The Role of Intraoperative Neuromonitoring (IONM)
DavidBarnkow
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56 slides
Mar 26, 2015
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About This Presentation
This presentation introduces medical professionals and allied healthcare associates to the fundamental rationale, objectives, techniques, and utilizations of intraoperative neurophysiologic monitoring (IONM).
Slide Content
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who? What? When? Where? Why? How?Who? What? When? Where? Why? How?
Image Source: http://themostimportantnews.com/archives/new-poll-45-percent-of-american-doctors-would-consider-quitting-or-retiring-if-Image Source: http://themostimportantnews.com/archives/new-poll-45-percent-of-american-doctors-would-consider-quitting-or-retiring-if-
obamacare-is-adoptedobamacare-is-adopted
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who? What? When? Where? Why? How?Who? What? When? Where? Why? How?
Image Source: http://themostimportantnews.com/archives/new-poll-45-percent-of-american-doctors-would-consider-quitting-or-retiring-if-Image Source: http://themostimportantnews.com/archives/new-poll-45-percent-of-american-doctors-would-consider-quitting-or-retiring-if-
obamacare-is-adoptedobamacare-is-adopted
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-
problem.jpg, modified without permission.problem.jpg, modified without permission.
What?What?
What’s the problem?What’s the problem?
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-
problem.jpg, modified without permission.problem.jpg, modified without permission.
What?What?
What’s the problem?What’s the problem?
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-problem.jpg, Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-problem.jpg,
modified without permission.modified without permission.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-problem.jpg, Image Retrieved 9/11/2012 from: http://computingforsustainability.files.wordpress.com/2011/04/trolley-problem.jpg,
modified without permission.modified without permission.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
Iatrogenic injuryIatrogenic injury
Iatrogenic i·at·ro·gen·ic (ī-āt'r -jěn'ĭk) adj.
ə
Iatrogenic i·at·ro·gen·ic (ī-āt'r -jěn'ĭk) adj.
ə
Induced in a patient by a physician's Induced in a patient by a physician's
activity, manner, or therapy.activity, manner, or therapy.
The American Heritage® Stedman's Medical DictionaryThe American Heritage® Stedman's Medical Dictionary
Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
Iatrogenic injuryIatrogenic injury
Iatrogenic i·at·ro·gen·ic (ī-āt'r -jěn'ĭk) adj.
ə
Iatrogenic i·at·ro·gen·ic (ī-āt'r -jěn'ĭk) adj.
ə
Induced in a patient by a physician's Induced in a patient by a physician's
activity, manner, or therapy.activity, manner, or therapy.
The American Heritage® Stedman's Medical DictionaryThe American Heritage® Stedman's Medical Dictionary
Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
Iatrogenic neurological injury in spine surgery Iatrogenic neurological injury in spine surgery
can be caused by:can be caused by:
SurgicalSurgical
Distraction, compression or blunt traumaDistraction, compression or blunt trauma
Ischemia of neural structuresIschemia of neural structures
Thrombotic eventsThrombotic events
Anesthetic or Systemic ProblemsAnesthetic or Systemic Problems
Ischemia, Ischemia,
hypoxiahypoxia
hypothermiahypothermia
cervical extension during intubationcervical extension during intubation
PositioningPositioning
Direct compressionDirect compression
Compromised blood supplyCompromised blood supply
Neck and shoulder positioningNeck and shoulder positioning
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
Iatrogenic neurological injury in spine surgery Iatrogenic neurological injury in spine surgery
can be caused by:can be caused by:
SurgicalSurgical
Distraction, compression or blunt traumaDistraction, compression or blunt trauma
Ischemia of neural structuresIschemia of neural structures
Thrombotic eventsThrombotic events
Anesthetic or Systemic ProblemsAnesthetic or Systemic Problems
Ischemia, Ischemia,
hypoxiahypoxia
hypothermiahypothermia
cervical extension during intubationcervical extension during intubation
PositioningPositioning
Direct compressionDirect compression
Compromised blood supplyCompromised blood supply
Neck and shoulder positioningNeck and shoulder positioning
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
What is the incidence of iatrogenic injury in elective spine What is the incidence of iatrogenic injury in elective spine
surgery?surgery?
Iatrogenic neurological injuries in elective spinal surgery Iatrogenic neurological injuries in elective spinal surgery
without neurophysiological monitoring:without neurophysiological monitoring:
Anterior cervical discectomy – 0.46%Anterior cervical discectomy – 0.46%
Scoliosis correction - 0.23-3.2%Scoliosis correction - 0.23-3.2%
Intramedullary tumor resection - >23.8%Intramedullary tumor resection - >23.8%
Vauzelle C, Stagnara P, Jouvinroux P. Functional monitoring of spinal cord activity during spinal surgery. Vauzelle C, Stagnara P, Jouvinroux P. Functional monitoring of spinal cord activity during spinal surgery.
Clin Orthop Relat Res 1973;93:173-8Clin Orthop Relat Res 1973;93:173-8
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
What?What?
What’s the problem?What’s the problem?
What is the incidence of iatrogenic injury in elective spine What is the incidence of iatrogenic injury in elective spine
surgery?surgery?
Iatrogenic neurological injuries in elective spinal surgery Iatrogenic neurological injuries in elective spinal surgery
without neurophysiological monitoring:without neurophysiological monitoring:
Anterior cervical discectomy – 0.46%Anterior cervical discectomy – 0.46%
Scoliosis correction - 0.23-3.2%Scoliosis correction - 0.23-3.2%
Intramedullary tumor resection - >23.8%Intramedullary tumor resection - >23.8%
Vauzelle C, Stagnara P, Jouvinroux P. Functional monitoring of spinal cord activity during spinal surgery. Vauzelle C, Stagnara P, Jouvinroux P. Functional monitoring of spinal cord activity during spinal surgery.
Clin Orthop Relat Res 1973;93:173-8Clin Orthop Relat Res 1973;93:173-8
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Why?Why?
Why avoid iatrogenic injury?Why avoid iatrogenic injury?
To improve or maintain quality of life. To improve or maintain quality of life.
(WHO - HRQOL)(WHO - HRQOL)
People with spinal cord injury (SCI):People with spinal cord injury (SCI):
report lower sense of well-beingreport lower sense of well-being
score lower on physical, mental, and social health score lower on physical, mental, and social health
domainsdomains
Dijkers, M: Quality of life of individuals with spinal cord injury: A review of conceptualization, Dijkers, M: Quality of life of individuals with spinal cord injury: A review of conceptualization,
measurement, and research findings. J. Rehab Res & Dev, Supplement Number 1, Volume 42 Number measurement, and research findings. J. Rehab Res & Dev, Supplement Number 1, Volume 42 Number
3, May/June 2005, Pages 87-110. Retrieved 9/11/12 from 3, May/June 2005, Pages 87-110. Retrieved 9/11/12 from
http://www.rehab.research.va.gov/jour/05/42/3suppl1/dijkers.htmlhttp://www.rehab.research.va.gov/jour/05/42/3suppl1/dijkers.html
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Why?Why?
Why avoid iatrogenic injury?Why avoid iatrogenic injury?
To improve or maintain quality of life. To improve or maintain quality of life.
(WHO - HRQOL)(WHO - HRQOL)
People with spinal cord injury (SCI):People with spinal cord injury (SCI):
report lower sense of well-beingreport lower sense of well-being
score lower on physical, mental, and social health score lower on physical, mental, and social health
domainsdomains
Dijkers, M: Quality of life of individuals with spinal cord injury: A review of conceptualization, Dijkers, M: Quality of life of individuals with spinal cord injury: A review of conceptualization,
measurement, and research findings. J. Rehab Res & Dev, Supplement Number 1, Volume 42 Number measurement, and research findings. J. Rehab Res & Dev, Supplement Number 1, Volume 42 Number
3, May/June 2005, Pages 87-110. Retrieved 9/11/12 from 3, May/June 2005, Pages 87-110. Retrieved 9/11/12 from
http://www.rehab.research.va.gov/jour/05/42/3suppl1/dijkers.htmlhttp://www.rehab.research.va.gov/jour/05/42/3suppl1/dijkers.html
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Why?Why?
Why avoid iatrogenic injury?Why avoid iatrogenic injury?
To improve or maintain quality of life. (WHO – HRQOL)To improve or maintain quality of life. (WHO – HRQOL)
““Life expectancies for persons with SCI continue to Life expectancies for persons with SCI continue to
increase, but are still somewhat below life expectancies increase, but are still somewhat below life expectancies
for those with no SCI.”for those with no SCI.”
National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a
Glance, February 2012, retrieved 9/11/12 at Glance, February 2012, retrieved 9/11/12 at
https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202012%20Feb%20Final.pdfhttps://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202012%20Feb%20Final.pdf
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Why?Why?
Why avoid iatrogenic injury?Why avoid iatrogenic injury?
To improve or maintain quality of life. (WHO – HRQOL)To improve or maintain quality of life. (WHO – HRQOL)
““Life expectancies for persons with SCI continue to Life expectancies for persons with SCI continue to
increase, but are still somewhat below life expectancies increase, but are still somewhat below life expectancies
for those with no SCI.”for those with no SCI.”
National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a
Glance, February 2012, retrieved 9/11/12 at Glance, February 2012, retrieved 9/11/12 at
https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202012%20Feb%20Final.pdfhttps://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202012%20Feb%20Final.pdf
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Why?Why?
Why avoid iatrogenic injury?Why avoid iatrogenic injury?
Reduce the costs associated with iatrogenic injury.Reduce the costs associated with iatrogenic injury.
The average yearly health care and living expenses directly The average yearly health care and living expenses directly
attributable to SCI was $69,204 in February 2012 dollars. attributable to SCI was $69,204 in February 2012 dollars.
These figures do not include any indirect costs such as losses These figures do not include any indirect costs such as losses
in wages, fringe benefits and productivity. in wages, fringe benefits and productivity.
National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a Glance, National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a Glance,
February 2012, retrieved Sept. 11, 20112 at https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/FactsFebruary 2012, retrieved Sept. 11, 20112 at https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts
%202012%20Feb%20Final.pdf%202012%20Feb%20Final.pdf
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Why?Why?
Why avoid iatrogenic injury?Why avoid iatrogenic injury?
Reduce the costs associated with iatrogenic injury.Reduce the costs associated with iatrogenic injury.
The average yearly health care and living expenses directly The average yearly health care and living expenses directly
attributable to SCI was $69,204 in February 2012 dollars. attributable to SCI was $69,204 in February 2012 dollars.
These figures do not include any indirect costs such as losses These figures do not include any indirect costs such as losses
in wages, fringe benefits and productivity. in wages, fringe benefits and productivity.
National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a Glance, National Spinal Cord Injury Statistical Center, Birmingham, Alabama, Spinal Cord Injury Facts and Figures at a Glance,
February 2012, retrieved Sept. 11, 20112 at https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/FactsFebruary 2012, retrieved Sept. 11, 20112 at https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts
%202012%20Feb%20Final.pdf%202012%20Feb%20Final.pdf
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How can we avoid iatrogenic injury?How can we avoid iatrogenic injury?
Timely detection of changes in Timely detection of changes in
neurologic status allows neurologic status allows
therapeutic actiontherapeutic action to ameliorate to ameliorate
or avoid neurologic deficitsor avoid neurologic deficits.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How can we avoid iatrogenic injury?How can we avoid iatrogenic injury?
Timely detection of changes in Timely detection of changes in
neurologic status allows neurologic status allows
therapeutic actiontherapeutic action to ameliorate to ameliorate
or avoid neurologic deficitsor avoid neurologic deficits.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How can we detect changes in How can we detect changes in
neurologic status?neurologic status?
Functional vs. Structural AssessmentFunctional vs. Structural Assessment
Structural AssessmentStructural Assessment
RadiographyRadiography
SonographySonography
VisualizationVisualization
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How can we detect changes in How can we detect changes in
neurologic status?neurologic status?
Functional vs. Structural AssessmentFunctional vs. Structural Assessment
Structural AssessmentStructural Assessment
RadiographyRadiography
SonographySonography
VisualizationVisualization
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How can we detect changes in How can we detect changes in
neurologic status?neurologic status?
Function AssessmentFunction Assessment
Using provocative and non-provocative Using provocative and non-provocative
techniques.techniques.
Intraoperative Neurophysiologic Monitoring Intraoperative Neurophysiologic Monitoring
(IONM)(IONM)
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How can we detect changes in How can we detect changes in
neurologic status?neurologic status?
Function AssessmentFunction Assessment
Using provocative and non-provocative Using provocative and non-provocative
techniques.techniques.
Intraoperative Neurophysiologic Monitoring Intraoperative Neurophysiologic Monitoring
(IONM)(IONM)
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How is IONM performed?How is IONM performed?
Electrophysiologic AssessmentsElectrophysiologic Assessments
Non-ProvocativeNon-Provocative
Spontaneous electromyography (sEMG)Spontaneous electromyography (sEMG)
Electroencephalography (EEG)Electroencephalography (EEG)
ProvocativeProvocative
Triggered electromyography (tEMG)Triggered electromyography (tEMG)
Electroencephalography (EEG)Electroencephalography (EEG)
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Motor (MEP)Motor (MEP)
Nerve Conduction Study (NCS)Nerve Conduction Study (NCS)
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How is IONM performed?How is IONM performed?
Electrophysiologic AssessmentsElectrophysiologic Assessments
Non-ProvocativeNon-Provocative
Spontaneous electromyography (sEMG)Spontaneous electromyography (sEMG)
Electroencephalography (EEG)Electroencephalography (EEG)
ProvocativeProvocative
Triggered electromyography (tEMG)Triggered electromyography (tEMG)
Electroencephalography (EEG)Electroencephalography (EEG)
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Motor (MEP)Motor (MEP)
Nerve Conduction Study (NCS)Nerve Conduction Study (NCS)
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How effective is IONM?How effective is IONM?
Efficacy of IONM in Cervical Spine SurgeryEfficacy of IONM in Cervical Spine Surgery
Somatosensory evoked potentialsSomatosensory evoked potentials
sensitivity - sensitivity - 52% (+ correctly ID'd)52% (+ correctly ID'd)
specificity - specificity - 100% (- correctly ID'd)100% (- correctly ID'd)
PPV - PPV - 100% (true +/+calls)100% (true +/+calls)
NPV - NPV - 97% (true -/- calls)97% (true -/- calls)
Motor evoked potentialsMotor evoked potentials
sensitivity - sensitivity - 100%100%
specificity - specificity - 96%96%
PPV - PPV - 96%96%
NPV -NPV - 100%100%
ElectromyographyElectromyography
sensitivity -sensitivity - 46%46%
specificity - specificity - 73%73%
PPV - PPV - 3%3%
NPV -NPV - 97%97%
Kelleher MO, Tan G, Sarjeant R, Fehlings MG: Predictive value of intraoperative neurophysiological monitoring during cervical spine surgery: a prospective analysis Kelleher MO, Tan G, Sarjeant R, Fehlings MG: Predictive value of intraoperative neurophysiological monitoring during cervical spine surgery: a prospective analysis
of 1055 consecutive patients. J Neurosurg Spine. 2008 Mar;8(3):215-21.of 1055 consecutive patients. J Neurosurg Spine. 2008 Mar;8(3):215-21.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How effective is IONM?How effective is IONM?
Efficacy of IONM in Cervical Spine SurgeryEfficacy of IONM in Cervical Spine Surgery
Somatosensory evoked potentialsSomatosensory evoked potentials
sensitivity - sensitivity - 52% (+ correctly ID'd)52% (+ correctly ID'd)
specificity - specificity - 100% (- correctly ID'd)100% (- correctly ID'd)
PPV - PPV - 100% (true +/+calls)100% (true +/+calls)
NPV - NPV - 97% (true -/- calls)97% (true -/- calls)
Motor evoked potentialsMotor evoked potentials
sensitivity - sensitivity - 100%100%
specificity - specificity - 96%96%
PPV - PPV - 96%96%
NPV -NPV - 100%100%
ElectromyographyElectromyography
sensitivity -sensitivity - 46%46%
specificity - specificity - 73%73%
PPV - PPV - 3%3%
NPV -NPV - 97%97%
Kelleher MO, Tan G, Sarjeant R, Fehlings MG: Predictive value of intraoperative neurophysiological monitoring during cervical spine surgery: a prospective analysis Kelleher MO, Tan G, Sarjeant R, Fehlings MG: Predictive value of intraoperative neurophysiological monitoring during cervical spine surgery: a prospective analysis
of 1055 consecutive patients. J Neurosurg Spine. 2008 Mar;8(3):215-21.of 1055 consecutive patients. J Neurosurg Spine. 2008 Mar;8(3):215-21.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How effective is IONM?How effective is IONM?
Efficacy of IONM in Thorocolumbar Efficacy of IONM in Thorocolumbar
Spine Surgery (nerve root emphasis)Spine Surgery (nerve root emphasis)
SSEPsSSEPs
sensitivity - sensitivity - 29%29%
specificity - specificity - 95%95%
sEMGsEMG
sensitivity - sensitivity - 100%100%
specificity -specificity -23.7%23.7%
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How effective is IONM?How effective is IONM?
Efficacy of IONM in Thorocolumbar Efficacy of IONM in Thorocolumbar
Spine Surgery (nerve root emphasis)Spine Surgery (nerve root emphasis)
SSEPsSSEPs
sensitivity - sensitivity - 29%29%
specificity - specificity - 95%95%
sEMGsEMG
sensitivity - sensitivity - 100%100%
specificity -specificity -23.7%23.7%
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How effective is IONM?How effective is IONM?
Multimodal IONM reduces the relative risk of post-Multimodal IONM reduces the relative risk of post-
operative neurological complications in spine surgery by an operative neurological complications in spine surgery by an
estimated 49.4% at a mean cost of $63,387 per neurological estimated 49.4% at a mean cost of $63,387 per neurological
deficit averted.deficit averted.
Ney JP, Van der Goes DN, Watanabe JH: Cost-effectiveness of intraoperative neurophysiological monitoring for spinal Ney JP, Van der Goes DN, Watanabe JH: Cost-effectiveness of intraoperative neurophysiological monitoring for spinal
surgeries: Beginning steps, Clinical Neurophysiology, Volume 123, Issue 9, Pages 1705-1707, September 2012surgeries: Beginning steps, Clinical Neurophysiology, Volume 123, Issue 9, Pages 1705-1707, September 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
How?How?
How effective is IONM?How effective is IONM?
Multimodal IONM reduces the relative risk of post-Multimodal IONM reduces the relative risk of post-
operative neurological complications in spine surgery by an operative neurological complications in spine surgery by an
estimated 49.4% at a mean cost of $63,387 per neurological estimated 49.4% at a mean cost of $63,387 per neurological
deficit averted.deficit averted.
Ney JP, Van der Goes DN, Watanabe JH: Cost-effectiveness of intraoperative neurophysiological monitoring for spinal Ney JP, Van der Goes DN, Watanabe JH: Cost-effectiveness of intraoperative neurophysiological monitoring for spinal
surgeries: Beginning steps, Clinical Neurophysiology, Volume 123, Issue 9, Pages 1705-1707, September 2012surgeries: Beginning steps, Clinical Neurophysiology, Volume 123, Issue 9, Pages 1705-1707, September 2012
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
When?When?
When is IONM appropriate?When is IONM appropriate?
Identify iatrogenic nervous system compromise in a Identify iatrogenic nervous system compromise in a
timely fashion.timely fashion.
Ongoing monitoringOngoing monitoring
Identify neural structures through specific testing Identify neural structures through specific testing
procedures.procedures.
Time-Specific assessmentTime-Specific assessment
Identify when iatrogenic injury occurred in Identify when iatrogenic injury occurred in
experimental procedures.experimental procedures.
Ongoing monitoringOngoing monitoring
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
When?When?
When is IONM appropriate?When is IONM appropriate?
Identify iatrogenic nervous system compromise in a Identify iatrogenic nervous system compromise in a
timely fashion.timely fashion.
Ongoing monitoringOngoing monitoring
Identify neural structures through specific testing Identify neural structures through specific testing
procedures.procedures.
Time-Specific assessmentTime-Specific assessment
Identify when iatrogenic injury occurred in Identify when iatrogenic injury occurred in
experimental procedures.experimental procedures.
Ongoing monitoringOngoing monitoring
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Where?Where?
Where can IONM be performed?Where can IONM be performed?
On the hospital floorsOn the hospital floors
In Pre-Op HoldingIn Pre-Op Holding
In the Operating RoomIn the Operating Room
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Where?Where?
Where can IONM be performed?Where can IONM be performed?
On the hospital floorsOn the hospital floors
In Pre-Op HoldingIn Pre-Op Holding
In the Operating RoomIn the Operating Room
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who?Who?
Who provides IONM?Who provides IONM?
Technologists – Technical ComponentTechnologists – Technical Component
•Associate and Bachelor Degrees.Associate and Bachelor Degrees.
•Trained in the technical aspects of data collection. Trained in the technical aspects of data collection.
•Lack training and knowledge to provide Lack training and knowledge to provide
interpretation, diagnosis and treatmentinterpretation, diagnosis and treatment
Credentials:Credentials:
•ABRET - American Board of Registration of ABRET - American Board of Registration of
Electroencephalographic and Evoked Potential Electroencephalographic and Evoked Potential
Technologists Technologists
•CNIM - Certificate in Neurophysiologic CNIM - Certificate in Neurophysiologic
Intraoperative MonitoringIntraoperative Monitoring
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who?Who?
Who provides IONM?Who provides IONM?
Technologists – Technical ComponentTechnologists – Technical Component
•Associate and Bachelor Degrees.Associate and Bachelor Degrees.
•Trained in the technical aspects of data collection. Trained in the technical aspects of data collection.
•Lack training and knowledge to provide Lack training and knowledge to provide
interpretation, diagnosis and treatmentinterpretation, diagnosis and treatment
Credentials:Credentials:
•ABRET - American Board of Registration of ABRET - American Board of Registration of
Electroencephalographic and Evoked Potential Electroencephalographic and Evoked Potential
Technologists Technologists
•CNIM - Certificate in Neurophysiologic CNIM - Certificate in Neurophysiologic
Intraoperative MonitoringIntraoperative Monitoring
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who?Who?
Who provides IONM?Who provides IONM?
Non-Physician Surgical Neurophysiologist – Professional Non-Physician Surgical Neurophysiologist – Professional
ComponentComponent
•Non-MD providers with Doctorate Degrees.Non-MD providers with Doctorate Degrees.
•Technical Support for CNIMs.Technical Support for CNIMs.
•Technical ComponentTechnical Component
•Site-specific credentials may allow:Site-specific credentials may allow:
Supervision dutiesSupervision duties
Interpretation with treatment suggestions to Interpretation with treatment suggestions to
surgical team M.D.s.surgical team M.D.s.
Credentials:Credentials:
•ABNM – American Board of Neurophysiologic ABNM – American Board of Neurophysiologic
Monitoring Monitoring
•Diplomat – D.ABNMDiplomat – D.ABNM
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who?Who?
Who provides IONM?Who provides IONM?
Non-Physician Surgical Neurophysiologist – Professional Non-Physician Surgical Neurophysiologist – Professional
ComponentComponent
•Non-MD providers with Doctorate Degrees.Non-MD providers with Doctorate Degrees.
•Technical Support for CNIMs.Technical Support for CNIMs.
•Technical ComponentTechnical Component
•Site-specific credentials may allow:Site-specific credentials may allow:
Supervision dutiesSupervision duties
Interpretation with treatment suggestions to Interpretation with treatment suggestions to
surgical team M.D.s.surgical team M.D.s.
Credentials:Credentials:
•ABNM – American Board of Neurophysiologic ABNM – American Board of Neurophysiologic
Monitoring Monitoring
•Diplomat – D.ABNMDiplomat – D.ABNM
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who?Who?
Who provides IONM?Who provides IONM?
Clinical Neurophysiologist – Medical ComponentClinical Neurophysiologist – Medical Component
Medical Doctors – M.D. and D.O. With specific Medical Doctors – M.D. and D.O. With specific
certification.certification.
InterpretationInterpretation
DiagnosisDiagnosis
TreatmentTreatment
Credentials: Certification from;Credentials: Certification from;
ABPN - ABPN - American Board of Psychiatry and NeurologyAmerican Board of Psychiatry and Neurology
ABCN - ABCN - American Board of Clinical NeurophysiologyAmerican Board of Clinical Neurophysiology
ABEM - ABEM - American Board of Emergency MedicineAmerican Board of Emergency Medicine
ABNM – ABNM – American Board of Neurophysiologic American Board of Neurophysiologic
Monitoring Monitoring
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Who?Who?
Who provides IONM?Who provides IONM?
Clinical Neurophysiologist – Medical ComponentClinical Neurophysiologist – Medical Component
Medical Doctors – M.D. and D.O. With specific Medical Doctors – M.D. and D.O. With specific
certification.certification.
InterpretationInterpretation
DiagnosisDiagnosis
TreatmentTreatment
Credentials: Certification from;Credentials: Certification from;
ABPN - ABPN - American Board of Psychiatry and NeurologyAmerican Board of Psychiatry and Neurology
ABCN - ABCN - American Board of Clinical NeurophysiologyAmerican Board of Clinical Neurophysiology
ABEM - ABEM - American Board of Emergency MedicineAmerican Board of Emergency Medicine
ABNM – ABNM – American Board of Neurophysiologic American Board of Neurophysiologic
Monitoring Monitoring
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/12 from; http://en.wikipedia.org/wiki/File:Gray759.png
Anatomy ReviewAnatomy Review
Sensory InputSensory Input
Posterior Dorsal Column-Posterior Dorsal Column-
Lemniscal TractLemniscal Tract
Conveys touch, vibration Conveys touch, vibration
and proprioception and proprioception
information to the brain.information to the brain.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/12 from; http://en.wikipedia.org/wiki/File:Gray759.png
Anatomy ReviewAnatomy Review
Sensory InputSensory Input
Posterior Dorsal Column-Posterior Dorsal Column-
Lemniscal TractLemniscal Tract
Conveys touch, vibration Conveys touch, vibration
and proprioception and proprioception
information to the brain.information to the brain.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Anatomy ReviewAnatomy Review
Corticospinal TractCorticospinal Tract
Voluntary skilled Voluntary skilled
activityactivity
Pre-central gyrus of Pre-central gyrus of
cortex to spinal cord cortex to spinal cord
without interruptionwithout interruption
Retrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.pngRetrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.png
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Anatomy ReviewAnatomy Review
Corticospinal TractCorticospinal Tract
Voluntary skilled Voluntary skilled
activityactivity
Pre-central gyrus of Pre-central gyrus of
cortex to spinal cord cortex to spinal cord
without interruptionwithout interruption
Retrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.pngRetrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.png
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/2012 from; http://en.wikipedia.org/wiki/File:Medulla_spinalis_-_tracts_-Retrieved on 9/12/2012 from; http://en.wikipedia.org/wiki/File:Medulla_spinalis_-_tracts_-
_English.svg_English.svg
Anatomy ReviewAnatomy Review
Spinal Cord AnatomySpinal Cord Anatomy
Blood supply of dorsal 1/3 Blood supply of dorsal 1/3
of spinal cord via the two of spinal cord via the two
posterior spinal arteries.posterior spinal arteries.
Blood supply of the Blood supply of the
anterior 2/3 of spinal cord anterior 2/3 of spinal cord
via the single anterior via the single anterior
spinal artery.spinal artery.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/2012 from; http://en.wikipedia.org/wiki/File:Medulla_spinalis_-_tracts_-Retrieved on 9/12/2012 from; http://en.wikipedia.org/wiki/File:Medulla_spinalis_-_tracts_-
_English.svg_English.svg
Anatomy ReviewAnatomy Review
Spinal Cord AnatomySpinal Cord Anatomy
Blood supply of dorsal 1/3 Blood supply of dorsal 1/3
of spinal cord via the two of spinal cord via the two
posterior spinal arteries.posterior spinal arteries.
Blood supply of the Blood supply of the
anterior 2/3 of spinal cord anterior 2/3 of spinal cord
via the single anterior via the single anterior
spinal artery.spinal artery.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Anatomy ReviewAnatomy Review
Anterior Spinal ArteryAnterior Spinal Artery
Spinal cord blood Spinal cord blood
supply and watershed supply and watershed
regionsregions
Nuwer MR, Handbook of Clinical Neurophysiology Volume 8; Intraoperative Nuwer MR, Handbook of Clinical Neurophysiology Volume 8; Intraoperative
Monitoring of Neural Function.(2008). Elsevier, Daube and Mauguiere Eds. Pg 58Monitoring of Neural Function.(2008). Elsevier, Daube and Mauguiere Eds. Pg 58
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Anatomy ReviewAnatomy Review
Anterior Spinal ArteryAnterior Spinal Artery
Spinal cord blood Spinal cord blood
supply and watershed supply and watershed
regionsregions
Nuwer MR, Handbook of Clinical Neurophysiology Volume 8; Intraoperative Nuwer MR, Handbook of Clinical Neurophysiology Volume 8; Intraoperative
Monitoring of Neural Function.(2008). Elsevier, Daube and Mauguiere Eds. Pg 58Monitoring of Neural Function.(2008). Elsevier, Daube and Mauguiere Eds. Pg 58
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Anatomy ReviewAnatomy Review
Nerve RootsNerve Roots
Retrieved on 9/12/2012 from http://en.wikipedia.org/wiki/File:Spinal_nerve.svgRetrieved on 9/12/2012 from http://en.wikipedia.org/wiki/File:Spinal_nerve.svg
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Anatomy ReviewAnatomy Review
Nerve RootsNerve Roots
Retrieved on 9/12/2012 from http://en.wikipedia.org/wiki/File:Spinal_nerve.svgRetrieved on 9/12/2012 from http://en.wikipedia.org/wiki/File:Spinal_nerve.svg
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/12 from Retrieved on 9/12/12 from
http://upload.wikimedia.org/wikipedia/commons/a/ad/Foraminaintervertebrhttp://upload.wikimedia.org/wikipedia/commons/a/ad/Foraminaintervertebr
alia.pngalia.png
Anatomy ReviewAnatomy Review
Intervertebral Intervertebral
ForamenForamen
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/12 from Retrieved on 9/12/12 from
http://upload.wikimedia.org/wikipedia/commons/a/ad/Foraminaintervertebrhttp://upload.wikimedia.org/wikipedia/commons/a/ad/Foraminaintervertebr
alia.pngalia.png
Anatomy ReviewAnatomy Review
Intervertebral Intervertebral
ForamenForamen
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Techniques in IONMElectrophysiological Techniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Motor (MEP)Motor (MEP)
ElectromyographyElectromyography
Spontaneous EMG (sEMG)Spontaneous EMG (sEMG)
Triggered EMG (tEMG)Triggered EMG (tEMG)
Nerve Conduction Study (NCS) Nerve Conduction Study (NCS) low relevance to spine surgerylow relevance to spine surgery
Electroencephalography (EEG) Electroencephalography (EEG) low relevance to spine surgerylow relevance to spine surgery
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Techniques in IONMElectrophysiological Techniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Motor (MEP)Motor (MEP)
ElectromyographyElectromyography
Spontaneous EMG (sEMG)Spontaneous EMG (sEMG)
Triggered EMG (tEMG)Triggered EMG (tEMG)
Nerve Conduction Study (NCS) Nerve Conduction Study (NCS) low relevance to spine surgerylow relevance to spine surgery
Electroencephalography (EEG) Electroencephalography (EEG) low relevance to spine surgerylow relevance to spine surgery
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Electrophysiological
Techniques in IONMTechniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Stimulation: Stimulation:
electrical, peripheral mixed nerve.electrical, peripheral mixed nerve.
Recording:Recording:
neurogenic. peripheral, neurogenic. peripheral,
subcortical, cortical.subcortical, cortical.
Use:Use:
monitor dorsal spinal cord monitor dorsal spinal cord
(afferent) and afferent peripheral (afferent) and afferent peripheral
nervesnerves
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Electrophysiological
Techniques in IONMTechniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Stimulation: Stimulation:
electrical, peripheral mixed nerve.electrical, peripheral mixed nerve.
Recording:Recording:
neurogenic. peripheral, neurogenic. peripheral,
subcortical, cortical.subcortical, cortical.
Use:Use:
monitor dorsal spinal cord monitor dorsal spinal cord
(afferent) and afferent peripheral (afferent) and afferent peripheral
nervesnerves
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/12 from; http://en.wikipedia.org/wiki/File:Gray759.pngRetrieved on 9/12/12 from; http://en.wikipedia.org/wiki/File:Gray759.png
Electrophysiological Electrophysiological
Techniques in IONMTechniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Stimulation: Stimulation:
electrical, peripheral electrical, peripheral
mixed nervemixed nerve
Recording: Recording:
neurogenic. neurogenic.
peripheral, peripheral,
subcortical, corticalsubcortical, cortical
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Retrieved on 9/12/12 from; http://en.wikipedia.org/wiki/File:Gray759.pngRetrieved on 9/12/12 from; http://en.wikipedia.org/wiki/File:Gray759.png
Electrophysiological Electrophysiological
Techniques in IONMTechniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Somatosensory (SSEP)Somatosensory (SSEP)
Stimulation: Stimulation:
electrical, peripheral electrical, peripheral
mixed nervemixed nerve
Recording: Recording:
neurogenic. neurogenic.
peripheral, peripheral,
subcortical, corticalsubcortical, cortical
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Electrophysiological
Techniques in IONMTechniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Motor (MEP)Motor (MEP)
Stimulation: Stimulation:
Electrical or Electrical or
MagneticMagnetic
Recording: Recording:
Neurogenic - Spinal Neurogenic - Spinal
CordCord
Myogenic - Muscles Myogenic - Muscles
of Interestof Interest
Use:Use:
Monitor anterior Monitor anterior
spinal cord and spinal cord and
efferent peripheral efferent peripheral
nervesnerves
Retrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.pngRetrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.png
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Electrophysiological
Techniques in IONMTechniques in IONM
Evoked Potentials (EP)Evoked Potentials (EP)
Motor (MEP)Motor (MEP)
Stimulation: Stimulation:
Electrical or Electrical or
MagneticMagnetic
Recording: Recording:
Neurogenic - Spinal Neurogenic - Spinal
CordCord
Myogenic - Muscles Myogenic - Muscles
of Interestof Interest
Use:Use:
Monitor anterior Monitor anterior
spinal cord and spinal cord and
efferent peripheral efferent peripheral
nervesnerves
Retrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.pngRetrieved on 9/12/12 from:http://en.wikipedia.org/wiki/File:Gray764.png
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Techniques in IONMElectrophysiological Techniques in IONM
ElectromyographyElectromyography
Recording and interpretation of muscle activity in Recording and interpretation of muscle activity in
real time.real time.
Spontaneous EMG (sEMG)Spontaneous EMG (sEMG)
Stimulation: Stimulation:
NoneNone
Recording: Recording:
Continuous recording of muscles Continuous recording of muscles
innervated by nerve roots at riskinnervated by nerve roots at risk
Surface or needle electrodesSurface or needle electrodes
Use: Use:
Detect mechanical nerve root irritationDetect mechanical nerve root irritation
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Techniques in IONMElectrophysiological Techniques in IONM
ElectromyographyElectromyography
Recording and interpretation of muscle activity in Recording and interpretation of muscle activity in
real time.real time.
Spontaneous EMG (sEMG)Spontaneous EMG (sEMG)
Stimulation: Stimulation:
NoneNone
Recording: Recording:
Continuous recording of muscles Continuous recording of muscles
innervated by nerve roots at riskinnervated by nerve roots at risk
Surface or needle electrodesSurface or needle electrodes
Use: Use:
Detect mechanical nerve root irritationDetect mechanical nerve root irritation
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Techniques in IONMElectrophysiological Techniques in IONM
ElectromyographyElectromyography
Recording and interpretation of muscle activity in real Recording and interpretation of muscle activity in real
timetime
Triggered EMG (tEMG)Triggered EMG (tEMG)
Stimulation: Stimulation:
electricalelectrical
Recording: Recording:
Brief, time-locked muscle activityBrief, time-locked muscle activity
Use:Use:
Differentiate tissueDifferentiate tissue
Compute nerve conduction velocity Compute nerve conduction velocity
(NCV)(NCV)
Assess pedicle screw integrityAssess pedicle screw integrity
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Electrophysiological Techniques in IONMElectrophysiological Techniques in IONM
ElectromyographyElectromyography
Recording and interpretation of muscle activity in real Recording and interpretation of muscle activity in real
timetime
Triggered EMG (tEMG)Triggered EMG (tEMG)
Stimulation: Stimulation:
electricalelectrical
Recording: Recording:
Brief, time-locked muscle activityBrief, time-locked muscle activity
Use:Use:
Differentiate tissueDifferentiate tissue
Compute nerve conduction velocity Compute nerve conduction velocity
(NCV)(NCV)
Assess pedicle screw integrityAssess pedicle screw integrity
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Let us look at IONM in:Let us look at IONM in:
Spinal Deformity SurgerySpinal Deformity Surgery
Spinal Decompression SurgerySpinal Decompression Surgery
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
Let us look at IONM in:Let us look at IONM in:
Spinal Deformity SurgerySpinal Deformity Surgery
Spinal Decompression SurgerySpinal Decompression Surgery
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
Times of Risk:Times of Risk:
Induction: Low unless spinal instabilityInduction: Low unless spinal instability
Positioning: Low unless symptoms easily provokedPositioning: Low unless symptoms easily provoked
Surgical: Significant during deformity correctionSurgical: Significant during deformity correction
pedicle screw implantationpedicle screw implantation
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
Times of Risk:Times of Risk:
Induction: Low unless spinal instabilityInduction: Low unless spinal instability
Positioning: Low unless symptoms easily provokedPositioning: Low unless symptoms easily provoked
Surgical: Significant during deformity correctionSurgical: Significant during deformity correction
pedicle screw implantationpedicle screw implantation
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
Structures at Risk:Structures at Risk:
Primary: Primary:
Spinal cordSpinal cord
Mechanism: Cord distraction and compression, Mechanism: Cord distraction and compression,
ischemiaischemia
Nerve RootsNerve Roots
Mechanism: Trauma, compression, hardwareMechanism: Trauma, compression, hardware
Secondary: Secondary:
Peripheral nerves and brachial plexusPeripheral nerves and brachial plexus
Mechanism: Stretch and compressionMechanism: Stretch and compression
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
Structures at Risk:Structures at Risk:
Primary: Primary:
Spinal cordSpinal cord
Mechanism: Cord distraction and compression, Mechanism: Cord distraction and compression,
ischemiaischemia
Nerve RootsNerve Roots
Mechanism: Trauma, compression, hardwareMechanism: Trauma, compression, hardware
Secondary: Secondary:
Peripheral nerves and brachial plexusPeripheral nerves and brachial plexus
Mechanism: Stretch and compressionMechanism: Stretch and compression
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
Modalities Monitored:Modalities Monitored:
SSEP – dorsal spinal cord and peripheral nervesSSEP – dorsal spinal cord and peripheral nerves
MEP – ventral spinal cord and peripheral nervesMEP – ventral spinal cord and peripheral nerves
sEMG, tEMG – nerve rootssEMG, tEMG – nerve roots
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
Modalities Monitored:Modalities Monitored:
SSEP – dorsal spinal cord and peripheral nervesSSEP – dorsal spinal cord and peripheral nerves
MEP – ventral spinal cord and peripheral nervesMEP – ventral spinal cord and peripheral nerves
sEMG, tEMG – nerve rootssEMG, tEMG – nerve roots
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia with 63 year old female with 20 year history of C5-6 tetraplegia with
partial zone preservation to left C7 myotome, and post traumatic partial zone preservation to left C7 myotome, and post traumatic
tethered spinal cord due to MVA.tethered spinal cord due to MVA.
Planned procedure: cervical laminectomy, spinal cord Planned procedure: cervical laminectomy, spinal cord
untethering, expansion duraplasty.untethering, expansion duraplasty.
Spoiler Alert: These data suggested the possibility of transient Spoiler Alert: These data suggested the possibility of transient
changes in the left side sensory and motor neurological status changes in the left side sensory and motor neurological status
during this procedure.during this procedure.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Deformity SurgerySpinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia with 63 year old female with 20 year history of C5-6 tetraplegia with
partial zone preservation to left C7 myotome, and post traumatic partial zone preservation to left C7 myotome, and post traumatic
tethered spinal cord due to MVA.tethered spinal cord due to MVA.
Planned procedure: cervical laminectomy, spinal cord Planned procedure: cervical laminectomy, spinal cord
untethering, expansion duraplasty.untethering, expansion duraplasty.
Spoiler Alert: These data suggested the possibility of transient Spoiler Alert: These data suggested the possibility of transient
changes in the left side sensory and motor neurological status changes in the left side sensory and motor neurological status
during this procedure.during this procedure.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
Prepositioning Data – Ulnar and Tibial SSEPPrepositioning Data – Ulnar and Tibial SSEP
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
Prepositioning Data – Ulnar and Tibial SSEPPrepositioning Data – Ulnar and Tibial SSEP
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
Prepositioning Data - MEPPrepositioning Data - MEP
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
Prepositioning Data - MEPPrepositioning Data - MEP
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
9:20 - Post-positioning Data – Ulnar SSEP9:20 - Post-positioning Data – Ulnar SSEP
9:29 – Reposition left arm9:29 – Reposition left arm
9:39 – No Ulnar SSEP Cortical Response. Neck repositioned9:39 – No Ulnar SSEP Cortical Response. Neck repositioned
9:49 – Left Ulnar stimulation moved to elbow.9:49 – Left Ulnar stimulation moved to elbow.
9:59 – Patient returned to bed.9:59 – Patient returned to bed.
10:30 – Prone on OR table.10:30 – Prone on OR table.
10:33 – Median Stimulation in Ulnar Test10:33 – Median Stimulation in Ulnar Test
10:46 – Patient returned to bed.10:46 – Patient returned to bed.
11:02 – Surgery aborted.11:02 – Surgery aborted.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
9:20 - Post-positioning Data – Ulnar SSEP9:20 - Post-positioning Data – Ulnar SSEP
9:29 – Reposition left arm9:29 – Reposition left arm
9:39 – No Ulnar SSEP Cortical Response. Neck repositioned9:39 – No Ulnar SSEP Cortical Response. Neck repositioned
9:49 – Left Ulnar stimulation moved to elbow.9:49 – Left Ulnar stimulation moved to elbow.
9:59 – Patient returned to bed.9:59 – Patient returned to bed.
10:30 – Prone on OR table.10:30 – Prone on OR table.
10:33 – Median Stimulation in Ulnar Test10:33 – Median Stimulation in Ulnar Test
10:46 – Patient returned to bed.10:46 – Patient returned to bed.
11:02 – Surgery aborted.11:02 – Surgery aborted.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
Post-positioning Data – MEPPost-positioning Data – MEP
9:20 - Post-positioning Data – Ulnar SSEP9:20 - Post-positioning Data – Ulnar SSEP
9:29 – Reposition left arm9:29 – Reposition left arm
9:39 – No Ulnar SSEP Cortical Response. Neck repositioned.9:39 – No Ulnar SSEP Cortical Response. Neck repositioned.
9:49 – Left Ulnar stimulation moved to elbow.9:49 – Left Ulnar stimulation moved to elbow.
9:59 – Patient returned to bed.9:59 – Patient returned to bed.
10:30 – Prone on OR table.10:30 – Prone on OR table.
10:46 – Patient returned to bed.10:46 – Patient returned to bed.
11:02 – Surgery aborted.11:02 – Surgery aborted.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 tetraplegia63 year old female with 20 year history of C5-6 tetraplegia
Post-positioning Data – MEPPost-positioning Data – MEP
9:20 - Post-positioning Data – Ulnar SSEP9:20 - Post-positioning Data – Ulnar SSEP
9:29 – Reposition left arm9:29 – Reposition left arm
9:39 – No Ulnar SSEP Cortical Response. Neck repositioned.9:39 – No Ulnar SSEP Cortical Response. Neck repositioned.
9:49 – Left Ulnar stimulation moved to elbow.9:49 – Left Ulnar stimulation moved to elbow.
9:59 – Patient returned to bed.9:59 – Patient returned to bed.
10:30 – Prone on OR table.10:30 – Prone on OR table.
10:46 – Patient returned to bed.10:46 – Patient returned to bed.
11:02 – Surgery aborted.11:02 – Surgery aborted.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 63 year old female with 20 year history of C5-6
tetraplegiatetraplegia
Surgery was aborted.Surgery was aborted.
Clinical exam in post-op recovery demonstrated Clinical exam in post-op recovery demonstrated
no new neurological deficits.no new neurological deficits.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM in Spinal Deformity SurgeryIONM in Spinal Deformity Surgery
63 year old female with 20 year history of C5-6 63 year old female with 20 year history of C5-6
tetraplegiatetraplegia
Surgery was aborted.Surgery was aborted.
Clinical exam in post-op recovery demonstrated Clinical exam in post-op recovery demonstrated
no new neurological deficits.no new neurological deficits.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
Times of Risk:Times of Risk:
Induction: LowInduction: Low
Positioning: Moderate for mechanical irritation of nerve rootPositioning: Moderate for mechanical irritation of nerve root
Surgical: Significant during decompression.Surgical: Significant during decompression.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
Times of Risk:Times of Risk:
Induction: LowInduction: Low
Positioning: Moderate for mechanical irritation of nerve rootPositioning: Moderate for mechanical irritation of nerve root
Surgical: Significant during decompression.Surgical: Significant during decompression.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
Structures at Risk:Structures at Risk:
Primary: Primary:
Nerve rootsNerve roots
Mechanism: Trauma, stretchingMechanism: Trauma, stretching
Secondary: Secondary:
Spinal cordSpinal cord
Mechanism: IschemiaMechanism: Ischemia
Peripheral nerves and brachial plexusPeripheral nerves and brachial plexus
Mechanism: Compression, stretchingMechanism: Compression, stretching
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
Structures at Risk:Structures at Risk:
Primary: Primary:
Nerve rootsNerve roots
Mechanism: Trauma, stretchingMechanism: Trauma, stretching
Secondary: Secondary:
Spinal cordSpinal cord
Mechanism: IschemiaMechanism: Ischemia
Peripheral nerves and brachial plexusPeripheral nerves and brachial plexus
Mechanism: Compression, stretchingMechanism: Compression, stretching
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
Modalities Monitored:Modalities Monitored:
sEMG – nerve rootssEMG – nerve roots
SSEP – spinal cord and peripheral nervesSSEP – spinal cord and peripheral nerves
tEMG, MEP (optional)tEMG, MEP (optional)
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
Modalities Monitored:Modalities Monitored:
sEMG – nerve rootssEMG – nerve roots
SSEP – spinal cord and peripheral nervesSSEP – spinal cord and peripheral nerves
tEMG, MEP (optional)tEMG, MEP (optional)
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Laminectomy in progress.Laminectomy in progress.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Laminectomy in progress.Laminectomy in progress.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Rasp on End-plate prior to cage implantation.Rasp on End-plate prior to cage implantation.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Rasp on End-plate prior to cage implantation.Rasp on End-plate prior to cage implantation.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal 68 year old female with L4-5 DDD, spondylolisthesis, spinal
stenosis, radiculopathystenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Triggered EMG – Pedicle Screw Stimulation ThresholdsTriggered EMG – Pedicle Screw Stimulation Thresholds
Acceptable Limits Acceptable Limits >> 8 mA. 8 mA.
SiteSite Left Left Right Right
L4 screw L4 screw 8 mA (2nd, 15 mA) 8 mA (2nd, 15 mA) 30 mA30 mA
L5 screw L5 screw 36 mA 36 mA 33 mA33 mA
L5 nerve L5 nerve 0.2 mA0.2 mA
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal 68 year old female with L4-5 DDD, spondylolisthesis, spinal
stenosis, radiculopathystenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Triggered EMG – Pedicle Screw Stimulation ThresholdsTriggered EMG – Pedicle Screw Stimulation Thresholds
Acceptable Limits Acceptable Limits >> 8 mA. 8 mA.
SiteSite Left Left Right Right
L4 screw L4 screw 8 mA (2nd, 15 mA) 8 mA (2nd, 15 mA) 30 mA30 mA
L5 screw L5 screw 36 mA 36 mA 33 mA33 mA
L5 nerve L5 nerve 0.2 mA0.2 mA
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Examine left L4 pedicle due to low screw threshold.Examine left L4 pedicle due to low screw threshold.
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Spinal Decompression SurgerySpinal Decompression Surgery
68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy68 year old female with L4-5 DDD, spondylolisthesis, spinal stenosis, radiculopathy
Procedure: PSF, PLIF L4-5Procedure: PSF, PLIF L4-5
Examine left L4 pedicle due to low screw threshold.Examine left L4 pedicle due to low screw threshold.
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Times of Risk:Times of Risk:
Induction: Possibly SignificantInduction: Possibly Significant
Positioning: Possibly SignificantPositioning: Possibly Significant
Surgical: SignificantSurgical: Significant
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Times of Risk:Times of Risk:
Induction: Possibly SignificantInduction: Possibly Significant
Positioning: Possibly SignificantPositioning: Possibly Significant
Surgical: SignificantSurgical: Significant
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Structures at Risk:Structures at Risk:
Primary: Primary:
Spinal Cord, Cervical Nerve RootsSpinal Cord, Cervical Nerve Roots
Secondary: Secondary:
Recurrent Laryngeal Nerve, Brachial PlexusRecurrent Laryngeal Nerve, Brachial Plexus
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Structures at Risk:Structures at Risk:
Primary: Primary:
Spinal Cord, Cervical Nerve RootsSpinal Cord, Cervical Nerve Roots
Secondary: Secondary:
Recurrent Laryngeal Nerve, Brachial PlexusRecurrent Laryngeal Nerve, Brachial Plexus
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Modalities Monitored:Modalities Monitored:
MEPMEP
SSEPSSEP
Recurrent Laryngeal (CN X) Nerve sEMGRecurrent Laryngeal (CN X) Nerve sEMG
sEMGsEMG
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Modalities Monitored:Modalities Monitored:
MEPMEP
SSEPSSEP
Recurrent Laryngeal (CN X) Nerve sEMGRecurrent Laryngeal (CN X) Nerve sEMG
sEMGsEMG
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
59 year old male59 year old male
Dx: DDD C5-6Dx: DDD C5-6
Procedure: Artificial Disc C5-6Procedure: Artificial Disc C5-6
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
59 year old male59 year old male
Dx: DDD C5-6Dx: DDD C5-6
Procedure: Artificial Disc C5-6Procedure: Artificial Disc C5-6
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Artificial Disc C5-6Artificial Disc C5-6
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
IONM inIONM in
Anterior Cervical Discectomy and FusionAnterior Cervical Discectomy and Fusion
Artificial Disc C5-6Artificial Disc C5-6
Comprehensive Care of Spine Pathologies, October 13, 2012Comprehensive Care of Spine Pathologies, October 13, 2012
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
The EndThe End
The Role of Intraoperative NeuromonitoringThe Role of Intraoperative Neuromonitoring
David Barnkow, AuD, DABNM, CNIMDavid Barnkow, AuD, DABNM, CNIM
The EndThe End
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