal neurosurgery, as well as orthopedic spine, cerebrovascular, and descending aortic surgery. Indications for SEP mapping include sensorimotor cortex and dorsal column midline identification. Future advances could modify current recommendations.


Assuntos
Potenciais Somatossensoriais Evocados/fisiologia , Internacionalidade , Monitorização Neurofisiológica Intraoperatória/normas , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normas , Córtex Somatossensorial/fisiologia , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos
4.
Curr Opin Anaesthesiol ; 32(1): 101-107, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30507680

RESUMO

PURPOSE OF REVIEW: To summarize recent recommendations on intraoperative electroencephalogram (EEG) neuromonitoring in the elderly aimed at the prevention of postoperative delirium and long-term neurocognitive decline. We discuss recent perioperative EEG investigations relating to aging and cognitive dysfunction, and their implications on intraoperative EEG neuromonitoring in elderly patients. RECENT FINDINGS: The incidence of postoperative delirium in elderly can be reduced by monitoring depth of anesthesia, using an index number (0-100) derived from processed frontal EEG readings. The recently published European Society of Anaesthesiology guideline on postoperative delirium in elderly now recommends guiding general anesthesia with such indices (Level A). However, intraoperative EEG signatures are heavily influenced by age, cognitive function, and choice of anesthetic agents. Detailed spectral EEG analysis and research on EEG-based functional connectivity provide new insights into the pathophysiology of neuronal excitability, which is seen in elderly patients with postoperative delirium. SUMMARY: Anesthesiologists should become acquainted with intraoperative EEG signatures and their relation to age, anesthetic agents, and the risk of postoperative cognitive complications. A working knowledge would allow an optimized and individualized provision of general anesthesia for the elderly.


Assuntos
Anestesia Geral/efeitos adversos , Disfunção Cognitiva/prevenção & controle , Delírio do Despertar/prevenção & controle , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores Etários , Idoso , Envelhecimento/fisiologia , Anestésicos/efeitos adversos , Cognição/efeitos dos fármacos , Cognição/fisiologia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Monitores de Consciência , Eletroencefalografia/métodos , Eletroencefalografia/normas , Delírio do Despertar/diagnóstico , Delírio do Despertar/epidemiologia , Delírio do Despertar/etiologia , Humanos , Incidência , Monitorização Neurofisiológica Intraoperatória/instrumentação , Monitorização Neurofisiológica Intraoperatória/normas , Guias de Prática Clínica como Assunto
5.
J Clin Neurosci ; 61: 78-83, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30528129

RESUMO

BACKGROUND: Lumbar interbody spinal fusion (LIF) surgeries are performed to treat or prevent back pain in patients with degenerated intervertebral discs and a variety of spinal diseases. However, post-operative neurological complications may ensue. Intraoperative monitoring techniques have been used to predict and potentially reduce the risk of complications. METHODS: This study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict post-operative neurological deficits after LIF. All patients underwent LIF at UPMC from 2010 to 2012. One thousand fifty-seven patients had pre-operative baseline and continuous intraoperative SSEP monitoring. Statistical analysis was completed using SPSS version 22. No relevant disclosure. RESULTS: Patient outcomes were not significantly affected by age over 65, gender, obesity, and abnormal baselines. Lower extremity (LE) significant changes in SSEPs and LE loss of responses resulted in a sensitivity/specificity of 0.03/0.99 and 0.03/0.99; they had an AUC of 0.54/0.73 with a 95% confidence interval (CI) of [0.34, 0.74]/[0.29, 1.00]. CONCLUSIONS: Significant SSEP changes during LIF are a very specific but poorly sensitive indicator of perioperative neurological deficits. The odds ratio for LE loss of responses was 29.14 with a 95% CI of 1.79-475.5, so LE SSEP loss of responses can serve as a biomarker of perioperative neurological deficits after LIF.


Assuntos
Potenciais Somatossensoriais Evocados , Monitorização Neurofisiológica Intraoperatória/normas , Fusão Vertebral/métodos , Adolescente , Adulto , Idoso , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Região Lombossacral/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Sensibilidade e Especificidade
6.
Spine J ; 19(3): 377-385, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30025994

RESUMO

STUDY DESIGN: Case-control analysis of transcranial motor evoked potential (MEP) responses and clinical outcome. OBJECTIVE: To determine the sensitivity and specificity of MEPs to predict isolated nerve root injury causing dorsiflexion weakness in selected patients having complex lumbar spine surgery. SUMMARY OF BACKGROUND DATA: The surgical correction of distal lumbar spine deformity involves significant risk for damage to neural structures that control muscles of ankle and toe dorsiflexion. Procedures often include vertebral translation, interbody fusion, and posterior-based osteotomies. The benefit of using MEP monitoring to predict dorsiflexion weakness has not been well-established. The purpose of this paper is to describe the relationship between neural complications from lumbar surgery and intraoperative MEP changes. METHODS: Included were 542 neurologically intact patients who underwent posterior spinal fusion for the correction of distal lumbar deformity. Two myotomes, including tibialis anterior (TA) and extensor hallucis longus (EHL), were monitored. MEP and free-running electromyography data were assessed in each patient. Cases of new dorsiflexion weakness noted postoperatively were identified. Data in case and control patients were compared. There was no direct funding for this work. The Department of Anesthesiology and Perioperative Care provides salary support for authors one and six. Authors two and three report employment in the field of intraoperative neurophysiological monitoring as a study-specific conflict of interest. RESULTS: Twenty-five patients (cases) developed dorsiflexion weakness. MEP amplitude decreased in the injured myotomes by an average of 65 ± 21% (TA) and 60±26% (EHL), which was significantly greater than the contralateral uninjured side or for control subjects. (p < .01) Receiver operator characteristic (ROC) curves showed high sensitivity, specificity, and predictive value for changes in MEP amplitude using either the TA or EHL. Analysis of MEP changes to either TA or EHL yielded a superior ROC curve. Net reclassification improvement analysis showed assessing MEP changes to both TA and EHL improved the predictability of injury. CONCLUSIONS: The use of MEP amplitude change is highly sensitive and specific to predict a new postoperative dorsiflexion injury. Monitoring two myotomes (both TA and EHL) is superior to relying on MEP changes from a single myotome. Electromyography activity was less accurate but compliments MEP use. Additional studies are needed to define optimal intraoperative MEP warning thresholds.


Assuntos
Eletromiografia/métodos , Potencial Evocado Motor , Monitorização Neurofisiológica Intraoperatória/métodos , Vértebras Lombares/cirurgia , Fusão Vertebral/métodos , Adolescente , Adulto , Eletromiografia/normas , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/normas , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Fusão Vertebral/efeitos adversos
7.
J Clin Monit Comput ; 33(2): 175-183, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30374759

RESUMO

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.


Assuntos
Monitorização Neurofisiológica Intraoperatória/normas , Monitorização Neurofisiológica/normas , Neurofisiologia/normas , Humanos , Organização e Administração , Médicos , Sociedades Médicas , Estados Unidos
8.
Clin Neurophysiol ; 129(12): 2594-2601, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30448714

RESUMO

OBJECTIVE: To evaluate the clinical significance of intraoperative bulbocavernosus reflex (BCR) during untethering surgery in predicting post-operative voiding function. METHODS: We conducted a retrospective review of pediatric patients who underwent untethering surgery with available intraoperative baseline BCR. BCR response during surgery was classified into loss or maintenance. Post-operative voiding function was determined as worsened or maintained based on history, postvoid residual urine measurement, and urodynamic study (UDS). Data regarding demographics, diagnosis, pre-operative voiding difficulty, re-untethering, syrinx, and abnormalities in electromyography were collected for analysis. RESULTS: We included 106 patients, with a mean age of 3.3 years, and 49 patients were male. BCR was lost in 15 patients during surgery and voiding function worsened in 14 patients after surgery. Lumbosacral lipoma was the most common diagnosis, and 16 patients were diagnosed with lipomyelomeningocele (LMMC). The sensitivity and specificity of intraoperative BCR for post-operative worsening of voiding function were 35.7%, and 88.5% at 6 months, respectively. The diagnosis of LMMC was statistically significant in a logistic regression analysis. The specificity of BCR at 6 months in patients with diagnosis other than LMMC was 93.4%, and intraoperative BCR was significant in a logistic regression analysis. CONCLUSIONS: Intraoperative BCR during untethering could predict bladder function 6 months post-operatively with high specificity (88.5%), particularly in cases other than LMMC (93.4%), indicating that voiding function deterioration will not occur if intraoperative BCR is preserved. SIGNIFICANCE: Intraoperative BCR during untethering surgery is a useful tool to predict post-operative voiding outcome.


Assuntos
Monitorização Neurofisiológica Intraoperatória/métodos , Meningomielocele/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Reflexo Anormal , Transtornos Urinários/diagnóstico , Pré-Escolar , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/normas , Região Lombossacral/cirurgia , Masculino , Procedimentos Neurocirúrgicos/métodos , Valor Preditivo dos Testes , Transtornos Urinários/etiologia
9.
Laryngoscope ; 128 Suppl 3: S18-S27, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30291765

RESUMO

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.


Assuntos
Monitorização Neurofisiológica Intraoperatória/normas , Nervo Laríngeo Recorrente/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/normas , Paralisia das Pregas Vocais/prevenção & controle , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Laringe/patologia , Laringe/fisiopatologia , Invasividade Neoplásica , Nervo Laríngeo Recorrente/fisiopatologia , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/fisiopatologia , Tireoidectomia/efeitos adversos , Tireoidectomia/métodos , Paralisia das Pregas Vocais/etiologia
10.
Laryngoscope ; 128 Suppl 3: S1-S17, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30289983

RESUMO

This publication offers modern, state-of-the-art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence-based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision-making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope, 128:S1-S17, 2018.


Assuntos
Complicações Intraoperatórias/prevenção & controle , Monitorização Neurofisiológica Intraoperatória/normas , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Nervo Laríngeo Recorrente/cirurgia , Tireoidectomia/normas , Paralisia das Pregas Vocais/prevenção & controle , Humanos , Complicações Intraoperatórias/etiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Glândula Tireoide/inervação , Glândula Tireoide/cirurgia , Tireoidectomia/efeitos adversos , Tireoidectomia/métodos , Paralisia das Pregas Vocais/etiologia
11.
Stereotact Funct Neurosurg ; 96(5): 311-319, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30326475

RESUMO

BACKGROUND: Invasive electrode monitoring provides more precise localization of epileptogenic foci in patients with medically refractory epilepsy. The use of hybrid depth electrodes that include microwires for simultaneous single-neuron monitoring is becoming more widespread. OBJECTIVE: To determine the safety and utility of hybrid depth electrodes for intracranial monitoring of medically refractory epilepsy. METHODS: We reviewed the medical charts of 53 cases of medically refractory epilepsy operated on from 2006 to 2017, where both non-hybrid and hybrid microwire depth electrodes were used for intracranial monitoring. We assessed the localization accuracy and complications that arose to assess the relative safety and utility of hybrid depth electrodes compared with standard electrodes. RESULTS: A total of 555 electrodes were implanted in 52 patients. The overall per-electrode complication rate was 2.3%, with a per-case complication rate of 20.8%. There were no infections or deaths. Serious or hemorrhagic complications occurred in 2 patients (0.4% per-electrode risk). Complications did not correlate with the use of any particular electrode type, and hybrids were equally as reliable as standard electrodes in localizing seizure onset zones. CONCLUSIONS: Hybrid depth electrodes appear to be as safe and effective as standard depth electrodes for intracranial monitoring and provide unique opportunities to study the human brain at single-neuron resolution.


Assuntos
Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Eletrodos Implantados , Monitorização Neurofisiológica Intraoperatória/métodos , Neurônios/fisiologia , Convulsões/diagnóstico por imagem , Adulto , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia Resistente a Medicamentos/cirurgia , Eletrodos Implantados/normas , Eletroencefalografia/métodos , Eletroencefalografia/normas , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/normas , Masculino , Pessoa de Meia-Idade , Convulsões/fisiopatologia , Convulsões/cirurgia
12.
World Neurosurg ; 118: e304-e315, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30213379

RESUMO

OBJECTIVE: To evaluate the safety and accuracy of anatomic- and lateral fluoroscopic-guided placement of C2 pars/pedicle, C1 lateral mass screws, and freehand placement of C2 laminar screws. METHODS: All the patients who underwent posterior cervical/occipitocervical fixation that involved the placement of C1/C2 screws during a 5-year period (2011-2015) at our institute were included in this study. RESULTS: C1/C2 screws were placed in a total of 94 patients during this period. A total of 97 C1 lateral mass, 49 C2 pars, 24 C2 pedicle, and 82 C2 laminar screws were placed in these patients. C1 lateral mass screws and C2 pars/pedicle screws were placed under anatomic and lateral fluoroscopic guidance. C2 laminar screws were placed by a freehand technique. The mean length (range) of various C2 screws was 16.4 ± 2.6 mm (12-22 mm) for pars screws, 18.8 ± 2.7 mm (14-24 mm) for pedicle screws, and 25.6 ± 3.4 mm (18-32 mm) for laminar screws. Postoperative CT imaging done in all patients before discharge revealed malposition of 2 laminar screws with breach of the inner cortex. The position of the remaining C1/C2 screws was perfect. The superior and medial angulation of the pars screws and superior angulation of the pedicle screws as measured in postoperative CT images were found to significantly deviate from the angles described in the literature. There was no mortality, vertebral artery injury, or neurologic injury related to C1/C2 screw placement in this series. CONCLUSIONS: Anatomic and lateral fluoroscopic-guided placement of C2 pars/pedicle screws and C1 lateral mass screws and freehand placement of C2 laminar screws is extremely safe.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Monitorização Neurofisiológica Intraoperatória/normas , Parafusos Pediculares/normas , Cirurgia Assistida por Computador/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Fluoroscopia/métodos , Fluoroscopia/normas , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Cirurgia Assistida por Computador/instrumentação , Cirurgia Assistida por Computador/métodos , Adulto Jovem
13.
Clin Neurophysiol ; 129(11): 2245-2251, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30216908

RESUMO

OBJECTIVES: Well-designed longitudinal studies assessing effectiveness of intraoperative neurophysiologic monitoring (IONM) are lacking. We investigate IONM effects on cost and administrative markers for health outcomes in the year after cervical spine surgery. METHODS: We identified single-level cervical spine surgeries in commercial claims. We constructed linear regression models estimating the effect of IONM (controlling for patient demographics, pre-operative health, services during index admission) on total spending, neurological complications, readmissions, and outpatient opiate usage in the year following index surgery. RESULTS: IONM was associated with increased spending during index admission of $1229 (p = 0.001), but decreased spending post-discharge of $1615 (p = 0.010), for a net - $386 (p = 0.608) for the year after surgery. Shorter length of stay (0.116 days, p = 0.004) and fewer readmissions (20.5 per thousand, p = 0.036) accounted for some post-discharge savings. IONM was associated with decreased rates of nervous system complications (4/1000, p = 0.048) and post-discharge opiate use (17 prescriptions/1000, p = 0.050) in the year after index admission. CONCLUSIONS: IONM was associated with administrative markers suggesting improved health outcomes after cervical spine surgery without greater costs for the year. SIGNIFICANCE: This study suggests IONM may have lasting health and cost benefits.


Assuntos
Vértebras Cervicais/cirurgia , Análise Custo-Benefício , Monitorização Neurofisiológica Intraoperatória/economia , Complicações Pós-Operatórias/epidemiologia , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/normas , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos
14.
Spine (Phila Pa 1976) ; 43(17): 1231-1237, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-30106389

RESUMO

STUDY DESIGN: Retrospective study. OBJECTIVE: The goal of the study was to investigate the significance of a change in latency in monitoring of transcranial muscle-action potential (Tc-MsEP) waveforms. SUMMARY OF BACKGROUND DATA: Tc-MsEP has become a common approach in spine surgery due to its sensitivity and importance in motor function. Many reports have defined the alarm point of Tc-MsEP waveform as a particular decrease in amplitude, but evaluation of the waveform latency has not attracted as much attention. METHODS: The subjects were 70 patients who underwent spine surgery using intraoperative Tc-MsEP monitoring. The peak latency was defined as the period from stimulation until the waveform amplitude reached its peak. Relationships with postoperative paralysis were examined separately for latency delays of 5% or more and 10% or more, and in combination with a decrease in amplitude of 70% or more from baseline. RESULTS: Acceptable baseline Tc-MsEP responses were obtained from 1225 of 1372 muscles in the extremities (89.3%). Seven of the 70 patients (10%) had postoperative paralysis. A decrease in intraoperative amplitude of 70% or more from baseline occurred in 25 cases, with sensitivity 100%, specificity 71%, false positive rate 29%, and positive predictive value (PPV) 28% for prediction of postoperative paralysis. Compared to baseline, 15 cases had a latency delay of 5% or more, which gave a sensitivity of 100%, specificity of 87%, false positive rate of 0%, and PPV 47%, and 8 cases had a delay of 10% or more, which gave a sensitivity of 86%, specificity of 97%, false positive rate of 3%, and PPV 75%. A combination of a decrease in amplitude of 70% or more from baseline and a delay in latency of 10% or more from baseline had a sensitivity of 86%, specificity of 98%, and a false positive rate of 2%, and PPV 86%. CONCLUSION: Combined use of latency and amplitude could lead to reduction of false positives and increase of PPV in Br(E)-MsEP monitoring. LEVEL OF EVIDENCE: 3.


Assuntos
Potenciais Somatossensoriais Evocados/fisiologia , Monitorização Neurofisiológica Intraoperatória/normas , Doenças da Medula Espinal/fisiopatologia , Doenças da Medula Espinal/cirurgia , Estimulação Transcraniana por Corrente Contínua/normas , Adolescente , Adulto , Idoso , Criança , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Doenças da Medula Espinal/diagnóstico , Estimulação Transcraniana por Corrente Contínua/métodos , Adulto Jovem
15.
Acta otorrinolaringol. esp ; 69(4): 231-242, jul.-ago. 2018. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-180489

RESUMO

Introducción: La cirugía de tiroides y paratiroides (CTPT) se asocia a riesgo de lesión del nervio laríngeo recurrente, nervio laríngeo superior y cambios en la voz. La neuromonitorización intraoperatoria (NMIO), intermitente o continua, en CTPT evalúa el estado funcional de los nervios laríngeos y se utiliza progresivamente con más frecuencia. Esto obliga a adoptar puntos de acuerdo en los aspectos más controvertidos. Objetivo: Elaborar un documento de ayuda para orientar en la utilización de la NMIO en CTPT. Método: Consenso en grupo de trabajo mediante revisión sistemática y método Delphi. Resultados: Se identificaron 7 secciones sobre las que se establecieron puntos de acuerdo: indicaciones, equipo, técnica (parámetros de programación y registro), conducta en pérdida de señal, laringoscopia, voz e implicaciones legales. Conclusiones: La NMIO ayuda en la localización e identificación del nervio laríngeo recurrente, ayuda durante su disección, informa sobre su estado funcional al finalizar la cirugía y permite tomar decisiones en caso de pérdida de señal en el primer lado operado en una tiroidectomía bilateral programada o si había parálisis contralateral previa. La precisión de la NMIO depende de variables como la técnica realizada, la tecnología utilizada y la formación para la correcta ejecución de la técnica e interpretación de la señal. El documento presentado es un punto de inicio para futuros acuerdos en CTPT en cada una de las secciones de consenso


Introduction: Thyroid and parathyroid surgery (TPTS) is associated with risk of injury to the recurrent laryngeal nerve, superior laryngeal nerve and voice changes. Intraoperative neuromonitoring (IONM), intermittent or continuous, evaluates the functional state of the laryngeal nerves and is being increasingly used. This means that points of consensus on the most controversial aspects are necessary. Objective: To develop a support document for guidance on the use of IONM in TPTS. Method: Work group consensus through systematic review and the Delphi method. Results: Seven sections were identified on which points of consensus were identified: indications, equipment, technique (programming and registration parameters), behaviour on loss of signal, laryngoscopy, voice and legal implications. Conclusions: IONM helps in the location and identification of the recurrent laryngeal nerve, helps during its dissection, reports on its functional status at the end of surgery and enables decision-making in the event of loss of signal in the first operated side in a scheduled bilateral thyroidectomy or previous contralateral paralysis. The accuracy of IONM depends on variables such as accomplished technique, technology and training in the correct execution of the technique and interpretation of the signal. This document is a starting point for future agreements on TPTS in each of the sections of consensus


Assuntos
Humanos , Monitorização Neurofisiológica Intraoperatória/normas , Paratireoidectomia/normas , Tireoidectomia/métodos , Guias de Prática Clínica como Assunto
16.
World Neurosurg ; 115: e637-e644, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29709735

RESUMO

BACKGROUND: High-field intraoperative magnetic resonance imaging (MRI) has become increasingly available in neurosurgery centers. There is little experience with combined intraoperative MRI and intraoperative neurophysiologic monitoring (IONM). We report the first series, to our knowledge, of pediatric patients undergoing brain tumor surgery with 3T intraoperative MRI and IONM. METHODS: This pilot study included all consecutive children operated on for brain tumors between October 2013 and April 2016 in whom concomitant intraoperative MRI and somatosensory evoked potentials and motor evoked potentials were used. Neuromonitoring findings and related complications of all cases were retrospectively analyzed. RESULTS: During a 30-month period, 17 children (mean age 8.4 years; 3 girls) undergoing surgery met the study criteria. During intraoperative MRI, 483 IONM needles were left in place. Of these needles, 119 were located on the scalp, 94 were located above the chest, and 270 were located below the chest. Two complications with skin burns (first degree) were observed. In all patients, neuromonitoring was still reliable after MRI. In 1 case, a threshold increase for motor evoked potential stimulation (20 mA) was necessary after intraoperative MRI; in 2 cases, a reduction of 50% of the somatosensory evoked potential amplitude at the end of the surgery was observed compared with the values obtained before intraoperative MRI. CONCLUSIONS: The combination of intraoperative MRI and IONM can be safely used in pediatric patients. IONM data acquisition after intraoperative MRI was feasible and remained reliable.


Assuntos
Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/cirurgia , Monitorização Neurofisiológica Intraoperatória/normas , Imagem por Ressonância Magnética/normas , Segurança do Paciente/normas , Adolescente , Neoplasias Encefálicas/fisiopatologia , Criança , Pré-Escolar , Potenciais Somatossensoriais Evocados/fisiologia , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/estatística & dados numéricos , Imagem por Ressonância Magnética/estatística & dados numéricos , Masculino , Projetos Piloto , Estudos Prospectivos
17.
World Neurosurg ; 114: e1290-e1296, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29626681

RESUMO

BACKGROUND: External ventricular drainage (EVD) catheter placement is one of the most commonly performed neurosurgical procedures. The study's objective was to compare a computed tomography (CT) bolt scan-guided approach for the placement of EVDs with conventional landmark-based insertion. METHODS: In this retrospective case-control study, we analyzed patients undergoing bolt-kit EVD catheter placement, either CT-guided or landmark-based, between 2013 and 2016. The CT bolt scan-guided approach was based on a dose-reduced CT scan after bolt fixation with immediate image reconstruction along the axis of the bolt to evaluate the putative insertion axis. If needed, angulation of the bolt was corrected and the procedure repeated before the catheter was inserted. Primary endpoint was the accuracy of insertion. Secondary endpoints were the overall number of attempts, duration of intervention, complication rates, and cumulative radiation dose. RESULTS: In total, 34 patients were included in the final analysis. In the group undergoing CT-guided placement, the average ventricle width was significantly smaller (P = 0.04) and average midline shift significantly more pronounced (P = 0.01). CT-guided placement resulted in correct positioning of the catheter in the ipsilateral frontal horn in all 100% of the cases compared with landmark-guided insertion (63%; P = 0.01). Application of the CT-guided approach increased the number of total CT scans (3.6 ± 1.9) and the overall radiation dose (3.34 ± 1.61 mSv) compared with the freehand insertion group (1.84 ± 2.0 mSv and 1.55 ± 1.66 mSv). No differences were found for the other secondary outcome parameters. CONCLUSIONS: CT-guided bolt-kit EVD catheter placement is feasible and accurate in the most difficult cases.


Assuntos
Drenagem/normas , Serviços Médicos de Emergência/normas , Monitorização Neurofisiológica Intraoperatória/normas , Tomografia Computadorizada por Raios X/normas , Ventriculostomia/normas , Adulto , Idoso , Estudos de Casos e Controles , Cateterismo/métodos , Cateterismo/normas , Drenagem/métodos , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Ventriculostomia/métodos
18.
Expert Rev Neurother ; 18(4): 333-341, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29521555

RESUMO

INTRODUCTION: Radical glioma resection improves overall survival, both in low-grade and high-grade glial tumors. However, preservation of the quality of life is also crucial. Areas covered: Due to the diffuse feature of gliomas, which invade the central nervous system, and due to considerable variations of brain organization among patients, an individual cerebral mapping is mandatory to solve the classical dilemma between the oncological and functional issues. Because functional neuroimaging is not reliable enough, intraoperative electrical stimulation, especially in awake patients benefiting from a real-time cognitive monitoring, is the best way to increase the extent of resection while sparing eloquent neural networks. Expert commentary: Here, we propose a paradigmatic shift from image-guided resection to functional mapping-guided resection, based on the study of the dynamic distribution of delocalized cortico-subcortical circuits at the individual level, i.e., the investigation of brain connectomics and neuroplastic potential. This surgical philosophy results in an improvement of both oncological outcomes and quality of life. This highlights the need to reinforce the link between glioma surgery and cognitive neurosciences.


Assuntos
Mapeamento Encefálico/normas , Neoplasias Encefálicas/cirurgia , Glioma/cirurgia , Monitorização Neurofisiológica Intraoperatória/normas , Plasticidade Neuronal/fisiologia , Procedimentos Neurocirúrgicos/normas , Qualidade de Vida , Mapeamento Encefálico/métodos , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Neurocirúrgicos/métodos
19.
Clin Neurophysiol ; 129(1): 296-307, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29113719

RESUMO

OBJECTIVE: To develop and validate a detector that identifies ripple (80-200 Hz) events in intracranial EEG (iEEG) recordings in a referential montage and utilizes independent component analysis (ICA) to eliminate or reduce high-frequency artifact contamination. Also, investigate the correspondence of detected ripples and the seizure onset zone (SOZ). METHODS: iEEG recordings from 16 patients were first band-pass filtered (80-600 Hz) and Infomax ICA was next applied to derive the first independent component (IC1). IC1 was subsequently pruned, and an artifact index was derived to reduce the identification of high-frequency events introduced by the reference electrode signal. A Hilbert detector identified ripple events in the processed iEEG recordings using amplitude and duration criteria. The identified ripple events were further classified and characterized as true or false ripple on spikes, or ripples on oscillations by utilizing a topographical analysis to their time-frequency plot, and confirmed by visual inspection. RESULTS: The signal to noise ratio was improved by pruning IC1. The precision of the detector for ripple events was 91.27 ±â€¯4.3%, and the sensitivity of the detector was 79.4 ±â€¯3.0% (N = 16 patients, 5842 ripple events). The sensitivity and precision of the detector was equivalent in iEEG recordings obtained during sleep or intra-operatively. Across all the patients, true ripple on spike rates and also the rates of false ripple on spikes, that were generated due to filter ringing, classified the seizure onset zone (SOZ) with an area under the receiver operating curve (AUROC) of >76%. The magnitude and spectral content of true ripple on spikes generated in the SOZ was distinct as compared with the ripples generated in the NSOZ (p < .001). CONCLUSIONS: Utilizing ICA to analyze iEEG recordings in referential montage provides many benefits to the study of high-frequency oscillations. The ripple rates and properties defined using this approach may accurately delineate the seizure onset zone. SIGNIFICANCE: Strategies to improve the spatial resolution of intracranial EEG and reduce artifact can help improve the clinical utility of HFO biomarkers.


Assuntos
Eletrocorticografia/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Adolescente , Adulto , Criança , Eletrocorticografia/instrumentação , Eletrocorticografia/normas , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/normas , Masculino , Análise de Componente Principal , Razão Sinal-Ruído
20.
World Neurosurg ; 109: e24-e32, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28951183

RESUMO

BACKGROUND: Recent studies have shown higher accuracy rates of image-guided pedicle screw placement compared to freehand (FH) placement. However, data focusing on the impact of spinal navigation on the rate of revision surgeries caused by misplaced pedicle screws (PS) are scarce. OBJECTIVE: This study is aimed at identifying the rate of revision surgeries for misplaced PS comparing three-dimensional (3D) fluoroscopy navigation (3DFL) with FH PS placement. METHODS: A retrospective analysis was conducted of 2232 patients (mean age, 65.3 ± 13.5 years) with 13,703 implanted PS who underwent instrumentation of the thoracolumbar spine between 2007 and 2015. Group 1 received surgery with use of 3DFL (January 2011 to December 2015), group 2 received surgery in the FH technique (April 2007 to December 2015). Because the use of 3DFL was initiated in January 2011, the examined period for 3DFL-navigated surgeries is shorter. Patients routinely received postoperative computed tomography scans and/or intraoperative control 3D scans. RESULTS: There was an overall rate of revision surgeries for malpositioned PS of 2.9%. In the 3DFL group, the rate of secondary revision surgeries was significantly lower with 1.35% (15/1112 patients) compared to 4.38% (49/1120 patients) in the FH group, respectively (odds ratio, 3.35; P < 0.01). Of all PS in the 3DFL group (30/7548 PS), 0.40% needed revision surgery (P < 0.01) compared to 1.14% in the FH group (70/6155 PS). CONCLUSIONS: We were able to show that the use of 3DFL-navigated PS placement significantly reduces the rate of revision surgeries after posterior spinal instrumentation compared to freehand PS placement.


Assuntos
Monitorização Neurofisiológica Intraoperatória/tendências , Vértebras Lombares/cirurgia , Neuronavegação/tendências , Parafusos Pediculares , Reoperação/tendências , Vértebras Torácicas/cirurgia , Idoso , Feminino , Fluoroscopia/normas , Fluoroscopia/tendências , Humanos , Imagem Tridimensional/normas , Imagem Tridimensional/tendências , Monitorização Neurofisiológica Intraoperatória/normas , Vértebras Lombares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Neuronavegação/normas , Parafusos Pediculares/efeitos adversos , Estudos Retrospectivos , Cirurgia Assistida por Computador/normas , Cirurgia Assistida por Computador/tendências , Vértebras Torácicas/diagnóstico por imagem
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