52-Ye a r Old F o 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 1
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 • 2
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 3
Ba c kg ro und 4
Go a ls o f I ntra o pe ra tive Ne uro physio lo g ic a l Mo nito ring (I ONM) • 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 5
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 HIGH Probability of Neural Injury Early Detection And Warning of Altered Neural Function PREDICTION PREVENTION Late Warning: Harbinger of Neurologic Deficit LOW LARGE SMALL Neural Challenge 6
Asse ssme nt o f Ne uro lo g ic Risk 7
Assessment of Structures at Risk During Spine Surgery Sc hwa rtz a nd Se sto ka s, 2002
Ne uro mo nito ring Mo da litie s 9
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 • ing (I ONM), whic h c a n Intr aope r ative Ne ur ophysiologic al Monitor 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) • 10
I ONM Stra te g y E vo ke d Me a sure s Record Responses Proximally Activate Neural Elements (Somatosensory Evoked Proximally Potentials) Site of Signal Signal Surgery Flow Flow Activate Neural Elements Record Responses Distally Distally (Motor Evoked Potentials)
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 one 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 om 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 Dumitru, 1995
T ra nsc ra nia l E le c tric Mo to r E vo ke d Po te ntia ls 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 ough • subde r mal sc alp e le c tr ode s that ove r lie motor c or te x F ollowing de polar ization of c or tic al ne ur ons, • 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 ons, and go on to synapse with alpha motor ne ur ons Alpha motor ne ur on axons e xit thr ough the ir • c or r e sponding ne ur al for amina as spinal ne r ve r oots that inne r vate ske le tal musc le F ro m Bha lo dia e t a l., 2012 Sc hwa rtz e t a l. 2011
E le c tro myo g ra phy Spontane ous e le c tr omyogr aphy involve s the • r e c or ding of e le c tr ic al ac tivity pr oduc 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 oot 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 om e le c tr oc aute r y, or othe r suc h noxious stimuli that tr igge r ne r ve r oot de polar ization T r igge r e d e le c tr omyogr 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 obe 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
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 Sc he ma tic illustra tio n o f e le c tric a l pro b ing o f Mo de l illustra tio n o f me dia l pe dic le wa ll b re a c h me dia l pe dic le wa ll b re a c h 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) 16
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 17
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 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 • Rig ht L 5 Sc re w L e ft L 5 Sc re w I nitia l Stimula tio n T hre sho ld = 2.9 mA I nitia l Stimula tio n T hre sho ld = 31 mA Pe dic le Bre a c h L ike ly Pe dic le Bre a c h Unlike ly 18
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 Cage Plac e d 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 Right L 5 Sc r e w Sc re w re ta ine d Re positione d No c ha ng e in ME Ps thro ug ho ut surg ic a l c o urse 19
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 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 o f visua l a nd ra dio g ra phic inspe c tio n 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 T M ), 2017 F ro m the Spe c ia ltyCa re Ope ra tive Pro c e dura l Re g istry (SCOPE 20
Ne w I ONM T o 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 Se nsitivity a nd Spe c ific ity fo r Mo to r De fic its (n=16) Ne w o nse t mo to r de fic its (15 T rue Po sitive s 1 F a lse Ne g a tive ) 120.0% Arm We a kne ss 97.2% T he r e we r e no ne w 100.0% 93.8% postope r ative motor 80.0% F o o t Dro p de fic its in the 161 c ase s with ME P ale r ts 60.0% that we r e F ully Othe r L e g We a kne ss Re solve d by time of 40.0% c losur e 0 2 4 6 8 10 12 14 20.0% 12.50% 0.0% 15/ 16 Pr oc e dur e s had pe r siste nt ME P c hange s Se nsitivity SSE Ps Se nsitivity ME Ps Spe c ific ty ME Ps T M ), 2017 F ro m the Spe c ia ltyCa re Ope ra tive Pro c e dura l Re g istry (SCOPE 21
Ca se Study 2 Ca se Study 3 Dia g no sis: Ne uritis Dia g no sis: L 5 me ta sta tic tumo r Pro c e dure : L 4/ S1 rig ht T L I F with pe dic le sc re w fixa tio n 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 Ps fro m rig ht tib ia lis a nte rio r Ps during a tte mpte d pla c e me nt Pe rsiste nt loss of ME Re ve rsible loss of ME musc le fo llo wing pla c e me nt o f g ra ft a t L 4/ 5. T his o f L 5 c a g e . T he re we re no po sto pe ra tive ne uro lo g ic pa tie nt pre se nte d po sto pe ra tive ly with rig ht fo o t se q ue la e , c o nsiste nt with intra o pe ra tive re c o ve ry o f dro p, whic h sho we d pa rtia l re so lutio n within se ve ra l ME Ps. ho urs o f surg e ry. 22
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