Professional Documents
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Society for Progress and Innovations
for the Near East:
Updates and Cadaveric Bio-skills Workshop
Beirut, Lebanon
June 23 – 26, 2010
“Patient Transparent”
Intraoperative
Neurophysiological Monitoring in
Minimally Invasive Spine
Surgery (MISS)
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Introduction
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Introduction
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Types of Intraoperative
Neurophysiological Monitoring
(IOM)
For neurological complication avoidance!
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Spontaneous Electromyography
(sEMG)
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Myotomal Distribution of Spinal Nerve for Neuro-
monitoring
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Types of Mechanically Activated Spontaneous
(sEMG)
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Spontaneous Electromyography (sEMG)
IMPORTANT sEMG CLINICAL CORRELATION
AND APPLICATION IN MISS
1. Spike or burst activity indicates brief direct or indirect
contact to a nerve and can assist the surgeon in
navigating the instruments away from a particular
trajectory
2. Spikes and bursts can also inform the surgeon of the
instruments in proximity to the nerve root
3. During MISS, sEMG trains are of clinical significance, and
the surgeon is typically notified if these occur
4. Trains are continuous, repetitive EMG firing often caused
by continuous force applied to the nerve root
5. Trains of higher frequency and/or amplitude tend to
represent significant nerve fiber recruitment caused by
excessive force on the nerve and are likely to indicate a
high probability of nerve injury if a relevant manipulation
is sustained
6. These alerts a MISS surgeon for immediate corrective
action or intervention to prevent irreversible neural
trauma
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Pedicle Screw Stimulation
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Criteria for Pedicle Screw Thresholds
Threshold: > 8-10 mA Borderline Value: The pedicle wall and screw
position should be re-examined.
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Somatosensory Evoked Potentials
(SSEP)
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SSEP Pathways
Median
Nerve
Posterior Tibial
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Left Posterior Tibial Nerve (LPTN) – SSEP
C3’-C4’
Cortex
Cz’-Fpz
Cortex
Cs3-Fpz
Brainstem
LPF
Peripheral Nerve
0 100 mS
Surgical Site
Injury Intervention
Initiated
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Pre-op baseline PTN, SN, EMG & SSEP
Response
Monitoring Notes
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Thoracic cord injury
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Upper cervical cord injury
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Motor Evoked Potentials (MEP)
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Transcranial Motor Evoked
Potentials (TCMEP)
Electrical
stimulation of Muscle MEPs 20 mS
motor cortex
through the
scalp
Record
descending
spinal cord
potential (D-
Wave)
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TCMEP Changes During Lumbar Instrumentation
L Hand
L Leg
R Hand
R Leg
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Surface EEG Monitoring – BIS
System
• Another important IOM:
surface EEG - BIS (Bispectral
Index) (Aspect Medical Systems,
Newton, MA, USA) monitoring
during MISS
• Optimizes the depth of
anesthesia
• BIS Index measures the level of
consciousness of the patient and
helps to decrease the amount
of anesthetic medications used,
up to 40% less
• Optimal IV conscious sedation
with BIS Index range of 60-80
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Clinical Application
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EMG Monitoring – Stimulation of K-
wire
Response observed only on Vastus Medalis
NERVE ROOT:
Adductor Longus
Vastus Medialis
Tibialis Anterior
Gastrocnemius
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EMG Monitoring – Stimulation of K-wire
Response observed on ALL channels (muscles) resulting from
movement of K-wire only
NERVE ROOT:
Adductor Longus
Vastus Medialis
Tibialis Anterior
No Change in
Gastrocnemius Stimulation intensity
only movement of
location of K-wire
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Case Illustration I
Endoscopic Microdecompressive MISS for Lumbar
Herniated Disc and Stenosis L4-L5
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Case Illustration I
Neurotonic discharge changes in tracing, during placement of interspinous process spacer for
distraction/decompression of Stenosis L4-L5 caused by retraction of Cauda Equina
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Case Illustration I
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Endoscopic Lumbar MISS Surgery
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Lumbar Endoscopic MISS Case
Illustration I
With sEMG IOM monitoring, successful endoscopic microdecompression for extruded
herniated L4-5 disc
• 26 yo “Extreme
Athlete”, Motorcycle,
Rally car X-games
gold medalist
• Severe posttraumatic
L4-5 disc herniation
• Excellent relief from
outpatient
endoscopic MISS
• Return to rally car
racing in two weeks
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Lumbar Endoscopic MISS Case
Illustration II
With sEMG IOM monitoring, successful endoscopic microdecompression for large
extruded herniated L5-S1 disc
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Lumbar Endoscopic MISS Case
Illustration III
With sEMG IOM monitoring, successful endoscopic microdecompression for large
extruded post traumatic herniated L4-5 disc
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Cervical and Thoracic MISS Surgery
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Cervical Endoscopic MISS Case
Illustration IV
With sEMG IOM monitoring,
81 yo NS Professor
underwent successful
endoscopic cervical
discectomy, developed
transient extreme
bradycardia (30) detected
and monitored on the large
intra-op screen, of
SurgMatix system and
treated with atropine. Did well.
Discharged in 1 hour.
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Cervical Endoscopic MISS Case
Illustration V
With sEMG IOM monitoring English rock star had successful endoscopic cervical C3-4 discectomy for C3-4 disc herniation
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Thoracic Endoscopic MISS Case
Illustration VI
With sEMG IOM monitoring successful endoscopic thoracic MISS
T7 herniated disc
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Discussion and Comment
• An advanced technologically driven
MISS requires various less invasive
surgical instruments and advanced
complex technology than the usual
traditional spinal surgery
• The MISS spine surgeon has only limited
and restricted visualization of the surgical
field
• MISS has to depend on the preoperative
interpretation of pathology in relationship
to X-Rays, MRI, CT, 3D CT imaging studies
for pre surgical planning
• Intra-operatively C-Arm fluoroscopic
imaging, and endoscopic visualization on
real time basis facilitates the MISS
• It is aided by intraoperative
neurophysiological monitoring
especially with sEMG and other relevant
neuro-monitoring modalities in order to
avoid significant neurological complications
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Discussion and Comment
• SurgMatix® Is a “digital surgical
technology convergence and OR
control system”, involving
monitoring and recording of all wave
form and imaging data, including
sEMG, Pre-Operative, Intra-
Operative and Post-Operative
phases of MISS
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Discussion and Comment
SurgMatix intraoperative monitoring screen displays real time wave form,
imaging, vital signs, sEMG, BIS, IOM information to facilitate MISS surgery
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Conclusion:
• Utilization of intraoperative
neurophysiological monitoring, IOM
prevents neurological injury and
provides a safer MISS
• A thorough familiarity with the
various modalities available for
IOM - including especially sEMG,
and tEMG besides SSEPs, MEPs, is
a must for a endoscopic MISS
surgeon
• Knowledge MISS technique,
benefits and limitations of each
monitoring modality helps to
maximize the value of IOM
during MISS procedures
• An interdisciplinary approach to
IOM facilitates the optimization of
MISS technique and in preventing
neural trauma
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Hope you enjoyed this presentation!
“Arigato”
“Danke schön”
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