Historically, electromyography (EMG) is utilized early in the diagnostic evaluation of neuromuscular disorders, but its importance may be diminishing with more sophisticated genetic, imaging and immunohistochemistry inve...Historically, electromyography (EMG) is utilized early in the diagnostic evaluation of neuromuscular disorders, but its importance may be diminishing with more sophisticated genetic, imaging and immunohistochemistry investigations now available. In the present study, the diagnostic yield of EMG at predicting pathological abnormalities confirmed by muscle biopsy was determined at our neuroscience center. A retrospective study of consecutive cases reviewed at neuromuscular multidisciplinary meetings between 2007 and 2016 identified patients who had EMG and muscle biopsy as part of their diagnostic evaluation. EMG and biopsy findings were categorized as myopathic, neurogenic or normal. The diagnostic accuracy was determined by calculating the concordance between EMG and pathological findings. Of the 175 cases included in the analysis, there was definite concordance between EMG and muscle biopsy findings in 134 cases (76.6%). Abnormal EMG produced sensitivity of 87% and specificity of 65% for abnormal muscle biopsy. Seventeen patients had a normal EMG and an abnormal muscle biopsy, of which 6 had histopathological findings consistent with mitochondrial myopathy, central core myopathy or glycogen storage disorder. Conflicting EMG and muscle biopsy findings were observed in 10 cases. Inclusion body myositis, chronic neuromuscular disorders and dual pathologies were associated with discordant findings. This study demonstrates that EMG has accurate predictive value in diagnosing neuromuscular disorders at our neuroscience center. EMG retains a vital role, particularly in initial diagnostic evaluations of neuromuscular disorders.
Due to the coronavirus disease 2019 (COVID-19) pandemic, the state of Texas-limited elective procedures to conserve beds and personal protective equipment (PPE); therefore, between March 22 and May 18, 2020, admission to...Due to the coronavirus disease 2019 (COVID-19) pandemic, the state of Texas-limited elective procedures to conserve beds and personal protective equipment (PPE); therefore, between March 22 and May 18, 2020, admission to the epilepsy monitoring unit (EMU) was limited only to urgent and emergent cases. We evaluated clinical characteristics and outcomes of these patients who were admitted to the EMU. Nineteen patients were admitted (one patient twice) with average age of 36.26 years (11 female) and average length of stay 3 days (range: 2-9 days). At least one event was captured on continuous EEG (cEEG) and video monitoring in all 20 admissions (atypical in one). One patient had both epileptic (ES) and psychogenic non-epileptic seizures (PNES) while 10 had PNES and 9 had ES. In 8 of 9 patients with ES, medications were changed, while in 5 patients with PNES, anti-epileptic drugs (AED) were stopped; the remaining 5 were not on medications. Of the 14 patients who had seen an epileptologist pre-admission, 13 (or 93%) had their diagnosis confirmed by EMU stay; a statistically significant finding. While typically an elective admission, in the setting of the COVID-19 pandemic, urgent and emergent EMU admissions were required for increased seizure or event frequency. In the vast majority of patients (13 of 19), admission lead to medication changes to either better control seizures or to change therapeutics as appropriate when PNES was identified.
Lateral lumbar interbody fusion procedures are performed with multimodality neuromonitoring of the femoral nerve to prevent lumbosacral plexus and peripheral nerve injury from positioning, dilation, retraction, and hardw...Lateral lumbar interbody fusion procedures are performed with multimodality neuromonitoring of the femoral nerve to prevent lumbosacral plexus and peripheral nerve injury from positioning, dilation, retraction, and hardware implantation. The integrity of the femoral nerve can be continuously assessed during these procedures by Somatosensory Evoked Potentials of the Saphenous nerve (Sn-SSEPs). Sn-SSEPs are technically challenging to acquire and necessitate advanced troubleshooting skills with a more rigid anesthetic regimen and physiological parameters. We performed a retrospective analysis of Sn-SSEP data for 100 consecutive lateral lumbar surgeries where the stimulation electrodes were placed distally below the knee and medial to the tibia bone (i.e., DSn-SSEPs). Monitorable baseline responses were present in 87% of patients after the exclusion of fourteen cases where the tibial nerve SSEP was absent, quadriceps transcranial electrical motor evoked potentials (TCeMEPs) were absent or not utilized. Sex, age, body mass index (BMI), diagnosis, mean arterial pressure (MAP), inhalational anesthetic levels, reliability of ulnar and posterior tibial nerve SSEPs, and the reliability of femoral nerve innervated quadriceps TCeMEPs were evaluated but were not of statistically significant consequence between cases where the DSn-SSEP was present or absent in this study. We found the utilization of DSn-SSEPs to be a valuable adjunct to femoral nerve monitoring. Stimulation electrode placement is easy to palpate with clear anatomical borders. Significant muscle artifact and patient movement from stimulation do not affect waveform morphology, allowing for continuous and reliable monitoring. We recommend including DSn-SSEPs to optimize recordings during lateral lumbar procedures.
Multimodal intraoperative neurophysiologic monitoring (IONM) can be utilized as an adjunct to lumbar spinal instrumentation in order to aid with avoidance of neurologic complications. The most commonly utilized modalitie...Multimodal intraoperative neurophysiologic monitoring (IONM) can be utilized as an adjunct to lumbar spinal instrumentation in order to aid with avoidance of neurologic complications. The most commonly utilized modalities include somatosensory-evoked potentials, motor-evoked potentials, and electromyography. Somatosensory-evoked potentials (SSEPs) allow for continuous assessment of the dorsal columns of the spinal cord and are therefore most useful during procedures with a posterior approach to the cervical and thoracic spine. Motor-evoked potentials (MEPs) and electromyography (EMG) can be applied intermittently to assess motor nerve function. The utility of each individual modality can be largely dependent on the surgical approach. Approaches to lumbar spinal instrumentation can be generally categorized as anterior, lateral, and posterior. For lateral approaches, electromyography can be helpful in identifying neural structures crossing the surgical field to prevent injury. In posterior and anterior approaches, somatosensory-evoked potentials and motor-evoked potentials can be used to assess nerve injury during and after maneuvers for decompression and instrumentation. Additionally, during the placement of pedicle screws, direct stimulation with triggered electromyography can be used to detect the pedicle cortex's breach. The efficacy of intraoperative neuromonitoring is dependent on prompt and accurate recognition of changes in signals. This is then followed by accurate recognition of the cause for these changes and appropriate responses by the surgeon, anesthesiologist, and monitoring personnel to correct the change.
MEPs are recommended for patients undergoing lumbar and lumbosacral procedures in which intraoperative neuromonitoring (IONM) is being utilized. While electromyography (EMG) provides critical nerve root proximity informa...MEPs are recommended for patients undergoing lumbar and lumbosacral procedures in which intraoperative neuromonitoring (IONM) is being utilized. While electromyography (EMG) provides critical nerve root proximity information, spontaneous EMG discharges are relatively poor at reliably diagnosing spinal nerve root dysfunction. In contrast, research indicates that MEPs are both sensitive and specific in diagnosing evolving spinal nerve root dysfunction. There is conflicting evidence, however, and it must be emphasized that the value of adding MEPs is only realized when practices and techniques are optimized. The ideal anesthetic plan is an optimized total intravenous anesthetic (TIVA) regimen. Selection of appropriate anesthetics and dosing is important for optimizing baseline response amplitudes and promoting diagnostic confidence in analyzing signal changes. An adaptive set of alert criteria that account for baseline amplitude and morphology fluctuations should guide the determination of significant signal change. The therapeutic impact of accurate diagnostic information depends on the timeliness of diagnosis and intervention. Prior to the start of surgery, a plan to obtain MEPs at least once every 10 minutes during the active part of the procedure and after every significant surgical maneuver should be agreed upon, and the intervention plan should include but not be limited to possible removal of hardware and release of retraction or distractive forces. In summary, MEPs can improve monitoring of at-risk nerve root function, but the accuracy and therapeutic impact of such monitoring depend on perioperative planning and communication that optimize use of this modality.
Many algorithms, checklists, and escalation pathways have been created to encourage perioperative teams to share a mental model and approach patient care as a team. Respecting and empowering the many voices involved in p...Many algorithms, checklists, and escalation pathways have been created to encourage perioperative teams to share a mental model and approach patient care as a team. Respecting and empowering the many voices involved in patient care is crucial to avoid errors and improve patient safety. None of the concepts described herein are novel; however, sustained improvements in operating room culture remain elusive in many organizations. The implementation of practices directed toward driving change in operating room culture has led to improvements in Occupational Safety and Health Administration (OSHA) recordables, perioperative communication, and patient care practices. In this paper, we will review the importance of culture, mutual accountability, and communication in improving patient care, and share several of the processes that have been created at our pediatric tertiary care center.
A useful reference for practitioners of neuromonitoring that explains how to anticipate, avoid, and properly attend to technical problems that may arise while providing intraoperative neuromonitoring (IONM) in spinal pro...A useful reference for practitioners of neuromonitoring that explains how to anticipate, avoid, and properly attend to technical problems that may arise while providing intraoperative neuromonitoring (IONM) in spinal procedures.
In healthcare, it is not uncommon for neurodiagnostic technologists to provide care and testing for patients who are in restraints or in need of restraints. When properly used, restraints ensure patient safety and the sa...In healthcare, it is not uncommon for neurodiagnostic technologists to provide care and testing for patients who are in restraints or in need of restraints. When properly used, restraints ensure patient safety and the safety of others while allowing the continuation of life saving tests and treatments. Oversight for restraint use is provided by outside agencies such as the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC). Improper use of restraints can lead to serious sanctions by both organizations and can negatively impact patients, leaving them with emotional and psychological trauma. The process of restraint management such as ordering, implementing, or monitoring restrained patients is not within the scope of practice for neurodiagnostic technologists. Restraints should only be utilized as a last resort for the safety of the patient to receive proper care. This paper seeks to inform Technologists on what does and does not constitute a restraint, and the factors that should be considered before making the decision to request use of restraints in order to perform neurodiagnostic testing.
Ambulatory electroencephalography (AEEG) seeks to capture inter-ictal epileptiform activity or paroxysmal events when patients are not in the clinic. Skin inflammation is a common complication of prolonged EEG monitoring...Ambulatory electroencephalography (AEEG) seeks to capture inter-ictal epileptiform activity or paroxysmal events when patients are not in the clinic. Skin inflammation is a common complication of prolonged EEG monitoring. This non-randomized study aimed to investigate the performance of two commonly used cream-based methods of electrode application in reducing electrode-induced skin injury among patients undergoing AEEG monitoring. A non-randomized interventional study was conducted from July to December 2019 in the Neurosciences Ambulatory Care Unit at Royal Prince Alfred Hospital, Australia. Patients were enrolled into two groups: i) Group T, which received Ten20® Conductive Paste with Tensive® Conductive Adhesive Gel as the primary approach to electrode application; ii). Group E, which received EC2⁺® Conductive Cream as the primary approach to electrode application. Patients in Group T were enrolled in the 1st and 3rd week of the month, and patients in Group E were enrolled in the 2nd and 4th week for each month of the study. A total of 152 patients participated in this study. Two sub-groups were established: those who were monitored for two days (Group T; n = 36, Group E; n = 30) and those who were monitored for four days (Group T; n = 43, Group E; n = 43). Significant (p < 0.05) differences indicating greater inflammation in the Group E were noted for both Day 2 and Day 4 participants. Skin injury/inflammation was significantly less using the standard method (Group T: Ten20® with Tensive® gel) when compared to EC2⁺® (Group E) as the conductive material at the electrode site.