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President's Message - August 2019

Posted By Richard W. Vogel, Wednesday, July 31, 2019

Members,

My last President’s Message was in June. This has been a busy month. On the personal front, I moved to a new home and took a week’s vacation to unplug and recharge. Now, I’m back to work for you.

I want to give you an update on some of the things we’re working on, as well as make some comments related to the NPR storyabout IONM that broke on June 17th.

Here’s a bullet point list of some projects we’re working on presently.

  • Reviewing contracts for upcoming meetings. Our management partner, Affinity Strategies, is working hard trying to secure locations and hotels. In that process, our Executive Committee is working to select the best locations and review potential contracts with hotels.
    • As you know, a primary goal of mine is to get our hotel prices down and make them affordable for all.
    • Our 2020 Annual Meeting has been moved from Chicago to St. Louis. It will be held May 15-17, 2020. 
  • Collaborating with other societies, like ASET, to coordinate various projects that we’re collaborating on. One example is patient awareness and advocacy.
  • Our Taskforce on Diversity is off the ground and presently being coordinated by Dr. Tara Stewart
  • We also launched a “Sponsor Taskforce” to seek input from our industry partners. This taskforce is being led by Leah Hanson. They are presently working on our 2020 prospectus.
  • I’ve been working with Affinity Strategies to update our branding and communications.
    • We’ll no longer bombard you with emails. You can expect to see e-blasts from us approximately every 2 weeks. The President’s Message will come in the first e-blast of the month.
    • You’ll get a reminder to register on the day of a webinar.
    • Everything that comes from the ASNM will be branded the same and look clean and consistent.
  • We’ve made a few changes to the membership application:
    • Removed CV requirement for membership application. Students must still upload proof of student status in a relevant program.
    • I am personally reviewing every question on the membership application and we will update/alter them as needed to ensure we are attracting a diverse membership. Remember, the ASNM is open to anyone with an interest in IONM, regardless of background, education, training, experience or role in IONM.
  • We’ve made a few changes to the website:
    • We included headshots on leadership page so you can see who represents you.
    • While it is in the very early stages, we are working to develop a section of the website dedicated to educating patients about IONM. We have some awesome volunteers working on this project. I expect it to take the better part of a year to complete. 

Now, I’d like to spend the rest of my message commenting on the NPR Story:

Unless you’ve lived in a cave for the last two months, I’m sure you are aware of the story that NPR broke about a patient in Texas receiving an Explanation of Benefits for IONM to the tune of $94K.

The first thing I want to say is my heart goes out to the patient, Liv Cannon, and her fiancé, Cole Chiumento. It’s bad enough having a complex spine disorder and a complex spine surgery, but to receive a large EOB is certainly scary for anyone. The anxiety Liv and Cole must have felt wondering if they would ever receive a bill, well, I can only imagine.

The second thing I want to say is that I spoke to NPR for about 30 minutes, but they only used 2 quotes from me. Both of them were used out of context. I want to give you a couple of examples taken directly from the article. What you see below in italicsis what NPR reported in print. Anything in [brackets]is my comment on that particular statement.

There is an ongoing debate about whether neuromonitoring is needed for all spinal surgery. But it is standard for a complicated operation like the one Cannon had, says Richard Vogel, president of the American Society of Neurophysiological Monitoring[There are no quotation marks here. So, this is not a quote. This is a summary of a conversation I had with the reporter in which I talked about regional differences in the use or nonuse of IONM by surgeons, and how some surgeons feel that lower risk cases do not require IONM. Regardless, I stand behind the accuracy of this statement as it is printed.].

On the other hand, a $94,000 charge for the service can't be justified, Vogel says. [Again, no quotation marks, not a quote. This is the reporter’s interpretation of the quote below].

"You're not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring," Vogel says. [This statement is surrounded by quotation marks. This is a direct quote, and the context of this quote was related to the cases in Colorado which the reported asked me about. As an independent individual, I stand behind this statement. The ASNM, however, is not in a position to determine what one can or cannot charge for IONM. If you want to read why, you’ll have to read my statement that I gave to NPR in the paragraphs that follow below].

Most neuromonitoring companies charge reasonable fees for a valuable service and are upfront about their ownership and financial arrangements, he says. But some companies are greedy and submit huge bills to an insurance company, hoping they won't be challenged, he adds. [Again, no quotation marks, not a quote. This is a summary. I stand behind the accuracy of this comment].

Even worse, "some neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons," Vogel says. [This statement is surrounded by quotation marks. You can review my written statement for context. I stand behind the accuracy of this statement, too.].

Last year, Vogel's group published a position statement condemning these "kickback arrangements" and other unethical business practices. [Again, the primary context was the Colorado story.].

 

Now that I’ve given you some info about my quotes, I thought it might be helpful to our members to read some of what I actually said to NPR, so you can see the context for some of my comments, AND so you can see all the good stuff they never even used: What you see in bold below are the questions I was asked, and then you can see below each how I responded.

What is the evidence that neuromonitoring (IONM) is beneficial for patients?

In general, the evidence is quite good in support of neuromonitoring’s benefits across the wide range of surgical procedures in which it is used. Aside from any risk to the nervous system coming directly from the surgical procedure, studies also show that IONM can detect and prevent positioning related injuries that may result from a patient laying in the same position for a long time during surgery. So, the utility of neuromonitoring is greater than what many people initially consider.

Recently, a number of studies have been published in prestigious journals questioning the utility and value of neuromonitoring, but those studies are so fundamentally flawed, the very fact that they were even published is a testament to how broken our peer review system is in the scientific and medical literature. At the end of the day, these studies have little merit, but their publication brings to light some important considerations regarding evidence for neuromonitoring. Specifically, evaluating the neuromonitoring literature is challenging because there’s tremendous variability in how surgeons use it. This heterogeneity confounds many comparative studies. Also, critics argue that there are no class I studies evaluating neuromonitoring, but the same is true for many medical interventions, including spinal decompression and fusion surgery. In order to develop class I studies, patients would have to be randomized to groups receiving IONM or no IONM in high risk surgery, and the ethics of withholding a treatment which is largely considered standard is questionable. 

Which patients need neuromonitoring?

Neuromonitoring is performed in a wide variety of surgeries, including brain, spine, cardiothoracic and ear/nose/throat, just to name a few. All of these procedure pose some risk to the patient’s nervous system, which can result in weakness, paralysis, loss of sensation, loss of hearing, loss of sight, loss of bowel/bladder control, etcetera. So, it may be indicated for any surgical procedure in which the patient’s nervous system is at risk. 

What has led to the rapid expansion of neuromonitoring?

Many people have argued that use of neuromonitoring expanded secondary to the availability of personnel created when we introduced the telemedicine model of one physician remotely supervising many technologists, but there’s no evidence to support this. Indeed, a highly qualified and educated workforce was available long before this model was introduced.

The real drivers of the expansion are education and liability. Regarding education, many surgeons now understand the utility and value of neuromonitoring for protecting their patients. Whereas neuromonitoring started in spine surgery, it has now expanded to include surgery on other parts of the body. The number of surgeries performed in the US continues to grow, and the types of surgeries that neuromonitoring benefits continues to expand as well.

Regarding liability, there’s tremendous pressure on surgeons and hospitals from the medicolegal community. There’s always a fear of being sued. Using neuromonitoring is thought to reduce a surgeon’s liability, so they use it for their own protection.

How much does neuromonitoring typically cost?

I think we need to break this down two different ways, so I going to rephrase your question both ways and answer each independently:

How much does it cost to perform the service?

We can start by asking how much does it cost a neuromonitoring company (or hospital) to perform the service on a single patient. Neuromonitoring is like any other business where you have salaries, equipment, supplies, travel and overhead. The break-even amount can vary significantly from one group to another. Hospitals and insurance companies often want to pay as little as possible, but they’re just bargaining for lower quality patient care. The unfortunate consequence of driving down prices is a less educated and competent work force using lower quality equipment. So, neuromonitoring can be done inexpensively at the risk of lower quality patient care, or it can be more expensive to get expert neurophysiologists working in the operating room with the most advanced monitoring equipment. 

How much is the average cost to consumer (payor)?

The next question is, how much should it cost the insurance company, or the patient. I have to start by saying that I’m not an expert in medical billing, which is extremely complex, and neuromonitoring is no exception. The cost to consumer (payor) can vary simply depending on the type of monitoring performed and the length of surgery, but these factors alone do not account for the exorbitant charges that are billed for neuromonitoring. Those charges come from a fee schedule that each neuromonitoring group generates to determine what they will charge insurance companies for performing the service. This is based on CPT codes (current procedural terminology) that identify which neuromonitoring tests were used. The usual, customary and reasonable fees associated with these codes are updated annually in a medical fee manual published by Practice Management Information Corporation. For each code, PMIC publishes rates in the 50th, 75thand 90thpercentile based on national averages. In developing a fee schedule, neuromonitoring groups use these numbers, and adjust them by their geographic location. So, there is a basis for developing specific fees for specific neuromonitoring tests. The problem is that some groups are greedy, and they can just double or triple the end product to get more money, and insurance companies are simply unaware or don’t care. The other method that some companies use to develop their fee schedule is to see what Medicare recommends from their fee schedule, then charge a multiple. The basis for determining the multiple is beyond the range of my expertise. 

There have been news reports of some patients receiving very high bills for neuromonitoring. Is that a problem in the field?

The first thing we have to do is differentiate between what is a bill, and what is not a bill. Most frequently, patients receive something in the mail from their insurance company called an Explanation of Benefits. It’s a summary of charges and coverages, and it always says somewhere “this is not a bill”, but patients often get scared and come to expect an impending bill when they see some amount of money listed under a section entitled “your responsibility” or “provider may bill you”. The amount listed is just the difference between what the doctor charged the insurance company and what the insurance company is contracted to pay. Attempting to collect that difference from the patient is called “balance billing”, which is prohibited in some states, but not all. So, patients may or may not be responsible for some portion of the balance. How much the patient actually owes depends mostly on the patient’s co-insurance, deductible and co-pay. It’s all related to the patient’s individual insurance plan. So, if the patient owes anything, it may be far less than expected.

In rare circumstances, patients do actually get very large bills. Unfortunately, many patients these days have high deductible plans with no OON benefits. So, they’re going in to have what is often a very expensive procedure with little in the way of financial protection.  The best thing a patient can do is contact the doctor and the insurance company and ask them to advocate for you. There are ways to reduce costs. Even then, most neuromonitoring groups don’t put patients into collection unless they received a check from the insurance company and failed to turn it over to the rendering provider.

The biggest concern for our field is the fact that some groups charge excessive fees in order to gain business by paying the money back to surgeons. It’s a big enough problem that the ASNM took the bold step last year of publishing a position statement on business practices in neuromonitoring. We’re not in a position to tell providers how much they can charge insurance companies, but we are in a position to express concern over why they charge such high fees and what they do with the money. A growing problem in the US right now is groups paying surgeons a kickback to use neuromonitoring. So, some percentage of that patient’s large bill is funneled back to the surgeon as an incentive to use a specific neuromonitoring group. While the practice is technically legal in a few states, the AMA is clear in their view that the practice is unethical, and we feel the same way. 

How and when should patients be informed that neuromonitoring services will be an out-of network service?

Best case scenario, the patient should be informed by the surgeon or hospital at the time when the surgery is booked. Unfortunately, 99% of IONM is considered elective. So, surgeons and hospitals may fear that, if they tell the patient IONM is OON, the patient will choose not to have their surgery at that location. Hospitals/surgeons are afraid of losing the business. So, the patient is often informed in the minutes just before surgery when they sign the consent for neuromonitoring.

The most unfortunate part of all this is that the OON status of most neuromonitoring companies is actually the fault of the insurance companies who are supposed to be advocating for their patients. Many IONM groups actually try to go in network, but the insurance companies only accept a limited number of neurologists in their network, most of whom don’t do neuromonitoring. So, a neuromonitoring group attempting to bring their neurologists in network is often denied.

On top of that, the fees are driven up by insurance companies’ refusal to negotiate with neuromonitoring groups, which would only make charges more reasonable for all. That alone could save the insurance industry tens of millions of dollars per year.

Neuromonitoring’s pervasive OON statues is mostly the result of the fact that insurance companies don’t understand IONM, and they’re not willing to listen.

How can consumers avoid a surprise bill for neuromonitoring?

If the patient actually receives a bill in the mail, the best thing to do is to call the provider. They can usually help to reduce the cost by working with the patient to appeal to the insurance company to reprocess the claim at in-network prices. This could save hundreds or thousands of dollars.

In terms of actually avoiding a surprise bill, some states have laws against surprise bills, while others do not. So, it’s difficult to know if you are protected. The best thing a patient can do is ask his/her surgeon which ancillary services will be used during surgery. Neuromonitoring is just one type of ancillary service. From there, the patient can find out of the provider is in-network, or ask their insurance company what they can do to process the claim at in-network prices. 

 

So, that’s my President’s Message for August 2019. I hope you’re all enjoying your summer. I’ll be back in September with another update from the front lines.

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NASS Posts IONM Podcast Episode 2 - "Can't Anyone Monitor The Case?"

Posted By Richard W. Vogel, Thursday, March 7, 2019

Be sure to check out the new neuromonitoring podcast from the North American Spine Society (NASS), developed by ASNM members who Chair the NASS Section on Intraoperative Neurophysiological Monitoring. 

 

In each of the 12 Episodes this season, Section Co-Chairs Drs. Adam Doan and Rich Vogel will discuss "How to Optimize Neuromonitoring". 

 

In Episode 2, they address the question, "Can't anyone cover the case?" 

 

"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."

 

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:  Announcement  Podcast 

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Neuromonitoring Podcast from NASS

Posted By Richard W. Vogel, Tuesday, January 15, 2019

ASNM Members Launch Neuromonitoring Podcast Through NASS:

The ASNM is happy to annouce the new neuromonitoring podcast from the North American Spine Society, developed by ASNM members who Chair the NASS Section on Intraoperative Neurophysiological Monitoring.

In each of the 12 Episodes this season, Section Co-Chairs Drs. Adam Doan and Rich Vogel will discuss "How to Optimize Neuromonitoring".

In Episode 1, they address the question, "What information is critical to communicate to the neuromonitoring team in advance of surgery, and how far in advance?"

 

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 Members Participate in Ask The Experts Video

Posted By Richard W. Vogel, Tuesday, December 4, 2018

As we mentioned in a recent post, NASS has a topical video series called Ask the Experts in which experts in various fields go on camera to discuss a specific topic. At this meeting, Drs. Vogel, Doan and Sestokas went on camera to tackle the question, What are the real criteria for a neuromonitoring alert in spine surgery?

Surgeons may think pedicle screw thresholds below 10 mA are an alert, or apply the old 50%/10% rule for SSEPs, or use presence/absence for MEPs, but all of examples are wrong for one reason or another. The experts stressed the importance of precision medicine, treating each patient as an individual, and considering data changes in the context of various factors. In this video, Dr. Vogel served as a moderator and posed a series of questions to Drs. Doan and Sestokas. 

Enjoy:

 

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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Neuromonitoring at NASS

Posted By Richard W. Vogel, Monday, November 19, 2018

ASNM Members Formally Represent Neuromonitoring at NASS:

The North American Spine Society (NASS) is a global, multidisciplinary medical society that utilizes education, research and advocacy to foster the highest quality, ethical, value- and evidence-based spine care for patients. Many people think that NASS is a “spine surgeon society”, but that’s not exactly true. Members actually come from a wide variety of backgrounds, including neuromonitoring, and a common interest in “spine” is the tie that binds all NASS members.

In 2017, after 40 years of working in spine surgery, neuromonitoring had no representation within NASS. That all changed in 2018, thanks to the leadership of ASNM members Dr. Rich Vogel (President -Elect) and Dr. Adam Doan (member, Representation and Advocacy Committee). Drs. Vogel and Doan submitted an application to NASS (later approved) to form a Section on Intraoperative Neurophysiological Monitoring (IONM). A “Section” is like a Committee, but with a more specific focus. NASS’s mission to advance global spine care is accomplished, at least in part, through the collective works of its Councils, Committees and Sections.

As Co-Founders and Co-Chairs of the new Section on IONM, Drs. Vogel and Doan are now part of NASS’s leadership, representing the neuromonitoring community and helping to advance global spine care. Many of the founding members of the NASS Section on IONM are also members of the ASNM, including: Dr. Robert Holdefer, Dr. Nancy Mirarchi, Dr. John Ney (ASNM Board) and Dr. Anthony Sestokas. Other founding members include Dr. David van der Goes (health economist) and Dr. Todd Wetzel (spine surgeon and neuromonitoring advocate). This group has been very successful in their first year as a Section representing IONM in NASS.

NASS 2018 Annual Meeting:

The 33rd Annual Meeting of NASS was held Sep 24 - 29, 2018 in Los Angeles, Ca. At this meeting the Section on Intraoperative Neurophysiological Monitoring took part in the following events:

Neuromonitoring Symposium:

Drs. Vogel and Doan hosted NASS’s first symposium devoted specifically to IONM, which was planned entirely by the Section’s founding members. The Symposium was entitled, Analyzing the Utility, Evidence & Value of Neuromonitoring in Spine Surgery. Drs. Vogel and Doan served as moderators, introducing speakers and keeping the agenda running on time. Here are the lectures the we planned and the speakers we invited:

  • Point-Counterpoint: On the Utility of Neuromonitoring in Spine Surgery
    • Joshua E. Heller, MD and Steven M. Theiss, MD
  • What Represents Good Study Design and Good Evidence in Neuromonitoring and Why?
    • Robert N. Holdefer, PhD
  • Cost-Effectiveness Modeling and Surgical Risk in Neuromonitoring
    • John P. Ney, MD, MPH and David N. van der Goes, PhD
  • Barriers to Quality and Safety in the Performance of Neuromonitoring
    • Richard Vogel, PhD
  • Neuromonitoring and Precision Medicine: The Problem of Heterogeneity
    • Anthony K. Sestokas, PhD
  • International Speaker IONM Experience
    • Abdul Karim Msaddi, MD (Dubai, UAE)

At the end of the day, this Symposium was a great success. We went 45 overtime with Q&A from the audience. We’re already in the beginning stages of planning the next Symposium for the 2019 meeting.

Abstract Session:

Drs. Vogel and Doan also had the opportunity to moderate an abstract session. The topic was chosen by NASS based on research abstracts submitted to the meeting. This particular abstract session was entitled, Navigation and Intraoperative Neuromonitoring. Once again, Drs. Vogel and Doan served as moderators, introducing speakers and keeping the agenda running on time. They also had the opportunity to choose a “best abstract” and award the presenting author with a certificate.

The best abstract in this session was: A Novel MRI-Based Classification of Spinal Cord Shape and CSF Presence at the Curve Apex to Assess Risk of Intraoperative Neuromonitoring Data Loss with Thoracic Spinal Deformity Correction by Drs. Sielatycki, Makhni, Lehman and Lenke from Columbia University/NY Presbyterian.

The authors used a novel, MRI-based spinal cord risk classification scheme (Type 1, 2, or 3) to identify patients at risk of losing monitoring data during surgery. Results demonstrated patients with a spinal cord deformed against the apical concave pedicle (Type 3) had 28 times greater odds of losing monitoring data during surgery vs. Type 1 (normal cord with adequate CSF) and Type 2 (normal cord without CSF between cord and concave pedicle).

Ask the Experts:

NASS has a topical video series called As the Experts in which experts in various fields go on camera to discuss a specific topic. At this meeting, Drs. Vogel, Doan and Sestokas went on camera to tackle the question, What are the real criteria for a neuromonitoring alert in spine surgery?

Surgeons may think pedicle screw thresholds below 10 mA are an alert, or apply the old 50%/10% rule for SSEPs, or use presence/absence for MEPs, but all of examples are wrong for one reason or another. The experts stressed the importance of precision medicine, treating each patient as an individual, and considering data changes in the context of various factors. In this video, Dr. Vogel served as a moderator and posed a series of questions to Drs. Doan and Sestokas. We hope the video will ultimately be made publicly available for all to see.

Dr. W. Bryan Wilent Won a Best Paper Award:

The NASS 2018 Scientific Program Committee received an overwhelming 1,200 abstract submissions, but only the 21 highest-rated abstracts earned the coveted “Best Paper” designation. This year, two neuromonitoring abstracts were named best paper, and one was authored by ASNM Board Member and Research Committee Chair Dr. Bryan Wilent.

This Best Paper abstract was entitled: Diagnostic Accuracy And Clinical Impact Of Motor Evoked Potential (MEP) Monitoring During 4425 Posterior Extradural Lumbosacral Procedures Involving The L5 Vertebra.

Dr. Wilent’s study is the largest of many recently-published studies demonstrating the utility of MEPs in lumbar spine surgery.

Looking to 2019:

The IONM Section is already at work developing proposals for the 2019 NASS Annual Meeting, which will be held in Chicago September 25-28. You can support these endeavors by joining NASS and/or submitting your research when abstract submission open in 2019. For more information, contact Rich Vogel.

 

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:  Announcement 

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Correlating MEPs and Preop Motor Function

Posted By Lanjun Guo, MD, MSc, DABNM, FASNM, Tuesday, June 5, 2018

This blog post will summarize a paper recently published by a member of the ASNM's Board of Directors, Lanjun Guo, MD, MSc, DABNM, FASNM. Dr. Guo trained as a neurosurgeon in China and is now a prominent clinical neurophysiologist practicing in California. She is active in multiple societies, including the ASNM and ISIN. The post below was written by Dr. Guo. Thanks for reading! RV

The Correlation Between Recordable MEPs and Motor Function During Spinal Surgery for Resection of Thoracic Spinal Cord Tumor

This paper examined the association between preoperative motor function of patients’ lower extremities and intraoperative motor evoked potential (MEP) recording.

 Patients undergoing thoracic spinal cord tumor resection were studied. Patients’ motor function was checked immediately before the surgical procedure. MEP responses were recorded from the tibialis anterior and foot muscles, and the hand muscles were used as control. Electrical current with train of eight pulses, 200 to 500 volts was delivered through two corkscrews placed at C3’ and C4’ sites. Anesthesia was maintained by total intravenous anesthesia (TIVA) using a combination of propofol and remifentanil after induction with intravenous propofol, remifentanil, and rocuronium. Rocuronium was not repeated. Bispectral Index was maintained between 40 to 50.

From 178 lower limbs of the 89 patients,  myogenic MEPs (m-MEPs) could be recorded from 100% (105/105) of the patients with 5 out of 5 motor strength in lower extremity; 90% (36/40) from the patients with 4/5 motor strength; only 25 % (5/20) with 3/5; and 12.5% (1/8) with 2/5 motor strength; None (0/5) were able to be recorded if the motor strength was 1/5. Therefore, it was concluded that the ability to record m-MEPs is closely associated with the patient’s motor function. They are difficult to obtain if motor function is 3/5 motor strength in the lower extremity. They are almost impossible to record if motor function is worse than 3/5.

Excerpt: Manual Muscle Test Grading Scale

Number Clinical Exam 
 0  No muscle movement. Flaccid paralysis.
 1  Visible muscle twitch, but no movement at the joint.
 2  Able to move in horizontal plane, but not against gravity.
 3  Able to move against gravity, but not against resistance.
 4  Able to move against resistance, but less than normal.
 5  Full strength against resistance

 Generation of m-MEPs depends on the excitability of the alpha-motor neurons in the anterior horns and excitability of the neuromuscular junction. Muscle MEPs can be generated only if the resting potential of alpha-motor neurons reaches the firing threshold, and thus, transmits this activity via motor axons of the peripheral nerves and neuromuscular junctions to the muscle.

The m-MEPs are affected by anesthetic drugs. Anesthetics impair the motor cortex’s ability to generate multiple descending volleys, the I waves. They also depress the excitability of the entire spinal cord, including the alpha-motor neuron pool. Because the D wave is resistant to anesthetic depression, the anesthetic effect at the alpha-motor neurons can be overcome at low anesthetic concentrations by high-frequency multipulse stimulation through transcranial stimulation.   The multiple D waves followed by stimuli to the motor cortex summate at the anterior horn cell to generate a subsequent myogenic response. The temporal accumulation of several cortico-motoneuronal excitatory postsynaptic potentials (EPSPs) is necessary to bring motor neurons from the resting state to the firing threshold during general anesthesia.

 However, transcranial stimuli only activate a small and variable subpopulation of the lower motor neuron pool to generate MEPs. Therefore, the m-MEPs are substantially more difficult to record in patients with underlying neurological abnormalities, such as spinal cord tumor. In practice, although a patient may maintain some motor function and can move their legs, MEPs may still not be recordable from muscles of the lower extremity.  There are previous studies correlating intraoperative recordings of m-MEPs during different types of spine surgery with the preoperative motor function, although the detailed information about the relation between the recordable MEPs and the grade of motor function were not reported.

 There are a number of methodological considerations in this study. The number of lower limbs with poor grade function was relatively small, only 33 lower limbs with 3/5 grade or less compared to 145 lower limbs with 5/5 or 4/5 grade. Different stimulation methods, such as different stimulating sites on the skull, different stimulation inter-stimulus interval, and /or different stimulating pulses, were not compared. Therefore, the recordable m-MEPs rate in clinical practice may be higher if different stimulating montages were tested.

 The current study provided evidence and confirmed the clinic experience that it can be difficult to obtain m-MEPs during a surgery when the patient has motor weakness, even the patient could still move legs. It also indirectly provide the information that if MEPs lost during surgery due to surgical manipulation, the patients may still have some motor function postoperatively, but most likely that would be worse than 3/5 motor strength.

References:

Guo L, Li Y, Han R, Gelb AW. The Correlation Between Recordable MEPs and Motor Function During Spinal Surgery for Resection of Thoracic Spinal Cord Tumor. J Neurosurg Anesthesiol. 2018 Jan;30(1):39-43.

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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Major Publication Questions Utility and Value of Neuromonitoring – ASNM Responds!

Posted By Richard W. Vogel, Friday, May 25, 2018

A recent paper published by Hadley et al1 in Neurosurgery claims that IONM has very little utility and value in spine surgery. They base this claim on a rather biased review of the literature and they call it a guideline.

It would all be a hard pill to swallow, but necessary nonetheless, if their observations were objective, if their findings were valid. Unfortunately, what we have come to call The Hadley Paper is little more than a biased repudiation of IONM in spine surgery, written by 4 neurosurgeons who don’t typically use IONM and seem to have little understanding of how it works.

You should have little doubt that this paper graced the inbox, or crossed the desk, of every spine surgeon with whom you work. Make no mistake, your surgeons are talking about it in their circles. We have already observed that some surgeons have discontinued using IONM simply based on this paper alone.

If they haven’t already, your surgeons may raise it as a topic of conversation with you. Whether that happens or not, you must be prepared to proactively educate your surgeons about the flaws in this paper and why it should be summarily dismissed.

The scale of the paper is so large, the reputation of the journal so prestigious, that this paper could have a significant impact on the future of our field. Indeed, many insurance carriers will likely use this paper to deny IONM claims and this could further drive down reimbursements and leave us in ruin.

This is a serious situation, and we want you to be aware of what is going on and what the ASNM is doing to help!

First, Drs. Bryan Wilent (Chair, Research Committee) and Rich Vogel (ASNM President-Elect) started a project last year, approved by the Board, in which the ASNM would write letters to the editor of journals in response to what we call bad literature. We loosely defined bad literature as papers invalidated by serious methodological flaws and having a high enough profile to do significant harm to our profession.

A few papers have come up for discussion, but we didn’t invest the energy because they were low profile and self-published. So, we didn’t write any letters for the first year, and then we saw The Hadley Paper.

Given the obvious and significant negative implications that come from publication of The Hadley Paper, the ASNM wrote our first Letter to the Editor2, on behalf of our membership, to point out some of the most egregious flaws. Incidentally, we weren’t the only Society to write a letter, but we were the first.

If you aren’t able to access The Hadley Paper due to limited institutional permissions, then you should at least read our Letter to the Editor of Neurosurgery. We have permission to post the original on our website.

Incidentally, Hadley and Colleagues respondedto our Letter with what can only be described as an affirmation of what we knew all along: they have little understanding of IONM and how it works. They’ve actually made matters worse by responding to us, and now we’re beginning to hear from spine surgeons around the country who contact us. They say, “[Hadley et al.] don’t speak for us and don’t represent us.”. Perhaps you'll understand why upon reading their reply.

The reader may also find amusing some of their ostentatious claims. As an example, Hadley et al. asserted that one of their authors was an expert because he studied critical appraisal of the medical literature for 5 years. Just to give you some perspective on that claim, of all the authors of the Letter to the Editor that the ASNM wrote, I’m probably one of the most junior by age, and I’ve been studying critical appraisal of the medical and scientific literature for 20 years.

More vexing than amusing is the unsubstantiated claims against the ASNM, made perhaps in an attempt to belittle our society and our profession. For example, Hadley et al. said, [the ASNM] is “perhaps unfamiliar with the rigorous, and sometimes frustrating, peer review process required before endorsement by our specialty societies, which may lead to extensive revisions and in-depth questions regarding statements and approach.” I’m sure this really irritated ASNM President, Dr. Jeff Gertsch, who recently oversaw the rewrite of our Professional Practice Guidelines. Anyway, if Hadley et al. had done a basic search of the literature, or our website, they would have found quite a few such guidelines authored by the ASNM that went through the very same process. 

This brings me to the second thing the ASNM is doing to help. Several of our members are heavily involved in the North American Spine Society (NASS). We now have a Section on Intraoperative Neurophysiological Monitoring. The Section is co-founded and co-chaired by ASNM Member Dr. Adam Doan and ASNM President-Elect Dr. Rich Vogel. Other founding members include Drs. Tony Sestokas, Bob Holdefer and John Ney, among others.

At the 2018 NASS Annual Meeting in Los Angeles, we will have our first symposium on IONM in which we have an objective review of the utility and value of IONM presented by surgeons, neurophysiologists, neurologists and a health policy economist. We will also have an abstract session in which a best paper is chosen.

Other work within NASS includes authoring a coverage policy on IONM, international speaking, and developing webinars and podcasts for 2019. All of this is being done by members of the ASNM, some of whom you elected to the Board. Inter-society cooperation is certainly the way to go!

Anyway, we thank you for taking the time to read this and we strongly recommend you take the time to read our Letter to the Editor. After all, we wrote it for you.

The ASNM is doing lots of things for you, and we hope to use our blog to be better at communicating to keep you in the know. Be sure to subscribe and keep reading!

References:

  1. Hadley MN, Shank CD, Rozzelle CJ, Walters BC. Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery. 2017 Nov 1;81(5):713-732.
  2. Vogel R, Balzer J, Gertsch J, Holdefer RN, Lee GR, Moreira JJ, Wilent B, Shils JL. Letter: Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery. 2018 Jun 1;82(6):E190-E191.
  3. Hadley MN, Shank CD, Rozzelle CJ, Walters BC. In Reply: Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery. 2018 Jun 1;82(6):E192-E193.

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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Board Update - Committee Repopulation

Posted By Administration, Tuesday, May 15, 2018

Update from the ASNM Board of Directors:

At our last Board Meeting, it came to our attention that each of our 8 standing committees has dozens (if not hundreds) of members, many of whom don’t even know they’re on a committee. How did this happen? It turns out that the process for joining a committee was simply to click a button expressing interest during the initial ASNM membership application. Many people expressed interests in multiple committees. So, some of you may belong to multiple committees and probably don’t even know it.

In seeking to make our committees more efficient and effective as they manage their work and meet the overall mission of the Society, we realize that we need to do some repopulating. The committees and their functions will remain the same as outlined in our bylaws, but we need to start fresh with committee membership.

Here’s the process for committee repopulation and how you can get/remain involved:

  1. The glitch that allowed people to automatically join committees during initial membership application has already been fixed.
  2. We will poll each Committee Chair to determine who are the core, active members of each committee. These individuals will be contacted and given the opportunity to remain part of the committee. If the individuals are members of multiple committees, they may be asked to make a choice and focus their efforts on one committee.
  3. All “extra” committee members (i.e., those who aren’t presently participating) will be removed from all committees so we can start fresh.
  4. Each committee will meet to determine how many members they need to accomplish their work. Where there is need, openings will be made for ASNM members to fill.
  5. We will send out an email to all ASNM members asking if you are interested in committee participation. That email will give you instructions on how to join a committee if space is available.

Remember that committee work is voluntary. When considering committee participation, think about how much time and energy is required and whether or not you are able to dedicate that time and energy. It is best if you participate in only one committee so you don’t stretch yourself too thin.

Being part of a committee is definitely not just about putting something new on your resume or CV. This should be service to the profession that produces meaningful results and introduces members to networking opportunities. Everyone on a committee will be expected to participate in meetings and pull their weight to accomplish the committee’s work. Anyone who isn’t doing their part may be removed from the committee to make room for someone else.

How can you get involved? You don’t have to do anything right now. We’ll contact you in a few weeks to gauge your interest. Until then, check out the names of the different committees and the kinds of work they do. Think about where your interests lie, and what you’d like to see the ASNM accomplish. Your voice matters, and the best way to make a change is to jump in and help!

Tags:  Announcement 

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President's Message - May 2018

Posted By Joseph J. Moreira, M.D., Monday, May 14, 2018

Dear Membership,

The time has come to pass the gavel, officially, to Jeff Gertsch. I will make this brief but just wanted to thank the membership for making this past year possible. The commitment you all made to this society year after year keeps us moving forward and flourishing as a profession. We have excellent educational offerings and make progress in the field due mainly to your support and participation. Your ongoing interest and support is what drives us on the ASNM board. To that end I ask that all of you consider serving in any capacity possible. The new year comes quickly, and many hands are needed. Please consider running for office, joining a committee, speaking at a meeting, running a webinar, searching for and recruiting new members etc.

I want to thank our amazing board of directors and members of the executive committee as well as Apex Management for all their efforts and support. We accomplished a great many things this year but there is a tremendous amount of uphill work to be done. I will give all my efforts and support to the new President and board members and will do my best to keep things moving forward in our field. I ask you all to do the same.

Thank you again for this humbling experience and I am always available to help in any way. All the best to our new leadership, we are in excellent hands.

Best, Joe

Tags:  President's Message 

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ASNM Releases Position Statement on Business Practices in Neuromonitoring

Posted By Administration, Wednesday, March 14, 2018

Breaking News!

 In a newly-released Position Statement, the ASNM takes a stand on business practices related to neuromonitoring.

Read the entire position statement here.

Tags:  Announcement 

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