ION Intraoperative Neurophysiology
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1 ION Intraoperative Neurophysiology EMG Course in Bucharest, September 18-19, 2012 Roland Flink Prof MD PhD Department of Clinical Neurophysiology What to monitor? Cortical function Tumour surgery Epilepsy surgery Spinal cord function Scoliosis Tumours Tethered cord Malformations (MMC) Conus/cauda Tumours Malformations (MMC) Roots Plexus Peripheral nerve Tumours (Schwannoma) Trauma lesions Cranial nerves Brainstem tumours Acusticus neurinoma Cochleaimplant facial nerve 1
2 Electrocorticography Corticography - recording epileptiform activity during epilepsy surgery identifying the irritative zone - use of grid electrodes - peroperatively - extroperatively (long time monitoring) - use of electrocorticography instrument 2
3 Cortical motor mapping Direct cortical stimulation - identify primary motor area - stimulation with use of grid electrodes or monopolar stim electrode manually held by the surgeon - MEP recording from hand- and forearm muscles 3
4 To avoid seizures!! No of patients X 50 Hz stimulation biphasic pulse, pulsduration 0,3 ms Seizures V Short train of pulses 5 pulses, pulsduration 0,5 ms, 4 ms interval About 220 Hz Jan Jun 2005 July Oct 2012 No seizures 1 sekund 50 Hz Short train pulses APB FDS EDC Repeted short train pulses 4
5 Peroperative median nerve SEP Cortical motor mapping Median SEP phase reversal - identify central sulcus between motor and sensor gyrus - recording with grid electrodes peroperatively N N M S Sulcus 5
6 Spinal cord monitoring Spinal cord monitoring with MEP and SEP - scoliosis surgery and spinal cord surgery MEP - transcranial electrical stimulation using subdermal screw electrodes - MEP recording from tib ant, abd hall and abd dig min - Amplitude reduced with % = larm look for: - technical problems - change in anesthesia (bolus of propofol) - fall in blood pressure - Identify other causes to lesions - root lesions (screws or other root manipulation) - prolonged pressure on plexus/peripheral nerve Kortikografi - språk mapping - motor mapping - spinal monitorering - conus/cauda - perifera nerver 6
7 Spinal cord monitoring - SEP Stimulation tibial nerve Stimulation median nerve (control) Recording fossa poplitea Cortical recording 7
8 Spinal cord monitoring - MEP Transcranial electrical stimulation Needle recording abd hall Needle recording tib ant Needle recording abd dig min (control) Spinal cord monitoring Screw electrodes (platinum) Needle electrodes (platinum) Transcranial electrical stimulator Short cables 8
9 MEP Transient spinal cord dysfunction SEP - Stimulation n tibialis / n medianus / n ulnaris - Reduced amplitude, parameter to monitor BILD 9
10 D waves D-vågor - singel stimulations using subdermal screw electrodes - do not elicit MEP - no muscle jerking can be perfomed continously - reduction >50% considered to correlate to permanent motor deficit Conus/Cauda Often malformations - MMC / Diastematomyeli / Tethered cord Multimodal technique - direct nerve root stimulation - free running EMG - SEP - MEP (optional) - F-response (optional) Recording from L2-S4 (including muscles from pelvic floor, sphincters) 10
11 Digital camera in the operation microscope VL TA GM AH EAS Peripheral nerves / roots / plexus Monitor - neurolysis/nerve reconstruction - cochleaimplant and acusticus neurinoma surgery - facial nerve Multimodal technique - direct nerve root stimulation - free running EMG - SEP - MEP (optional) - F-response (optional) Abd hall Abd hall CMAP from abd hall, tibial nerve stimulated at knee 11
12 Pitfalls and problems Technical problems Anesthesia Artefacts Communicate with the surgeon Pitfalls and problems Propofol (Diprivan ) Remifentanil (Ultiva ) No muscle relaxantia Avoid Halothane (Fluothane ) Anesthesia 12
13 Pitfalls and problems Why using platinum needle electrodes? Pitfalls and problems Why using platinum needle electrodes? The needle has become a sacrificeanode and are loosing material to the tissue by an electro -chemical process 13
14 Pitfalls and problems Why using platinum needle electrodes? 14
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