52-Ye a r Old F o rme r Divisio n 1 Ba ske tb a ll Pla ye r Ne e ds - - PowerPoint PPT Presentation

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52-Ye a r Old F

• rme r Divisio n 1 Ba ske tb a ll

Pla ye r Ne e ds Pe dic le Sc re ws

“SSE P” Ma ke s Sure I Do No t Ma ke Mista ke s

Ortho pa e dic Summit 2017 L a s Ve g a s, NV Antho ny K . Se sto ka s, PhD, DABNM, F ASNM Chie f Clinic a l Offic e r – I ONM Spe c ia ltyCa re

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Disc lo sure s

• Spe c ia ltyCa re – E

mplo ye e

• Spe c ia ltyCa re – Sto c k
• E

dito ria l Bo a rd – Jo urna l o f Clinic a l Mo nito ring a nd Co mputing

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Ob je c tive s

• Re vie w ne uro lo g ic risk fa c to rs during lumb a r spine

surg e ry with pe dic le sc re w instrume nta tio n

• I

de ntify I ONM mo da litie s suite d to surve il ne uro lo g ic struc ture s a t risk o f ia tro g e nic injury

• Re vie w multi-institutio na l e xpe rie nc e o f a na tio na l

I ONM se rvic e pro vide r

• I

nve stig a te ne w I ONM o ppo rtunity to impro ve sa fe ty during lumb a r spine surg e ry

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Ba c kg ro und

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• Pre ve nt ne uro lo g ic injury b y fa c ilita ting time ly

de te c tio n a nd re ve rsa l o f impe nding ne uro lo g ic insult

• Mitig a te the e ffe c ts o f ne uro lo g ic injury with

e a rly de te c tio n a nd a ppro pria te tre a tme nt Go a ls o f I ntra o pe ra tive Ne uro physio lo g ic a l Mo nito ring (I ONM)

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Ro le o f I ONM I n Pre ve ntio n vs. Pre dic tio n o f I a tro g e nic Ne ura l I njury

Probability of Neural Injury

Neural Challenge

HIGH LOW SMALL LARGE

Early Detection And Warning of Altered Neural Function Late Warning: Harbinger of Neurologic Deficit

PREDICTION PREVENTION

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Asse ssme nt o f Ne uro lo g ic Risk

Assessment of Structures at Risk During Spine Surgery

Sc hwa rtz a nd Se sto ka s, 2002

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Ne uro mo nito ring Mo da litie s

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Wha t is “SSE P”?

• SSE

P is a n a c ro nym fo r So ma to se nso ry E vo ke d Po te ntia ls

• SSE

P is a lso use d c o llo q uia lly to re fe r mo re b ro a dly to multimo da lity

Intr aope r ative Ne ur

• physiologic al Monitor

ing (I

ONM), whic h c a n inc lude se ve ra l diffe re nt ne uro physio lo g ic a l te sts tha t surve il ne ura l e le me nts a t risk o f injury during spine surg e ry

• So ma to se nso ry E

vo ke d Po te ntia ls (SSE P)

• T

ra nsc ra nia l E le c tric Mo to r E vo ke d Po te ntia ls (tc e ME P)

• Spo nta ne o us E

le c tro myo g ra phy (spE MG)

• T

rig g e re d E le c tro myo g ra phy (trE MG)

Activate Neural Elements Proximally

Site of Surgery

Activate Neural Elements Distally

Signal Flow Signal Flow

Record Responses Distally (Motor Evoked Potentials)

Record Responses Proximally (Somatosensory Evoked Potentials)

I ONM Stra te g y E vo ke d Me a sure s

Dumitru, 1995

So ma to se nso ry E vo ke d Po te ntia ls

• Mixe d ne r

ve somatose nsor y e voke d pote ntials (SSE Ps) ar e e lic ite d by e le c tr ic al stimulation applie d to a pe r iphe r al ne r ve (e .g. ulnar , me dian, poste r ior tibial, pe r

• ne al)
• Poste r

ior tibial ne r ve stimulation initiate s an affe r e nt ne ur al volle y that e nte r s the spinal c or d via the lumbo- sac r al ple xus

• T

he affe r e nt volle y asc e nds within the poste r ior se nsor y c olumn and me dial le mnisc al pathways of the spinal c or d and br ainste m r e spe c tive ly, and is r e laye d fr

• m

the thalamus to the c or te x via the inte r nal c apsule .

F ro m Bha lo dia e t a l., 2012

T ra nsc ra nia l E le c tric Mo to r E vo ke d Po te ntia ls

Sc hwa rtz e t a l. 2011

• T

r ansc r anial e le c tr ic motor e voke d pote ntials ar e myoge nic r e sponse s e lic ite d by the applic ation of e le c tr ic al stimulation to the br ain

• E

le c tr ic al pulse tr ains ar e applie d thr

• ugh

subde r mal sc alp e le c tr

• de s that ove r

lie motor c or te x

• F
• llowing de polar

ization of c or tic al ne ur

• ns,

e ffe r e nt ne ur al signals c our se down the inte r nal c apsule to the c audal me dulla whe r e the major ity of c or tic ospinal tr ac t (CST ) fibe r s de c ussate and de sc e nd into the spinal c or d motor pathways

• CST

axons the n e nte r the spinal c or d gr ay matte r , inte r ac t with spinal c or d inte r ne ur

• ns,

and go on to synapse with alpha motor ne ur

• ns
• Alpha motor

ne ur

• n axons e xit thr
• ugh the ir

c or r e sponding ne ur al for amina as spinal ne r ve r

• ots that inne r

vate ske le tal musc le

F ro m Bha lo dia e t a l., 2012

E le c tro myo g ra phy

• Spontane ous e le c tr
• myogr

aphy involve s the r e c or ding of e le c tr ic al ac tivity pr

• duc e d by

ske le tal musc le in r e sponse to ac ute ir r itation of a spinal ne r ve r

• ot se c ondar

y to me c hanic al c ontac t, dir e c t tr ac tion, he at- dispe r sion fr

• m

e le c tr

• c aute r

y, or

• the r

suc h noxious stimuli that tr igge r ne r ve r

• ot de polar

ization

• T

r igge r e d e le c tr

• myogr

aphy de te c ts musc le ac tivation following dir e c t or indir e c t e le c tr ic al stimulation of a ne r ve (e .g. using a hand- he ld, ste r ile , monopolar pr

• be that is insulate d down

to the tip)

F ro m Bha lo dia e t a l., 2012

Mo nito ring Mo da litie s fo r L umb a r Spine Surg e ry T ra ditio na l Mo de l

Sc hwa rtz a nd Se sto ka s, 2002

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T e sting fo r Pre se nc e o f Me dia l Pe dic le Wa ll Bre a c h using T rig g e re d E MG

I sle y e t a l. 2012 Ca la nc ie e t a l. 1994

Mikula e t al. (2016) pe r for me d a syste matic r e vie w and me ta- analysis of 26 studie s (2932 patie nts, 15,065 sc r e ws) Poole d se nsitivity of tr E MG for de te c tion of misplac e d sc r e w = 0.78 (95% CI =0.73 – 0.81) Poole d spe c ific ity of tr E MG for de te c tion of misplac e d sc r e w = 0.94 (95% CI =0.94 – 0.95)

Mo de l illustra tio n o f me dia l pe dic le wa ll b re a c h Sc he ma tic illustra tio n o f e le c tric a l pro b ing o f me dia l pe dic le wa ll b re a c h

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F lo w Dia g ra m fo r Pe dic le Sc re w T e sting

Sc hwa rtz a nd Se sto ka s, 2002

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• Ca se Study I

A – E le c tric a l Stimula tio n Use d to T e st fo r Pe dic le Bre a c h Rig ht L 5 Bre a c h De te c te d

L e ft L 5 Sc re w I nitia l Stimula tio n T hre sho ld = 31 mA Pe dic le Bre a c h Unlike ly Rig ht L 5 Sc re w I nitia l Stimula tio n T hre sho ld = 2.9 mA Pe dic le Bre a c h L ike ly

Dia g no sis: L 4-5 spo ndylo listhe sis with ste no sis Pro c e dure : L 4-5 la mine c to my, fa c e te c to my, tra nsfo ra mina l lumb a r inte rb o dy fusio n with pe dic le sc re w fixa tio n

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• Rig ht L

5 Sc re w Re po sitio ne d F ina l Stimula tio n T hre sho ld = 7.3 mA Sc re w re ta ine d No c ha ng e in ME Ps thro ug ho ut surg ic a l c o urse

Ca se Study I B – ME P Use d to Mo nito r F unc tio na l I nte g rity o f L umb a r Ro o ts

Base line s Sc r e ws Plac e d De c ompr e ssing Right L 5 Sc r e w Re positione d Cage Plac e d

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Pe dic le Sc re w T e sting Multi-institutio na l E xpe rie nc e 2013-2017

6,805 Po sitive T e sts in 4,629 o f 45,431 (10.2%) L umb a r Spine Pro c e dure s tha t Utilize d Pe dic le Sc re w T e sting

5 ye a r tre nd sug g e sts a de c re a se in the o ve ra ll inc ide nc e o f pe dic le b re a c he s o ve r time I n so me c a se s a fte r a pe dic le b re a c h a le rt, the surg e o n ma y e le c t to a c c e pt the e xisting sc re w pla c e me nt b a se d o n re sults

• f visua l a nd ra dio g ra phic inspe c tio n

F ro m the Spe c ia ltyCa re Ope ra tive Pro c e dura l Re g istry (SCOPE

T M), 2017

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Ne w I ONM T

• o l in L

umb a r Spine Surg e ry

Dia g no stic Va lue o f ME Ps

Dia g no stic Ac c ura c y a nd T he ra pe utic I mpa c t o f Mo to r E vo ke d Po te ntia l (ME P) Mo nito ring During 4425 Po ste rio r L umb o sa c ra l Surg e rie s I nvo lving the L 5 Ve rte b ra

12.50% 93.8% 97.2% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0% Se nsitivity SSE Ps Se nsitivity ME Ps Spe c ific ty ME Ps

Se nsitivity a nd Spe c ific ity fo r Ne w o nse t mo to r de fic its

2 4 6 8 10 12 14 Othe r L e g We a kne ss F

• o t Dro p

Arm We a kne ss

Mo to r De fic its (n=16) (15 T rue Po sitive s 1 F a lse Ne g a tive )

15/ 16 Pr

• c e dur

e s had pe r siste nt ME P c hange s T he r e we r e no ne w postope r ative motor de fic its in the 161 c ase s with ME P ale r ts that we r e F ully Re solve d by time of c losur e

F ro m the Spe c ia ltyCa re Ope ra tive Pro c e dura l Re g istry (SCOPE

T M), 2017

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Pe rsiste nt loss of ME Ps fro m rig ht tib ia lis a nte rio r

musc le fo llo wing pla c e me nt o f g ra ft a t L 4/ 5. T his pa tie nt pre se nte d po sto pe ra tive ly with rig ht fo o t dro p, whic h sho we d pa rtia l re so lutio n within se ve ra l ho urs o f surg e ry.

Re ve rsible loss of ME Ps during a tte mpte d pla c e me nt

• f L

5 c a g e . T he re we re no po sto pe ra tive ne uro lo g ic se q ue la e , c o nsiste nt with intra o pe ra tive re c o ve ry o f ME Ps.

Dia g no sis: L 5 me ta sta tic tumo r Pro c e dure : Po ste rio r L 5 c o rpe c to my w/ c a g e & pe dic le sc re ws Dia g no sis: Ne uritis Pro c e dure : L 4/ S1 rig ht T L I F with pe dic le sc re w fixa tio n

Ca se Study 2 Ca se Study 3

Mo nito ring Mo da litie s fo r L umb a r Spine Surg e ry E vo lving Mo de l

Ada pte d fro m Sc hwa rtz a nd Se sto ka s, 2002

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Re fe re nc e s

Bha lo dia VM, Se sto ka s AK , Sc hwa rtz DM. I ntra o pe ra tive ne uro mo nito ring during spine surg e ry. I n: Ande rso n DG, Va c c a ro AR, e ds. De c isio n Making in Spinal Care . Vo l Cha pte r 67. 2nd E ditio n e d. Ne w Yo rk: T hie me Me dic a l Pub lishe rs I nc ; 2012. Dumitru D. E le c tro dia g no stic Me dic ine . E lse vie r; 1995. Ca la nc ie B, Ma dse n P, L e b wo hl N. Stimulus-e vo ke d E MG mo nito ring during tra nspe dic ula r lumb o sa c ra l spine instrume nta tio n. initia l c linic a l re sults. Spine (Phila Pa 1976). 1994;19(24):2780-2786. I sle y MR, Zha ng XF , Ba lze r JR, L e ppa ne n RE . Curre nt tre nds in pe dic le sc re w stimula tio n te c hniq ue s: L umb o sa c ra l, tho ra c ic , a nd c e rvic a l le ve ls. Ne uro diag n J. 2012;52(2):100-175. Mikula AL , Willia ms SK , Ande rso n PA. T he use o f intra o pe ra tive trig g e re d e le c tro myo g ra phy to de te c t mispla c e d pe dic le sc re ws: A syste ma tic re vie w a nd me ta -a na lysis. J Ne uro surg Spine . 2016;24(4):624-638. Sc hwa rtz,D.M., Se sto ka s,A.K. A syste ms-b a se d a lg o rithmic a ppro a c h to intra o pe ra tive ne uro physio lo g ic a l mo nito ring during spina l surg e ry. Se minars in Spine Surg e ry. 2002;14(2):136-145. Sc hwa rtz DM, Se sto ka s AK , Do rma ns JD. I ntra o pe ra tive ne uro physio lo g ic a l mo nito ring during c o rre c tive spine surg e ry in the g ro wing c hild. I n: Akb a rnia BA, Ya zic i M, T ho mpso n GH, e ds. T he Gro wing Spine : Manag e me nt o f Spine Diso rde rs in the Yo ung Child. Be rlin: Spring e r; 2011:515. Spe c ia ltyCa re Pro c e dura l Ope ra tive Re g istry (SCOPE

T M), Spe c ia ltyCa re , I

nc . Se sto ka s, A.K ., T e sda hl, E .A., Wile nt, W.B., Ha rro p, J.S. Wig g ins, C.R., Co he n, J., Do Mo to r E vo ke d Po te ntia ls (ME Ps) I mpro ve Ne uro mo nito ring Se nsitivity during L umb a r Spine Surg e ry? Co ng re ss

• f Ne uro lo g ic a l Surg e o ns Annua l Me e ting , Bo sto n, MA, Oc to b e r 7-11, 2017

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