Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
Quarterly Newsletter
Summer 2015
From the Editor
AUGUST - 2015
Newsletter Index
PAGE ONE
Welcome to the Summer edition of the NMUK newsletter!
Message from the editor
As you may have been aware our greatly valued newsletter editor
emigrated to Canada last year. Until now Fiona has kindly continued in this role remotely, producing informative and interesting
newsletters on our behalf for which we are truly grateful. Sadly for
us Fiona has decided to stepdown from this role to concentrate on
life in her new country. Yes we’ve all seen the tv-show and dreamt
about the possibilities for a moment or two, yet Fiona has gone and
done it! On behalf of the NMUK steering group, I would like to
thank Fiona for all her hard work over the years and wish her all
the best in her new life away from the UK.
NMUK Announcements
Having wished Fiona well I would like to introduce myself, my
name is Alex I have been a member of the NMUK steering group
for several years and up to now I have concentrated on managing
the website. It's with great pleasure that I have taken over as
newsletter editor, I only hope I manage to fulfil the role as well as
my predecessor.
I hope the new look isn't to offensive to the eye, it is a work in progress and with your feedback will continue to evolve to meet the
needs and interests of the subscribers. Please do not hesitate to
email me with content, comments and suggestions (address below). In the mean time I hope you manage to enjoy the remainder
of our Great British summer.
PAGE TWO
Message from the Chair
PAGE THREE
NMUK December Forum @ Great
Ormond Street
PAGE FOUR
Upcoming Meetings & Events
PAGE FIVE & SIX
Meet the Steering group.
PAGE SEVEN - ELEVEN
Meeting Review
PAGE TWELVE
Meeting Feedback
PAGE THIRTEEN
Disclaimer
I look forward to hearing from you.
Alexander Woodhams - NMUK Newsletter Editor/Web Admin
NMUK Announcements
- IMPORTANT INFORMATION SUBCRIPTION RENEWALS
As a result of the NMUK guarantee company formation NMUK has
had to change its bank account details. We are trying to get this
sorted out as soon as possible but unfortunately it will mean that
you will have to change your direct debit details for the renewal
of subscriptions on 1st of October 2015.
NMUK FORUM
Registration now open!!
for the NMUK winter Forum in conjunction with
Great Ormond Street Hospital/UCL Institute of Child
Health, see page 3 for further details.
Questions or comments? Please feel free to contact us by email: editor@neuromonitoringUK.org
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
Quarterly Newsletter
Summer 2015
AUGUST - 2015
PAGE TWO
Message from the Chair
Since our last newsletter we have had our NMUK meeting at Sheffield (22-23rd April 2015) held, for the first time, in
parallel with the British Scoliosis Society. Thank you to the BSS executive and local hosts in Sheffield for inviting us and
making us feel very welcome. Thank you to committee members who helped make the event such a success, the
speakers and for the commercial sponsors who attended. Feedback comments from the meeting were excellent
and in particular for our 2 international guest speakers: Prof Tod Sloan and Dr Francesco Sala who both gave inspiring presentations. For more details see Katy Danbys meeting review below.
As per my announcement to subscribers at the beginning of June 2015, Neuromonitoring UK is now registered as a
company limited by guarantee. We have also applied to HMRC for 'not for profit' status and we are awaiting their
reply. Unfortunately as part of this process we are having to change the bank account details - see note on page
one.
The company registration process required us to submit new company articles and memorandum to companies
house. This meant our old NMUK constitution needs updating and will become the NM UK by-laws. The new by-laws
will complement the company articles. When these are ready for member approval I will be sending out an online
poll. Please do take the opportunity to vote- it should be quick and simple and save us taking up valuable time with
business issues at the NMUK meetings.
The NMUK committee currently comprises of 11 of the original steering group who have become directors and guarantors of the new organisation: Helen Grover, Lindsay Henderson, Karen Plumb, Julia Loughran, Alex Woodhams,
Katy Danby, Peter Walsh, Rosemary Steele, Diane Boothman, Dale Darbyshire and Vania Pinto. Long term steering
group member Debra Beer and newsletter editor Fiona Cave have stepped down. On behalf of NMUK I would like
to thank both of them for their contributions over the years. Fiona has been responsible for developing and producing our newsletter for the last few years, even continuing from distance since she emigrated to Canada for which
we are all very grateful.
We have 3 applicants for the vacant committee positions and so there will also be an online subscriber vote for
these- look out for the email with voting link which will be sent out soon.
We have also announced the next NMUK IONM forum which is to be held at Great Ormond Street Hospital on Monday 7th December 2015. I am extremely grateful to Ivana Jancovic (ivana.jankovic@gosh.nhs.uk) for volunteering
to arrange this forum. There will be more neurosurgical monitoring content to this forum. Once again NM UK has
been able to offer this at no cost to long term existing subscribers, although there will be a £30 fee for nonsubscribers to cover costs (lunch, beverages event insurance etc). We have decided to follow the format of previous forums held with a 1 day, relatively small meeting to encourage discussion as this has been well received in the
past. This means numbers are limited and we need to know numbers for catering by the beginning of November.
Registration forms and provisional programme for the forum are attached- don't delay places are limited!
And finally congratulations to the 3 committee members who have become Mums this year (and one more to go!).
Thank you for your continued support for NMUK.
Helen
Helen Grover, Csci - Chairman, Neuromonitoring UK
Questions or comments? Please feel free to contact us by email: editor@neuromonitoringUK.org
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
Quarterly Newsletter
Summer 2015
AUGUST - 2015
PAGE THREE
NMUK IONM Forum December 2015 Registration is now Open!
NMUK are pleased to announce a one day forum for intra-operative
neuromonitoring professionals to be held at:
UCL Institute of Child Health
Date: Monday 7th of December 2015
Time: 09:30 - 15:45
Venue: Leolin Price Lecture Theatre
Institute of Child Health
30 Guildford Street,
Great Ormond Street Hospital, London
on Monday 7th December 2015
Great Ormond Street Hospital are delighted to host NM UK’s Autumn forum 2015. This is the ideal
platform to share and discuss ideas, problems, new techniques etc with colleagues from other IONM
centres around the country. Hence the day will consist of presentations and case studies with a largely
neurosurgical theme this time. The local organiser for this event is Ivana (ivana.jankovic@gosh.nhs.uk).
Registration will be from 9:30 for a 10am start and is scheduled to end at 1545hrs. The meeting will
include a light lunch and tea/coffee breaks. Please register by 14th November 2015 to book your place.
How much will it cost?
London, WC1N 1EH
Closest Transport Links:
Underground Stations:
Russell Square (Piccadilly Line)
Holborn (Central & Piccadilly lines)
Main line stations:
King’s Cross, St. Pancreas
Euston.
Free for current NMUK subscribers*
£30 for non-subscribers (the £30 fee will include the 2015/16 subscription to NM UK).
£15 for new NM UK subscribers**
* free for delegates who are NMUK subscribers as of 1st April 2015 and have also renewed
their subscription for 2015/16 (subscription renewals are due on 1st October 2015).
**For new subscribers (joined since 1st April 2015) the cost will be reduced to £15 as long as
you have also renewed your subscription for 2015/16.
NMUK FORUM
Registration now open!! for the NMUK
winter Forum in conjunction with Great
Ormond Street Hospital/UCL Institute of
Child Health, see page 5 for further details.
Questions or comments? Please feel free to contact us by email: editor@neuromonitoringUK.org
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
Quarterly Newsletter
Summer 2015
AUGUST - 2015
PAGE FOUR
NMUK IONM Forum December 2015 Registration is now Open!
Date: Monday 7th of December 2015
09:30 – 10.00
Registration and Refreshments
10.00 – 10.05
Welcome to the Forum
Host Department Representative
10.05 - 10.45
1st Presentation - 40 mins
Dr Matthew Pitt: anatomy of the cranial nerves; Ivana
Jankovic monitoring of cranial nerves
10.45 - 11.15
2nd Presentation - 30 mins
Brett Sanders: En Bloc Spondylectomy for spinal tumours.
11.15 - 11.40
Break for Refreshments
11.40 - 12.00
3rd Presentation - 20 mins
Alex Woodhams.: Aortic Aneurysm Repair surgery.
30 Guildford Street,
12.00 – 12.30
4th Presentation – case studies (2 x 15mins)
Case presentations:
London, WC1N 1EH
1230-1240
Discussion
12.40 - 13.30
Lunch
13.30 - 14.00
5th Presentation - 30 mins
Mr Dominic Thompson: sacral lipomas
14.00 - 14.20
6th Presentation - 2omins
Ivana Jankovic : monitoring of the surgery of the sacral region
14.25 - 14.55
7th Presentation - 30 mins
Mr Kristian Aquilina: Selective Dorsal Rhizotomy (SDR)
1455 – 15.10
Break for Refreshments
15.10-1530
8th Presentation - 20 mins
Peter Walsh: SDR monitoring
15.30 – 1545
Round group discussions – 15 mins
What should we include in the IOM Protocols?
1545
Close
Time: 09:30 - 15:45
Venue: Leolin Price Lecture Theatre
Institute of Child Health
Closest Transport Links:
Underground Stations:
Russell Square (Piccadilly Line)
Holborn (Central & Piccadilly lines)
Main line stations:
King’s Cross, St. Pancreas
Euston.
UPCOMING EVENTS & MEETINGS
8th Annual CANM IONM Symposium Montreal, Quebec Sep 25 - 26, 2015
Website: http://www.canm.ca/symposium.html
ANS Autumn Conference Belfast Sep 25 - 26th 2015
Website: http://www.ansuk.org
5th Congress of International Society of Intraoperative Neurophysiology,
Rio de Janeiro Nov 9-14th 2015
Website: http://isinrio2015.org/
NMUK FORUM
NMUK IONM Winter Forum , London Dec 7th 2015
Registration now open!! for the NMUK
winter Forum in conjunction with Great
Ormond Street Hospital/UCL Institute of
Child Health, see page 5 for further details.
Website: http://www.neuromonitoringuk.org
Questions or comments? Please feel free to contact us by email: editor@neuromonitoringUK.org
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
Meet the NMUK Team!
AUGUST - 2015
PAGE FIVE
Contact information:
Email:
chair@neuromonitoringuk.org
Work Tel:
01603 287316
Links & Publications:
https://uk.linkedin.com/pub/helen-grover/71/908/14
http://www.researchgate.net/profile/Helen_Grover
Chair:
Helen Grover, CSci
Job Title:
Clinical Physiologist (Neurophysiology)
Workplace: Dept of Clinical Neurophysiology, Norfolk and Norwich
University Hospital, Colney Lane, Norwich. NR7 4UY.
Since 2005 I have lead and developed the multimodal monitoring service for the Orthopaedic
surgeons in Norwich. Our neuromonitoring consists of routine upper and lower limb SEP and MEP
plus fee run EMG and triggered EMG (Electrophysiological Pedicle Integrity Testing) mostly for spinal deformity surgery cases. This is about 1/4 of my workload and I've also led the development
of the department’s electrophysiology of vision service (VEP, ERG) as well as performing routine
EEG and NCS work.
I started in Neurophysiology back in 1985 and spent the first 9 years of my career at St Bartholomew’s Hospital, London where I first became involved in neuromonitoring (neurosurgical).
I have been involved in NMUK since its inception, initially as Secretary, but more recently (and rather reluctantly!) as chair.
I have undertaken 2 national surveys of intra-operative neuromonitoring in the UK on behalf of
NM UK. I founded and manage the SCM-UK and NIM Eclipse users google web forums. I have 2
recent journal publications (see reasearchgate link above) and am currently involved with our
surgeons looking at the efficacy of pedicle tract testing in spinal deformity surgery and am a
member of the planning committee for the Joint National Audit Project (ANS/BSCN).
Questions or comments? Please feel free to contact us by email: editor@neuromonitoringUK.org
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
Meet the NMUK Team!
AUGUST - 2015
PAGE SIX
Contact information:
Email: secretary@neuromonitoringuk.org
Secretary:
Karen Plumb (nee Holmes) BSc., MSc., CNIM
Job Title:
Clinical Neurophysiology Technologist,
Educational Lead
Workplace:
Department of Clinical Neurophysiology,
Royal National Orthopaedic Hospital, Stanmore. HA7 4LP
I have worked in the field of intraoperative monitoring for over 12 years, and monitor complex orthopaedic and peripheral nerve injury cases at the Royal National Orthopaedic Hospital (RNOH) in Stanmore. The
department monitors in excess of 1000 spinal cases and 200 peripheral cases each year, so the majority of
my time is spent in the operating room.
Previous research interests include intraoperative monitoring during total shoulder replacement, and electromyography in the role of obstetric brachial plexus palsy.
As a Clinical Educator I have a keen interest in the advancement of educational opportunities for those in
the field of intraoperative monitoring. I have presented at national and international intraoperative monitoring conferences. I have also hosted 2 NMUK forums at the RNOH and recently travelled to Canada to
learn more about intraoperative techniques and educational programmes.
I am a founding committee member of NM UK and was Membership Secretary prior to becoming Secretary.
Please share your experience !
As the number of people involved with neuromonitoring within the UK grows, we feel it would be
of great benefit to our community if we could share and learn from our experiences.
In an attempt to encourage this we will start by introducing members of the NMUK steering
group, highlighting their areas of expertise and special interests. This information will also be available for review in the members area of the NMUK website.
We would very much like as many members of NMUK as possible to volunteer a little information
about the area of monitoring they are involved in and any special interests that they may have.
We would hope that this would encourage interaction between departments around the country, an informal support network, to aid learning and service development. Please don’t be shy,
this could be of benefit to us all! If you would like to submit your information please contact the
editor by email editor@neuromonitoringUK.org
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
BSS Meeting Review - Sheffield City Hall
22nd
–
23rd
April 2015
AUGUST - 2015
PAGE SEVEN
The British Scoliosis Society Meeting was
held this year in City Hall Sheffield and for
the first time ever Neuromonitoring UK were
invited to hold a parallel meeting, this report
reviews the meeting in detail.
INTRODUCTION
Organising a meeting parallel to the British Scoliosis Society took some co-ordination, led by
our new Chairperson Helen Grover the meeting program took shape. We were fortunate
enough to be allocated some funding to attract two eminent international speakers, namely
Professor Tod Sloan (anaesthetist with extensive experience in neuromonitoring from University of Colorado and Texas USA) and Dr Francesco Sala (neurosurgeon with a special interest in
neuromonitoring from Verona in Italy who is also the current president of ISIN). Lindsay Henderson (clinical physiologist from Edinburgh) offered to help run an instructional day along with
Dr Ian Scivill (clinical scientist from Sheffield) presenting IOM techniques to trainee surgeons
on Tuesday the 21st April, the feedback from which we understand to have been excellent.
DAY 1
The meeting commenced with an excellent talk from Helen Grover, CP from Norwich and current chair of NMUK, about optimisation of
MEPs. I will try to sumarise the most striking points I gleaned from Helen’s talk. The first was that Tamakus et al (Tamakus et al. Differential rates of false-positive findings in transcranial electric motor evoked potential monitoring when using inhalational anesthesia versus total
intravenous anesthesia during spine surgeries. Spine J 2014 ; 14 (8); 1440-6) found that the use of inhalational gases had the potential to
increase false positive MEPs by 5x, this point was reinforced later in the meeting by Professor Tod Sloan but it seemed that most centres
now are using a primarily TIVA driven anaesthetic regime whilst the patient has spinal cord monitoring. Helen was very clear that the single most important factor in improving the reliability of MEPs in her department was the addition of EEG channels to her standard set up.
Two channels of EEG allows the IOM professional to have an idea as to the level of the depth of anesthesia as the level of anesthesia
increases the reliability and robustness of the MEPs decreases. Ivana Jankovich expanded o this point on day two of the meeting and this
is certainly something that has prompted me to suggest a change of our current protocol in our department. Helen also spoke about the
representation of different muscle groups at the level of the anterior horn cells in the spinal cord, despite being a relatively small muscle in
comparison to some of the other large leg muscles abductor hallucis (AH) has a greater representation in the anterior horn cells than the
quadriceps, for example, and thus alpha motor neurons are more likely to reach threshold and cause a muscle contraction at a lower level
of stimulus than that required to ellicit a contraction from the quadriceps. Helen also spoke about the alteration of technical parameters to
improve the MEPs and these included altering stimulus intensity, the inter-stimulus interval, number of pulses and changing from a biphasic to a monophasic pulse (the biphasic pulse increases pulse energy and you should not exceed 50mJ IEC safety limit if using this technique). Spatial facilitation where you almost ‘prime’ the motor pathways prior to using an MEP by stimulating the nerve peripherally between 30Hz for 1 sec and 50Hz for 5 seconds may help you to illicit an MEP response. Helen also made the point that it is possible for
MEPs to fade over the course of the surgery and alterations to technical options may be required. If you are not stimulating frequently
enough it is difficult to tell whether the MEPs have simply faded or if you have a genuine loss of response, a genuine loss of responds
tends to occur very quickly whilst a fade will occur over a longer period of time.
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
BSS Meeting Review - Sheffield City Hall
22nd
–
23rd April
2015
AUGUST - 2015
PAGE EIGHT
Next up we had a talk from Lindsay Henderson (Clinical Physiologist from Edinburgh and current Membership Secretary of NM UK) on
valuing your IOM team. The emergence of physiologist or non-medical led services is likely to continue and develop for the foreseeable
future. Lindsay reiterated the point that surgeons are able to check with physiologists/IOM professionals regarding their experience and
the number of cases monitored and for this reason it is a good idea to document cases undertaken, similarly it is entirely appropriate for
physiologists to check with surgeons that they are clear on the type of monitoring being undertaken and any limitations this may have.
Poor communication has been shown to be a significant contributing factor where harm has occurred. Lindsay spoke about human factors
training, a training course developed through her Trust which she said really helped improve understanding around why and how people
might make mistakes. One of the possible suggestions around improving relationships and communication with the surgical team was to
perhaps offer to provide some training for surgical registrars in intraoperative monitoring when they start. Another suggestion was to put
together a series of IOM key performance indicators in order to be able to audit your service.
The next talk we had was from Dr Francesco Sala, neurosurgeon and current president of ISIN from Verona on D-wave monitoring in spinal cord surgery: Why? When? And How? D-waves are elicited by a single stimulus square wave pulse and recorded by an epidural electrode below the level of the lesion being operated on. D-wave latencies increase and amplitude decreases as it travels down the spinal
cord to the point that D-waves are unsuitable for monitoring below the level of T11. Fibers innovated as part of the D-wave are very important in locomotion and are highly sensitive. Patients who arrive for surgery in poor motor condition are likely to have poorly monitorable
D-waves. Dr Sala described the advantages of D-wave recording as being that these are fast conducting fibres which give stable and robust responses during deepening anesthesia and muscle relaxant may be used if required. D-wave recording does not cause the patient
to twitch and they may be run continuously. The disadvantages of using D-waves are that they can be tricky to record if a syrinx is present,
if there are multi-level spinal cord tumors or in patients who have been undergoing radiotherapy. In young children <1yrs old D-waves can
be very difficult to record due to the immaturity of the nervous system, myelination of the lumbar spinal cord occurs between 1-2yrs of age.
Perhaps the most important point regarding D-wave recording is that it is NOT suitable for use in scoliosis surgery, this is because when
the spinal column is de-rotated and straightened the change in position of the cord within the vertebral column can cause fluctuations in Dwave amplitude due to changing proximity of the cord to the epidural electrode, also the muscle MEPs will disappear more rapidly than Dwaves in the event of a spinal cord injury. In terms of alert criteria, when the muscle MEPs are lost and D-waves decrease >50% in amplitude an irreversible motor deficit has occurred. If MEPs are lost but the D-wave remains unchanged or changes but remains above 50% of
its baseline amplitude a transient motor deficit may have occurred, this transient deficit may remain for up to about 3 months.
Dr Ian Scivill from Sheffield delivered an excellent talk regarding the British Spine Registry. This was the first I had heard of this registry
and the idea behind it is to create a national database to collate statistics from all of the scoliosis surgeries undertaken. The set-up of this
database has been funded by the British Association of Spinal Surgeons. Technically the surgeon owns the data about their patients so
before an intraoperative monitoring professional attempts to add information to this database they must have liased with the operating surgeon first. There is a field in the database specifically regarding the intraoperative monitoring for the case and this field may be able to be
completed more fully if it is completed by the IOM team, all other fields should be completed by the surgeon. In order to access the BSR email mail@bsrcentre.co.uk, use this e-mail address also to leave comments and suggestions regarding the database. Ian asked for feedback regarding the content of the IOM section and will be asking for feedback from us via the SCM-UK google group.
Mr Pradeep Madhavan spinal surgeon spoke about the work he and his monitoring team have been working on in Taunton Somerset.
There are currently no published recommendations for what to do in the event of a significant change in the IOM during scoliosis surgery.
Pradeep and his team have been working on an algorithm to follow to help provide clarity in the situation where spinal cord monitoring
raises an issue. The importance of using a checklist was highlighted by the use of the WHO procedure now legally a must in this country
prior to surgery, Mr Madhavan pointed out that this has helped reduce harm to patients worldwide by 60%.
Mr Am Rai, spinal surgeon, from Norwich spoke about the difficulties of pedicle screw insertion from a surgical perspective. An interesting
statistic that was mentioned was a study where a group of spinal surgeons were put in a room and given 20 screws each and 25% of surgeons made at least one medial breach somewhere. This topic was followed up later in the event by Helen Grover who spoke about pedicle tract testing. Sex, age, maturity, curve pattern and magnitude are related to the potential progression of a curve and it is during the
rapid growth phase in adolescence where a scoliosis might occur, in girls this is slightly younger at 12 years as opposed to 14yrs in boys.
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
BSS Meeting Review - Sheffield City Hall
22nd
–
23rd April
2015
AUGUST - 2015
PAGE NINE
Prof Tod Sloan addressed the whole conference which consisted of ourselves, surgeons and anesthetists. Prof Sloane discussed the uses
and interactions of various anesthetic agents and their appropriateness in their use with IOM. The aims of an anesthetic is to provide amnesia, unconsciousness, antinociception and immobility, each of the drugs discussed provided some of these components to varying degrees, so the principle of using more than one drug to provide all four components was discussed. The choice of drugs depends on what
you want to achieve, drugs act at the brainstem to produce unconsciousness and of course we must bear in mind that the SEP travels
through the thalamus. To keep the patient immobile under general anesthetic the spinal reflex must be compromised and this is a balancing act between drugs in order to prevent the patient moving but at the same time maintaining the SEPs. Propofol is the best drug at producing unconsciousness, amnesia and immobility however increasing doses of Propofol will reduce the amplitude of the SEP. Opioids can
provide the function of blocking out noxious stimuli and by balancing an opioid with Propofol a choice anesthetic regime could be achieved
to work with the IOM. Ketamine blocks the noxious stimuli excellently by working on NMDA receptors, it can enhance the SEP and MEP in
the correct doses and reduce the need to extra Propofol, however it can be hallucinogenic. Low dose inhalational agents i.e. Sevoflourane
or Desflourane of 0.5 MAC have also been shown to be used successfully with TIVA and IOM in neurologically healthy patients.
Helen Grover gave an excellent talk on pedicle tract testing. In thoracic screws the likelihood of a breach is greater than in lumber screws,
less than 1% of thoracic breaches will cause a neurological deficit but those that do can be serious as a medial breach at thoracic level can
cause a spinal cord injury. Thoracic screw testing using the single pulse technique as is used for lumbar screws may not be sufficient to
detect a medial breach as there have been increased false positives/negatives in thoracic screws when using this technique. The repetitive
pulse train technique (Calancie B, Donohue M, Harris C, Canute G, Singla A, Kaitlin G. Wilcoxen, Moquin R. Neuromonitoring with pulsetrain stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 1. Methods and alarm criteria.
Journal of Neurosurgery: Spine, 2014; 1 DOI: 10.3171/2014.2.SPINE13648). Calancie B, Donohue M, Moquin R. Neuromonitoring with
pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2. The role of feedback.
Journal of Neurosurgery: Spine, 2014; 1 DOI: 10.3171/2014.2.SPINE13649) has been shown to be much more reliable in thoracic screws,
this involves stimulating the screw tract and recording from distal muscles in the lower limbs, the spinal cord rather than the nerve root is
stimulated in this technique. Suggested stimulation parameters, as per the Calancie et al study, are repetitive pulse trains at 4 x0.2ms pulses at 2ms ISI (30Hz) at 3x trains/sec. This is a more successful technique to use in the thoracic spine as the level at which stimulation of
the cord occurs is less than in the lumbar spine. Helen has been using this method in Norwich for the past years and reports 41 of 348
screw tracts showed a positive thoracic pedicle test and of these 18 were confirmed by the surgeon to be actual breaches (although postoperative CT scans were not being performed and so the actual number of true positives may in fact be higher).
Brett Sanders from Queens Square, London, spoke about an audit he had conducted regarding IOM training provision in the UK. Outside
of the UK there are accredited training programs for IOM. 13 UK centres completed the audit and 62% of these had an in house training
program. The importance of keeping records of numbers of cases performed by each physiologist was discussed, in IOM training outside
of the UK evidence must be provided to show that a certain number of cases has been performed before a certificate is awarded. A discussion followed about the possibility of NM UK group adopting the training manual. It was suggested that trainees maintain a log of their monitored cases as evidence along with completion of a training manual. Brett will follow up on this project.
The day was rounded off with a formal dinner in Cutlers Hall.
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
BSS Meeting Review - Sheffield City Hall
22nd
–
23rd April
2015
AUGUST - 2015
PAGE TEN
DAY 2
On day two of the meeting Prof Sloan started off by delivering a very interesting talk on the patient, their physiology and positioning and
how these variables might affect our monitoring. An alteration in the patient’s core temperature can produce a relatively small change in
the SEP when recorded from the spinal column but a huge change can be seen when recording from the cortex. The nervous system also
responds differently in different places in terms of the time it takes to fail following hypoxia, the peripheral nerves can function for the longest (20-45 minutes) while the cerebral cortex can start to fail after just 20 seconds, the spinal grey matter can function for 1-2 minutes, the
spinal white matter (sensory pathways) 7-18 minutes and the spinal white matter (motor) for 11 minutes. So….MEPs are only affected immediately if the spinal grey matter is ischaemic, an interesting point I thought. Just raising the blood pressure in the event of an ischaemic
change can prevent an irreversible change occurring. A raised intracranial pressure can resist blood flow into the brain or spine as can
increased blood viscosity. The patient’s arms should be positioned forward of the plane of the body, ulnar neuropathy can be caused by
excessive flexion, whilst excessive flexion of the neck can cause quadra paresis/plegia. The ‘prone’ position does have an associated risk
of blindness caused by ischemia in the posterior optic nerve, believed to be related to venous pressure, visual evoked potentials have
been reported not to be sensitive to this change.
Mushtaq Shaikh gave us an excellent talk on his involvement with ‘the A-Team’ on a charity trip to India where spinal surgical corrective
procedures were carried out on seriously deformed children who were struggling in life because of their deformity, intraoperative monitoring was carried out by Mushtaq on all of the patients.
Ivana Jankovic went on to give an excellent talk about the use of EEG monitoring in scoliosis surgery. GOSH have undertaken a study of
104 patients undergoing intraoperative monitoring for spinal deformity and these were divided into 3 groups depending upon what their
EEG showed at the beginning and end of the procedure. The EEGs were graded as either A1, A2 or A3, A1 being the lightest level of sedation and A3 for EEGs showing burst suppression. The gradings were then linked to the level of stimulus required to elicit MEPs. The A2A2 group required a mean stimulus of 119mA at the start of the procedure and this increased to 129mA by the end. The A3-A2 group required a mean stimulus intensity of 134mA at the outset and 135mA by the end of the procedure whilst patients who remained at A3
throughout require 124mA stimulus at the outset and 154mA by the end of the procedure. Ivana found that having the EEG monitoring in
her armory has helped her be able to identify a true event as MEP traces may be lost if the patient is in burst suppression.
Dale Derbyshire spoke about hemodynamics and MEP monitoring, reiterating that the regular documentation of blood pressure changes
can be very helpful when trying to interpret changes in intraoperative monitoring and the degree to which a blood pressure change can
affect the monitoring is very patient specific.
Lindsay Henderson gave a very personal account of the experience of electrode burns in her department, which has now occurred twice.
Both occurred under the surface earth electrode and were small circular burns positioned where the wire lead leaves the pad. Lindsay and
her team had the patients seen by a dermatologist who confirmed these were indeed burns and not skin allergies. No definitive cause was
identified for the burns but it is likely that they were electrical burns from diathermy current returning to the IOM ground rather than the diathermy ground. The surgeon has agreed to reduce the diathermy settings and since then there has been no further recurrence. It seems it
might be important to ensure a low impedance between the skin and the ground electrode.
Mahboob Raja gave a very interesting talk on how intraoperative monitoring services differ between the UK and the States. Roughly half of
IOM services in the States are delivered by private companies whilst the other half comes from hospitals with specifically employed staff.
IOM must be interpreted by a consultant medic which usually means real time links to theatres, up until very recently the medic could be
viewing up to 20 IOM cases simultaneously though this is likely to change soon. The consultant is able to bill for each case that is running
simultaneously, hence the more cases at the same time the more lucrative the work. Mahboob discussed litigation and the major questions
involved are who did what? Who didn’t do what they should have? And who can be held responsible? Mahboob reiterated the need to document absolutely everything and to document the surgeon’s response to your comments. There are currently no federal or state requirements in terms of accreditation but hospitals do require you to have the CNIM.
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
BSS Meeting Review - Sheffield City Hall
22nd
–
23rd April
2015
AUGUST - 2015
PAGE ELEVEN
Gareth Thomas (CP from Norwich) spoke about a case he was involved in in Norwich where there was unilateral loss of MEPs in a patient
with Freidreich’s Ataxia during a scoliosis correction. Freidreich’s Ataxia is the most common autosomal recessive ataxia which affects
sensory pathways in the spinal cord, the motor pathways remain relatively intact. Pre-operatively the patient had absent SSEPs but magnetic stimulation did evoke some pre-operative MEPs. In the surgery upper and lower limb SSEPs were absent from the outset. MEPs
were elicited with 8 pulses at 600V. An iatrogenic surgical event occurred at right T5, MEP responses from the right lower limbs became
absent, and surgically a pedicle finder had impacted the cord and caused a cord contusion. After 10 long minutes there were partial return
of responses to AH and VL, it took 50 minutes for responses to return to baseline levels. The patient had instrumentation from T4-L1 and
on day 1 post-operatively there was decreased sensation and power in the right leg, by day 9 this was improving, by day 50 there remained some altered sensation in the right calf and instability at right knee.
We all trooped back across to the main lecture theatre for Mr Ben Taylor and Mr Sean Malloy’s talk on the pitfalls of adult deformity surgery. Adult degenerative scoliosis falls into a couple of categories, it is either due to degeneration in a pre-existing scoliosis or due to degeneration of the spine resulting in a deformity. Deformities can be either contained (affecting part of the spine) or uncontained (affecting
the whole spine and subsequently posture). Adult deformity surgery carries a high risk of complications; 40% have a peri-operative complication of some kind. Sagittal imbalance is the best indicator of a poor outcome if seen pre or post-operatively. Sometimes surgery can resolve the presenting problem but then cause a worse subsequent problem later on. Mr Malloy talked us through many case studies of adult
deformity corrections and there was little doubt that the patients in whom operations were deemed successful had a vastly improved quality of life however as described the potential pitfalls in this surgery certainly give it a level of risk.
Back in the NMUK meeting room Mr Thanos Tsirikos and Mr Christopher Adams delivered an excellent talk around the efficacy of multimodal IOM in preventing neurological injury in spinal deformity surgery. Mr Tsirikos began by outlining the aims of spinal deformity surgery.
Previous instrumentation systems were unable to effectively de-rotate the spine so considerable work was also carried out on the chest
wall with a lot of post-operative complications and pain with stays on ITU. Pedicle screw construct allow for improved fixation to the spine.
The greatest risk of screw misplacement (which has been reported as having an incidence of up to 15%) occurs in the thoracic spine between T4 and T7 as the spinal cord occupies most of the spinal canal at this point. The risk of injury to the spinal cord or nerves in spinal
deformity surgery is quoted as 1:600 (figures from 2011). Medial breaches can cause a los of MEPs in some cases. In Edinburgh it has
been found that transient false positive events are primarily caused by a reduction in BP. Schuerman’s kyphosis carries a slightly greater
risk than adolescent idiopathic scoliosis for a real surgical event. Mr Adams went on to discuss the benefits they have seen in Edinburgh in
the value of MDT and morbidity and mortality meetings in IOM. Edinburgh have kept a database of all of their cases monitored since 2009.
Finally Helen Grover and I attended a session around IOM coding back in the main lecture theatre delivered by Mr Ashley Cole. This
turned out to be really rather interesting, living and working in the South West I had not realised that in terms of the tariff attracted by deformity surgery the South West attracts one of the lowest tariffs in the country simply because of our location. I had also not realized that
paediatric work generally attracts a higher tariff than the adult deformity work despite some of the adult work being very complex in some
cases. I had also not realised that it is possible to claim a higher payment if the patient has complications associated with their surgery. I
came away from this talk feeling that the system is complicated and knowledge of how it works is imperative if Trusts are not to lose out in
being paid for the work they have undertaken.
Overall this meeting I felt was a resounding success, it was the first time in 3 years that I was not scheduled to deliver a talk or chair a session and I had the invaluable opportunity to just sit listen and learn and I really feel I have taken away some knowledge and understanding
which I had not had before and also importantly there are some points which I am going to return to our department with and discuss and
potentially implement changes as soon as they have been discussed and agreed. Well done NMUK team for facilitating such an excellent
multidisciplinary meeting.
Mrs Katy Danby
NMUK.
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
BSS Meeting - Feedback
AUGUST - 2015
Prepared by Rosie Steele
PAGE TWELVE
Great
International
Speakers
Training for IOM practitioners:
Important subject that needs discussion
What
enthusiasm!
Fab. You've given some
good ideas to investigate!
very clear and useful
information
Interactive and enjoyable
Very informative & well-paced
Fantastic, very valid points
What you would like to see
NMUK doing in the future?
What you liked most about the
meeting:
# More neuromonitoring case studies
Very clear explanations
of tech# Formalisation
guidelines
for IONM
niques
# More joint meetings with the surgeons and anaesthetists
# More on training competencies and
portfolio contents
# Provide speaker contact details in
order to obtain copies of slides/
presentations
# Similar well-structured events with
variety of topics
International Guest Speakers
Joint venue with surgeons
Sala and Sloan lectures
Given lots of ideas for new things to try
Speakers and overall organisation
Involvement of anaesthetists & surgeons
Fantastic Programme
Diverse range of subjects presented
Networking with IONM colleagues
Well organised & informative
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372
Neuromonitoring UK
Promoting Excellence in Neurological Monitoring throughout the UK.
Quarterly Newsletter
Summer 2015
AUGUST - 2015
PAGE THIRTEEN
PLEASE HELP US DEVLOPE THIS NEWSLETTER!
If you have any questions or comments please feel free to contact us via
email: editor@neuromonitoringUK.org
We are keen that this newsletter becomes an interactive medium for members to share their experiences, allowing each other to learn, develop their own practice and forge inter-department links.
If you have something you wish to share with us, or questions and suggestions for content to appear in this newsletter please do not hesitate to contact us.
Many thanks
Alex Woodhams - NMUK Newsletter Editor
Disclaimer.
This newsletter contains information about the special interest
group NMUK and events it has organised and those organised
by other groups. The information it contains is not advice, and
should not be treated as such.
You must not rely on the information in the newsletter as an alternative to professional training and advice from an appropriately qualified neurophysiologist, medical professional or other
specialist training organisation.
NMUK place information on non-NMUK meetings here for the
benefit of its' membership. The NMUK are not responsible for
the content or quality of these meetings and it is the responsibility of the individual to determine the suitability of any particular
event.
Neuromonitoring UK Registered Office: 49 Station Road, Polegate, East Sussex, BN26 6EA , England. Company Number: 9563372