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President's Message: November 2020

Posted By Faisal Jahangiri, Monday, October 19, 2020

Dear Members, 
 
First of all,  I would like to congratulate ASNM, CANM, and committee chair groups that pulled off a fantastic Fall meeting. Willy Boucharel and Lanjun Guo From ASNM and Kristine Pederson and Marshall Wilkinson from CANM did an excellent job organizing this meeting. On behalf of the ASNM board of directors, I would like to thank the President of the CANM, Dr. Jamie Johnston, for her support in planning this symposium. 
 
This first joint ASNM/ CANM joint meeting was initially planned for an in-person meeting in Vancouver, Canada. Due to the current COVID-19 pandemic, ASNM and CANM Executive Committees and the Board of Directors decided to proceed with the Fall Symposium as a virtual meeting to ensure our members, attendees, and speakers' safety. The virtual platform allowed attendees to benefit from this program across the globe. We had a total of 208 attendees registered, reaching ten different countries. We cannot thank our attendees and sponsors enough for their continued support of the ASNM. We hope we can reach more people in the field of IONM with more meetings with rich content. 

Please check out our website if you would like to purchase the recordings of the ASNM/CANM Fall Virtual Symposium. You can also click here!

Best Regards, 
Faisal Jahangiri, MD, CNIM, DABNM, FASNM, FASET 
ASNM President

 


 

Awards Update

The ASNM bylaws define a Fellow as someone who has made outstanding contributions to the field of neurophysiological monitoring, which may include a significant contribution to ASNM and has been a member of the Society in good standing for at least five years. The Fellowship subcommittee reviews all nominations and makes a recommendation to the Board of Directors. The Board of Directors shall be the final authority in the granting of Fellowship. This year the Fellowship status has been awarded to Dr. Jeffrey Gertsch for his outstanding contribution to ASNM and the field of IONM. Please join me to congratulate him as a new Fellow of the ASNM.

For the other newly created award categories:

The Founder's Award will be awarded annually to an ASNM member in good standing whose commitment to the profession of IONM is evident by contributions to the Society, contributions to the literature, and/or commitment to delivering the highest quality of patient care in IONM. This year Lawrence Wierzbowski has been awarded the ASNM Founder's Award.

The Service Award will be annually awarded as needed to an ASNM member in good standing who contributes significantly to the Society, now or in the past, through active participation on the Board and Committee work. This year Patty Warf has been awarded our Service Excellence Award.

The Outstanding Contribution to a Committee Award will be awarded annually to an ASNM member in good standing whose contributions to a committee over the last year have been deemed above and beyond.This year we had four award winners for being an Outstanding Committee Member,  Dr. Jay Shils ASNM Secretary, Dr. Jeff Balzer ASNM Education Committee Chair,  Kent Rice ASNM Fellowship Subcommittee chair, and Faisal Jahangiri (I was not involved in the decision 😊) as a Previous Membership Committee chair. 

The Outstanding Publication in a Peer-Reviewed Journal Award will be annually awarded to an ASNM Member in good standing who made significant contributions to a published research paper deemed outstanding or important by the ASNM Research Committee. The paper must have been published in a peer-reviewed journal within the previous calendar year (i.e., 2020 award for a paper published in 2019, whether in print or Epub ahead of print) as well as indexed. Pay to publish papers, book chapters, book reviews, and letters to editors do not qualify. The nomination is made by the Research Committee. This year Dr. Jeff Balzer has been awarded our Outstanding Publication Award.

 


 

Call to Join a Committee

I am inviting all members to step forward and volunteer to join one of the ASNM committees. We need new committee members and fresh ideas. The ASNM standing committees are Education, Finance, Guidelines and Standard of Care, Membership, Representation and Advocacy, Research, and Ethics Committees. If someone would like to join, please submit your curriculum vitae to ASNM@affinity-strategies.com

 


 

Call for Speakers

If you or someone you know of would like to speak at ASNM'S 2021 Winter Virtual Meeting or our 2021 Annual Virtual Meeting, please reach out to ASNM@affinity-strategies.com. If interested, please include the presenter's name, credentials, the name of the event they would like to speak at, and the topic they would like to present.

 


 

Diversity Task Force Volunteers Wanted

Want to make a difference in the future of IONM? Join us to identify the barriers for women, racial minorities, and LGBTQ members to participating within ASNM and the broader IONM community.  Join ASNM's Diversity Taskforce and share your ideas on how to improve diversity within our community. If you would like to join this task force please reach out to Tara Stewart at tara@ionmlife.com.

 


 

Meeting & Webinar Schedule 


Meeting Schedule 

  • Winter 2021 Virtual Symposium: The ASNM Board of Directors has decided to begin 2021 with another Virtual Symposium. COVID-19 has changed the way meetings will take place, and, in the event COVID-19 impacts 2021, we would like to provide our members with educational content and the opportunity to receive CME and CEU's for the content. The dates for this meeting will be posted before the end of next month.

  • 2021 Annual Meeting in Dallas, Texas, will be potentially moved to 2022 as an in-person meeting, given the current state of COVID-19. More information to follow.
     
  • 2021 Fall Virtual Symposium: The ASNM Board of Directors has officially voted on the ASNM continuing to have our Fall meeting be virtual as well. 

 
Webinars: All webinars are at 7 pm EST 
Gregory Heuer will present a webinar on Monday, November 16, "The Surgical Treatment of Tethered Cords." Please Click Here to Register Today! 
 
Cheryl Wiggins will present the first webinar of next year on Wednesday, January 13, 2021, "Out on a limb: Key IONM Concepts for Peripheral Orthopedic Surgery."  REGISTRATION TO COME! 
 
CNIM Concepts Mini-Course 
We will be hosting another CNIM Concepts course in the Spring of 2021 on April 3, April 10, and April 17. REGISTRATION TO COME

 


 

Upcoming Ballot for Elections

The ASNM 2021 Board of Directors Election Ballot was emailed to all members yesterday, on Thursday, October 15. Members have two weeks to fill the ballot out until Thursday, October 29, 2020. Once the two weeks are up, we will tally up all the votes and send all the nominees the results. Once the nominees have been made aware, we will inform the membership of the election results. Please make sure you vote!

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President's Message: July 2020

Posted By Faisal Jahangiri, Thursday, September 24, 2020
Dear Members,

I hope everyone is staying safe. We are working on multiple projects for our members, and I want to update you about the important steps we have taken recently. First, I would like to welcome our new BOD member Larry Wierzbowski who had taken the seat of Laura Hemmer when she became President-Elect.

ASNM Clinical Effectiveness Ad-hoc Sub-committee: After discussions with many ASNM members, I have created ASNM Clinical Effectiveness Ad-hoc Subcommittee, which is co-chaired by Megan Alcauskas and Ryan Rosenhahn. This subcommittee will focus on the value and medical necessity of IONM in lumbar surgeries. It will submit proposals and recommendations within 90 days of its creation to the BOD. I want to thank all the members and advisors of the subcommittee for their time, efforts, and dedication to the ASNM and IONM.

September BOD Meeting: This year, the ASNM Board of Directors meeting will be conducted virtually on September 12th, 2020, from 9:00 am - 3:00 pm CST. This meeting is for our Board of Directors to meet and discuss the workings of the Society.

Meeting Schedule

  • September ASNM/CANM Virtual Symposium: The ASNM has partnered with CANM for this year’s Fall Symposium. The meeting was initially scheduled to take place Live in Vancouver, Canada. However, given the current state of COVID-19, we have decided to pivot to a Virtual Symposium. The ASNM Fall Committee Chairs and the CANM Fall Committee Chairs have been meeting to get the meeting agenda fixed for the virtual symposium. The new agenda, registration information, and the meeting format will be posted on our website very soon. The meeting will be held on the same dates as scheduled on September 19-20.

  • Winter 2021 Virtual Symposium: The ASNM Board of Directors has decided that we will begin 2021 with another Virtual Symposium. COVID-19 has changed the way meetings take place, and in the event COVID-19 impacts 2021, we would like to provide our members with educational content as well as the opportunity to receive CME and CEUs for the content. The date for this meeting has not yet been decided, but we hope to have more information out after our Fall Symposium.

  • 2021 Annual Meeting in Dallas, Texas: We are hoping that by May, we will be able to host our Annual Meeting in-person. As of now, the meeting will be hosted on May 20-23, 2021, at the Sheraton Dallas Hotel. Once we get closer to the event, more information about the meeting will be communicated to our members. We cannot wait to see everyone in person again!

Call to Speakers for 2021:
If you or someone that you know of, would like to speak at ASNM’S 2021 Winter Virtual Meeting or our Annual Meeting in Dallas, please reach out to ASNM@affinity-strategies.com. If interested, please include the presenter’s name, their credentials, the name of the event they would like to speak at, and the topic that they would like to present.

Webinars: All webinars are at 7 pm EST: ASNM will continue to offer educational activities in summer. Jeremy Bamford will present the webinar, Intraoperative Sensory and Motor Mapping of the Human Homunculus, on July 15th. Please click HERE to Register Today!

Julie Trott will present the webinar, Impact of Anesthesia on the Diagnostic Process of IONM During Spine Procedures: An Interactive Review, on August 26th. Please Click HERE to Register Today!

CNIM Concepts Mini-Course: We will be hosting another CNIM Concepts course this Fall. The dates are September 26th, October 3rd, and October 10th, 2020, 10:00 am – 1:00 pm EST. If you or your colleagues are planning to take CNIM, these courses will help in preparing for the CNIM exam. Please click HERE to register.

Thank you for your continued support and for being a valuable member.

Faisal Jahangiri
MD, CNIM, D.ABNM, FASNM, FASET
President, ASNM

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President's Message: June 2020 — ASNM Statement of Solidarity

Posted By Faisal Jahangiri, Thursday, September 24, 2020
Dear ASNM Members,

The ASNM Board believes it is crucial at this time, to publicly state our support for each and every patient, member, colleague and other healthcare professional regardless of his/her race, religion, ethnicity, or sexual orientation.

We recognize that many people are hurting right now. As health care providers and clinicians of diverse backgrounds who treat patients of every background, we remain committed to continuing to promote diversity, inclusivity, and equality within the entire IONM field.

The ASNM has been taking steps to ensure our Society embraces and promotes diversity and inclusion. The creation of the Diversity Taskforce in 2019 is one of those steps and will serve to make sure our Board and membership embody and promote equality in our field. We will continue to build upon this taskforce to ensure a brighter future for the ASNM and all providers in this field.

Respectfully,
The ASNM Board of Directors

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President's Message: May 2020

Posted By Faisal Jahangiri, Thursday, September 24, 2020
Dear ASNM Members:

I am very excited and humbled to become the President of the American Society of Neurophysiological Monitoring (ASNM) for the year 2020-21. When starting as a medical student thirty-five years ago in Pakistan, or while driving hundreds of miles daily as a new IONM technologist covering surgeries in various states (some years later in the USA), I had not thought that one day I would be leading a premier organization like ASNM. But here I am writing this letter to you - it is truly an honor and a blessing of God.

I moved to the USA in 1992, along with my wife for higher education. After completing my graduate education in Biomedical Engineering, I started my career as a technologist in Detroit, MI, with Biotronic. Over the past two decades, I have been fortunate to work in diverse IONM capacities such as a technologist, neurophysiologist, supervisor, trainer, and as an educator. I have provided in-house and remote-physician oversight for a wide range of procedures. Over the years, I have worked with some phenomenal people in various companies. To all of them, I say thank you for being my colleague, educator, and friend. Some of the IONM companies where I have worked include Sentient, Impulse, Specialitycare, Safe Passage, and Neuro Alert. I have also done IONM-related work in Saudi Arabia, Qatar, and Pakistan. Currently, I work with Axis Neuromonitoring in their Richardson, TX location. I am blessed working with people at Axis that care about improving IONM to the best of its capacity. I have been an active member of the ASNM since 2002. I have volunteered in membership, education, research, guidelines, monitor, and applied philanthropic committees. I have been fortunate to have attended every annual meeting since 2002; however, this year will be the first time, where I would have missed a physical meeting of ASNM. I pray that we meet again under better circumstances.

Let’s first discuss some of the challenges we as IONM people face under the current times. The current COVID-19 situation has significantly changed not only our personal lives but the manner under which we operate professionally. The beginning of the pandemic saw the cancellation of elective surgeries, which significantly affected IONM services as well. We have soon picked after; however, we are not out of the woods yet. We need to keep striving to keep ‘IONM’ out of the ‘elective’ category. As IONM professionals, one of the most critical tasks that we should always keep in mind is to educate the healthcare staff around us about the essential nature of IONM. The current pandemic has resulted in the world being connected more than ever in the virtual environment. It has thus made it easier to educate about IONM with all the different platforms available for meetings, webinars, and such. No longer do we have to wait to meet in conferences to disseminate knowledge about IONM. We can do so at the click of a button with groups of various sizes. Reimbursement for IONM services by insurance companies is another challenge that we in the ASNM society face regularly. However, I feel that this challenge is again primarily related to the lack of information and education that is prevalent about the necessity of IONM services. This second challenge is also perhaps related to some unethical practices by a handful of IONM practitioners that have resulted in insurance companies getting into the practice of denying IONM claims.

Let’s talk about education now. Over the past years, first, as a member and later as the membership committee chair, I have been able to get your inputs about education. ASNM has been successfully offering multiple webinars free to its members every year. This year we had a successful virtual winter symposium, and recently our first Town Hall Motor Evoked Potentials (MEP) Interactive Webinar. We plan to provide more educational activities for our members this year – however, a tremendous amount of work is needed in the coming years. We need new people to volunteer in various committees. I request every member to pitch in their services, whether it be joining a committee, speaking at a meeting, submitting new research for conferences, or running for office, etc. I would like to invite you to participate in multicenter high caliber research, publish outcome studies to show the benefits of IONM, ask colleagues and friends to join as members, combine forces with other related organizations, educate the insurance companies about the benefits of IONM and strengthen our advocacy efforts to lobby for ASNM and IONM related issues.

Over the next year, we will continue to strengthen our professionalism through education, training, research, and better resources. I believe if we work hard and together, ASNM will become stronger and better and reemerge as a leading society in the field of IONM. We are proud of our past and excited about the ASNM future.

I would like to thank ASNM past president, Rich Vogel, for his dedication and contribution to the ASNM. I would also like to thank the outgoing Board of Directors Jeff Gertsch, Leah Hanson, Bryan Wilent, and of our members for making last year possible. I would like to thank everyone else at ASNM here that I have not mentioned by name – thanks for being a mentor, an educator, and for raising the ranks of ASNM at which it stands today. I would like to welcome our new President-Elect, Dr. Laura Hemmer, and board members Clare Gale, Cheryl Wiggins, Tara Stewart, Lanjun Guo, and Larry Wierzbowski. Special thanks to our industry sponsors for their continuous support and a tremendous job by our management team at Affinity Strategies.

Thank you again for this opportunity.

Best regards,
Faisal R. Jahangiri
MD, CNIM, D.ABNM, FASNM, FASET
President ASNM

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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.

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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.

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President's Message - April 2020

Posted By Rich 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

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COVID-19 Precautions

Posted By Rich 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 Rich 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.

 

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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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