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

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

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

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

FIVE Key Points from the Papers

1. The MEP alert criterion is critical

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

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

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

2. MEPs > sEMG in diagnosing nerve root dysfunction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

Disclaimer:

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

Tags:  In the Literature 

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President's Message - November 2019

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

Dear Members,

 

Just a few announcements this month:

 

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

 

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

 

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

 

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

 

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

            

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

 

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

 

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

 

Disclaimer:

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

 

Tags:  President's Message 

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ASNM Committee Updates

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

Members,

 

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

 

Education Committee (Chair: Dr. Jeff Balzer):

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

 

Ethics Committee (Chair: Dr. Bob Sclabassi):

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

 

Finance Committee (Chair: Willy Boucharel):

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

 

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

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

 

Membership Committee (Chair: Clare Gale):

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

 

Nominations Committee (Chair: Dr. Jay Shils):

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

 

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

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

 

Research Committee (Chair: Dr. Miriam Donohue):

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

 

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

 

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

 

Disclaimer:

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

 

Tags:  Announcement 

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President's Message - October 2019

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

Dear Members,

 

We just finished our 2019 Fall Symposium in Boston. I was excited to hear from attendees and exhibitors alike that this was one of the best meetings they ever attended. Attendees liked the variety of speakers/topics and the practical advice for all levels of practitioner. Exhibitors liked the attendance, room setup, foot traffic and engagement. I’d like to extend my congratulations to our Program Chairs, Drs. Joe Moreira and Faisal Jahangiri, who developed the educational content. I’d like to thank all of our speakers, and a very special thank you to our industry partners for sponsoring the event. We couldn’t have done it without you!!

 

I think the success of our 2019 Fall Symposium foreshadows what is to come from future ASNM meetings. In taking office as ASNM President, I promised to double down on education, experiment with new technologies, expand our annual meeting and make the ASNM the best place in the world to learn about IONM. At this moment, today, there is no question in my mind that the ASNM has emerged as the nation’s premier resource for IONM education, we’re just getting started.

 

I’m happy to announce that the 2020 ASNM Winter Symposium will be a (mostly) virtual meeting to be held in early 2020. In a major departure from our traditional symposia, we will be offering a live, interactive, world-wide broadcast of the meeting. This allows attendees to get the same premier education they’ve come to expect from the ASNM, and without having to pay additional cost of travel and hotel. So, you can get your CMEs/CEUs in your pajamas! Of course, we still expect to offer in-person attendance to a limited number of participants. We’re still working out the specifics/logistics and finalizing the dates, but we expect to make formal announcements very soon. So, stay tuned. 

 

This leads me to the 2020 ASNM Annual Meeting. This will be our biggest and best meeting that we’ve ever hosted. We’re incorporating new formats, new technologies, new topics and new speakers. I won’t say any more right now, but I will say this: if you’re going to travel to one meeting in 2020, you will definitely want to make sure it is the ASNM Annual Meeting May 15-17 in St. Louis, MO.

 

Finally, if you have been a speaker at a recent ASNM meeting, or are a frequent audience attendee, you may have noticed that we’ve been changing our requirements for what speakers need to disclose, as well as what can/can’t appear on slides. We do this for two reasons, 1) because some of it is required by our CME provider, and 2) so the audience can readily detect any bias in a presentation.

 

When I say “bias”, I’m talking about bias driven by economic influence, not individual opinions about how to practice. So, someone saying that you should do BCR on all spine cases is certainly free to present evidence to support that argument; however, someone whose company sells the latest “BCR electrode” stands to make financial gain from that statement, and the audience has the right to know that. Also, we’re learning new things from our CME provider. For example, if you work for an academic institution, you can put your institution name and symbol on you slides, but you cannot do that if you work for a private company. So, we’re making changes to our rules over time to maintain transparency for the audience, as well as compliance to rules set forth by our CME and CEU providers. We hope you will understand and bear with us while we hone our technique.

 

Happy Halloween everyone. No matter where you live, I hope you get to enjoy some of the beautiful fall foliage that we see in the north. It’s a wonderful time to travel. I’ll be back in November 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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President's Message - September 2019

Posted By Administration, Thursday, September 5, 2019

Dear Members,

 

Summer is winding down and the cool winds of fall are beginning to make their way to my home state of Pennsylvania. This is my favorite time of year, but right now my thoughts are with the people affected by hurricane Dorian. I hope all of our members, as well as their loved ones, in affected areas are somewhere safe.

 

Over the past month, we’ve been busy getting ready for the upcoming Board Meeting, which will be held on Friday September 13th, just before our Fall Symposium in Boston, Massachusetts. More on the symposium in a few minutes. 

 

If you’ve ever wondered what goes on at our Board Meetings, you can always attend one as they are open to all members. In general, we discuss the business of running a society and shaping a profession. Each Committee gives reports to update us on their projects. We discuss various topics and takes votes on proposals that will shape the direction of the ASNM. I think it is excellent experience to serve on a board, and I’d encourage everyone to run for office at some point in their career. If you’re looking for a good entry point to get some experience, I’d strongly encourage you to start by serving on one of our Standing Committees. Feel free to contact me if you’d like to get involved. 

 

One big project we’ve been working on in August is a major update to our 2019 Industry Prospectus for 2020. You may remember from my Incoming President’s Addressthat I wanted to work more closely with our industry partners. In doing so, I created an Industry Partner Taskforceto advise us on certain topics that impact our partners. In developing our 2020 Industry Prospectus, we’ve worked closely with this Taskforce to ensure it works well for the ASNM and our partners who support our Society. The Board still needs to vote on the 2020 Prospectus, so it won’t be available for a few weeks. Stay tuned!

 

In the middle of August, I traveled to Kansas City to attend ASET’s Annual Meeting. The Neurodiagnostic Society celebrated its 60thyear. I had the opportunity to meet with ASET leadership to continue our close collaboration. As usual, I had a wonderful and productive conversation with ASET Immediate Past President Susan Agostini and the new ASET President, Connie Kubiac. I look forward to our continued collaboration. 

 

In late August, neuromonitoring was again in the national spotlightand, sadly, not in a positive light. I think we are on the verge of seeing more national news stories related to out of network (OON) billing for neuromonitoring. While the OON status of many companies is mostly the fault of the insurance industry refusing to allow us to be in-network, the news stories will sensationalize this and blame the IONM profession as a whole. Those of you who are engaged in business practices of questionable ethics (you know who you are), you’re not helping matters because stories that break about you will only make the rest of us look bad. 

 

Anyway, I’m sure you’re all aware of the NPR story about IONM that broke on June 17th. Well, a different version of this story also aired on NBC Nightly News with Lester Holton August 18th. In this segment, Ms. Cannon’s story was reported by Catie Beck in the Your Money Your Lifesegment. This particular story did not use quotes or comments from me, but it did talk about surprise bills and paint IONM in a negative light. 

 

On a more positive note, there was also a recent story about IONM published in Neurosurgery Market Watch. Among those interviewed for the story include myself, Dr. Faisal Jahangiri (ASNM President-Elect), Dr. Jay Shils (ASNM Secretary) and Dr. Marc Nuwer (longtime ASNM member and Fellow).

 

Turning to the future, the ASNM Fall Symposium will be held September 13-15at the Hyatt Regency Boston. You can view the program online and register here . There will be three pre-conference workshops covering the 10-20 system, TCD and electrode safety. As usual, the main conference will feature a variety of new speakers covering a variety of new topics. If you’re one of those people who continues to think of that ASNM as presenting stale topics with the same old speakers, I’d encourage you to set aside your prejudice and check out our program. Also, if you can’t make the fall symposium, I’d strongly encourage you to plan to attend our 2020 Annual Meeting in St. Louis, MO. We’re planning a bunch of new activities that will transform your meeting experience.

 

So, that’s my President’s Message for September 2019. In my October President’s Message, I’ll tell you about how our Fall Symposium went, and give you important updates from our Board Meeting. I hope you’re all enjoying the closing days of summer. I’ll be back in October with another update from the front lines. Thanks for being a valued member!

 

Rich Vogel, PhD

ASNM President

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In the Literature: Predicting Motor Recovery After Surgery of Tumors in Motor Eloquent Areas

Posted By Richard W. Vogel, Thursday, September 5, 2019

In this blog post, one of our members stepped up to the challenge of helping us review recent papers from the literature. Many thanks to Christopher Halford! If any readers would like help by writing summaries of recent papers, please contact me (ASNM President Rich Vogel). The post below was written by Christopher D. Halford BA, R. EEG/EP T., CNIM.

 

 In the article "Postoperative navigated transcranial magnetic stimulation to predict motor recovery after surgery of tumors in motor eloquent areas" by Seidel, et al., published in the June 2019 edition of Clinical Neurophysiology, the authors approach a very interesting topic. As the title says, they attempted to use post-operative transcranial magnetic stimulation (TMS) on patients to see if a present MEP could predict patient recovery following an intraoperative change in dcMEPs and/or tcMEPs that resulted in a post-operative motor deficit.

 Throughout the article the authors explain their methodology in great detail. They included essential information like the majority of the standards they used for establishing their criteria for changes in intraoperative MEP testing, the time frame used in the study to test the patient post-op, and a detailed chart showing the important information for each patient in the study including pre- and post-op strength changes, individual intraoperative MEP change (with recovery of signal or a lack thereof), recovery of strength from day one, one week, and one month post-op, etc. The authors make educating the reader of their testing and results, along with prior research done in this area (with many citations of pertinent scholarly articles to support each statement of fact or claim that guided their methods) a very high priority of their publication.

 Results:

 All of the 13 patients included in this study presented with a decrease in post-operative motor function compared to their pre-op exam. Within one week post-op (average=3.8 days) the researchers tested each patient and were able to record an MEP through navigated transcranial magnetic stimulation in 11 of the 13 patients. Ten of the 11 that had had a recordable MEP after TMS demonstrated a positive functional recovery by 30 days post-op, demonstrating this method has a positive predictive value (PPV) of 90.9%. Of the remaining two that did not have a post-op MEP after navigated TMS both had minimal to no recovery of function after one month post-op while one patient that had a post-op MEP from magnetic stimulation did not show improvement (based off of their progress criteria).

 Conclusion:

 In this article Seidel et al. show the reader the basis for his study done by other researchers (whose evidence and findings are stated and cited in this article) but they also expand these conclusions as well. As they point out, they extend their testing and results to lower limb motor function (as well as including upper limb) and propose the value of this technique for possible determination of patients that might benefit from aggressive post-op therapy that may have otherwise been seen as candidates that would benefit little from it. Also, the authors offer the prospective benefit of TMS for assessing more secondary and/or associative motor areas of the brain in a way not possible using only intraoperative tc or dcMEPs, which was also one of the key focuses of their testing.

 Limitations:

 The authors are very good about citing the sample size as the biggest limitation of their study. However with the solid outcomes of this limited sample size the authors have demonstrated that additional research will likely have merit. They also acknowledge that though the tumor locations for each resection were in different eloquent areas, each did have a limit of 3 to 8-cms distance from motor eloquent areas. Although the authors did inform the reader of most of their intraoperative criteria for evaluating and reporting change, it is still somewhat incomplete given that they didn’t list what specific surgical maneuvers were/could have been used to respond to intraoperative MEP changes, once an alarm criteria had been met. Also, more detailed stim parameters, anesthesia regimen/changes, and individual alarm criteria for each intraoperative change would be valuable for study reproduction. As mentioned they did provide much of these aspects but these key components would be crucial for complete replication.

 The IONM Big Picture Perspective:

 The article offers a potential technique of great value: a method that might indeed help determine the likelihood that a post-operative deficit is either going to be transient or permanent. Although this is an incredibly valuable determination (both to surgeons and patients/families), adaptation of this into the clinical setting could be a difficult task considering the cost of magnetic stimulators to those hospitals and facilities that don’t have preexisting needs for this technology. However, for those that do have this technology onsite, this could be a tremendous opportunity to consider research opportunities. If larger, repeated studies could further support the preliminarily data shown in this current article, then it could serve as evidential support for convincing hospitals to invest the necessary funds to acquire this technology and implement this type of monitoring. The development of a neuromonitoring test that would allow a surgeon to tell a patient, with confidence, that their new deficit will be only temporary has the potential to be a critical area where neuromonitoring could directly contribute to improving patient care. I encourage those that have the interest and the means to help to contact the authors, compile all information needed to replicate the study and move this research forward. 

 References:

Seidel, K., Hani, L., Lutz, K., Zbinden, C., Redmann, A., Consuegra, A., . . . Schucht, P. (2019). Postoperative navigated transcranial magnetic stimulation to predict motor recovery after surgery of tumors in motor eloquent areas. Clinical Neurophysiology,130(6), 952-959.

 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 - August 2019

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

Members,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

Which patients need neuromonitoring?

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

What has led to the rapid expansion of neuromonitoring?

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

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

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

How much does neuromonitoring typically cost?

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

How much does it cost to perform the service?

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

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

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

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

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

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

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

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

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

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

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

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

How can consumers avoid a surprise bill for neuromonitoring?

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

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

 

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

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

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

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

 

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

 

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

 

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

 

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

Tags:  Announcement  Podcast 

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Neuromonitoring Podcast from NASS

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

ASNM Members Launch Neuromonitoring Podcast Through NASS:

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

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

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

 

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

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ASNM Members Participate in Ask The Experts Video

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

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

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

Enjoy:

 

Disclaimer:

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

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