Multimodal intraoperative monitoring: an overview and proposal of methodology based on 1,017 cases

Abstract

To describe different currently available tests of multimodal intraoperative monitoring (MIOM) used in spine and spinal cord surgery indicating the technical parameters, application and interpretation as an easy understanding systematic overview to help implementation of MIOM and improve communication between neurophysiologists and spine surgeons. This article aims to give an overview and proposal of the different MIOM-techniques as used daily in spine and spinal cord surgery at our institution. Intensive research in neurophysiology over the past decades has lead to a profound understanding of the spinal cord, nerve functions and their intraoperative functional evaluation in anaesthetised patients. At present, spine surgeons and neurophysiologist are faced with 1,883 publications in PubMed on spinal cord monitoring. The value and the limitations of single monitoring methods are well documented. The diagnostic power of the multimodal approach in a larger study population in spine surgery, as measured with sensitivity and specificity, is dealt with elsewhere in this supplement (Sutter et al. in Eur Spine J Suppl, 2007). This paper aims to give a detailed description of the different modalities used in this study. Description of monitoring techniques of the descending and ascending spinal cord and nerve root pathways by motor evoked potentials of the spinal cord and muscles elicited after transcranial electrical motor cortex, spinal cord, cauda equina and nerve root stimulation, continuous EMG, sensory cortical and spinal evoked potentials, as well as direct spinal cord evoked potentials applied on 1,017 patients.The method of MIOM, continuously adapted according to the site, stage of surgery and potential danger to nerve tissues, proved to be applicable with online results, reliable and furthermore teachable.

The diagnostic value of multimodal intraoperative monitoring (MIOM) during spine surgery: a prospective study of 1,017 patients

“…This was usually accomplished using propofol or ketamine in combination with short acting opioids, as described in the methodology paper in this supplement [16]. Muscle relaxants were only used for intubation, but usually not during surgery.…”

Stimulation of Pedicle Screws with Diathermy: Is it a Viable Option to Detect Breaches?

“…Numerous checks ranging from basic ones such as probing the pedicle screw track with pedicle sound and intraoperative C-arm imaging to sophisticated modalities such as navigation-assisted screw insertion, iso-C 3-dimensional fluoroscopy imaging, and electrophysiological tests including SSEP, MEP and EMG tracing have been employed to decrease incidence of pedicle screw breach [2,6,10,11]. Among all these modalities, SSEP is the only realtime monitoring.…”

“…Direct electrical stimulation of pedicle screws is an accepted modality to assess screw malposition [2,3]. The present study aims to prospectively study the role of direct stimulation of pedicle screws using monopolar diathermy in the "cutting" mode, as an adjuvant modality to assess screw malposition, particularly in a setup which does not have advanced electrophysiological monitors or navigation facilities.…”

Usefulness of multi-channels in intraoperative spinal cord monitoring: multi-center study by the monitoring committee of the Japanese Society for Spine Surgery and related research

“…1; and (3) cases recorded at institutions where loss of amplitude was used as the alarm point. Cases where inhalation anesthesia was used or muscle relaxants were used as maintenance anesthesia was excluded from the baseline data [21].…”