Peripheral nerve stimulation (PNS) is defined as the application of electric stimulation to the peripheral nervous system and to a specific nerve. For the most part, the goal of PNS has been treatment of pain. Later, PNS...Peripheral nerve stimulation (PNS) is defined as the application of electric stimulation to the peripheral nervous system and to a specific nerve. For the most part, the goal of PNS has been treatment of pain. Later, PNS use expanded to indications other than pain including epilepsy and depression, which involves stimulation of the vagus nerve, sleep apnea with stimulation of the hypoglossal nerve, respiratory insufficiency, involving phrenic nerve stimulation, and many others. The overarching peripheral neuromodulation approach involves three modalities: conventional PNS, which implies direct placement of stimulating electrode leads over the affected peripheral nerve(s); percutaneous PNS, which implies insertion of stimulating electrode leads near the target nerve with appropriate guidance; and peripheral nerve field stimulation, which requires placement of electrode leads to stimulate smaller nerves and nerve endings in the affected target area. Monitoring peripheral nerves during surgery through electrophysiological methods is a highly valuable option, offering crucial real-time information to the surgical team. While preoperative testing provides helpful data for decision-making, intraoperative neurophysiological monitoring (IONM) fills in gaps that cannot be addressed by preoperative studies. IONM assesses the nervous system during surgery to prevent potential damage to critical neurological structures. It serves the next main purposes: detecting and minimizing iatrogenic injuries, mapping nervous structures to identify the target nerve, and assessing the functionality of the nerve. In this article we review currently available information about the utilization of IONM during PNS procedures.
Chiari malformation types 1 and 1.5 can be treated with posterior fossa decompression, though surgical techniques vary considerably, with more aggressive approaches often considered for type 1.5. Given this variability,...Chiari malformation types 1 and 1.5 can be treated with posterior fossa decompression, though surgical techniques vary considerably, with more aggressive approaches often considered for type 1.5. Given this variability, an objective intraoperative marker of adequate decompression would support more tailored surgery. While brainstem auditory evoked potentials (BAEPs) have been explored in pediatric populations, their utility in adults remains unstudied. We present a 26-year-old female with Chiari 1.5 and symptoms including migraines, visual disturbances, balance issues, and right-hand clumsiness. She underwent a BAEP-guided, minimally invasive decompression involving a C1 laminectomy, linear dural opening, and tonsillar cauterization. Intraoperative BAEP monitoring allowed for a targeted, less extensive decompression, resulting in significant clinical improvement. This case highlights the potential utility of BAEPs in adult Chiari decompression, suggesting a role for further investigation of this technique in optimizing outcomes while minimizing invasiveness.
The reliability of Thai certificate qualifications for Advanced Sleep Technicians (ASTs) and Sleep Disorders Specialists (SDSs) in manual polysomnography (PSG) scoring has not been previously evaluated. This study assess...The reliability of Thai certificate qualifications for Advanced Sleep Technicians (ASTs) and Sleep Disorders Specialists (SDSs) in manual polysomnography (PSG) scoring has not been previously evaluated. This study assessed the reliability of PSG scoring performed by ASTs, an SDS, and an automated scoring system (AUTO) at Thammasat University Hospital, Thailand. A retrospective analysis of 250 PSG recordings conducted between September 2022 and February 2023 classified patients into four groups based on the apnea-hypopnea index (AHI): No OSA (AHI <5), mild OSA (AHI 5-15), moderate OSA (AHI 15-30), and severe OSA (AHI >30), comprising 11, 77, 105, and 57 cases, respectively. Scoring reliability was compared among ASTs, SDSs, and AUTO. A single-blinded SDS independently scored the PSG data without knowing the AST's scoring to ensure an unbiased assessment. Across more than 630,000 epochs, the Kappa (κ) statistic demonstrated stronger agreement between AST and SDS (κ = 0.980, 95% CI 0.976-0.984) than between AST and AUTO (κ = 0.599, 95% CI 0.543-0.655), indicating significant differences ( < .0001). For mixed apneas (MAs), intraclass correlation coefficients (ICCs) showed the highest consistency between AST and SDS (ICC = 0.998, 95% CI 0.997-0.998) compared to AST and AUTO (ICC = 0.869, 95% CI 0.836-0.897). Significant differences were observed between AST and SDS compared to AST and AUTO across most metrics (P < .0487). While ASTs and SDSs demonstrated excellent scoring consistency, AUTO scoring was notably less accurate, suggesting that the AUTO system requires further refinement to ensure reliable clinical use.
At Ann & Robert H. Lurie Children's Hospital of Chicago, the increasing volume of video EEGs, extended diagnostic recording times, higher patient acuity, and variability in EEG connection techniques among neurodiagnostic...At Ann & Robert H. Lurie Children's Hospital of Chicago, the increasing volume of video EEGs, extended diagnostic recording times, higher patient acuity, and variability in EEG connection techniques among neurodiagnostic technologists (NDTs) contributed to a rise in device-related skin injuries. In response, the Epilepsy Monitoring Unit (EMU) adopted Lean Six Sigma, a structured improvement methodology that combines the principles of Lean (waste reduction) and Six Sigma (defect reduction). This approach was implemented alongside humble inquiry and a psychologically safe environment, empowering the NDT team to identify root causes and drive meaningful change.Through root cause analysis, the neurodiagnostic team developed and implemented six key interventions: Targeted retraining in skin education and terminologyIntegrated evidence-based products (Mepitel and Mepilex)Strengthened collaboration with bedside nursesImplemented standardized work for EEG electrode application and head-wrapping techniquesStandardized skin checks and documentationEstablished a skin compliance monitoring system using the electronic medical recordAs a result, over the past three fiscal years, the rate of video EEG electrode-related injuries has decreased by 70%, while NDT compliance with skin checks and documentation has improved from 26% to 85%.This quality improvement article examines the application of the Define, Measure, Analyze, Improve, and Control (DMAIC) framework in achieving these outcomes.
Artificial intelligence-integrated electroencephalography (AI-EEG) has demonstrated promise in the early detection of nonconvulsive status epilepticus (NCSE), particularly in emergency and intensive care settings with li...Artificial intelligence-integrated electroencephalography (AI-EEG) has demonstrated promise in the early detection of nonconvulsive status epilepticus (NCSE), particularly in emergency and intensive care settings with limited access to trained EEG technologists. This review includes 20 studies, of which 12 were incorporated into a meta-analysis assessing the diagnostic accuracy of AI-EEG. The pooled sensitivity reached 95%, with a specificity of 83%. However, when the pretest probability of NCSE is 40%, false positives may occur in approximately one in seven patients. Commercial AI-EEG platforms have shown a reduction in unnecessary antiepileptic drug (AED) administration compared to clinical judgment alone. Four prospective cohort studies reported a 26% relative risk reduction (RR -0.26; 95% CI -0.50 to -0.02; p = .03) in unnecessary AED use. Additionally, AI-EEG shortened the median time to EEG acquisition in resource-limited settings-from 4.5 hours (IQR 3.2-6.8) to 2.1 hours (IQR 1.5-3.4). A sub-analysis from an industry-sponsored trial suggested potential benefits of AI-EEG in reducing morbidity and ICU length of stay, though evidence remains insufficient for definitive conclusions. Despite these advantages, rapid-deployment AI-EEG systems face challenges: lack of video integration makes it difficult to distinguish seizures from artifacts or behavioral events, and limited electrode coverage may miss central brain activity. Moreover, AI algorithms tend to overread sharp and spike activities compared to human interpretation. Further investigator-initiated studies are needed to evaluate the diagnostic yield of AI-EEG beyond its simplified setup, assess its true impact on patient outcomes, and determine its feasibility for large-scale clinical implementation. .
Epilepsy surgery encompasses a wide range of procedures aimed at reducing or eliminating seizures. In these procedures, there are opportunities to employ intraoperative neurophysiology to map the epileptic focus and accu...Epilepsy surgery encompasses a wide range of procedures aimed at reducing or eliminating seizures. In these procedures, there are opportunities to employ intraoperative neurophysiology to map the epileptic focus and accurately identify functional areas of the brain. In cases of drug-resistant epilepsy where onset is diffuse, multifocal, or in an eloquent region of the brain, resection is not possible, and neuromodulation can be considered to reduce the seizure burden. While resective or ablative therapy aims to be curative, neuromodulation techniques for epilepsy are generally considered palliative. The goal of neuromodulation is to use an implantable device with electrodes and a pulse generator to use electrical energy to interfere with the nervous system. Three neuromodulation modalities have been approved by the United States FDA for epilepsy: vagus nerve stimulation, deep brain stimulation of the anterior nucleus of the thalamus, and responsive neurostimulation. While rates of seizure freedom with neuromodulation are lower than with resection of an epileptogenic focus, many patients experience >50% reduction in seizures, and results improve with time, suggesting both acute and chronic benefits with these therapies.
Intraoperative neuromonitoring (IONM) has emerged as a transformative tool in spinal cord stimulation (SCS) and dorsal root ganglion (DRG) procedures, enabling precise lead placement under general anesthesia. It also add...Intraoperative neuromonitoring (IONM) has emerged as a transformative tool in spinal cord stimulation (SCS) and dorsal root ganglion (DRG) procedures, enabling precise lead placement under general anesthesia. It also addresses the safety aspect of placement in an asleep patient while also mitigating the challenges of traditional awake techniques. This paper outlines the protocols and benefits of IONM, with a focus on electromyography (EMG) and somatosensory evoked potentials (SSEP) for real-time guidance during thoracic, cervical, and DRG stimulator placement. It explores how IONM optimizes myotomal-to-dermatomal mapping, improves paresthesia coverage, and enhances outcomes by reducing revision rates. Additionally, the paper evaluates waveform-specific neuromodulation effects, highlighting advancements in personalized pain management through innovative stimulation paradigms and potential mechanisms of action.
Current shunting is a potential cause of false negative threshold values whenever triggered EMG is utilized. We present a case where we stimulated percutaneously placed pedicle screws both with and without an insulated d...Current shunting is a potential cause of false negative threshold values whenever triggered EMG is utilized. We present a case where we stimulated percutaneously placed pedicle screws both with and without an insulated dilator to show the potential difference in threshold values. Our findings suggest that the risk of current shunting associated false negatives when stimulating pedicle screws placed via minimally invasive percutaneous approaches may be higher unless insulated dilators are utilized.
Deciding whether an epilepsy is of focal or generalized origin is necessary for establishing treatment options. Sometimes it is not a clear diagnosis. It is important to consider patient history, EEG presentation, clinic...Deciding whether an epilepsy is of focal or generalized origin is necessary for establishing treatment options. Sometimes it is not a clear diagnosis. It is important to consider patient history, EEG presentation, clinical semiology, and imaging with these decisions. Presented is a case study of a patient with presumed generalized epilepsy but with focal features. A diagnostic evaluation was performed to ultimately decide if her epilepsy was focal or generalized, and whether she could be a surgical candidate for resection.
Intraoperative neurophysiological monitoring (IONM) has emerged as a pivotal technology in neurosurgery, significantly enhancing patient safety and surgical outcomes by providing real-time monitoring of neurological func...Intraoperative neurophysiological monitoring (IONM) has emerged as a pivotal technology in neurosurgery, significantly enhancing patient safety and surgical outcomes by providing real-time monitoring of neurological functions. Despite its recognized benefits, the adoption and development of IONM in regions like West Africa have been relatively slow, with Ghana pioneering its introduction and utilization. This report explores the evolution of IONM in Ghana, initiated by FOCOS Hospital, and examines its expansion across the region. The report highlights key developments, including the first use of IONM during complex spine surgeries such as scoliosis, kyphosis and kyphoscoliosis deformity correction and brain tumor surgeries. Challenges, such as the scarcity of trained professionals, limited access to essential equipment, and the high cost of implementation are discussed. The future outlook of IONM in Ghana and potentially other West African and by extension, other low- and middle-income countries looks promising with planned expansions in training and certification programs to meet the growing demand. This report underscores the transformative potential of IONM in improving surgical care and patient outcomes in Ghana, West Africa, and other low- and middle-income countries advocating for increased regional support and investment in this crucial healthcare technology.
Developmental and/or epileptic encephalopathy with spike-wave activation in sleep (D/EE-SWAS), formerly electrical status epilepticus of sleep (ESES), is a rare childhood-onset epilepsy characterized by continuous spike...Developmental and/or epileptic encephalopathy with spike-wave activation in sleep (D/EE-SWAS), formerly electrical status epilepticus of sleep (ESES), is a rare childhood-onset epilepsy characterized by continuous spike waves seen in sleep with or without associated seizures. D/EE-SWAS affects children ages 2-12 years and shows characteristic pattern of continuous spike-and-wave discharges during non-rapid eye movement (NREM) sleep (CSWS) on electroencephalography (EEG) with a high density of spikes. Generalized D/EE-SWAS is found in patients with acquired symptoms of progressive neurocognitive and/or behavioral regression. D/EE-SWAS with focal discharges has been reported with focal deficits. We present a 3.5-year-old boy with focal D/EE-SWAS who changed dominant handedness. He was innately right-hand dominant with obvious preference for scribbling and feeding himself with his right hand per his mother, though developed focal seizures and D/EE-SWAS of the left hemisphere and became left-hand dominant for all activities. Following medical treatment, he again used his right hand with ambidextrous handwriting. We report the first case of change in handedness with focal D/EE-SWAS. We review the available diagnostics and treatments of Landau-Kleffner syndrome (LKS) and D/EE-SWAS.
Artificial intelligence (AI) is revolutionizing clinical neurophysiology (CNP), particularly in its applications to electroencephalography (EEG), electromyography (EMG), and polysomnography (PSG). AI enhances diagnostic...Artificial intelligence (AI) is revolutionizing clinical neurophysiology (CNP), particularly in its applications to electroencephalography (EEG), electromyography (EMG), and polysomnography (PSG). AI enhances diagnostic accuracy and efficiency while addressing interrater variability and the growing data volume. The evolution of AI tools, from early mimetic methods to advanced deep learning techniques, has significantly improved spike and seizure detection in EEG and facilitated whole EEG evaluations, reducing the workload on clinicians. In EMG, AI demonstrates promise in identifying motor unit abnormalities and analyzing audio signals, though challenges persist due to limited datasets and clinical context considerations. PSG scoring has seen substantial integration of AI, with systems achieving high accuracy through uncertainty estimation and selective manual review, but limitations remain in analyzing epileptic activity and classifying certain sleep stages. As a "co-pilot," AI augments human expertise by improving quality control, standardizing clinical trials, and enabling rapid data review, particularly for less experienced providers. Future AI advancements in CNP aim to shift from isolated data interpretation to providing clinical context, considering patient history, treatment options, and prognostic implications. While the potential of generative AI and "AI-omics" is transformative, the importance of thoughtful integration to augment rather than replace human expertise must be emphasized, ensuring that AI becomes a tool for collaboration and innovation in medicine.
When faced with challenging behaviors from pediatric patients, technologists can often feel unprepared. This can lead to poor appointment outcomes as well as unintended traumatic experiences for patients. It is important...When faced with challenging behaviors from pediatric patients, technologists can often feel unprepared. This can lead to poor appointment outcomes as well as unintended traumatic experiences for patients. It is important to understand the role the technologist plays in providing high-quality care that addresses behavioral concerns while minimizing trauma; however, training and education in this area of patient care is limited in the field of neurodiagnostics. This lack of training and education can deter technologists from working with the pediatric population. This article aims to address core reasons for displayed behaviors in pediatric patients as well as the risks associated with not addressing the behaviors during EEG lead placements. In an effort to continue striving for high-quality, family-centered care in the field of pediatric neurodiagnostics, proposed interventions such as the CARE process and distraction are outlined and discussed.