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In the Literature: Intraoperative direct cortical stimulation motor evoked potentials: Stimulus parameter recommendations based on rheobase and chronaxie

Posted By Jay L. Shils, PhD, DABNM, FASNM, Monday, February 10, 2020
Updated: Wednesday, January 29, 2020

Article Title: Intraoperative direct cortical stimulation motor evoked potentials: Stimulus parameter recommendations based on rheobase and chronaxie 

 

Article Summary:

 

The choice of stimulation parameters for direct cortical stimulation is based primarily on observational data. This data has suited us well over time but there were no specific true basic neurophysiologic studies that could better help define the optimal stimulation parameters. 

 

An important property of a nerve and more specifically neural tissue is the strength duration (S-D) curve. This curve relates how much energy is needed to activate a nerve based on the stimulation intensity and the pulse width of a square shaped pulse, which is what we in the neurophysiology community use to stimulate the nerve or neural tissue. 

 

When evaluating the strength duration curve there are two key properties of this curve, the Rheobase (Rb) and the Chronaxie (Cx). The Rb is the smallest stimulation amplitude that can cause a nerve (axon) to generate an action potential (AP). It is defined for a infinitely long pulse width (DC current pulse), all pulse width’s smaller than this value will require a greater stimulation amplitude to generate an action potential. 

 

The Cx is the pulse width value on the strength duration curve that crosses the stimulation amplitude value that is two times the Rb current. The Cx is a excitability time constant. The Cx point on the curve also defines the minimal energy point for AP generation. 

 

In the paper by Abalkhail et. al. they investigate the Rb and Cx to help define the optimal interstimulus interval (ISI) and the pulse width (D) for direct cortical stimulation. Common parameters used in the operating room for DCS are an ISI of either 2 or 4 mSec and a pulse width of 500 uSec.

 

Key points from this paper

  1. Standard S-D curves are based on single pulse stimulation. This study evaluated the S-D using a pulse train. They were not able to determine if the S-D curve was based on the complete pulse train or a set of individual pulses. Additionally, the S-D curve for this study is a composite of the axon in the CST and the alpha-motor neuron (AM). First, a AP needs to be generated in the CST and second that AP, or set of APs needs to cause the AM to fire. If neither of those occurs there will be no MEP. Yet, the data is still valuable since we are activating this network and the network still has a minimal energy point even if individual elements of that network are not being activated at their minimal energy points.
  2. Evaluation of basic neurophysiological parameters of neural tissue can come from standard tools that we are already using in the operating room. By just varying pulse width and amplitude of the stimulus it is possible to optimize the stimulation parameters to each patient. But given the data in this paper the values are relatively constant. In Abalkhail the values of Cx varied between 160 uSec and 200 uSec which is more than half of the common 500 uSec pulse that is most commonly used for DCS.
  3. The strength duration curve does not take ISI into consideration thus the authors evaluated these values for multiple ISI values. This is important because they used the Rb to define the lowest stimulation current needed to generate an action potential. This value was for an ISI of 4 mSec which is a common value used in the OR presently.
  4. It is critical to note that using these changes in parameters the actual values that indicate safety distances may vary and this was not part of their study.

 

Reference:

  1. Abalkhail TM, et. al. Clinical Neurophysiology. 2017;128:2300-2308

 

Disclaimer: 

The views, thoughts, and opinions expressed in this blog post  are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

Tags:  In the Literature 

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In the Literature: Factors that Modify the Risk of Intraoperative Seizures Triggered by Electrical Stimulation During Supratentoral Functional Mapping

Posted By Christopher D. Halford, Wednesday, February 5, 2020
Updated: Wednesday, January 29, 2020

Article Title: Factors that Modify the Risk of Intraoperative Seizures Triggered by Electrical Stimulation During Supratentoral Functional Mapping

Overview:

This paper presents information from a very large retrospective sample (544 cases) and attempts to demonstrate whether intraoperative seizures can be reduced during functional mapping (as the title says). The article also discusses some facts and information about intraoperative seizures caused by direct cortical electrical stimulation previously published by other authors. They begin by discussing the specific risks of intraoperative seizures: 1) “during awake craniotomies… there is no airway,” 2) the state of the neurons in “the post-ictal state… can impede, at least temporarily, the continuation of reliable mapping,” 3) “postictal cortical depression usually results in an increase in the mapping threshold that is hard to predict; this further hinders reliable mapping,” 4) “seizures can spread to eloquent cortical regions distinct from those stimulated resulting in the false localization of eloquent cortex” (pp. 1058-1059).

The goal of this study is to demonstrate “a better way to avoid the complications associated with intraoperative stimulation triggered seizures is to have a means of preventing them that can be broadly applied to all patients undergoing a mapping procedure and which will be effective regardless of the magnitude of the individual risk” (p. 1059).

 

Methods:

 

The authors reviewed 544 cortical mapping cases, “both awake [TIVA] and asleep,” done with either the Penfield method (“repetitive biphasic pulses at 60 Hz, pulse duration of 1 ms, intensities 1–15 mA applied using a bipolar handheld stimulator”) or what has been called the pulse-train method, “multi-pulse train technique,” or “high frequency anodal stimulation”(repetitive trains at 2 Hz, 6 pulses/train, train frequency 250 Hz, pulse duration 0.5 ms, intensity 1–22 mA applied using a monopolar handheld stimulator, with the active electrode connected to the anode (+ positive) and a subdermal needle electrode placed at the margin of the surgical field, connected to the cathode (- negative)) (p. 1059). 

 

The variables that were analyzed included data like gender, age, history of anti-epileptic drug (AEDs) use, etc. to see if particular variables would likely affect the likelihood that a patient would have an intraoperative seizure (defined as rhythmic runs of self-propagated stimulation triggered AD with a duration of 10 s or more) (p. 1059). The more pertinent correlational variables were thought to be variable 4 of 12, “pre-operative maintenance treatment with AED” (defined as, “daily oral administration of any AED regimen for at least 3 days prior to surgery”) and variable 5 of 12, “loading with AED (intravenous administration at the beginning of the surgery of: 1–500 mg or more of either levetiracetam, fosphenytoin or valproic acid; or 2–200 mg or more of lacosamide)” (p.1059)

 

Results:

 

Of the 544 surgical patients reviewed 330 (≈ 61%) had seizures before their surgery. Of the total reviewed 204 (≈ 38%) “were already receiving a maintenance daily AED dose at the time of the surgery.” Also, “356 patients (65.4%) received intravenous loading doses of AED.” Intraoperative seizures occurred 135 (≈ 25%) of patients. (p. 1060)

 

Of the 12 factors the authors analyzed the ‘factors were found to significantly increase the risk of triggering intraoperative seizures’ were: 

 

  1. Penfield method (OR = 2.16, p = 0.0002) (which in their final analysis increased the likelihood of causing an intraoperative seizure by 2x*)
  2.  awake state (OR = 1.61, p = 0.01)
  3. diffuse pathology (OR = 2.37, p = 0.002) (in which case the patient was 2.4x* more likely to have an intraoperative seizure)
  4. stimulation in the temporal lobe (OR = 1.72, p = 0.01)

 

However, of those four, the authors point out that ‘mapping during awake state was found to be collinear with the use of Penfield paradigm and thus the former was excluded from the final model. Also, “the effect of stimulation in the temporal lobe was positively confounded by the use of Penfield paradigm.”

 

Moreover, they found that “intravenous administration of loading doses of AED decreased the odds of triggering seizures by 45%” while no other factors (including “maintenance AED treatment” and “history of seizures”) were found to statistically affect the likelihood of intraoperative seizures. (p. 1061).

 

*kitchen sink multivariate logistic regression

 

Conclusion:

 

Of the patients that received a loading dose of AEDs, “about two thirds (73.3%) of the patients who received intra-venous loading with AED at the beginning of the surgery, had not been previously on maintenance AED” demonstrating that these patients were not receiving the potentially positive effects of maintenance AEDs but still saw a reduction in their intraoperative seizure risk. However, “about a fourth (26.7%)” of the AED loaded patients were on maintenance AEDs but pre-procedure “loading was performed in this… group because of lack of information regarding the effectiveness of the AED maintenance” (p. 1062) which the authors believe may have a “protective effect” for those persons with a ‘positive history of pre-operative seizures’ (p. 1064). In a nutshell the authors can claim, based off of a size case study, “our results show that AED can efficiently protect against electrical stimulation triggered seizures in humans and that such protective effect is independent of other risk factors” (pp. 1061-1062). The authors also caution readers that, ‘special attention should be given to cases where map

ping is performed via Penfield method of stimulation and in the presence of diffuse pathology’ (p. 1064).

 

Limitations:

 

The authors are comprehensive in the in their presentation of statistical methods and even an additional overview of many of the risk factors they included as they analyzed the information they collected (in the discussion section which I covered very briefly). However, and as the authors acknowledge and promise to address ‘in future prospective studies’ there are certain areas when dealing with seizure history of patients and their use of AEDs prior to surgery that could (and apparently will be) useful to technologists and neurophysiologists when previewing patient information while preparing for the potential risks our soon-to-be-monitored patient might face.

 

The IONM Big Picture Perspective:

 

If the information from this study were to be shared with, and implemented by, anesthesiologists and surgeons and the results reliably replicated then surgical teams involved in cortical mapping could potentially cut intraoperative seizures in half. Also, the benefits of avoiding the high costs risks of intraoperative seizures (briefly discussed in the first paragraph) would increase the usefulness and accuracy of intraoperative cortical mapping and thus increase overall safety for these patients. Finally, with the information presented in this article we can be better prepared as technologists and neurophysiologists to anticipate patients that are at the greatest risk for intraoperative seizures and be ready to act regardless of whether other members of the surgical team have converted this information into practice.

References:

  1. Dineen J, Maus DC, Muzyka I, See RB, Cahill DP, Carter BS, Curry WT, Jones PS, Nahed BV, Peterfreund RA, Simon MV. Factors that modify the risk of intraoperative seizures triggered by electrical stimulation during supratentorial functional mapping. Clin Neurophysiol. 2019 Jun;130(6):1058-1065.

 

Disclaimer: 

 

The views, thoughts, and opinions expressed in this blog post  are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

Tags:  In the Literature 

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President's Message - February 2020

Posted By Richard W. Vogel, Monday, February 3, 2020
Updated: Wednesday, January 29, 2020

Dear Members,

 

A lot has happened in the couple months since I’ve communicated to you, so let’s jump right in. 

 

Many people have contacted the ASNM over the last few months asking what’s happening with the 2020 Winter Symposium. We’ve also been dealing with lots of questions over the past few weeks about what’s going on with the leadership of the ASNM. I want to spend some time today talking to you about both of these things. 

 

The first thing that I want you all to know is that the leadership of this society is strong, our vision is clear, our direction is unwavering, and our Board is united. I can tell you all that achieving and maintaining this high level of organizational grit and chemistry is not easy, and doesn’t come without experiencing some bumps in the road, but our collective passion, perseverance and dedication to promoting the highest quality of patient care in IONM is what keeps us going. 

 

The second thing I want you to know, because it’s relevant, is that one of our Board Members, Dr. Gene Balzer, resigned from the BOD in late December, and the Executive Committee accepted his resignation. Dr. Balzer was a founding member of this Society, indeed a founding “father” in this profession, and he has a long-standing record of dedication to the ASNM and accomplishment as a leader within the Society. So, it goes without saying that his contributions will be missed. On a personal note, I can say that I consider Gene to be a friend and mentor, and I wish him well. 

 

I will also note that, in a Society of volunteers leading a profession notoriously plagued by apathy and disengagement, Gene was always one of those people who raised his hand to help. Gene was not just a member of the BOD, but he was also Chair of 2 of our Standing Committees, he was the sole Program Chair of the 2020 Winter Symposium, and Program Co-Chair of the 2020 Annual Meeting. We thank Gene for the work he did in all of these roles. The ASNM BOD will work together to back fill all of these roles with minimal disruption to our organization. 

 

Regarding the Winter Symposium, I can tell you that the symposium is full speed ahead. It will take place February 22-23, and it will be 100% virtual (no onsite presence). Attendees who sign up will experience a world-wide broadcast of educational content (some live and some pre-recorded, along with live Q&A from a panel of experts) and they can experience this content, including getting CME and CEUs from the comfort of their own home. This means we have completely eliminated expenses associated with travel and accommodations. 

 

The meeting is open to everyone, regardless of whether or not you are a member of the ASNM. The cost to view the content live is $300, again, regardless of membership status. If you just want to view the recorded symposium after the fact, the cost will be $400, but this option is open to members only. If you want to view the content live and get all the benefits of 2020 ASNM membership, you can purchase a package for $450 (for a total savings of $35). 

 

We have more-and-more people registering for this Symposium by the day. We also have exhibitors that have produced videos which will air during commercial breaks. Despite whatever setbacks we experienced, I have no doubt this grand experiment, this virtual symposium, will be a resounding success. 

 

Turning to our 2020 Annual Meeting, This meeting will be held May 15-17 in St. Louis, MO. I’ve taken over for Gene as one of the Program Co-Chairs, and I’m working with two rock stars to make this one of the best meetings ever: Rebecca Clark-Bash and Clare Gale. Together, we are developing an outstanding Program, which you can expect to see on our website by March 1 at the latest. 

 

The final meeting this year will be our Fall Symposium, and I’m very happy to announce that we have partnered with the Canadian Association of Neurophysiological Monitoring ht to develop a joint ASNM-CANM Symposium September 18-20, 2020 in Vancouver, BC. We’re very thankful to the leadership of CANM for joining forces with us in a shared venture, and shared vision, to build bridges in the IONM community. 

 

While I have you, just a couple other quick announcements. 

 

First, on January 15th, we sent an email to membership informing you that nominations for ASNM office are now open. This is your opportunity to choose who gets to be on the election ballot for ASNM office later this year. Please look for that email from Jan 15th. Think about who you’d like to see run for ASNM office, and submit their name. The deadline for submission is April 15th, but don’t wait that long or you’ll forget. Take action today!

 

Second, on February 1st, we send out an email to membership informing you that nominations for ASNM Fellowship are now open. If you know someone who meets the criteria, please do submit their name for consideration to receive this prestigious title. I can tell you that you will need to collect and submit a lot of information to nominate a candidate, so you need to start that process ASAP. Nominations close March 15th. Again, take action today!

 

Finally, I made due on my promise to roll out new awards to recognize members of the ASNM who make outstanding contributions in various ways. You can read about our awards on the website, but I want to give you a heads up that you can expect to see another call for award nominations in the weeks ahead. There is one award in particular that comes from nomination by general membership of the society, and we’ll be asking you to nominate someone special. 

 

I’m heading off to the ACNS meeting in NOLA. It reminds me of how important it is to participate in our profession, to be engaged and support the folks who are out here working to advance this profession. I encourage our members to also support our sister societies, like ACNS and ASET.

 

I’ll be back in March with another update from the front lines. Thanks for being a valued member!

 

Disclaimer:

 

The views, thoughts, and opinions expressed in this blog post are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

Tags:  President's Message 

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In the Literature: MEPs in Infants

Posted By W. Bryan Wilent, PhD, DABNM, FASNM, Friday, January 31, 2020
Updated: Wednesday, January 29, 2020

In the Literature: MEPs in Infants

 

IONM plays a critical role in pediatric spinal procedures. Preserving motor function is of paramount importance in any surgical procedure, but it is especially precious when the patient is an infant. There are, however, unique challenges and sensitivities associated with the IONM of infants; it is not uncommon for surgeons and surgical neurophysiologists to have questions regarding optimal MEP technique and the overall feasibility of MEPs.

 

There are three papers from this year that demonstrate the utility of MEPs in infants of less than 3 months age. Here are FOUR Key Insights from the papers and from Alier Franco, PhD, an author on the Flanders et al study and the manager of the IONM service at the Children’s Hospital of Philadelphia. 

 

1. MEPs can be safely performed and obtained at any age

  • Yi et al obtained MEPs in at least one extremity in 24 of 25 infants from 1.5 months to 3 months of age.
  • Aydinlar obtained MEPs in 15 infants from 1.5 months to under 12 months (average age 5.8 months) with at least one monitorable muscle from both upper and lower extremities in all infants.
  • Flanders et al set the bar illustrating robust MEPs in an infant at 15 days of life!

 

Thus, it has been shown that MEPs can safely and effectively be performed in infants at essentially any age.  There is no evidence to contraindicate MEPs from a safety perspective or data showing that MEPs cannot be obtained because of early age. 

 

2. The display window may need to be widened (200-300 ms) because of delayed responses

 

As illustrated in Flanders et al, the latency for lower extremity MEPs may be >100 ms, which is beyond the typical display window used for MEPs in adolescents or adults. This occurs because of the combination of pathology and a still maturing nervous system with slower conduction velocities. If responses from the lower extremities are absent at baseline using a 100 ms window, the window should be expanded to check for responses that are delayed.

 

3. TIVA and anesthesia management are critical

 

Continuous communication with anesthesia and titrating TIVA in concert with hemodynamic management ensure optimal conditions for reliable neonatal evoked potentials. The presence of any residual inhalational agents can significantly impede the reliability of MEPs throughout the procedure. High doses of propofol are often needed at induction with neonates and infants, but concentrations should be titrated to minimal safe levels throughout the course of the procedure. Awareness of decreases in core body temperature, to which infants are susceptible, is also important, as this cooling can significantly affect morphology, latency, and (in extreme cases) the monitorability of evoked potentials. 

 

 

4. Will often have to vary the stimulation parameters and use higher intensities

 

When using constant voltage technique for MEPs, intensities of >500V are often needed, and that is assuming a high train count, i.e. > 7 pulses and a pulse width up to 75 microsec. Regarding the optimal ISI, 2 ms (500 Hz) is effective and lower ISIs such as 1 ms (1000 Hz) are typically less effective, but note however, that neonates and early infants can sometimes require longer ISIs such as 5 ms (200 Hz) train and/or double train stimulation. Overall, baseline monitorability can be highly dependent on stimulus parameters and thus varying stimulus parameters is sometimes critical. 

 

References: 

 

  • Flanders TM, Franco AJ, Hines SJ, Taylor JA, Heuer GG, “Neonatal intraoperative neuromonitoring in thoracic myelocystocele: a case report.”, Child Nerv Syst, 2019, Nov 10
  • Aydinlar EI, Dikmen PY, Kocak M, Baykan N, Seymen N, Ozek MM, “Intraoperative Neuromonitoring of Motor-Evoked Potentials in Infants Undergoing Surgery of the Spine and Spinal Cord”, J Clinic Neurophys, 2019, 36 (1): 60-66
  • Yi YG, Kim K, Shin HI, Bang MS, Kim HS, Choi J, Wang KC, Kim SK, Lee JY, Phi JH, Seo HG, “Feasibility of intraoperative monitoring of motor evoked potentials obtained through transcranial electrical stimulation in infants younger than 3 months”, J Neurosurg Pediatr. 2019 Mar 15:1-9. 

 

Disclaimer: 

 

The views, thoughts, and opinions expressed in this blog post  are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

 

Tags:  In the Literature 

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In the Literature: Technical Tips: A Checklist for Responding to Intraoperative Neuromonitoring Changes

Posted By Scott Mohr, BS, CNIM, MBA, Wednesday, January 29, 2020

Article Title: Technical Tips: A Checklist for Responding to Intraoperative Neuromonitoring Changes. 

 

The Big Question:

 

How can checklists enhance a neuromonitoring team’s response to changes in patient neurophysiologic data? The Duke Health System neurodiagnostic department recently published an article detailing their experiences coordinating the entire surgical team with an action-oriented checklist. The checklist - based off of the Vitale format - establishes defined roles and responses for each member of the surgical team, which are initiated once the neuromonitoring technologist reports a change in patient data (Vitale, et al. 2014). The Duke experiment provides the neuromonitoring community with a promising example of a neuromonitoring program effectively integrated with the surgical team.  This paper provides some evidence that working from a shared script can allow rapid and focused response to significant surgical events.

 

Background:

 

The positive impact of checklist practices in healthcare has been well documented since Dr. Atul Gawande published his landmark book The Checklist Manifesto.  When a health care team can develop uniform, standardized protocols for repeatable tasks, best practices develop which leave less room for error, omission, and confusion.  In essence, employing a checklist format can help prevent failure, which was a main tenet of Dr. Gawandes’ publication (Gawande, 2010).

 

Opportunities for failure abound when the neuromonitoring team identifies a change in data during a surgical procedure.  The oversight physician and the neuromonitoring personnel need to jointly identify the event, communicate the change to the surgical team, and work to troubleshoot possible technical causes, while maintaining timely documentation of the events.  Without education and awareness about the value of neuromonitoring data in critical situations, confusion and disregard can delay rapid interventions by the surgeon or the anesthesia team, which could negatively impact patient outcome.

 

The Duke team was looking to establish a uniform format that assigned everyone in the operating room a role once a neuromonitoring data change was announced.  Once the checklist was initiated by the neuromonitoring technologist in the room, each person would know their role in addressing the change.  For example, if the technologist reported a loss of motor responses, the anesthesiologist would take steps to prepare for a possible wakeup test.  The surgeon could reverse any surgical manipulations (if relevant), all while the technologist would work through the listed steps to troubleshoot technical components and optimize data collection.

 

Method:

            

The authors employed the Vitale checklist, published as a best practice for neuromonitoring reporting during spinal surgery.  The Vitale checklist was published in 2014 after a research team headed up by Dr. Michael Vitale sought to establish a consensus-based set of guidelines for reporting neuromonitoring changes in a format that coordinated the response of the surgical team as as whole.  The checklist resulted from extensive literature review and surveying of over 20 neurosurgeons.  The format was initially applied to standard, low-risk spinal procedures.

 

The Vitale checklist functions by breaking the OR team up into four categories based on their role.  These are Control of Room (head circulating nurse), Anesthetic/Systemic (head anesthesiologist and primary anesthesia provider), Technical/Neurophysiologic (the neurotechnologist and their oversight physician, and finally, Surgical (the surgeon and scrubbed personnel).  The checklist provides a defined response role for each category if the technologist reports a data change.

 

The first step for the Duke program was education and awareness for the surgical teams that would participate - the checklist format was only effective with full compliance from all personnel in the operating room.  In addition to training meetings, each member of the surgical team was given a copy of the Vitale checklist.  Each neuromonitoring platform had a copy of the checklist, and a laminated copy was posted to each operating room involved in the study.  The cases involved were entirely composed of spinal procedures.

 

Once a change was announced during a procedure by the technologist, the circulator (Control of Room) would read the steps out loud to the room.  Having a central coordinator providing verbal cues reduces confusion and enhances teamwork during the tense moments of a patient status change. 

 

Most all of the steps were standardized to a point where each team member could readily anticipate the actions of others.  The technologist, for example, would know that in response to a loss of cortical amplitude, the anesthesia provider would work to treat blood pressure and raise the mean pressure.  

 

The sample size for the study was 9 surgical participants (though the study does not make clear if this number refers to surgeons, surgical teams, or neuromonitoring personnel).  After an undisclosed duration for the study, participants were surveyed for their impressions and feedback.

 

Results:

 

A post-implementation survey of the 9 participants resulted in 100% of the sample population reporting the Vitale checklist clarified their role during a neuromonitoring data change, and respondents were more confident that the practice would lead to improved safety and efficiency.  Survey reports reveal the surgical staff feel the checklist streamlined their response to critical events when every moment counts.  The Duke neuromonitoring program reported at the time of this writing that they continue to revise and customize the checklist implementation in response to the continued feedback they have received.

 

Discussion:

 

What are some key takeaways from this report for the neuromonitoring community?  Dr. Gawande wrote that checklist practices enhance consistency of care and reduces errors born from omission and confusion (Gawande, 2010).  The ability to be confident in the next practical step you take - and predict your teammates’ actions - leads to a higher rate of success when time is critical and each decision carries greater weight on the patient’s outcome.

The Duke neuromonitoring department harnessed the mechanics of the Vitale checklist with these goals in mind.  They discovered the benefits of implementing these practices; faster response times, enhanced coordination of the surgical team, and reduced technical error.  An added benefit was the checklist itself as a documentation tool; the recording of actions and data collection provide an accurate and concise report for the surgeon after the surgery.  

 

Neuromonitoring organizations must continue to drive awareness and engagement in operating room culture and surgical workflow.  What the Duke team is doing here is an excellent example for our field; they are involving their team in upstream staff education and downstream surgeon follow-up while becoming actively involved in surgical event management during a patient status change.  This level of play is neuromonitoring at its best - the Duke team is part of the patient care experience, not a backup system sitting behind the anesthesia cart with a laptop.

            

There are some questions left to be answered after this report.  A sample size of 9 is a good start, but too small to draw confident conclusions about the impact of the Vitale Checklist.  Furthermore, the paper reports that “100% [of participants] agreed that the checklist positively impacted patient safety and case efficiency” (Rendahl and Hey, 2019).  Reports of 100% success in unquantifiable reporting often reflects an element of group think  - everyone involved in the practice felt like the checklist format was a good idea and was helpful to their daily practices in the operating room.  While this sentiment is encouraging, it doesn’t give the neuromonitoring community much to learn from.  In healthcare, we learn from systems and practices when they break, where they fail.  It would be helpful to read more about where this system went wrong, and whether or not a dissenting opinion could shed light on components of the protocol that could change for the better.

 

Dr. Gawande’s book mentions a study at Johns Hopkins that ties into current Surgical Time Out practices.  The study notes that when, at the beginning of the procedure, each nurse in the room was given the chance to state their name and any concerns they had before the procedure began, the participants were more likely to note potential problems and offer up viable solutions, leading to better outcomes.  Researchers dubbed this an ‘activation phenomenon’, and the empowerment experienced by the nurses in the Johns Hopkins study is reflected in the Duke neuromonitoring department’s checklist experiment (Gawande, 2009).  The neuromonitoring community will continue to benefit from checklist best practices such as this encouraging report.

 

References:

  1. Rendahl R, Hey LA. Technical Tips: A Checklist for Responding to Intraoperative Neuromonitoring Changes. The Neurodiagnostic Journal, 2019; 59:2, 77-81.
  2.  Gawande, A. (2010). The checklist manifesto: How to get things right. New York: Metropolitan Books.
  3.  Rebecca Rendahl & Lloyd A. Hey (2019) Technical Tips: A Checklist for Responding to Intraoperative Neuromonitoring Changes, The Neurodiagnostic Journal, 59:2, 77-81,
  4.  Vitale MG, Skaggs DL, Pace GI, Wright ML, Matsumoto H, Anderson RCE, Brockmeyer DL, Domans JP, Emans JB, Erickson MA, et al. 2014. Best practices in intraoperative neuromonitoring in spinedeformity surgery: development of an intraoperative checklist to optimize response. Spine Deform.2(5):333–339.

 

Disclaimer: 

 

The views, thoughts, and opinions expressed in this blog post  are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

Tags:  In the Literature 

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In the Literature: IONM of RLN During Thyroidectomy with Adhesive Skin Electrodes

Posted By Scott Mohr, CNIM, MBA, Friday, December 20, 2019

Article Review/Summary: Intraoperative Neuromonitoring of Recurrent Laryngeal Nerve During Thyroidectomy with Adhesive Skin Electrodes

The Big Question:

Can gel-based adhesive dermal electrodes serve as a suitable alternative to Nerve Integrity Monitor (NIM) endo-trachial (ET) tubes during Recurrent Laryngeal (RLN) monitoring for thyroidectomy procedures?  A research team based out of multiple institutes in the Republic of Korea joined forces to determine just that.  The strengths and limitations they discovered during their exploration invites further investigation into what could be a cost-effective and less-invasive alternative to standard NIM ET tube usage.

 

Background:

The IONM community can play a strong supporting role in ENT procedures such as thyroidectomies.  As cited in this paper, a former meta analysis support the position that RLN monitoring during thyroidectomies adds value to the surgical procedure; rapid and accurate identification of nerve tissue, reduction of vocal cord paralysis and overall improved surgical technique.  Monitoring of the RLN - a branch of cranial nerve X which innervates the intrinsic muscles of the larynx - is generally accomplished with electrodes either built into or adhesed to an ET tube and placed by intubation.  

However, this method offers certain complications.  Some anesthesiology programs have concerns about the size and potential esophageal damage NIM ET tubes can cause, and this concern extends to the brands of adhesive pads which are attached to the exterior of an ET tube prior to patient intubation.  Furthermore, NIM ET tubes can move during surgical manipulations or due to anesthesia team activity, leading to poor contact between the vocal folds and NIM ET tube, resulting in loss of signal (LOS).  

Finally, certain patient populations - such as difficult airway patients and certain pediatric cases - do not readily lend themselves to accurate NIM ET tube placement.  Having an alternate means of recording RLN activity during thyroid and other ENT procedures would be ideal.  Clearly, the subdermal adhesive pad recording technique warrants a closer look in this research paper. 

 

Objective:     

The research team recorded both free-run and handheld probe-triggered EMG activity from patients undergoing thyroidectomy procedures using both a NIMT ET tube with embedded recording electrodes and also dermal adhesive electrodes (referred to as ‘skin electrodes’ hence forth) to measure and compare the quality and quantity of data obtained from both techniques.  The research team wanted to ask the question, ‘could skin electrodes produce the same quality and reliability of data as a NIM ET tube?’

 

Methods:

Study participants - 39 patients in total - were intubated with a Medtronic Xomed NIM ET tube (6mm for women and 7mm for men).  Additionally, Medtronic Xomed adhesive gel pads skin electrodes were applied in the montage V1-R1 - R2 -V2  to lateralize the vocalis muscles.  During the course of the surgery, free-run EMG activity was monitored and the superior branch of the RLN was identified with a handheld stimulation probe.  Amplitude of these triggered responses were recording (in microvolts) as well as the responses’ latency (mSec). 

 

Results:

Fortunately, all 39 patients in the study awoke with no new deficits and experienced favorable outcomes.  After assessing the data collected, the researchers noted the following.  First, data was successfully collected in all 39 surgical instances from the skin electrodes.  This is in contrast to four episodes of Loss of Signal (LOS) from the NIM ET tube recording electrodes.  In essence, even when the ET tube failed to record data, the skin electrodes were able to record a triggered response during nerve stimulation.

Second, the recorded amplitude of responses was lower for the skin electrodes when compared to the NIM ET tube recording electrodes’ response amplitude - by a magnitude of four times.  Therefore, when comparing NIM ET tube recording versus skin electrode recording during nerve stimulation on the same patient, the amplitude of response was on average 4 times larger from NIM ET tube recording electrodes versus skin electrodes.  There was no difference in latency noted in any of the cases.

 

Discussion:

What does the data mean for the IONM community?  The researchers concluded that this study was an encouraging step toward establishing skin electrodes as an acceptable alternative to NIM ET tube and in situ needle recording for RLN monitoring during thyroidectomies.  With a study population of 39 patients, more data in future studies will be helpful in reinforcing the team’s conclusions.

For the neuromonitoring community, NIIM ET tube recording offers hurdles to our involvement in ENT procedures.  Many anesthesia programs and surgeons are wary of the bulk and potential for damage to the esophagus and trachea perceived as a risk of such recording devices.  Patients with difficult airways, tracheostomy patients and certain pediatric patients are often not good candidates for NIM ET tube recording.  

Most significantly, NIM ET tubes require accurate placement with a glidescope for good visualization of the vocal folds and recording electrode contact points.  Skin electrode placement offers easy visualization and accurate placement prior to prepping and draping the surgical site.  Anesthesia activity and surgical manipulations can displace NIM ET tube recording electrode contact, resulting in LOS.  This study suggests that skin electrodes do not experience the same rate of LOS as electrodes on an ET tube, a definite advantage of skin electrodes.

There are still questions that need to be answered.  Can the adhesive electrodes reliably retain good contact during prolonged procedures?  What if a patient has oily skin or other conditions precluding adhesive pad placement?  Larger incisions and retraction can displace the leads away from ideal recording locations, reducing their efficiency.  Above all, the consistent loss of recorded amplitude is a significant tradeoff when replacing NIM ET electrodes with skin electrodes.  Future inquires could provide a cost-effective and minimally invasive option for thyroidectomy patients, but until then, NIM ET tube electrodes recording of the RLN remains a best practice for the neuromonitoring community.

 

References:

Hyoung Shin Lee, Jungho Oh, Sung Won Kim, Yeong Wook Jeong, Che-Wei Wu, Feng-Yu Chiang, Kang Dae Lee. Intraoperative Neuromonitoring of Recurrent Laryngeal Nerve During Thyroidectomy with Adhesive Skin Electrodes.World J Surg. https://doi.org/10.1007/s00268-019-05208-3

 

Disclaimer: 

The views, thoughts, and opinions expressed in this blog post  are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

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Complete List of 2019 NASS IONM Podcasts With Links

Posted By Richard W. Vogel, Friday, December 20, 2019

This podcast series is about neuromonitoring and covers a range of educational topics aimed at optimizing patient care, decreasing cost and/or maximizing OR efficiency. The hosts are Drs. Rich Vogel and Adam Doan. Each episode is 5-10 mins.

 

Episode 1What information is critical to communicate to the IONM team and how far in advance of surgery?

Summary: It’s not uncommon for the IONM team to learn the details of the surgical procedure after incision, as it unfolds. This poses a number of problems. The IONM team needs to know detailed surgical plan, diagnosis and patient insurance information at least 48-hours in advance for non-emergent surgery. This will make IONM less likely to fail because the IONM team can make sure the correct equipment/electrodes/people are in the room, and the correct tests are being run with optimized anesthesia. This will also limit common issues with insurance. 

 

Episode 2Neuromonitoring in spine surgery, can’t anyone cover the case?

Summary: Did you know IONM is learned through on-the-job training, licensure does not exist, and certifications are not required for the technologist in your OR? After initial training, technologists can monitor very basic cases (e.g., PLIF), but they should spend years in training to learn more complex procedures (deformity, tumors). If a surgery isn’t booked accurately, the surgeon might get a very junior person assigned to a very complex case. Here we inform the listener of common practices around determining “competency” for performing IONM in spine surgery.

 

Episode 3Why does IONM need access to my patients and their charts before and after surgery?

Summary: It’s not uncommon for hospitals/surgeons to prohibit the IONM team from interfacing with the patient before surgery. In addition to needing informed consent, the team needs to assess the patient’s neuro status and history to interpret the IONM data. Imaging/charts help to develop an appropriate IONM plan. Facesheets are essential to reimbursement. When the IONM team is unable to access patient records, they are monitoring in the dark (and for free). 

 

Episode 4What are the anesthetic recommendations for neuromonitoring in various spine surgeries and why?

Summary: Here we discuss when and why we recommend total intravenous anesthesia (TIVA) vs 0.5 MAC. Is Ketamine really beneficial to MEPs? Why is Precedex contraindicated for MEPs? What train-of-four ratio is recommended for monitoring, when and why? We’ll answer all these questions and others.

 

Episode 5Does use of IONM necessarily add time to your surgery? 

Summary: The short answer is yes, but a closer look will show that it is negligible if the IONM team can work efficiently. We’ll discuss how setup can be optimized, and how baselines can be acquired in less than 10 seconds. We’ll also show how improved communication can reduce false positives and keep the surgery moving smoothly.

 

Episode 6How can you use neuromonitoring to guide and optimize positioning for spine surgery?

Summary: The patient is finally in position and neuromonitoring can’t get baselines. What do you do? If you elect to intervene, it’s a long process to retest baselines in a neutral position. Then, you have to reposition all over again. Here we presently a fast, efficient, systematic way to position a patient for any spine surgery to ensure the spinal cord is stable, and all peripheral nerves and plexi are not compressed or stretched. Also, we talk about positioning possibilities for all patients; not just those with unstable spines.

 

Episode 7Are there any real contraindications to MEPs.

Summary: Here we cut through the common myths associated with MEP contraindications. There are no absolute contraindications, and all of the relative contraindications have actually been shown to be quite safe. 

 

Episode 8What can you do to improve accuracy of pedicle screw stimulation?

Summary: Pedicle screw stimulation was developed and tested under very specific methods, but very few people follow these methods, and this reduces the accuracy. Here, we return to the basics and make recommendations that help even the most seasoned practitioner.

 

Episode 9Is it really an alert? Whence the criteria?

Summary: The criteria for calling an alert in IONM have evolved over the years and many people don’t know what the latest research says. This causes a lot of false positives (and some false negatives). Here we review what really constitutes an alert and how you can use IONM to improve accuracy.

 

 Episode 10Diagnostic accuracy of IONM from the neurophysiologist’s perspective.

Summary: Here we review the traditional diagnostic table (i.e., ± alert, ± deficit) and consider other factors like intervention, resolution of data, type of monitoring modality, etc. From here, we present an advanced diagnostic table that is inclusive of these factors. This has major implications for developing and interpreting research.

 

Episode 11Neuromonitoring lost their signals, now what?

Summary: Aside from checking wires and anesthesia, what else works? It turns out there is a lot one can do to restore signals. Here we review these checks and interventions.

 

 Episode 12Are wakeups always prolonged with neuromonitoring under TIVA?

Summary: It’s a common complaint: we use TIVA for MEPs, but the patients take forever to wake up from anesthesia. To combat this problem, many surgeons elect to discontinue IONM earlier in the procedure. Did you know IONM has the technology to guide the anesthesia team through a faster wakeup in most cases? It requires communication and collaboration, but it’s easy to do. Here we review these techniques.

 

Disclaimer:

The views, thoughts, and opinions expressed in this blog post  are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

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In the Literature: Utilization of MEPs During Posterior Lumbar Procedures to Diagnose and Avoid ‘Foot Drop’ Dorsiflexion Injuries

Posted By W. Bryan Wilent, Thursday, November 7, 2019

Foot drop is a condition resulting from nerve or nerve root injury in which patients cannot properly dorsiflex the foot. While it may be a focal deficit isolated to a couple muscles, it can have a devastating impact on a patients' quality of life.  Patients may not be able to walk without assistance, are prone to further injury due to falls, and are forced to live with the distress of being unable to perform previously normal activities. 

This injury can occur during posterior lumbar fusions, but unfortunately the IONM modalities typically used during these procedures (spontaneous EMG and posterior tibial nerve SSEPs) have been historically very poor in diagnosing the injury. But, there is good news from the literature! There are two papers from ‘The Spine Journal’ this year (Wilent et al, Lieberman et al) and one from ‘Spine’ (Tamkus et al) last year that focused on the ability of MEPs to accurately diagnose foot drop dorsiflexion injuries.  

FIVE Key Points from the Papers

1. The MEP alert criterion is critical

Diagnostic accuracy is dependent on using a 50-60% amplitude attenuation as the alert criterion for MEPs when diagnosing nerve root dysfunction.

In Lieberman et al, the average change in amplitude was 65% in the Tibialis Anterior (TA) muscle and 60% in Extensor Hallucis Longus (EHL) muscle. Tamkus et al found an average decrease of 59.5% (they linked TA and EHL in the recording channel). Wilent et al emphasized that it was typically a greater than 50% decrease in amplitude of TA MEPs that prompted an alert. 

It should be noted that while amplitude is most common MEP response characteristic assessed intraoperatively, Tamkus et al found that the area under the curve (AUC) of the response was slightly more reliable in diagnosing nerve root dysfunction. 

2. MEPs > sEMG in diagnosing nerve root dysfunction

HISTORICAL BELIEF: During spine procedures, sEMG monitors nerve root function and MEPs monitor cord function.

DATA SAYS: During spine procedures, sEMG (with subdermal needles) provides information about proximity to nerve roots or if mechanically manipulated but this modality does NOT reliably diagnose dysfunction; in contrast, MEPs do reliably diagnose spinal cord motor dysfunction & motor nerve root dysfunction.

From Lieberman et al, “Our study further challenges the fidelity of EMG monitoring for detecting a nerve root injury. Out of 25 injured patients, only 10 (40%) had an episode of tonic EMG that occurred concurrently with acute changes in the MEPs. Moreover, no patients had any significant EMG activity that suggested motor nerve injury without also having MEP amplitude changes.”

Tamkus et al found that 40% of the patients with foot drop also had free-run EMG alerts that were reported. However, free-run EMG alerts were also reported in 56.9% of the procedures in which the patients had NO deficit. Thus, 56.9% of the time, sEMG did not portend dysfunction 100% of the time.

In Wilent et al, 100% of patients with nerve root injuries had unresolved MEPs, but only 14% of those procedures had an EMG alert called.

3. Contrary to what is commonly thought, MEPs do NOT have many false positives

Of the 4,382 procedures in Wilent et in which patients had no new deficit, only 15 had a false positive unresolved TA MEP alert. That’s it. Just 0.3% of procedure had false positive isolated TA MEP alerts.  The overall specificity of MEPs was 97.9%, which was higher than the specificity of sEMG.  

Lieberman et al reported, “For detecting any injury, a 50% threshold represents a desirable balance between sensitivity (96%) and specificity (97%)”.

Using an alert criterion of a >50% decrease in amplitude, Tamkus et al found that the sensitivity was 100% and the specificity was 87.9%. This specificity was lower than the other two studies; however, as Tamkus et al notes in their conclusion, a total intravenous regimen (TIVA) should be considered to reduce the number of false positives. In their study, a balanced anesthesia regimen with inhalational agents at 0.5 MAC was employed; in contrast, in Lieberman et al, a propofol and opioid TIVA regimen was primarily used and inhalational agents were used only occasionally and if so always limited to 0.3 MAC and were always removed if signals were initially weak or fading.

4. The precipitating event is most likely related to stretch after vertebral displacement and NOT pedicle screw insertion

Neuromonitoring during posterior lumbar fusion is often focused on the safe insertion of pedicle screws, but that surgical maneuver does not typically correlate with the intraoperative diagnosis of foot drop dysfunction. 

Tamkus et al stated “No pedicle bone violation was reported in any of the patients with the foot drop.”

Liberman et al stated, “Injury rates were highest among patients who underwent reduction of high-grade L5-S1 spondylolisthesis or had a PSO. All seven injured high-grade spondylolisthesis patients had MEP amplitude changes between 14 and 55 minutes after reduction of the spondylolisthesis. Seven of the nine injuries in the PSO group occurred after closure of the osteotomy (five after L5 PSO; two after L4 PSO).”

Wilent et al provides an example where the MEPs were reduced in amplitude after L4-5 distraction. 

Thus, the precipitating event is typically vertebral distraction/displacement likely resulting in a stretch of the neve root.

5. If MEPs are resolved, deficits are avoided.   #Therapeutic impact

Lieberman et al stated, “Many of our subjects sustained large reductions in MEP amplitude (e.g., >50%) during their surgical procedures. These transient changes resolved and these subjects did not develop new weakness. We were not able to measure the frequency of these events nor correlate them to the patient’s risk of developing an injury.”

 Wilent et al reported 100% of the patients which TA MEPs were resolved by closure had no new deficits postoperatively. Most procedures in which TA MEPs were resolved involved a clear surgical intervention, as shown in the aforementioned example on which a prompt intervention to release distraction resulted in the resolution of the MEPs and the patient had no postoperative dysfunction.  

CAVEAT: For IONM to have a therapeutic impact, you not only need an accurate diagnosis (correct MEP alert criterion), you need a timely diagnosis and a proper intervention. This is only accomplished via relatively continuous MEP acquisition and immediate communication so an alert has context within the sequence of surgical events. This facilitates clinical decision making and impacts the therapeutic benefit of interventions.

References:

  • Wilent, WB, Tesdahl, EA, Harrop JS, Welch WC, Cannestra AF, Poelstra KA, Epplin-Zapf T, Stivali T, Cohen J, Sestokas AK, “Utility of motor evoked potentials to diagnose and reduce lower extremity motor nerve root injuries during 4,386 extradural posterior lumbosacral spine procedures”, The Spine Journal, 2019
  • Lieberman JA, Lyon R, Jasiukaitis P, Berven SH, Burch S, Feiner J The reliability of motor evoked potentials to predict dorsiflexion injuries during lumbosacral deformity surgery: the importance of multiple myotomal monitoring”, The Spine Journal, 19: 377-385, 2019
  • Tamkus A, Rice KS, Hoffman G, “Transcranial motor evoked potential alarm criteria to predict foot drop injury during lumbosacral surgery”, Spine, 15;43(4):E227-E233, 2018

Disclaimer:

The views, thoughts, and opinions expressed in this blog post  are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

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President's Message - November 2019

Posted By Richard W. Vogel, Thursday, October 31, 2019

Dear Members,

 

Just a few announcements this month:

 

ASNM elections open this coming Monday (November 4th). Please look for an email from the ASNM with a link to access information about the candidates, and a link to access the ballot. We have 2 people running for one open position as ASNM President, and 9 running for 4 open positions on the ASNM Board of Directors. Once ballots open, you will have 2 weeks to vote. We’ll announce the winning candidates in December. Winning candidates will take office at the ASNM Annual Meeting in May of 2021.

 

Our new industry prospectus is out, on time, as promised. I’d like to thank our Exhibitor Taskforce, Executive Committee and the team at Affinity for all the hard work that went into developing this prospectus. As our society grows and experiments with new educational platforms, we’ve elected to offer our industry partners a variety of new options to tailor their support of the ASNM to their individual needs.

 

We finally have a date for the ASNM 2020 Winter Symposium. It will be held Feb 22-23. As I said previously, this will be a (mostly) virtual meeting, consisting of a live, interactive, world-wide internet broadcast. We’ll plan to air commercials from our sponsors between talks. 

 

Symposium attendees will be able to attend via an internet portal without the expenses associated with travel. Virtual attendees will be able to purchase individual sessions or the entire symposium. The fee structure will significantly reduce member’s cost unit of CME and CEU. Limited in-person audience attendance is available.

 

Why are we doing this? Because you asked for it! Last year, we conducted a membership survey which indicated that members wanted, 1) more innovative speakers and formats, 2) effective utilization of their time, and 3) lower cost CME/CEU options. Ask and you shall receive! This is a big experiment for us, and I certainly hope you will join us in February. I’d like to thank the Representation and Advocacy Committee for coordinating the membership survey, and many thanks to Dr. Gene Balzer for his vision and hard work in developing this virtual meeting program.

            

Finally, I have a very big and exciting announcement to make. I’m bringing in a very special guest as my Presidential Speaker at the 2020 ASNM Annual Meeting. This meeting will be held May 15-17, 2020 in St. Louis, Missouri. If you want to know who it is and why I’m bringing this person in, you’ll have to watch my November President’s video

 

If you want to go back and watch my previous monthly video messages, just search for “ASNM President” on youtube.

 

I hope you all have a very happy Thanksgiving. I’ll be back in December with another update from the front lines. Thanks for being a valued member!

 

Disclaimer:

The views, thoughts, and opinions expressed in this blog post are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

 

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ASNM Committee Updates

Posted By Richard W. Vogel, Thursday, October 10, 2019

Members,

 

In an effort to keep you informed of what the ASNM is doing for you, each Committee’s ongoing work will be summarized for you on a semi-annual basis (or more frequent if needed). This update is current as of the 2019 Fall Board Meeting.

 

Education Committee (Chair: Dr. Jeff Balzer):

This committee was very pleased with the success of all our educational offerings. Our Fall Symposium was a resounding success, as is our new, bi-annual online, interactive CNIM Prep course taught by James Watt. Our fall course is in progress and we have more than 40 people registered. One great thing about this course is it is free to members. So, you can actually sign up to become an ASNM member (and get all the benefits of membership) for a small fraction of what it would cost to register for the CNIM prep! 

 

Ethics Committee (Chair: Dr. Bob Sclabassi):

You don’t hear much from this committee on purpose because they operate independent of the Board to maintain autonomy and remain free of any actual or apparent influence. This committee is presently reviewing our Conflict of Interest Policy and is expected to make recommendations for potential changes. The goal is to ensure ASNM Leaders can't influence topics of discussion or vote on motions where a conflict may exist. That's not to say that we're experiencing a problem. We just don't want there to be any potential for that problem to occur. Better to be proactive, right? The review of our COI policy is not done, potential changes are not approved, but we will update you as things unfold.

 

Finance Committee (Chair: Willy Boucharel):

This committee just makes sure our finances are in good shape and we can operate as a society. There is no ongoing work, and we’re very stable financially. 

 

Guidelines and Standards of Care Committee (Chair: Dr. Gene Balzer):

This committee is working on a Facial Nerve Monitoring Guideline which is almost done.

 

Membership Committee (Chair: Clare Gale):

The Membership Committee is busy as always. Dr. Faisal Jahangiri completed his term as Chair (Thank you!!!). The new Chair is now Clare Gale. Our membership continues to increase as we expand and improve our membership benefits. One new announcement is that the ASNM is rolling out new awards to recognize the hard work of our members. It would be a lot to write, but you can learn more about these awards in the October President’s Message video. Frequencies and descriptions of these awards are subject to change as we finalize them in prep for our 2020 Annual Meeting. 

 

Nominations Committee (Chair: Dr. Jay Shils):

This is a new ad-hoc committee which is being written into the updated Bylaws. This committee will oversee nominations and elections. Moving forward, all nominees for ASNM Board or elected leadership positions will be required to disclose financial relationships so our membership has a better idea of who they are voting for and what factors may influence how they perform as a leader in the ASNM. Elections for Board and President will open very soon. Stay tuned for that!

 

Representation & Advocacy Committee (Chair: Dr. Gene Balzer):

This committee is working to develop videos for patient education. They are also working to revise/expand our Position Statement on Business Practices in IONM. Stay tuned for a new version to be released in the weeks ahead.

 

Research Committee (Chair: Dr. Miriam Donohue):

The Research Committee is now called the “Research & Technology Committee”. Dr. Bryan Wilent completed his term as Chair (Thank you!!). The new Chair is now Dr. Miriam Donohue. This committee recently submitted a Letter to the Editor in response to a high profile and low quality paper published in the literature. This Committee is also charged with periodically posting article summaries on our Blog. Recently, ASNM Member, Chris Halford, summarized an article, which you can read here. Thank you, Chris!!

 

So, that’s our Committee Update for the second half of 2019. We’ll update you again sometime in the first half of 2020. 

 

Are you interested in getting involved in Committee work? Contact one of the committee chairs and ask if there is an opening.

 

Disclaimer:

The views, thoughts, and opinions expressed in this blog post are solely those of the author(s). Blog posts do not represent the thoughts, intentions, strategies or policies of the author’s employer or any organization, committee or other group or individual, including the ASNM. The ASNM, along with the author(s) of this post, makes no representations as to the completeness, accuracy, suitability, validity, usefulness or timeliness of any information in this blog and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. All information is provided on an as-is basis. Any action you may take based upon the information on this website is strictly at your own risk.

 

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