This podcast series is about neuromonitoring and covers a range of educational topics aimed at optimizing patient care, decreasing cost and/or maximizing OR efficiency. The hosts are Drs. Rich Vogel and Adam Doan. Each episode is 5-10 mins.
Episode 1: What information is critical to communicate to the IONM team and how far in advance of surgery?
Summary: It’s not uncommon for the IONM team to learn the details of the surgical procedure after incision, as it unfolds. This poses a number of problems. The IONM team needs to know detailed surgical plan, diagnosis and patient insurance information at least 48-hours in advance for non-emergent surgery. This will make IONM less likely to fail because the IONM team can make sure the correct equipment/electrodes/people are in the room, and the correct tests are being run with optimized anesthesia. This will also limit common issues with insurance.
Episode 2: Neuromonitoring in spine surgery, can’t anyone cover the case?
Summary: Did you know IONM is learned through on-the-job training, licensure does not exist, and certifications are not required for the technologist in your OR? After initial training, technologists can monitor very basic cases (e.g., PLIF), but they should spend years in training to learn more complex procedures (deformity, tumors). If a surgery isn’t booked accurately, the surgeon might get a very junior person assigned to a very complex case. Here we inform the listener of common practices around determining “competency” for performing IONM in spine surgery.
Episode 3: Why does IONM need access to my patients and their charts before and after surgery?
Summary: It’s not uncommon for hospitals/surgeons to prohibit the IONM team from interfacing with the patient before surgery. In addition to needing informed consent, the team needs to assess the patient’s neuro status and history to interpret the IONM data. Imaging/charts help to develop an appropriate IONM plan. Facesheets are essential to reimbursement. When the IONM team is unable to access patient records, they are monitoring in the dark (and for free).
Episode 4: What are the anesthetic recommendations for neuromonitoring in various spine surgeries and why?
Summary: Here we discuss when and why we recommend total intravenous anesthesia (TIVA) vs 0.5 MAC. Is Ketamine really beneficial to MEPs? Why is Precedex contraindicated for MEPs? What train-of-four ratio is recommended for monitoring, when and why? We’ll answer all these questions and others.
Episode 5: Does use of IONM necessarily add time to your surgery?
Summary: The short answer is yes, but a closer look will show that it is negligible if the IONM team can work efficiently. We’ll discuss how setup can be optimized, and how baselines can be acquired in less than 10 seconds. We’ll also show how improved communication can reduce false positives and keep the surgery moving smoothly.
Episode 6: How can you use neuromonitoring to guide and optimize positioning for spine surgery?
Summary: The patient is finally in position and neuromonitoring can’t get baselines. What do you do? If you elect to intervene, it’s a long process to retest baselines in a neutral position. Then, you have to reposition all over again. Here we presently a fast, efficient, systematic way to position a patient for any spine surgery to ensure the spinal cord is stable, and all peripheral nerves and plexi are not compressed or stretched. Also, we talk about positioning possibilities for all patients; not just those with unstable spines.
Episode 7: Are there any real contraindications to MEPs.
Summary: Here we cut through the common myths associated with MEP contraindications. There are no absolute contraindications, and all of the relative contraindications have actually been shown to be quite safe.
Episode 8: What can you do to improve accuracy of pedicle screw stimulation?
Summary: Pedicle screw stimulation was developed and tested under very specific methods, but very few people follow these methods, and this reduces the accuracy. Here, we return to the basics and make recommendations that help even the most seasoned practitioner.
Episode 9: Is it really an alert? Whence the criteria?
Summary: The criteria for calling an alert in IONM have evolved over the years and many people don’t know what the latest research says. This causes a lot of false positives (and some false negatives). Here we review what really constitutes an alert and how you can use IONM to improve accuracy.
Episode 10: Diagnostic accuracy of IONM from the neurophysiologist’s perspective.
Summary: Here we review the traditional diagnostic table (i.e., ± alert, ± deficit) and consider other factors like intervention, resolution of data, type of monitoring modality, etc. From here, we present an advanced diagnostic table that is inclusive of these factors. This has major implications for developing and interpreting research.
Episode 11: Neuromonitoring lost their signals, now what?
Summary: Aside from checking wires and anesthesia, what else works? It turns out there is a lot one can do to restore signals. Here we review these checks and interventions.
Episode 12: Are wakeups always prolonged with neuromonitoring under TIVA?
Summary: It’s a common complaint: we use TIVA for MEPs, but the patients take forever to wake up from anesthesia. To combat this problem, many surgeons elect to discontinue IONM earlier in the procedure. Did you know IONM has the technology to guide the anesthesia team through a faster wakeup in most cases? It requires communication and collaboration, but it’s easy to do. Here we review these techniques.
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