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Keil LG, Bomar JD, Bower CR, Venne MH, Curran PF, Upasani VV. Intraoperative Neuromonitoring During Periacetabular Osteotomy Provides Actionable Alerts. JB JS Open Access 2025; 10:e24.00126. [PMID: 40094075 PMCID: PMC11896103 DOI: 10.2106/jbjs.oa.24.00126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2025] Open
Abstract
Background Bernese periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia and femoroacetabular impingement has become increasingly common, with a corresponding increase in the incidence of adverse outcomes. The rate of major neurological injury (excluding lateral femoral cutaneous nerve injury) during PAO has been reported to be around 2%. Previous publications have recommended the use of intraoperative neuromonitoring (IONM) to mitigate risk of major neurological injury during PAO, but its use has not become universal among PAO surgeons as it has among spine surgeons. The purpose of this study was to report the incidence and clinical significance of IONM alerts in a single-surgeon, consecutive cohort of patients treated with Bernese PAO. Methods After a permanent peripheral nerve injury during a PAO without IONM, IONM has been used at our institution in every PAO. Motor evoked potentials and somatosensory monitoring are performed throughout the procedure. We conducted a retrospective review of all PAOs performed after this practice change between 2017 and 2023. Medical records were reviewed for all IONM alerts, surgical team responses to alerts, and postoperative neurological status. Results All 94 PAOs performed with IONM in 82 patients during the study period were included. The mean age was 19 years (range 11-38). Significant IONM alerts occurred in 10 of 94 PAOs (11%) in 10 patients. Of these 10 alerts, 6 resulted in action taken by the surgical team including adjustment of acetabular fragment correction, leg repositioning, or stockinette or boot loosening. The remaining 4 alerts were due to anesthetic or systemic causes or technical issues with the neuromonitoring electrodes. No patients had a detectable neurological deficit postoperatively. Conclusions IONM may produce alerts in approximately 1 in 9 periacetabular osteotomies. These alerts are actionable and may improve patient safety and minimize the non-negligible risk of major nerve injury. This study provides additional evidence to support the utility of IONM in PAO. Level of Evidence Level III-retrospective cohort study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lukas G. Keil
- Department of Orthopedics, Rady Children's Hospital, San Diego, California
| | - James D. Bomar
- Department of Orthopedics, Rady Children's Hospital, San Diego, California
| | | | | | - Patrick F. Curran
- Department of Orthopedics, Rady Children's Hospital, San Diego, California
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Toleikis JR, Pace C, Jahangiri FR, Hemmer LB, Toleikis SC. Intraoperative somatosensory evoked potential (SEP) monitoring: an updated position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2024; 38:1003-1042. [PMID: 39068294 PMCID: PMC11427520 DOI: 10.1007/s10877-024-01201-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Somatosensory evoked potentials (SEPs) are used to assess the functional status of somatosensory pathways during surgical procedures and can help protect patients' neurological integrity intraoperatively. This is a position statement on intraoperative SEP monitoring from the American Society of Neurophysiological Monitoring (ASNM) and updates prior ASNM position statements on SEPs from the years 2005 and 2010. This position statement is endorsed by ASNM and serves as an educational service to the neurophysiological community on the recommended use of SEPs as a neurophysiological monitoring tool. It presents the rationale for SEP utilization and its clinical applications. It also covers the relevant anatomy, technical methodology for setup and signal acquisition, signal interpretation, anesthesia and physiological considerations, and documentation and credentialing requirements to optimize SEP monitoring to aid in protecting the nervous system during surgery.
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Affiliation(s)
| | | | - Faisal R Jahangiri
- Global Innervation LLC, Dallas, TX, USA
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
| | - Laura B Hemmer
- Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Lee CS, Hwang CJ, Lee DH, Cho JH, Park S. Risk Factors and Exit Strategy of Intraoperative Neurophysiological Monitoring Alert During Deformity Correction for Adolescent Idiopathic Scoliosis. Global Spine J 2024; 14:2012-2021. [PMID: 36916149 PMCID: PMC11418700 DOI: 10.1177/21925682231164344] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To elucidate the risk factors of intraoperative neurophysiological monitoring (IONM) alert during deformity correction surgery for adolescent idiopathic scoliosis (AIS) and to describe the outcomes of patients who underwent staged correction surgery due to IONM alert during the initial procedure. METHODS We reviewed 1 024 patients with idiopathic scoliosis who underwent deformity correction and were followed-up for ≥1 year. The pre-and postoperative Cobb angle of the major structural curve, operative time, estimated blood loss (EBL), number of levels fused, event that caused the IONM alert, and intervention required for the recovery of the signal were recorded. Patients who received IONM alerts (alert group) and those who did not (non-alert group) during the operation were compared. RESULTS Compared to the non-alert group, the alert group had a significantly greater preoperative Cobb angle of the major structural curve (P < .001), number of levels fused (P = .003), operative time (P < .001), and EBL (P < .001). The percentage of correction did not significantly differ between the 2 groups (P = .348). Eight patients (.8%) underwent a staged operation because the IONM signal alert hindered correction of the deformity. The percentage of correction of patients who underwent staged operation was 64.9 ± 15.1%, and no permanent neurologic deficits occurred. CONCLUSION A greater magnitude of preoperative deformity and surgical extent increases the risk of cord injury identified by IONM alerts during correction of deformities in patients with AIS. However, in patients in whom the IONM alert cannot be recovered or reproduced by proceeding with deformity correction, surgeons can minimize the risk by aborting the initial procedure and completing the correction using staged operations.
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Affiliation(s)
- Choon Sung Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang-Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sehan Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Adkins G, Mirallave Pescador A, Koht A, Gosavi S. Intraoperative neuromonitoring in intracranial surgery. BJA Educ 2024; 24:173-182. [PMID: 38646449 PMCID: PMC11026914 DOI: 10.1016/j.bjae.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 04/23/2024] Open
Affiliation(s)
- G.B. Adkins
- South East School of Anaesthesia, London, UK
| | | | - A.H. Koht
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Mohamed OS, Darwish MM, Mousa MM, Abd Elaziz AEH, Mohamed AK. Impact of mode of anesthesia on ischemia modified albumin, operative conditions, and outcome in emergency craniotomies. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2022.2154011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
| | - Mohab Mohamad Darwish
- Neurosurgery, Minia university hospital, Faculty of medicine, Minia university, Minia, Egypt
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Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
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Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
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Predictive Value of Multimodality Intraoperative Neurophysiological Monitoring During Cardiac Surgery. J Clin Neurophysiol 2023; 40:180-186. [PMID: 34510090 DOI: 10.1097/wnp.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION This study aimed to determine the ability of multimodality intraoperative neurophysiologic monitoring, including somatosensory evoked potentials (SSEP) and EEG, to predict perioperative clinical stroke and stroke-related mortality after open-heart surgery in high-risk patients. METHODS The records of all consecutive patients who underwent coronary artery bypass grafting, and cardiac valve repair/replacement with high risk for stroke who underwent both SSEP and EEG recording at the University of Pittsburgh Medical Center between 2009 and 2015 were reviewed. Sensitivity and specificity of these modalities to predict in-hospital clinical strokes and stroke-related mortality were calculated. RESULTS A total of 531 patients underwent open cardiac procedures monitored using SSEP and EEG. One hundred thirty-one patients (24.67%) experienced significant changes in either modality. Fourteen patients (2.64%) suffered clinical strokes within 24 hours after surgery, and eight patients (1.50%) died during their hospitalization. The incidence of in-hospital clinical stroke and stroke-related mortality among patients who experienced a significant change in monitoring compared with those with no significant change was 11.45% versus 1.75%. The sensitivity and specificity of significant changes in either SSEP or EEG to predict in-hospital major stroke and stroke-related mortality were 0.93 and 0.77, respectively. CONCLUSIONS Intraoperative neurophysiologic monitoring with SSEP and EEG has high sensitivity and specificity in predicting perioperative stroke and stroke-related mortality after open cardiac procedures. These results support the benefits of multimodality neuromonitoring during cardiac surgery.
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Shalita C, Sankey EW, Bergin SM, McManigle J, Buckley AF, Radtke R, Torres C, Dear GL, Thompson EM. Successful Neonatal, Intraoperative Neuromonitoring in the Surgical Correction of a Thoracic Dermal Sinus Tract: Technical Note. Pediatr Neurosurg 2022; 57:295-300. [PMID: 35512661 DOI: 10.1159/000524924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/29/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intraoperative neuromonitoring (IONM) is commonly used during surgery of the spine and spinal cord for early surveillance of iatrogenic injury to the central and peripheral nervous system. However, for infants and young children under 3 years of age, the use of IONM is challenging due to incomplete central and peripheral myelination. CASE PRESENTATION We report a case of a T4-T6 dermal sinus tract (DST) that was resected on day of life 23, with the successful use of IONM. CONCLUSION To our knowledge, this is the youngest reported case of the use of IONM in the surgical correction of a DST in a neonatal patient. This case demonstrates the potential efficacy of IONM in neonatal spine surgery and the techniques used to adapt the technology to an immature nervous system.
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Affiliation(s)
- Chidyaonga Shalita
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | - Eric W Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stephen M Bergin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - John McManigle
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Anne F Buckley
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Rodney Radtke
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Claudia Torres
- Neurodiagnostic Services, Duke University Medical Center, Durham, North Carolina, USA
| | - Guy L Dear
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric M Thompson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Chandran R, De Sousa K, Koo SH, Lim YY, Shang L, Paiputra F, Tan JH, Ching TTH, Khoo X. A device to detect leakage at the patient end of total intravenous anaesthesia. J Med Eng Technol 2021; 46:95-101. [PMID: 34881660 DOI: 10.1080/03091902.2021.2006349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The use of total intravenous anaesthesia (TIVA) is limited by concerns of disconnections of the tubing, resulting in accidental awareness. We designed a sensor device to detect leakages at the patient end and notify the medical personnel, thereby allowing immediate intervention in preventing awareness. For moisture detection, resistive sensing was selected as the working principle. The prototype was in proximity to the tubing from the TIVA pump and the patient's intravenous cannula, and able to detect leakages in all potential leakage sites and activate an alarm. Our device consists of a disposable bandage (sensor), attached to a reusable clamp that is directly coupled to a central module (SparkFun MicroView, a small microcontroller with built-in Organic Light-Emitting Diode (OLED) display). The disposable bandage is wrapped around the possible leakage sites. Crucially, the disposable bandage is integrated with two separate moisture sensing threads. When moisture is present, the central module detects a drop in resistance across the moisture sensing threads and activates a flashing LED and buzzer. We have successfully created a functional leak detection device, comprising a moisture sensing bandage and an audio and visual alert system, to address the problem of undetected TIVA leakages at the patient end.
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Affiliation(s)
- Rajkumar Chandran
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore, Singapore
| | - Kalindi De Sousa
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore, Singapore
| | - Seok Hwee Koo
- Clinical Trials and Research Unit, Changi General Hospital, Singapore, Singapore
| | - Yin Yu Lim
- Ministry of Health Holdings, Singapore, Singapore
| | - Lei Shang
- Ministry of Health Holdings, Singapore, Singapore
| | - Fleming Paiputra
- Pillar of Engineering Product Development, Singapore University of Technology and Design, Singapore, Singapore
| | - Joanne Huishan Tan
- Pillar of Engineering Product Development, Singapore University of Technology and Design, Singapore, Singapore
| | - Terry Tsz Him Ching
- Pillar of Engineering Product Development, Singapore University of Technology and Design, Singapore, Singapore
| | - Xiaojuan Khoo
- Pillar of Engineering Product Development, Singapore University of Technology and Design, Singapore, Singapore.,Science, Mathematics and Technology, Singapore University of Technology and Design, Singapore, Singapore
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Furlan D, Deana C, Orso D, Licari M, Cappelletto B, DE Monte A, Vetrugno L, Bove T. Perioperative management of spinal cord injury: the anesthesiologist's point of view. Minerva Anestesiol 2021; 87:1347-1358. [PMID: 34874136 DOI: 10.23736/s0375-9393.21.15753-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is one of the most devastating events a person can experience. It may be life-threatening or result in long-term disability. This narrative review aims to delineate a systematic step-wise airways, breathing, circulation and disability (ABCD) approach to perioperative patient management during spinal cord surgery in order to fill some of the gaps in our current knowledge. METHODS We performed a comprehensive review of the literature regarding the perioperative management of traumatic spinal injuries from May 15, 2020, to December 13, 2020. We consulted the PubMed and Embase database libraries. RESULTS Videolaryngoscopy supplements the armamentarium available for airway management. Optical fiberscope use should be evaluated when intubating awake patients. Respiratory complications are frequent in the acute phase of traumatic spinal injury, with an estimated incidence of 36-83%. Early tracheostomy can be considered for expected difficult weaning from mechanical ventilation. Careful intraoperative management of administered fluids should be pursued to avoid complications from volume overload. Neuromonitoring requires investments in staff training and cooperation, but better outcomes have been obtained in centers where it is routinely applied. The prone position can cause rare but devastating complications, such as ischemic optic neuropathy; thus, the anesthetist should take the utmost care in positioning the patient. CONCLUSIONS A one-size fit all approach to spinal surgery patients is not applicable due to patient heterogeneity and the complexity of the procedures involved. The neurologic outcome of spinal surgery can be improved, and the incidence of complications reduced with better knowledge of patient-specific aspects and individualized perioperative management.
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Affiliation(s)
- Davide Furlan
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Daniele Orso
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Maurizia Licari
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Barbara Cappelletto
- Section of Spine and Spinal Cord Surgery, Department of Neurological Sciences, ASUFC University Hospital of Udine, Udine, Italy
| | - Amato DE Monte
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Medicine (DAME), University of Udine, Udine, Italy - .,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Medicine (DAME), University of Udine, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
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Vissarionov SV, Syundyukov AR, Nikolaev NS, Kuzmina VA, Kornyakov PN, Maksimov MN, Mikhailova IV. The use of intraoperative neurophysiological monitoring in dorsal resection of hemivertebrae. PEDIATRIC TRAUMATOLOGY, ORTHOPAEDICS AND RECONSTRUCTIVE SURGERY 2021; 9:267-276. [DOI: 10.17816/ptors61946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND: Congenital disorders of vertebrae formation are a common pathology in children. Intraoperative neurophysiological monitoring is a mandatory procedure, although it may not be effective enough due to the immature neural structures and the use of inhalation anesthetics in young children.
AIM: To study aims to investigate the characteristic features of intraoperative neurophysiological monitoring in children with a congenital deformity of the spine during dorsal resection of the hemivertebrae.
MATERIALS AND METHODS: 42 patients aged 117 years with a congenital deformity of the spine underwent 46 resections of the abnormal vertebra from an isolated dorsal approach (egg-shell technique). Intraoperative neurophysiological monitoring at the stages of the operation included a muscle relaxant test (TOF), transcranial electrical stimulation of the motor cortex (TCeMEP), control of the approach to the nerve (N. Proxy), correct placement of the pedicle screw (Screw Integrity), and EMG recording of the electromyogram. The accuracy of the screw placement was assessed by the Gerzbien method, and the presence of neurological disorders was tested by the Frenkel scale. The effect of inhalation anesthetic (sevoran) on motor evoked potentials was monitored by regulating its delivery, and the dependence on the age of patients was evaluated.
RESULTS: The average age of patients was 7.7 4.5 years, and the TOF value was 80.5 17%. In 41 patients, the N. Proxy test was unremarkable, while in one patient, the 812 mA value did not require a change in the trajectory of the screws. From the beginning of sevoran and intraoperatively, motor evoked potentials from all tested muscles were recorded in 54.8% of patients; in children over 8 years old, this was observed in 92.8%, in children under 8 years old in 35.7% of cases in their age groups. In other patients, motor evoked potentials were most often not recorded from the muscles of the thigh and lower leg after sevoran administration. In children over 8 years old in 7.2%, under 8 years old in 83.3% of patients; Interestingly, in 7.2% of patients who are under 8 years of age, motor evoked potentials were not initially recorded from any muscle. Withdrawal of sevorane in 30.9% of patients allowed intraoperative motor evoked potentials to be obtained from all tested muscles in 100% of cases. For adequate management of anesthesia, 5 patients (50%) 14 years old and one patient 6 years old (5.6%) did not receive sevoran, and motor evoked potentials were recorded from the abdominal muscles. This allowed to assess the conduction only at the thoracic level and are required increased vigilance of surgeons when carrying out any corrective manipulations.
CONCLUSIONS: Intraoperative neurophysiological monitoring with dorsal hemivertebra resection is an effective method that allows controlling the neurological complications during manipulations on the spine.
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Pacreu S, Vilà E, Moltó L, Fernández‐Candil J, Fort B, Lin Y, León A. Effect of dexmedetomidine on evoked-potential monitoring in patients undergoing brain stem and supratentorial cranial surgery. Acta Anaesthesiol Scand 2021; 65:1043-1053. [PMID: 33884609 DOI: 10.1111/aas.13835] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/29/2021] [Accepted: 04/03/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Dexmedetomidine is used as adjuvant in total intravenous anaesthesia (TIVA), but there have been few studies concerning its effect on intraoperative neurophysiological monitoring (IONM) during cranial surgery. Our aim was to study the effect of dexmedetomidine on IONM in patients undergoing brain stem and supratentorial cranial surgery. METHODS Two prospective, randomized, double-blind substudies were conducted. In substudy 1, during TIVA with an infusion of propofol and remifentanil, 10 patients received saline solution (SS) (PR group) and another 10 (PRD group) received dexmedetomidine (0.5 mcg/kg/h). Total dosage of propofol and remifentanil, intensity, latency and amplitude of motor-evoked potentials following transcranial electrical stimulation (tcMEPs) as well as somatosensory-evoked potentials (SSEP) were recorded at baseline, 15, 30, 45 minutes, and at the end of surgery. In order to identify differences in the same patient after dexmedetomidine administration, we designed substudy 2 with 20 new patients randomized to two groups. After 30 minutes with TIVA, 10 patients received dexmedetomidine (0.5 mcg/kg/h) and 10 patients SS. The same variables were recorded. RESULTS In substudy 1, propofol requirements were significantly lower (P = .004) and tcMEP intensity at the end of surgery was significantly higher in PRD group, but no statistically significant differences were observed for remifentanil requirements, SSEP and tcMEP latency or amplitude. In substudy 2, no differences in any of the variables were identified. CONCLUSIONS The administration of dexmedetomidine at a dosage of 0.5 mg/kg/h may reduce propofol requirements and adversely affect some neuromonitoring variables. However, it can be an alternative on IONM during cranial surgeries. REDEX EudraCT: 2014-000962-23.
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Affiliation(s)
- Susana Pacreu
- Anaesthesiology, Reanimation, and Pain Therapy Unit Parc de Salut MARInstitut Mar d'Investigacions Mèdiques (IMIM) Barcelona Spain
| | - Esther Vilà
- Anaesthesiology, Reanimation, and Pain Therapy Unit Parc de Salut MARInstitut Mar d'Investigacions Mèdiques (IMIM) Barcelona Spain
| | - Luis Moltó
- Anaesthesiology, Reanimation, and Pain Therapy Unit Parc de Salut MARInstitut Mar d'Investigacions Mèdiques (IMIM) Barcelona Spain
| | - Juan Fernández‐Candil
- Anaesthesiology, Reanimation, and Pain Therapy Unit Parc de Salut MARInstitut Mar d'Investigacions Mèdiques (IMIM) Barcelona Spain
| | - Beatriz Fort
- Anaesthesiology, Reanimation, and Pain Therapy Unit Parc de Salut MARInstitut Mar d'Investigacions Mèdiques (IMIM) Barcelona Spain
| | - Yiyang Lin
- Neurology Unit Neurophysiologic Section Parc de Salut MAR Barcelona Spain
| | - Alba León
- Neurology Unit Neurophysiologic Section Parc de Salut MAR Barcelona Spain
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Sigmundsson F, Kuchalik J, Fadl S, Holy M, Joelson A. The unique challenges of Brugada syndrome in spinal deformity surgery. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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14
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Selby LV, Fernandez-Bustamante A, Ejaz A, Gleisner A, Pawlik TM, Douin DJ. Association Between Anesthesia Delivered During Tumor Resection and Cancer Survival: a Systematic Review of a Mixed Picture with Constant Themes. J Gastrointest Surg 2021; 25:2129-2141. [PMID: 34100251 DOI: 10.1007/s11605-021-05037-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/04/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgery is required for cure of most solid tumors, and general anesthesia is required for most cancer surgery. The vast majority of cancer surgery is facilitated by general anesthesia using volatile inhalational agents such as isoflurane and sevoflurane. Only recently have the immunologic and oncologic effect of inhalational agents, and their alternative, propofol-based total intravenous anesthesia (TIVA), come under investigation. METHODS Between January 2019 and June 2020, English language articles on PubMed were searched for the keywords "Propofol" "TIVA" or "IV anesthesia" and either "cancer surgery" or "surgical oncology." Duplicates were removes, manuscripts classified as either in vitro, animal, translational, or clinical studies, and their results summarized within these categories. RESULTS In-vitro and translational data suggest that inhalational anesthetics are potent immunosuppressive and tumorigenic agents that promote metastasis, while propofol is anti-inflammatory, anti-tumorigenic, and prevents metastasis development. Clinically there is a recurring association, based largely on retrospective, single institution series, that TIVA is associated with significant improvements in disease-free interval and overall survival in a number of, but not all, solid tumors. The longer the surgery is, the more intense the surgical trauma is, the more aggressive the malignancy is, and the higher likelihood of an association is. DISCUSSION Prospective randomized trials, coupled with basic science and translational studies, are needed to further define this association.
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Affiliation(s)
- Luke V Selby
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA.
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15
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Asimakidou E, Abut PA, Raabe A, Seidel K. Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review. Cancers (Basel) 2021; 13:2803. [PMID: 34199853 PMCID: PMC8200078 DOI: 10.3390/cancers13112803] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/31/2022] Open
Abstract
During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Pablo Alvarez Abut
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
- Department of Neurosurgery, Clínica 25 de Mayo, 7600 Mar del Plata, Argentina
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
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16
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Gisi G, Boran OF. Anesthesia management during meningomyelocele repair alongside motor-evoked potentials in a newborn and a small infant. Childs Nerv Syst 2020; 36:3053-3057. [PMID: 32221655 DOI: 10.1007/s00381-020-04579-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 03/12/2020] [Indexed: 11/26/2022]
Abstract
Intraoperative neuromonitoring has become an increasingly commonly applied practice during surgical operations for preventing formation of neurological damage. Although it has been used on adults for a long time, the benefits and techniques of applying it in small children are not clear. We applied two different anesthesia protocols during meningomyelocele repair alongside motor-evoked potentials in a newborn and a small infant. We discussed our anesthesia management method and the effects of anesthesia on intraoperative neuromonitoring in our two very young cases in only one of which we obtained significant records.
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Affiliation(s)
- Gokce Gisi
- Faculty of Medicine, Department of Anesthesiology and Reanimation, Sutcu Imam University, Kahramanmaras, Turkey.
| | - Omer Faruk Boran
- Faculty of Medicine, Department of Anesthesiology and Reanimation, Sutcu Imam University, Kahramanmaras, Turkey
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17
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Neurophysiological monitoring of spinal cord function during spinal deformity surgery: 2020 SRS neuromonitoring information statement. Spine Deform 2020; 8:591-596. [PMID: 32451978 DOI: 10.1007/s43390-020-00140-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/11/2020] [Indexed: 12/28/2022]
Abstract
The Scoliosis Research Society has developed an updated information statement on intraoperative neurophysiological monitoring of spinal cord function during spinal deformity surgery. The statement reviews the risks of spinal cord compromise associated with spinal deformity surgery; the statement then discusses the various modalities that are available to monitor the spinal cord, including somatosensory-evoked potentials, motor-evoked potentials, and electromyographic (EMG) options. Anesthesia considerations, the importance of a thoughtful team approach to successful monitoring, and the utility of checklists are also discussed. Finally, the statement expresses the opinion that utilization of intraoperative neurophysiological spinal cord monitoring in spinal deformity surgery is the standard of care when the spinal cord is at risk.
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18
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Busch DR, Lin W, Cai C, Cutrone A, Tatka J, Kovarovic BJ, Yodh AG, Floyd TF, Barsi J. Multi-Site Optical Monitoring of Spinal Cord Ischemia during Spine Distraction. J Neurotrauma 2020; 37:2014-2022. [PMID: 32458719 DOI: 10.1089/neu.2020.7012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Optimal surgical management of spine trauma will restore blood flow to the ischemic spinal cord. However, spine stabilization may also further exacerbate injury by inducing ischemia. Current electrophysiological technology is not capable of detecting acute changes in spinal cord blood flow or localizing ischemia. Further, alerts are delayed and unreliable. We developed an epidural optical device capable of directly measuring and immediately detecting changes in spinal cord blood flow using diffuse correlation spectroscopy (DCS). Herein we test the hypothesis that our device can continuously monitor blood flow during spine distraction. Additionally, we demonstrate the ability of our device to monitor multiple sites along the spinal cord and axially resolve changes in spinal cord blood flow. DCS-measured blood flow in the spinal cord was monitored at up to three spatial locations (cranial to, at, and caudal to the distraction site) during surgical distraction in a sheep model. Distraction was halted at 50% of baseline blood flow at the distraction site. We were able to monitor blood flow with DCS in multiple regions of the spinal cord simultaneously at ∼1 Hz. The distraction site had a greater decrement in flow than sites cranial to the injury (median -40 vs. -7%,). This pilot study demonstrated high temporal resolution and the capacity to axially resolve changes in spinal cord blood flow at and remote from the site of distraction. These early results suggest that this technology may assist in the surgical management of spine trauma and in corrective surgery of the spine.
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Affiliation(s)
- David R Busch
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, Texas, USA
| | - Wei Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Chunyu Cai
- Department of Pathology, University of Texas Southwestern, Dallas, Texas, USA
| | - Alissa Cutrone
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee, USA
| | - Jakub Tatka
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Brandon J Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas F Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Radiology, University of Texas Southwestern, Dallas, Texas, USA
| | - James Barsi
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, New York, USA
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19
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Preethi J, Bidkar PU, Cherian A, Dey A, Srinivasan S, Adinarayanan S, Ramesh AS. Comparison of total intravenous anesthesia vs. inhalational anesthesia on brain relaxation, intracranial pressure, and hemodynamics in patients with acute subdural hematoma undergoing emergency craniotomy: a randomized control trial. Eur J Trauma Emerg Surg 2019; 47:831-837. [PMID: 31664468 DOI: 10.1007/s00068-019-01249-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/15/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The major goals of anesthesia in patients with severe traumatic brain injury (TBI) are-maintenance of hemodynamic stability, optimal cerebral perfusion pressure, lowering of ICP, and providing a relaxed brain. Although both inhalational and intravenous anesthetics are commonly employed, there is no clear consensus on which technique is better for the anesthetic management of severe TBI. METHODS Ninety patients, 18-60 years of age, of either gender, with GCS < 8, posted for emergency evacuation of acute subdural hematoma were enrolled in this prospective trial, and they were randomized into two groups of 45 each. Patients in group P received propofol infusion at 100-150 mg/kg/min for maintenance of anesthesia and those in group I received ≤ 1 MAC of isoflurane. Hemodynamic parameters were monitored in all patients. ICP was measured at the dural opening and brain relaxation was assessed by the operating surgeon on a four-point scale (1-perfectly relaxed, 2-satisfactorily relaxed, 3-firm brain, and 4-bulging brain) at the dural opening. It was reassessed at dural closure. RESULTS Brain relaxation, both at dural opening and closure, was significantly better in patients who received propofol compared to those who received isoflurane. ICP was significantly lower (25.47 ± 3.72 mmHg vs. 23.41 ± 3.97 mmHg) in the TIVA group. Hemodynamic parameters were well maintained in both groups. CONCLUSIONS In patients with severe TBI, total intravenous (Propofol)-based anesthesia provided better brain relaxation, maintained a lower ICP along with better hemodynamics when compared to inhalational anesthesia. CLINICAL TRIAL REGISTRATION Clinical trials registry (NCT03146104).
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Affiliation(s)
- Jayakumar Preethi
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Prasanna Udupi Bidkar
- In Charge Neuroanaesthesiology Division, Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India.
| | - Anusha Cherian
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Ankita Dey
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Swaminathan Srinivasan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Sethuramachandran Adinarayanan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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20
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Cha GD, Kang D, Lee J, Kim D. Bioresorbable Electronic Implants: History, Materials, Fabrication, Devices, and Clinical Applications. Adv Healthc Mater 2019; 8:e1801660. [PMID: 30957984 DOI: 10.1002/adhm.201801660] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/14/2019] [Indexed: 12/13/2022]
Abstract
Medical implants, either passive implants for structural support or implantable devices with active electronics, have been widely used for the diagnosis and treatment of various diseases and clinical issues. These implants offer various functions, including mechanical support of biological structures in orthopedic and dental applications, continuous electrophysiological monitoring and feedback of electrical stimulation in neuronal and cardiac applications, and controlled drug delivery while maintaining arterial structure in drug-eluting stents. Although these implants exhibit long-term biocompatibility, surgery for their retrieval is often required, which imposes physical, biological, and economical burdens on the patients. Therefore, as an alternative to such secondary surgeries, bioresorbable implants that disappear after a certain period of time inside the body, including bioresorbable active electronics, have been highlighted recently. This review first discusses the historical background of medical implants and briefly define related terminology. Representative examples of non-degradable medical implants for passive structural support and/or for diagnosis and therapy with active electronics are also provided. Then, recent progress in bioresorbable active implants composed of biosignal sensors, actuators for therapeutics, wireless power supply components, and their integrated systems are reviewed. Finally, clinical applications of these bioresorbable electronic implants are exemplified with brief conclusion and future outlook.
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Affiliation(s)
- Gi Doo Cha
- Center for Nanoparticle ResearchInstitute for Basic Science (IBS) Seoul 08826 Republic of Korea
- School of Chemical and Biological EngineeringInstitute of Chemical ProcessesSeoul National University (SNU) Seoul 08826 Republic of Korea
| | - Dayoung Kang
- Center for Nanoparticle ResearchInstitute for Basic Science (IBS) Seoul 08826 Republic of Korea
- School of Chemical and Biological EngineeringInstitute of Chemical ProcessesSeoul National University (SNU) Seoul 08826 Republic of Korea
| | - Jongha Lee
- Center for Nanoparticle ResearchInstitute for Basic Science (IBS) Seoul 08826 Republic of Korea
- School of Chemical and Biological EngineeringInstitute of Chemical ProcessesSeoul National University (SNU) Seoul 08826 Republic of Korea
| | - Dae‐Hyeong Kim
- Center for Nanoparticle ResearchInstitute for Basic Science (IBS) Seoul 08826 Republic of Korea
- School of Chemical and Biological EngineeringInstitute of Chemical ProcessesSeoul National University (SNU) Seoul 08826 Republic of Korea
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21
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Lee HC, Ryu HG, Kim HJ, Park Y, Yoon SB, Yang SM, Oh HW, Jung CW. Excessive remifentanil during total intravenous anesthesia is associated with increased risk of pain after robotic thyroid surgery. PLoS One 2018; 13:e0209078. [PMID: 30550587 PMCID: PMC6294434 DOI: 10.1371/journal.pone.0209078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/29/2018] [Indexed: 01/16/2023] Open
Abstract
The widespread use of remifentanil during total intravenous anesthesia (TIVA) has raised concerns about the risk of postoperative remifentanil-associated pain. Although a recent meta-analysis suggests that remifentanil-associated pain is unlikely to occur in patients with TIVA because of the protective effect of co-administered propofol, the evidence is not conclusive. We retrospectively assessed 635 patients who received robotic thyroid surgery under TIVA to evaluate the risk of remifentanil-associated pain. Postoperative pain was evaluated using 11-point numeric rating scale (NRS). Time dependent Cox proportional hazards regression analysis was used to determine the risk factors of treatment-requiring pain (NRS > 4) during the first 48 postoperative hours. Postoperative pain rapidly decreased, and treatment-requiring pain remained in 12.8% (81 out of 635) of patients at 48 hours postoperatively. After adjusting for the time-dependent analgesic consumption, intraoperative use of remifentanil > 0.2 mcg/kg/min was a positive predictor of postoperative pain with a hazard ratio of 1.296 (95% C.I., 1.014–1.656, P = 0.039) during 48 hours after surgery. In conclusion, excessive use of remifentanil during TIVA was associated with increased risk of pain after robotic thyroid surgery. Prospective trials are required to confirm these results and determine whether decreasing remifentanil consumption below the threshold can reduce postoperative pain.
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Affiliation(s)
- Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho-Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Jun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoonsang Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seong Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Won Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail:
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22
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Yoshihara H, Pivec R, Naam A. Positioning-Related Neuromonitoring Change During Anterior Cervical Discectomy and Fusion. World Neurosurg 2018; 117:238-241. [DOI: 10.1016/j.wneu.2018.06.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/28/2022]
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23
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Busch DR, Davis J, Kogler A, Galler RM, Parthasarathy AB, Yodh AG, Floyd TF. Laser safety in fiber-optic monitoring of spinal cord hemodynamics: a preclinical evaluation. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-9. [PMID: 29923371 PMCID: PMC8357330 DOI: 10.1117/1.jbo.23.6.065003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/30/2018] [Indexed: 05/02/2023]
Abstract
The prevention and treatment of spinal cord injury are focused upon the maintenance of spinal cord blood flow, yet no technology exists to monitor spinal cord ischemia. We recently demonstrated continuous monitoring of spinal cord ischemia with diffuse correlation and optical spectroscopies using an optical probe. Prior to clinical translation of this technology, it is critically important to demonstrate the safety profile of spinal cord exposure to the required light. To our knowledge, this is the first report of in situ safety testing of such a monitor. We expose the spinal cord to laser light utilizing a custom fiber-optic epidural probe in a survival surgery model (11 adult Dorset sheep). We compare the tissue illumination from our instrument with the American National Standards Institute maximum permissible exposures. We experimentally evaluate neurological and pathological outcomes of the irradiated sheep associated with prolonged exposure to the laser source and evaluate heating in ex vivo spinal cord samples. Spinal cord tissue was exposed to light levels at ∼18 × the maximum permissible exposure for the eye and ∼ ( 1 / 3 ) × for the skin. Multidisciplinary testing revealed no functional neurological sequelae, histopathologic evidence of laser-related injury to the spinal cord, or significant temperature changes in ex vivo samples. Low tissue irradiance and the lack of neurological, pathological, and temperature changes upon prolonged exposure to the laser source offer evidence that spinal cord tissues can be monitored safely with near-infrared optical probes placed within the epidural space.
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Affiliation(s)
- David R. Busch
- University of Texas Southwestern, Department of Anesthesiology and Pain Management, Dallas Texas, United States
- University of Texas Southwestern, Department of Neurology and Neurotherapeutics, Dallas, Texas, United States
- University of Pennsylvania, Department of Physics and Astronomy, Philadelphia, Pennsylvania, United States
- Address all correspondence to: David R. Busch, E-mail: ; Thomas F. Floyd, E-mail:
| | - James Davis
- Stony Brook University Medical Center, Department of Pathology, Stony Brook, New York, United States
| | - Angela Kogler
- Stony Brook University Medical Center, Department of Anesthesiology, Stony Brook, New York, United States
- Stony Brook University, Department of Biomedical Engineering, Stony Brook, New York, United States
| | - Robert M. Galler
- Stony Brook University Medical Center, Department of Neurosurgery, Stony Brook, New York, United States
| | - Ashwin B. Parthasarathy
- University of South Florida, Department of Electrical Engineering, Tampa, Florida, United States
| | - Arjun G. Yodh
- University of Pennsylvania, Department of Physics and Astronomy, Philadelphia, Pennsylvania, United States
| | - Thomas F. Floyd
- University of Texas Southwestern, Department of Anesthesiology and Pain Management, Dallas Texas, United States
- Address all correspondence to: David R. Busch, E-mail: ; Thomas F. Floyd, E-mail:
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The Correlation Between Recordable MEPs and Motor Function During Spinal Surgery for Resection of Thoracic Spinal Cord Tumor. J Neurosurg Anesthesiol 2018; 30:39-43. [DOI: 10.1097/ana.0000000000000386] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
STUDY DESIGN Review of techniques and description of institutional clinical experience. OBJECTIVE To provide a historical review and description of key neuromonitoring concepts, focusing on neurogenic motor-evoked potentials and descending neurogenic evoked potentials, and to review the authors' experience with neuromonitoring techniques in children and adults undergoing spinal deformity surgery. SUMMARY OF BACKGROUND DATA The original form of neuromonitoring, the Stagnara wake-up test, remains the "gold standard" for detecting true neurological deficits. Multiple newer modalities involving cortical and muscular monitoring, such as somatosensory evoked potentials and motor evoked potentials, have been developed and are widely used. Descending and neurogenic evoked potentials are becoming more common for neuromonitoring in patients undergoing spinal deformity surgery. METHODS A PubMed search for literature related to "neuromonitoring" was performed, and recent, as well as historical, articles were reviewed. Clinical experience regarding the use of neuromonitoring in adult and pediatric spinal deformity surgery was obtained from institutional experts. RESULTS Although not regularly used, the Stagnara wake-up test remains the gold standard for detecting neurological injury. Somatosensory evoked potentials measure signals transmitted from the periphery to the cortex and have historically been widely used but are limited by delay, poor localization, and the inability to detect damage to motor tracts. Motor evoked potentials continue to be used widely and measure muscular activity after cortical stimulation, but they are difficult to interpret in patients with underlying motor disorders and cannot be continuously monitored. Newer techniques such as descending neurogenic evoked potentials and neurogenic motor evoked potentials monitoring are used at some high-volume centers. CONCLUSIONS Familiarity with the history of neuromonitoring in spinal deformity surgery and an understanding of the physiological systems used for neuromonitoring provide a framework from which spine surgeons can select appropriate monitoring for their patients.
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Errando CL, Blanco T, Díaz-Cambronero Ó. Repeated sugammadex reversal of muscle relaxation during lumbar spine surgery with intraoperative neurophysiological multimodal monitoring. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:533-538. [PMID: 27216713 DOI: 10.1016/j.redar.2016.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/11/2016] [Accepted: 03/16/2016] [Indexed: 06/05/2023]
Abstract
Intraoperative neurophysiological monitoring during spine surgery is usually acomplished avoiding muscle relaxants. A case of intraoperative sugammadex partial reversal of the neuromuscular blockade allowing adequate monitoring during spine surgery is presented. A 38 year-old man was scheduled for discectomy and vertebral arthrodesis throughout anterior and posterior approaches. Anesthesia consisted of total intravenous anesthesia plus rocuronium. Intraoperatively monitoring was needed, and the muscle relaxant reverted twice with low dose sugammadex in order to obtain adequate responses. The doses of sugammadex used were conservatively selected (0.1mg/kg boluses increases, total dose needed 0.4mg/kg). Both motor evoqued potentials, and electromyographic responses were deemed adequate by the neurophysiologist. If muscle relaxation was needed in the context described, this approach could be useful to prevent neurological sequelae. This is the first study using very low dose sugammadex to reverse rocuronium intraoperatively and to re-establish the neuromuscular blockade.
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Affiliation(s)
- C L Errando
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
| | - T Blanco
- Servicio de Neurofisiología Clínica, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Ó Díaz-Cambronero
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Politécnico La Fe, Valencia, Spain
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27
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The contribution of neurophysiology in the diagnosis and management of cervical spondylotic myelopathy: a review. Spinal Cord 2016; 54:756-766. [PMID: 27241448 DOI: 10.1038/sc.2016.82] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 03/24/2016] [Accepted: 04/06/2016] [Indexed: 12/11/2022]
Abstract
STUDY DESIGN Topical review of the literature. OBJECTIVE The objective of this review article was to assess indications and usefulness of various neurophysiological techniques in diagnosis and management of cervical spondylogenic myelopathy (CSM). METHODS The MEDLINE, accessed by Pubmed and EMBASE electronic databases, was searched using the medical subject headings: 'compressive myelopathy', 'cervical spondylotic myelopathy (CSM)', 'cervical spondylogenic myelopathy', 'motor evoked potentials (MEPs)', 'transcranial magnetic stimulation', 'somatosensory evoked potentials (SEPs)', 'electromyography (EMG)', 'nerve conduction studies (NCS)' and 'cutaneous silent period (CSP)'. RESULTS SEPs and MEPs recording can usefully supplement clinical examination and neuroimaging findings in assessing the spinal cord injury level and severity. Segmental cervical cord dysfunction can be revealed by an abnormal spinal N13 response, whereas the P14 potential is a reliable marker of dorsal column impairment. MEPs may also help in the differential diagnosis between spinal cord compression and neurodegenerative disorders. SEPs and MEPs are also useful in follow-up evaluation of sensory and motor function during surgical treatment and rehabilitation. EMG and NCS improve the sensitivity of cervical radiculopathy detection and may help rule out peripheral nerve problems that can cause symptoms that are similar to those of CSM. CSP also shows a high sensitivity for detecting CSM. CONCLUSION Neuroimaging, especially magnetic resonance imaging, represents the procedure of choice for the diagnosis of CSM, but a correct interpretation of morphological findings can be achieved only if they are correlated with functional data. The studies reported in this review highlight the crucial role of the electrophysiological studies in diagnosis and management of CSM.
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Singh H, Vogel RW, Lober RM, Doan AT, Matsumoto CI, Kenning TJ, Evans JJ. Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide. SCIENTIFICA 2016; 2016:1751245. [PMID: 27293965 PMCID: PMC4886091 DOI: 10.1155/2016/1751245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/04/2016] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route.
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Affiliation(s)
- Harminder Singh
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Richard W. Vogel
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Robert M. Lober
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Adam T. Doan
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Craig I. Matsumoto
- Sentient Medical Systems, 11011 McCormick Road, Suite 200, Hunt Valley, MD 21031, USA
| | - Tyler J. Kenning
- Department of Neurosurgery, Albany Medical Center, Physicians Pavilion, First Floor, 47 New Scotland Avenue, MC 10, Albany, NY 12208, USA
| | - James J. Evans
- Thomas Jefferson University Hospital, Department of Neurosurgery, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA
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Howick J, Cohen BA, McCulloch P, Thompson M, Skinner SA. Foundations for evidence-based intraoperative neurophysiological monitoring. Clin Neurophysiol 2016; 127:81-90. [DOI: 10.1016/j.clinph.2015.05.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 04/09/2015] [Accepted: 05/08/2015] [Indexed: 10/23/2022]
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Vasculopathy, Ischemia, and the Lateral Lumbar Interbody Fusion Surgery: Report of Three Cases. J Clin Neurophysiol 2015; 32:e41-5. [PMID: 26629762 DOI: 10.1097/wnp.0000000000000136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Multi-modal neurophysiologic monitoring consisting of triggered and spontaneous electromyography and transcranial motor-evoked potentials may detect and prevent both acute and slow developing mechanical and vascular nerve injuries in lateral lumbar interbody fusion (LLIF) surgery. In case report 1, a marked reduction in the transcranial motor-evoked potentials on the operative side alerted to a 28% decrease in mean arterial blood pressure in a 54-year-old woman during an L3-4, L4-5 LLIF. After hemodynamic stability was regained, transcranial motor-evoked potentials returned to baseline and the patient suffered no postoperative complications. In case report 2, a peroneal nerve train-of-four stimulation threshold of 95 mA portended the potential for a triggered electromyography false negative in a 70-year-old woman with type 2 diabetes, peripheral neuropathy, and body mass index of 30.7 kg/m undergoing an L3-4, L4-5 LLIF. Higher triggered electromyography threshold values were applied to this patient's relatively quiescent triggered electromyography and the patient suffered no postoperative complications. In case report 3, the loss of right quadriceps motor-evoked potentials detected a retractor related nerve injury in a 59-year-old man undergoing an L4-5 LLIF. The surgery was aborted, but the patient suffered persistent postoperative right leg paresthesia and weakness. These reports highlight the sensitivity of peripheral nerve elements to ischemia (particularly in the presence of vascular risk factors) during the LLIF procedure and the need for dynamic multi-modal intraoperative monitoring.
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Jain A, Khanna AJ, Hassanzadeh H. Management of intraoperative neuromonitoring signal loss. ACTA ACUST UNITED AC 2015. [DOI: 10.1053/j.semss.2015.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Zanatta P, Linassi F, Mazzarolo AP, Aricò M, Bosco E, Bendini M, Sorbara C, Ori C, Carron M, Scarpa B. Pain-related Somato Sensory Evoked Potentials: a potential new tool to improve the prognostic prediction of coma after cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:403. [PMID: 26573633 PMCID: PMC4647335 DOI: 10.1186/s13054-015-1119-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/28/2015] [Indexed: 11/23/2022]
Abstract
Introduction Early prediction of a good outcome in comatose patients after cardiac arrest still remains an unsolved problem. The main aim of the present study was to examine the accuracy of middle-latency SSEP triggered by a painful electrical stimulation on median nerves to predict a favorable outcome. Methods No- and low-flow times, pupillary reflex, Glasgow motor score and biochemical data were evaluated at ICU admission. The following were considered within 72 h of cardiac arrest: highest creatinine value, hyperthermia occurrence, EEG, SSEP at low- (10 mA) and high-intensity (50 mA) stimulation, and blood pressure reactivity to 50 mA. Intensive care treatments were also considered. Data were compared to survival, consciousness recovery and 6-month CPC (Cerebral Performance Category). Results Pupillary reflex and EEG were statistically significant in predicting survival; the absence of blood pressure reactivity seems to predict brain death within 7 days of cardiac arrest. Middle- and short-latency SSEP were statistically significant in predicting consciousness recovery, and middle-latency SSEP was statistically significant in predicting 6-month CPC outcome. The prognostic capability of 50 mA middle-latency-SSEP was demonstrated to occur earlier than that of EEG reactivity. Conclusions Neurophysiological evaluation constitutes the key to early information about the neurological prognostication of postanoxic coma. In particular, the presence of 50 mA middle-latency SSEP seems to be an early and reliable predictor of good neurological outcome, and its absence constitutes a marker of poor prognosis. Moreover, the absence 50 mA blood pressure reactivity seems to identify patients evolving towards the brain death.
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Affiliation(s)
- Paolo Zanatta
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Federico Linassi
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Anna Paola Mazzarolo
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Maria Aricò
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Enrico Bosco
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Matteo Bendini
- Unit of Neuroradiology, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Carlo Sorbara
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Carlo Ori
- Department of Anesthesia and Intensive Care, Padova University Hospital, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
| | - Michele Carron
- Department of Anesthesia and Intensive Care, Padova University Hospital, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
| | - Bruno Scarpa
- Department of Statistical Sciences, Padova University, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
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Park JH, Hyun SJ. Intraoperative neurophysiological monitoring in spinal surgery. World J Clin Cases 2015; 3:765-773. [PMID: 26380823 PMCID: PMC4568525 DOI: 10.12998/wjcc.v3.i9.765] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/30/2014] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
Recently, many surgeons have been using intraoperative neurophysiological monitoring (IOM) in spinal surgery to reduce the incidence of postoperative neurological complications, including level of the spinal cord, cauda equina and nerve root. Several established technologies are available and combined motor and somatosensory evoked potentials are considered mandatory for practical and successful IOM. Spinal cord evoked potentials are elicited compound potentials recorded over the spinal cord. Electrical stimulation is provoked on the dorsal spinal cord from an epidural electrode. Somatosensory evoked potentials assess the functional integrity of sensory pathways from the peripheral nerve through the dorsal column and to the sensory cortex. For identification of the physiological midline, the dorsal column mapping technique can be used. It is helpful for reducing the postoperative morbidity associated with dorsal column dysfunction when distortion of the normal spinal cord anatomy caused by an intramedullary cord lesion results in confusion in localizing the midline for the myelotomy. Motor evoked potentials (MEPs) consist of spinal, neurogenic and muscle MEPs. MEPs allow selective and specific assessment of the functional integrity of descending motor pathways, from the motor cortex to peripheral muscles. Spinal surgeons should understand the concept of the monitoring techniques and interpret monitoring records adequately to use IOM for the decision making during the surgery for safe surgery and a favorable surgical outcome.
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Rozet I, Metzner J, Brown M, Treggiari MM, Slimp JC, Kinney G, Sharma D, Lee LA, Vavilala MS. Dexmedetomidine Does Not Affect Evoked Potentials During Spine Surgery. Anesth Analg 2015; 121:492-501. [DOI: 10.1213/ane.0000000000000840] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Total intravenous anaesthesia versus inhaled anaesthetics in neurosurgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Anestesia total intravenosa versus anestésicos inhalados en neurocirugía. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Total intravenous anaesthesia versus inhaled anaesthetics in neurosurgery☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543001-00003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Effect of mild hypothermic cardiopulmonary bypass on the amplitude of somatosensory-evoked potentials. J Neurosurg Anesthesiol 2014; 26:161-6. [PMID: 24492514 DOI: 10.1097/ana.0000000000000016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Several neurophysiological techniques are used to intraoperatively assess cerebral functioning during surgery and intensive care, but the introduction of hypothermia as a means of intraoperative neuroprotection has brought their reliability into question. The present study aimed to evaluate the effect of mild hypothermia on somatosensory-evoked potentials' (SSEPs) amplitude and latency in a cohort of cardiopulmonary bypass (CPB) patients as the temperature reached the steady-state. MATERIALS AND METHODS The amplitude and latency of 4 different SSEP signals--N9, N13, P14/N18 interpeak, and N20/P25--were evaluated retrospectively in 84 patients undergoing CPB during normothermic (36°C±0.43°C) and mild hypothermic (32°C±1.38°C) conditions. SSEPs were recorded in normothermia immediately after the induction of anesthesia and in hypothermia as the temperature reached its steady-state, specifically, when the nasopharyngeal temperature was equivalent to the rectal temperature (±0.5°C). A paired-samples t test was performed for each SSEP to test the differences in latencies and amplitudes between normothermic and hypothermic conditions. RESULTS Compared with normothermia, hypothermia not only significantly increased the latency of all SSEPs, N9 (P<0.001), N13 (P<0.001), P14/N18 (P<0.001), and N20/P25 (P<0.001), but also the amplitude of N9 (P<0.001) and N20/P25 (P<0.001). CONCLUSIONS The increased amplitude in particularly of cortical SSEPs (N20/P25), detected specifically during steady-state hypothermia, seems to support the clinical utility of this methodology in monitoring the brain function not only during cardiac surgery with CPB, but also in other settings like therapeutic hypothermia procedures in an intensive care unit.
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Chambers KJ, Pearse A, Coveney J, Rogers S, Kamani D, Sritharan N, Randolph GW. Respiratory Variation Predicts Optimal Endotracheal Tube Placement for Intra-operative Nerve Monitoring in Thyroid and Parathyroid Surgery. World J Surg 2014; 39:393-9. [DOI: 10.1007/s00268-014-2820-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Epstein NE. What you need to know about ossification of the posterior longitudinal ligament to optimize cervical spine surgery: A review. Surg Neurol Int 2014; 5:S93-S118. [PMID: 24843819 PMCID: PMC4023010 DOI: 10.4103/2152-7806.130696] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/19/2013] [Indexed: 11/04/2022] Open
Abstract
What are the risks, benefits, alternatives, and pitfalls for operating on cervical ossification of the posterior longitudinal ligament (OPLL)? To successfully diagnose OPLL, it is important to obtain Magnetic Resonance Images (MR). These studies, particularly the T2 weighted images, provide the best soft-tissue documentation of cord/root compression and intrinsic cord abnormalities (e.g. edema vs. myelomalacia) on sagittal, axial, and coronal views. Obtaining Computed Tomographic (CT) scans is also critical as they best demonstrate early OPLL, or hypertrophied posterior longitudinal ligament (HPLL: hypo-isodense with punctate ossification) or classic (frankly ossified) OPLL (hyperdense). Furthermore, CT scans reveal the "single layer" and "double layer" signs indicative of OPLL penetrating the dura. Documenting the full extent of OPLL with both MR and CT dictates whether anterior, posterior, or circumferential surgery is warranted. An adequate cervical lordosis allows for posterior cervical approaches (e.g. lamionplasty, laminectomy/fusion), which may facilitate addressing multiple levels while avoiding the risks of anterior procedures. However, without lordosis and with significant kyphosis, anterior surgery may be indicated. Rarely, this requires single/multilevel anterior cervical diskectomy/fusion (ACDF), as this approach typically fails to address retrovertebral OPLL; single or multilevel corpectomies are usually warranted. In short, successful OPLL surgery relies on careful patient selection (e.g. assess comorbidities), accurate MR/CT documentation of OPLL, and limiting the pros, cons, and complications of these complex procedures by choosing the optimal surgical approach. Performing OPLL surgery requires stringent anesthetic (awake intubation/positioning) and also the following intraoperative monitoring protocols: Somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), and electromyography (EMG).
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Affiliation(s)
- Nancy E Epstein
- Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, N.Y. 11051, USA
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Mesquita RC, D’Souza A, Bilfinger TV, Galler RM, Emanuel A, Schenkel SS, Yodh AG, Floyd TF. Optical monitoring and detection of spinal cord ischemia. PLoS One 2013; 8:e83370. [PMID: 24358279 PMCID: PMC3865183 DOI: 10.1371/journal.pone.0083370] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 11/01/2013] [Indexed: 12/14/2022] Open
Abstract
Spinal cord ischemia can lead to paralysis or paraparesis, but if detected early it may be amenable to treatment. Current methods use evoked potentials for detection of spinal cord ischemia, a decades old technology whose warning signs are indirect and significantly delayed from the onset of ischemia. Here we introduce and demonstrate a prototype fiber optic device that directly measures spinal cord blood flow and oxygenation. This technical advance in neurological monitoring promises a new standard of care for detection of spinal cord ischemia and the opportunity for early intervention. We demonstrate the probe in an adult Dorset sheep model. Both open and percutaneous approaches were evaluated during pharmacologic, physiological, and mechanical interventions designed to induce variations in spinal cord blood flow and oxygenation. The induced variations were rapidly and reproducibly detected, demonstrating direct measurement of spinal cord ischemia in real-time. In the future, this form of hemodynamic spinal cord diagnosis could significantly improve monitoring and management in a broad range of patients, including those undergoing thoracic and abdominal aortic revascularization, spine stabilization procedures for scoliosis and trauma, spinal cord tumor resection, and those requiring management of spinal cord injury in intensive care settings.
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Affiliation(s)
- Rickson C. Mesquita
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Institute of Physics, University of Campinas, Campinas, São Paulo, Brazil
| | - Angela D’Souza
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York, United States of America
- Department of Biomedical Engineering, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Thomas V. Bilfinger
- Department of Surgery, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Robert M. Galler
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Asher Emanuel
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Steven S. Schenkel
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Arjun G. Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Thomas F. Floyd
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York, United States of America
- Department of Biomedical Engineering, Stony Brook University Medical Center, Stony Brook, New York, United States of America
- * E-mail:
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Ziewacz JE, Berven SH, Mummaneni VP, Tu TH, Akinbo OC, Lyon R, Mummaneni PV. The design, development, and implementation of a checklist for intraoperative neuromonitoring changes. Neurosurg Focus 2013; 33:E11. [PMID: 23116091 DOI: 10.3171/2012.9.focus12263] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECT The purpose of this study was to provide an evidence-based algorithm for the design, development, and implementation of a new checklist for the response to an intraoperative neuromonitoring alert during spine surgery. METHODS The aviation and surgical literature was surveyed for evidence of successful checklist design, development, and implementation. The limitations of checklists and the barriers to their implementation were reviewed. Based on this review, an algorithm for neurosurgical checklist creation and implementation was developed. Using this algorithm, a multidisciplinary team surveyed the literature for the best practices for how to respond to an intraoperative neuromonitoring alert. All stakeholders then reviewed the evidence and came to consensus regarding items for inclusion in the checklist. RESULTS A checklist for responding to an intraoperative neuromonitoring alert was devised. It highlights the specific roles of the anesthesiologist, surgeon, and neuromonitoring personnel and encourages communication between teams. It focuses on the items critical for identifying and correcting reversible causes of neuromonitoring alerts. Following initial design, the checklist draft was reviewed and amended with stakeholder input. The checklist was then evaluated in a small-scale trial and revised based on usability and feasibility. CONCLUSIONS The authors have developed an evidence-based algorithm for the design, development, and implementation of checklists in neurosurgery and have used this algorithm to devise a checklist for responding to intraoperative neuromonitoring alerts in spine surgery.
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Affiliation(s)
- John E Ziewacz
- Department of Neurosurgery, University of California, San Francisco, California 94143-0332, USA
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Abstract
During the last 30 years intraoperative electrophysiological monitoring (IOEM) has gained increasing importance in monitoring the function of neuronal structures and the intraoperative detection of impending new neurological deficits. The use of IOEM could reduce the incidence of postoperative neurological deficits after various surgical procedures. Motor evoked potentials (MEP) seem to be superior to other methods for many indications regarding monitoring of the central nervous system. During the application of IOEM general anesthesia should be provided by total intravenous anesthesia with propofol with an emphasis on a continuous high opioid dosage. When intraoperative MEP or electromyography guidance is planned, muscle relaxation must be either completely omitted or maintained in a titrated dose range in a steady state. The IOEM can be performed by surgeons, neurologists and neurophysiologists or increasingly more by anesthesiologists. However, to guarantee a safe application and interpretation, sufficient knowledge of the effects of the surgical procedure and pharmacological and physiological influences on the neurophysiological findings are indispensable.
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Chen Z, Lerman J. Protection of the remaining spinal cord function with intraoperative neurophysiological monitoring during paraparetic scoliosis surgery: a case report. J Clin Monit Comput 2011; 26:13-6. [DOI: 10.1007/s10877-011-9325-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 12/01/2011] [Indexed: 10/14/2022]
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Buvanendran A, Thillainathan V. Preoperative and postoperative anesthetic and analgesic techniques for minimally invasive surgery of the spine. Spine (Phila Pa 1976) 2010; 35:S274-80. [PMID: 21160390 DOI: 10.1097/brs.0b013e31820240f8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A review of methods to optimize anesthesia and analgesia for minimally invasive spine procedures. OBJECTIVE To provide information to surgeons and anesthesiologists of methods to provide optimal anesthesia and pain control for minimally invasive spine surgery with an emphasis on preoperative planning. SUMMARY OF BACKGROUND DATA Postoperative pain management in patients undergoing minimally invasive spine surgery is a challenge for the perioperative anesthesiologist. In addition to the incisional pain, trauma to deeper tissues, such as ligaments, muscles, intervertebral discs, and periosteum are reasons for significant pain. The increasing number of minimally invasive surgeries and the need for improved and rapid return of the patient of functionality have brought the perioperative anesthesiologist and the surgeon closer. METHODS We undertook a review of the literature currently available on anesthesia and analgesia for minimally invasive spine surgery with an emphasis on preoperative planning. A large number of reports of randomized controlled clinical trials with respect to perioperative anesthetic and postoperative pain management for minimally invasive spine surgery are reviewed and the applicability of some of the principles and protocols used for other types of minimally invasive surgical procedures are placed in the context of spine surgery. RESULTS It is important to understand and implement a multimodal analgesic therapy during a patient's preoperative visits. Perioperative multimodal analgesia with a fast-track anesthetic protocol is also important and provided in the manuscript. This protocol poses a challenge to the anesthesiologist with respect to neurophysiologic monitoring, which requires further study. The postoperative analgesic management should be a continuance of the multimodal analgesia provided before surgery. Some drugs are not appropriate for patients undergoing fusion surgery because of their effect on bone healing. CONCLUSION An optimal preoperative, perioperative, and postoperative anesthesia and analgesia protocol is important to best possible pain relief and rapid return to normal function. Communication between the anesthesiologist and spine surgeon is important to achieve a protocol with the best short- and long-term outcomes for the benefit of the patient.
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