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In the Literature: Utility of Motor and Somatosensory Evoked Potentials for Neural Thermoprotection in Ablations of Musculoskeletal Tumors

Posted By Christopher Halford, Monday, May 18, 2020

Article Title: Utility of Motor and Somatosensory Evoked Potentials for Neural Thermoprotection in Ablations of Musculoskeletal Tumors

 

The Big Question:

 

First, let me apologize up front for the quote-heavy content of this write-up. Though I have been in the field of IONM for a while I have not had experience with ablations of musculoskeletal tumors so immediately this articles title intrigued me.

 

Essentially there are two techniques of ablation outlined in this article: cryoablation (where the tumor cells and adjacent tissue is frozen) and radio frequency ablation (which has the opposite effect by essentially cooking the tumor and adjacent tissue).

 

Though there is a history of studying the risks of these procedures, the published data shows a varying degree of risk and deficit percentages for each ablation modality. Although the authors (Yoon, et al.) cite many of these this publication seeks to further determine the utility of SSEPs and MEPs for these surgeries where the tumor ablation can potentially put a nearby neural structure at risk (thus the title).

 

Background:

 

As with all IONM, though it goes without saying, I liked the statement: “The inclusion of IONM was determined by the performing interventional radiologist based on qualitative risk assess-ment for nerve injury, ie, proximity to the spinal cord or spinal and/or peripheral nerves” (p. 2).

 

For the sake of the readers’ understanding and the fact that the results section included a lot of information I’ve included the specifics of both the methods and the results directly rather than paraphrase, with some mild revisions.

 

Method:

           

As reported in the study,

 

Warning criteria for abnormal SSEP changes were defined as a 60% reduction in baseline amplitude and/or 10% increase in latency per the institutional standards for spinal surgeries. Similarly, for TCeMEP monitoring, an abnormal change was defined as a 100-V increase above baseline threshold activation for a given myotome. When TCeMEP or SSEP warning criteria were met, the ablations were immediately terminated… (p.5)

 

Results:

 

As also reported in the study:

 

Warning criteria for TCeMEP and/or SSEP monitoring were met in 12 of 30 procedures (40%). Seven of 30 (23%) met warning criteria for TCeMEPs, 3 (10%) met warning criteria for SSEPs, and 2 (7%) met warning criteria for both. Eleven of these 12 procedures (92%) were cryoablations, and only 1 (8%) was an RF ablation. Nine of these 12 procedures (75%) targeted tumors involving the spine, and the remaining 2 (25%) involved the scapula.

 

[During the surgical period] five of the 12 abnormal TCeMEP/SSEP changes (42%) did not recover, with the remaining 7 (58%) being transient.

 

Three of 5 procedures with unrecovered abnormal changes (60%) and 2 of 7 procedures with transient abnormal changes (29%) had new charted motor (n = 1) and/or sensory (n = 4) symptoms.

 

As a whole, any abnormal TCeMEP or SSEP change was 100% sensitive… and 72% specific.,.. for neurologic sequelae, whereas any unrecovered change was 60% sensitive.. and 92% specific ….

 

Any abnormal TCeMEP change was 100% sensitive… and 72% specific… for new motor deficits; unrecovered TCeMEP changes had the same sensitivity, but a specificity of 93% …. Any abnormal SSEP activity change was 75% sensitive… and 92% specific… for new sensory deficits or radicular pain; unrecovered SSEP activity changes were 50% sensitive… and 100% specific. (p. 5)

 

Discussion:

 

In a nutshell, the authors’ acknowledge the sample size was small and the numbers related to risk in this study varied from other studies (though there are a number of contributing factors for this). In the end a total of 16% of patients done at this facility had reported IONM changes conveyed (based off the facility’s reporting criteria) that emerged from surgery with notable deficits. All of these patients with identified deficits were a result of cryoablation versus radio frequency ablation. Based off the sensitivity and specificity it seems that Neuromonitoring assisted in accurately identifying which patients could expect to have neurological deficits post-operatively. Unfortunately, as the authors also acknowledge, this is predictive versus preventative, the most important goal of IONM.

 

In conclusion, and on a brighter note, in the authors’ words:

 

Despite [the] limitations, the present study shows a correlation between neurologic sequelae and increased latency and/or decreased amplitude of SSEPs or an increase in TCeMEP threshold stimulation during percutaneous ablation procedures of musculoskeletal tumors. Monitoring of SSEPs and TCeMEPs should be considered in ablations in which there is concern for neural thermal injury

 

References:

 

  • J Vasc Interv Radiol. 2020 Apr 24. pii: S1051-0443(19)31079-6. doi: 10.1016/j.jvir.2019.12.015. Utility of Motor and Somatosensory Evoked Potentials for Neural Thermoprotection in Ablations of Musculoskeletal Tumors. Yoon JT, Nesbitt J, Raynor BL, Roth M, Zertan CC, Jennings JW.

 

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: Use of the train-of-five bipolar technique to provide reliable, spatially accurate motor cortex identification in asleep patients

Posted By Christopher Halford, Monday, May 18, 2020

Article Title: Use of the train-of-five bipolar technique to provide reliable, spatially accurate motor cortex identification in asleep patients

 

The Big Question:

 

The authors (Bander, et al.) point out that monopolar stimulation for direct cortical brain mapping is quickly become the standard when compared to the previous method of mapping: “low-frequency bipolar stimulation mapping” (also known as the Penfield method). However, the authors wanted to compare using what they refer to as “train-of-five” (also referred to as multipulse or pulse-train) stimulation to the low-frequency bipolar simulation mapping.

 

Background:

 

The idea behind this experiment is twofold. First is that the potential risk for tissue damage is possibly higher based off data recorded in animal studies (p. 1). And second, “monopolar [train-of-five] stimulation [causes] diffuse, radial spread of electrical stimulation that leads to spatially inaccurate motor cortex identification” (p.2).

 

Method:

            

Thirteen patients were used in this study. The two things this study wanted to compare was the reliability of locating the motor cortex through direct cortical stimulation when comparing low-frequency bipolar stimulation and train-of-five bipolar stimulation and the occurrence of intraoperative seizures (a known risk of any direct cortical stimulation, especially low-frequency bipolar stimulation). 

 

The authors’ used four steps for motor mapping and monitoring during these cases. First they would use SSEP phase reversal testing to identify the central sulcus. Next they would identify the regions of motor cortex at risk using the train-of-five bipolar stimulation technique while using the strip used for phase reversal to watch for after discharges through EEG monitoring. Then they would use low-frequency bipolar stimulation to see if they could re-identify those same areas of the motor cortex they had previously mapped using train-of-five stimulation. Finally they would run direct cortical MEPs using the strip for the duration of the resection at a rate of every “2–15 seconds” (p. 3).

 

Results:

 

When comparing methods the authors identified the motor cortex in all 13 patients using the train-of-five technique (max stim intensity = 53 V ± 17.7 V) compared to only 4 times with the low-frequency stimulation technique (max stim intensity = 8 mA ± 2.2 mA).

 

No seizures occurred when using the train-of-five technique while two seizures occurred during the low-frequency stimulation technique along with two instances of after discharges that did not progress to seizures. These number line up very closely with other studies testing the seizure frequency when using the low-frequency (or Penfield) technique.

 

Discussion:

 

The authors acknowledge a “lack of comparison with a monopolar [train-of-five] stimulation” (along with “small sample size”) as limitations to this study however I would say neither of these should have a big impact on the whether this information is useful and the technique should be further tested and verified. 

 

Comparison to monopolar direct cortical stimulation would likely be of little use considering this technique (monopolar multipulse stimulation) is already becoming the mainstream method for cortical mapping. However, if it could be demonstrated that the direct risk of tissue damage is a serious factor linked to monopolar stimulation, the bipolar pulse train technique presented by the authors could be relevant very quickly. Also, though the sample size is small successful recording in 100% of patients indicates a high potential for reliability (in my opinion).

 

The technique of bipolar/monopolar, Penfield/Multipulse techniques have been compared in subcortical mapping by Szelenyi, et al. in 2011. They found that multipulse stimulation, whether with a monopolar or bipolar probe, was superior for stimulation for subcortical mapping versus the low-frequency (50 Hz) stimulation technique.

 

This article appears to offer a promising, potentially reliable stimulation alternative in an area of IONM that has received a lot of attention in recent years.

 

References:

  • Neurosurg Focus. 2020 Feb 1; 48(2):E4. doi: 10.3171/2019.11.FOCUS19776. Use of the train-of-five bipolar technique to provide reliable, spatially accurate motor cortex identification in asleep patients. Bander ED, Shelkov E, Modik O, Kandula P, Karceski SC, Ramakrishna R1
  • Clin Neurophysiol. 2011 Jul; 122(7):1470-5. doi: 10.1016/j.clinph.2010.12.055. Intra-operative subcortical electrical stimulation: a comparison of two methods. Szelényi A1, Senft C, Jardan M, Forster MT, Franz K, Seifert V, Vatter H.

 

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 - April 2020

Posted By Richard W. Vogel, Monday, April 6, 2020

Dear Members,

 

As I look back on my year as ASNM President, I am reminded of Shakespeare's Henry IV who once remarked, "Uneasy lies the head that wears a crown". To King Henry I say, “Indeed”.

 

The President of the ASNM volunteers his or her time to work nights and weekends for the benefit of this profession and everyone who works in it. Set aside for the year are hobbies, goals, dreams and time with family and friends. There are nights of lost sleep amid persistent feelings of stress and worry. There are thousands of emails to read and respond to. There are hundreds of decisions to make; each, it seems, with lobbying from different points of view. The President of the ASNM experiences admiration and disregard, support and opposition, loyalty and betrayal. Amid all of this, one comes to recognize that the dominant feeling about this profession, coming from those who work in the profession, is one of indifference. That, I believe, takes the greatest toll... indifference. Heavy lies the crown indeed.

 

Despite all of these feelings, my presidency has proven to be ephemeral in hindsight. It seems like only yesterday when I gave my Incoming President’s Address at the ASNM Annual Meeting in May of 2019. And, here we are a year later, ready to transition to a new President. Despite the emergence of the COVID-19 virus, which has put the whole world on hold and caused us to cancel our much-anticipated Annual Meeting, this past year has been a successful one for me, and for the ASNM.

 

A lot of people have asked if my final President’s Message was going to be another big speech, similar to the long, passionate address that I delivered last year. The answer to that question is no. My feeling is that a speech of such magnitude should probably be reserved for exactly what I used it for... to unleash a scathing indictment of an entire profession and reveal a strategic vision for how it can be improved over both the short and long term. So, no big exit speech. Today, my final message to the ASNM Membership will simply consist of a few important things I want to say before I pass the torch.

 

As I look back on my presidency, I can honestly say that I’m proud of every decision I made and every action I took. As President, I experienced both success and failure. In hindsight, I am left only with peace of mind knowing that I led the ASNM with integrity, I persevered through difficult times, and I learned some important lessons that I’ll take with me to the next stage of life. At the end of the day, I’m proud of what we’ve accomplished in the ASNM and happy to see us moving in the right direction.

 

I would like to take a moment and extend my sincere thank you to every single person who stepped up over the last year and offered to help. In fact, so many people answered my call to assist, we weren’t even able to use everyone’s help. Having too much help is always an asset in a volunteer society. So, thank you to everyone who offered to volunteer their time to the ASNM.

 

I’d also like to thank the people who supported me over the last year, both personally and professionally. My supporters are too numerous to name, but you know who you are, and I want you to know that I’m deeply appreciative of you.

 

Over the next few weeks, I’ll be working with Faisal to make sure we have a smooth transition of leadership on May 4th, 2020. I am confident in Faisal’s leadership and I certainly hope everyone will give him the help, support and encouragement he needs to have a successful year.

 

So, what’s next for me? Well, I will remain on the Executive Committee for one year in the position of “Immediate Past President”. After that, I will cycle off of the ASNM Board entirely. We’re moving in the right direction. Now, it’s time for new leaders to emerge and take us to the next level. Personally, I’m going to take a step back and focus on me. It’s about time for that.

 

It has been an honor and a privilege serving as ASNM President.

 

Sincerely,

 

Rich Vogel, PhD, DABNM, FASNM

ASNM President 2019-2020

Tags:  President's Message 

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COVID-19 Precautions

Posted By Richard W. Vogel, Monday, March 16, 2020
Updated: Monday, March 16, 2020

Dear Members:

We are in uncharted waters as a society as we face a pandemic that is unprecedented in our lifetimes. We are gathering data and charting and changing course as needed.

Right now in the United States, as already done in other countries, we need to 1) limit social interaction to “flatten the curve” to prevent a major sudden spike in cases of COVID-19 that would overwhelm health care facilities and compromise the ability to effectively treat patients, 2) protect those most at risk of developing severe symptoms (over 60, multiple underlying conditions, immunocompromised) 3) maintain basic societal needs (healthcare, food services, gas stations, utility services etc ), while 4) maintaining mental health and perspective.

As IONM professionals, we are patient care providers and we have a responsibility to continue to answer the call with prudence. We must maintain that responsibility, but how exactly do we continue to prudently provide care?

For IONM professionals, we should be following the recommendations of the CDC, our PCPs, and our healthcare facilities. Some things that IONM professionals can/should do now would be to: 

  1.  Increase our vigilance with infection control measures
    1. All equipment, including keyboards and mice, should be cleaned after every patient (not after every day).
    2. For hand cleansing, you should be washing your hands or using hand sanitizer immediately 1) before and after touching a patient or any patient equipment 2) after taking off gloves and before touching any keyboard, mouse, or patient equipment, 3) entering and exiting patient care and operating rooms.
  2. Practice social-distancing and avoid congregate settings. As patient care providers, it’s important that we minimize our risk so that we can continue to serve society.
  3. Immediately self-quarantine if you have a fever and dry cough and contact your PCP/Urgent Care facility. 
  4. Inform your organization/healthcare facility if you experience any exposure risk to someone with confirmed COVID-19.  The CDC has provided Guidance for HealthCare Personnel (HCP) to continue to provide care depending on their exposure risk in a personal/public setting or in the healthcare setting
    1. Health-care providers determined to have experienced MEDIUM or HIGH Risk-Level Exposure will need to be actively monitored and are excluded from working in the healthcare setting for 14 days since last exposure.
    2. Health-care providers determined to have experienced LOW Risk-Level Exposure will need to perform self-monitoring with delegated supervision until 14 days after the last potential exposure but may continue to work and provide in a healthcare setting. Please refer the detailed guidance in the link’s above. 

Definitions:

Social distancing means remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.

Congregate settings are crowded public places where close contact with others may occur, such as shopping centers, movie theaters, stadiums.

Close contact is defined as either A) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case, or B) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on)

HIGH or MEDIUM Risk (Brief overview, please see guidelines for detail if experience any exposure level)

  1.  Are living with or providing care in a nonhealthcare setting (such as a home) for a person with symptomatic laboratory-confirmed COVID-19 infection.
  2. Had prolonged contact with COVID-19 patient who was NOT wearing a facemask AND the PPE did not include both EYE Protection AND a facemask or respirato
  3.  Had prolonged contact with COVID-19 patient who was wearing a facemask AND the HCP was NOT wearing a facemask or respirator

 

LOW Risk  (Brief overview, please see guidelines for detail if experience any exposure level)

  1.  Was in the same indoor environment (e.g., a classroom, a hospital waiting room) as a person with symptomatic laboratory-confirmed COVID-19 for a prolonged period but did NOT meet the definition of close contact
  2. Had prolonged contact with COVID-19 patient who was wearing a facemask AND the HCP PPE included wearing a facemask or respirator

 

A special thank you to W. Bryan Wilent for drafting this message!

 

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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President's Message - March 2020

Posted By Richard W. Vogel, Friday, March 6, 2020
Updated: Wednesday, March 4, 2020

Dear Members,

 

We just finished our 2020 Winter Virtual Symposium and it was a resounding success!! We had more than 90 attendees logged in, and over 120 total attendees if you include faculty and Board members. The exhibitors who submitted video commercials got lots of air time, benefiting from the individual attention of all attendees. We got so much positive feedback on all fronts. This is definitely something that we’ll consider doing again. 

 

As we begin to look toward our big 2020 Annual Meeting, I want you to know that award nominations close March 15th. We have two awards that you can nominate someone for right now. Click the link below to learn about these award, and please take the time to nominate someone!

 

Founders Award.

ASNM Fellow.

 

Winners of these awards, and others, will be recognized at the Saturday Luncheon at the 2020 Annual Meeting.

 

Speaking of the Annual Meeting, registration is open. We're starting to get lots of questions about whether or not the annual meeting will happen as concerns over COVID-19 escalate. As of now, we have no plans to cancel or alter the meeting, but we are preparing, as should you. My recommendation is to book your travel now, rather than wait; here's why: many airlines are presently offering indefinite waiving of change fees if you book travel in the next couple of weeks. So, under these circumstances, booking travel is of little risk. I also recommend buying travel insurance as an added precaution. In the meantime, we're full speed ahead with planning for this meeting!

 

Last year, in my inauguration speech, I asked an audience of over 200 people to raise their hand if they would pledge to go home, tell two people about the ASNM and bring them back to the meeting in 2020. Every...single...person in that room raised his/her hand high! If everyone in that room keeps their promise, we will have over 600 people at this meeting. What about you? Did you raise your hand? Time to dig deep again and look within. Are you the type of person who makes a pledge and keeps it? Now is the time to make that decision. Register for the 2020 Annual Meeting and bring someone along! The meeting will be held May 15-17, 2020 in St. Louis, Missouri.

 

In case you missed my previous announcement, I’ve invited someone very special to be my Presidential Speaker, Dr. Marty Makary. His work is known the world over, he’s published 2 NYT best-selling books, he’s frequently interviewed on national and international news outlets, and he fills venues of thousands every time he speaks, so we’re very lucky to have him in such an intimate setting. 

 

The last thing I want to let you know is that the ASNM Board is presently working on a major overhaul of the Bylaws. The Bylaws are essentially our constitution. They describe how we govern ourselves. This update is long overdue because the Bylaws are written for a smaller organization, and they are outdated. I’m telling you all of this because you need to be part of the process. Once we have a draft done, we will send an announcement to the entire membership, opening a 30 day window for you to submit comments. Look for an email from the ASNM around March 25th. We’ll need to close the comment period by April 24th in order have the Bylaws done in time for the Annual Meeting in May. That's the plan, anyway. 

 

Thank you all for taking the time to read. I hope you'll take time to nominate someone for one of our awards. I hope you all can enjoy the waning days of the winter season. I’ll be back in April 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: Solutions to the technical challenges embedded in the current methods for intraoperative peripheral nerve action potential recordings

Posted By Christopher Halford, Wednesday, March 4, 2020

In the Literature:  Solutions to the technical challenges embedded in the current methods for intraoperative peripheral nerve action potential recordings

 

 The Big Question/Background:

This paper begins by giving an overview of the challenges of recording intraoperative nerve action potentials (NAPs). The objectives of the authors, in a nutshell, was to test the current method for stimulating and recording NAPs and see if a more effective way to obtain reliable responses could be found. In their own words, “The authors’ goal was to improve intraoperative NAP recording techniques by revisiting the methods in an experimental setting” (p. 1).

 

Method:          

Animal testing on non-human primates was used initially to attempt to remove the typically confounding stimulus artifact caused by recording potentials so close to the stimulation source. They used the standard method of lifting the nerve from the surrounding tissue but faced the same stimulus artifact problems that negatively affects NAP recording. They then tried a novel technique where they used a saline-soaked gauze under or around the portion of the nerve between the stimulation and recording sites. The end result was that the stimulus artifact was removed and the NAPs were recorded at significantly larger amplitudes at lower stimulus thresholds and with very little stimulus induced interference. 

 

The authors hypothesized that the saline gauze created a salt bridge between the outside of the nerve and the surrounding tissue thus preventing the stimulus current from looping back on, around, or through the nerve and confounding the equipment’s average/amplifier (termed “the loop effect” (p.6)). Next the authors, based off the information they had obtained through the gauze salt bridging, successfully recorded NAPs with the same conclusions by simply using insulated stimulation and recording electrodes and not lifting (“nonlifting technique” p. 6) the nerve from the surrounding tissue. The authors suggest that by isolating both the stimulation and recording mediums in the electrodes the current loop that the gauze prevented was prevented in the same fashion.

 

Finally they verified their results through a “stimulus polarity switch test and by the intensity-response function test” (p. 3). This is done by reversing polarity of the stimulation delivered to the nerve. Only the deflection of the stimulus artifact should change direction thus verifying your NAP. However, they also noted that when polarity was switched the stimulus threshold needed to generate the same NAP approximately doubled when stimulating anodally versus cathodally. Something to be aware of if the reader plans to attempt this method.

 

Finally they tested the “nonlifting technique” in the OR setting on patients and similar results occurred and the results were again verified with the intensity-response deflection test (p. 8).

 

Results:

Briefly explained, and again in the authors’ own words, “We identified exaggerated stimulus artifacts being a major problem and found bridge grounding to be a simple and effective solution. Ultimately, we brought our new methodology forward into clinical practice, where clinical rather than research equipment was used. The outcome was the same, validating the principal concept shared by recordings in these different settings” (p. 9).

 

Discussion:

The authors were able to consistently record action potentials in both the experimental and clinical settings by removing “the loop effect” with either “bridge grounding” with a saline-soaked gauze or by insulated stimulating and recording electrodes and not lifting nerve from the surrounding tissue (the grounding source) thus allowing that tissue to shunt the stimulus before looping back through the nerve.

 

The authors acknowledge the biggest limitation of this study was that, in the clinical setting, this technique (or more specifically the “bridge-grounding” version of this technique) was only tested on four patients intraoperatively. They encourage the IONM community to verify this technique through “systematic and quantitative evaluations of these methods, additional investigations in healthy and, more importantly, chronically injured nerves” (p. 9).

 

This method minimizes the major confounding factor in recording NAPs and could improve the confidence of technologists, neurophysiologists, and surgeons in the testing being done and the results displayed. If further testing found it to consistently work intraoperatively this research could have a major impact on the reliability and use of NAP recording.

 

References:

Wu G, Belzberg A, Nance J, Gutierrez-Hernandez S, Ritzl EK, Ringkamp M. Solutions to the technical challenges embedded in the current methods for intraoperative peripheral nerve action potential recordings. J Neurosurg. 2019 Aug 16:1-10.

 

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: Intraoperative Neuromonitoring during Spinal Cord Tumor Resections

Posted By Scott Mohr, BS, CNIM, MBA, Tuesday, February 25, 2020

Intraoperative Neuromonitoring (IONM) Is There a Role in Metastatic Spine Tumor Surgery?

 

The Big Question:

Can Intraoperative Neuromonitoring (IONM) make an impact on surgeons’ efforts to preserve patient quality of life during Metastatic Spinal Tumor Surgery (MSTS)?  The team of Kumar et al. published a retrospective study over the past year taking a closer look at the correlation between neuromonitoring utilization and the impact on the surgical outcome.  Did the data they uncovered suggest that IONM utilization during MSTS procedures makes an impact on patient outcomes?

Background:

Cancer is a nasty business, often causing loss of motor and sensory function in the course of its progression.  Our business in neuromonitoring is to provide the surgical team with the information they need to optimally preserve motor and sensory function within the constraints of the surgical procedure.  When surgery becomes part of the treatment plan for a patient with spinal metastases, surgeons often need to weigh risk versus reward.  Can a sufficient level of pain relief and preservation of function be achieved in light of possible further post-surgical deficits?  IONM becomes useful to a surgeon in these cases, and we as the neuromonitoring community stand to make a crucial difference in the patient’s quality of life.

The team of Kumar, et al. – consisting of specialists in ortho, trauma and spinal surgery – astutely noted a lack of literature quantifying the relationship between IONM and MSTS patient outcomes.  They engineered a retrospective study of 135 patients over the course of a seven -year time frame to match relationships between significant event alerts and patient outcome for MSTS patients.

Method:     

The study spans a seven-year period and includes surgical procedures on 135 patients, all with spinal cord metastases from various sources (the article provides a breakdown in table format, with lung and breast carcinomas being primary instigators).  The 135 surgical procedures were all performed by one of five surgeons and were monitored by one of two certified neuromonitoring technologists.

Monitoring was performed under and anesthetic regimen suited for TcMEP, EMG and somatosensory modalities.  Total Intravenous Anesthesia (TIVA) using fentanyl and propofol were administered to maintain an anesthetized state throughout the procedure.  Short-acting paralytics were administered during the intubation phase only, and Train of Four (TOF) was monitored during the surgical procedure to confirm absence of paralytic effect on the patient.

From a neuromonitoring perspective, patients were monitored on two different platforms the Nuvasive NVM5 and the Cadwell Elite system, employing from 20-32 channels depending on monitoring package and surgical approach.  All MEP data was elicited from transcranial stimulation from electrode sites C1 and C2.  Recording muscle groups ranged from deltoid, biceps brachii, brachioradialis, abductor digiti minimi, vastus medialis, tibialis anterior, extensor hallucis longus, abductor hallucis longus, and gastrocnemius, while somatosensory data was elicited from stimulation of the ulnar, median, and posterior tibial (PTN) nerves.  Somatosensory alert criteria included the ’50-10’ rule, or greater than 50 percent loss from baseline amplitude and greater than 10 percent increase in latency from baseline.  TcMEP responses were reported as either present or absent, and EMG alerts were reported upon observing “irregular, aperiodic bursts repeatedly elicited by surgical maneuvers greater than a 3 second period” (Kumar, et al. 2019).

A note about the patient population.  Of the 135 patients included in the study, seven were eliminated from data inclusion in the retrospective due to a lack of baseline data (i.e., no followable baselines to report to the surgeon, either sensory or motor). This narrows the field to 128 patients whose monitoring experiences contributed to the final report.  The population consisted of 61 males and 67 females who were on average 61 years of age.

Patients were scored pre-operatively based on the impact the metastases had on their quality of life using the ASIA score, so a note here about this format may be useful.  ASIA stands for American Spinal Injury Association, and the ASIA pre-operative score assesses motor and sensory function of a patient with a spinal injury.  The exact nature of the testing and scoring is perhaps a bit too complex for the scope of this literature review, but it is worth knowing some basics.  Ten muscle groups are assessed for motor function, five upper extremity and five lower extremity muscles, using range of motion (ROM), ability to move a limb against the force of gravity, active resistance, etc.  Sensation is assessed with pin prick applications along a series of dermatomes. A final letter grade is assigned to a patient; A, B, C, D or E.  Patients with a grade of E will have what is considered normal sensory and motor function, while letter grades B, C, and D cover patients with incomplete spinal cord injuries, demonstrating some deficits in motor or sensory function.  A patient with a grade of A has what is deemed a ‘complete’ injury and exhibits no motor or sensory function for purposes of ASIA scoring (SCIRE Project, 2016).

From a surgical perspective, of the 128 patients, 54 patients had surgery to address a neurological deficit, 66 underwent a procedure for instability pain and 8 were listed as going under the knife for intractable pain.  As mentioned earlier, seven patients were excluded from the study due to their ASIA scores; 5 patients had an ASIA score of A (total injury) and 2 had an ASIA score of C – all seven patients failed to present baseline data sufficient for monitoring and reporting to the surgeon during the procedure.

Results:

Of 128 with spinal cord metastases who underwent surgical procedures with neuromonitoring, 13 patients had significant alerts. That amounts to 10.2% of the patient population, or 1 in 10 patients.  Five patients had TcMEP alerts, 5 patients had TcMEP and somatosensory alerts, 2 patients experienced MEP and EMG alerts, while one patient had alerts in all three modalities.

Of the 128 patients included in the study, there were 114 true negatives, 13 true positives, and 1 false negative.  No false positive was reported.  Of the 114 procedures resulted in true negatives – no significant alerts were reported during the procedure and the patient woke up without additional deficits.  Of the 13 patients with true positives – patients where an alert was reported and either corrections resulted in a return to baseline, or the patient awoke with a deficit - occurred in 9 open procedures and 4 minimally invasive Surgical (MIS) procedures.

The paper further breaks down the true positives into three groups – Group A, Group B and Group C.  Group A included one patient (8.3% of the true positive patient population) who exhibited a decrease of signals during a lateral psoas approach.  The patient’s responses returned to baseline after the surgeon changed the plane through which the muscle dissection approach occurred.  Group B incorporated 5 patients (38.46% of the patient total) who experienced alerts during instrumentation.  Four of these patients’ data returned to baseline after either pedicle screw placement adjustment or decreasing the size of the interbody cage placed.  One of the patients in Group B did not experience data recovery to baseline after all available interventions were exhausted, and this patient did wake up with complete paraplegia. 

Finally, Group C included 7 patients (53.84% of true positives reported) where a significant alert was communicated during the decompression phase of the operating, and these patients all returned to baseline after the decompression was complete.

The final patient was reported as a false negative; the patient awoke with a C5 palsy post-operative after undergoing a cervical laminectomy with hardware placement.  Specifically, the right deltoid and biceps function degraded from a grade 5 to 2 immediately upon wakeup assessment.  The patient did recover to normal status at the 9-month post-operative mark.  This completes the total of procedures with a post-operative deficit; one true positive and one true negative, or 1.6% of the patient population.         

Discussion:

The authors conclude that IONM exhibited a high degree of sensitivity and specificity for detecting changes to neurologic status intraoperatively during MSTS procedures.  Of particular note is that a number of patients experienced changes in Somatosensory and motor data during the procedure that resolved after intervention by the surgical team.  These interventions included changing the surgical approach, trying a different placement or size of hardware, elevating patient’s mean arterial pressure or administering steroids depending on the scenario.  

Many of these patients’ IONM data changes resolved at that time, lending support to the concept that effective use of IONM can allow a surgeon to make informed course corrections during a procedure, mitigating the potential for post-operative deficits.  The goal in MSTS procedures is often to improve quality of life, either by reducing pain or restoring sensation and function when possible.  Surgical actions and conditions that put the patient at risk of incurring further post-operative deficits can be countermanded with use of IONM, making neuromonitoring a powerful tool in the surgeon’s kit when the procedural goal is to improve the patient’s quality of life.  The highest degree of accuracy reported in the study was with multimodal IONM, including TcMEP, somatosensory and EMG recording, both passively and with triggered mapping of nervous structures. This was followed by SSEPs in combination with TcMEP, EMG with SSEPs, and finally the lowest diagnostic sensitivity was produced when each of these modalities were used individual during a procedure, and not in concert with other IONM approaches.  This finding reinforces the principle that neuromonitoring is at its best when we as professionals can use the full range of our monitoring tools to produce the best results.

The article dives down in the one instance of a false negative included in the study, concluding it was likely a technical error, but providing no further description.  This paper provides an encouraging report on the impact of IONM on patient quality of life post-operatively when facing the challenges of spinal cord tumor metastases.  While the retrospective study is limited by the constraints of providing data from only two monitoring professionals in the service of five surgeons at one facility, the authors begin to fill in a literature gap that is much needed.  More information from other facilities reported in this manner on the impact of IONM on MSTS procedures will be of great benefit to the neuromonitoring community.

References:

  1. Kumar N, G V, Ravikumar N, Ding Y, Yin ML, Patel RS, Naresh N, Hey HWD, Lau LL, Liu G. Intraoperative Neuromonitoring (IONM): Is There a Role in Metastatic Spine Tumor Surgery? Spine (Phila Pa 1976). 2019 Feb 15;44(4):E219-E224.
  2. Noona, V., Mak, J., Zhu, J., Diab, K., Queree, M. (2016). American Spinal Injury Association Impairment Scale (AIS): International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Retrieved from https://scireproject.com/ (2020).

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: 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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