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  • 01 Apr 2014 1:21 PM | Neuro News (Administrator)

    Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws

    Charlottesville, VA (April 1, 2014). Researchers from Syracuse, New York, report a new, highly accurate, neuromonitoring method that can be used during thoracic spine surgery to prevent malpositioning of pedicle screws such that they enter the spinal canal and possibly cause postoperative neurological impairment. Findings of this prospective, blinded, and randomized study are reported and discussed in two companion papers published today online, ahead of print, in the Journal of Neurosurgery: Spine, specifically "Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 1: Methods and alarm criteria. Clinical article" and "Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2: The role of feedback. Clinical article" by Blair Calancie, Ph.D., and colleagues.


    Background

    Disorders of the back and spine are extremely common, particularly in older adults. Nerve roots or the spinal cord itself can become compressed, leading to neurological symptoms of pain, numbness, and weakness. Sometimes, spine surgery is required to treat these types of problems.

    The thoracic spine has 12 vertebrae, stacked on top of one another like building blocks. Each vertebra has a pair of "pedicles"undefinedshort, thick pieces of bone that connect the back part of a vertebra (the vertebral arch) with the front part (the vertebral body). Collectively, these structures enclose the spinal canal, through which the spinal cord passes from the base of the brain down to the upper lumbar vertebrae.

    Certain types of spine surgery require that neighboring vertebrae be fused together to prevent movement. This is frequently accomplished by placing bone fragments on selected vertebrae and mechanically stabilizing the vertebrae by implanting multiple bone screws, which are used to anchor a pair of rods placed along either side of the spine. The bone fragments grow into the patient's vertebrae and form a strong bone fusion.

    Modern spine fusion surgery is generally considered safe, but occasionally things can go wrong. When performed in the thoracic spine, bone screws are inserted into the pedicles with the screw tips ending in the vertebral body. If a screw is angled too far medially (inwardly into the spinal canal), it can compress and damage the spinal cord. This in turn can cause new neurological symptoms in the lower body and, in the worst case, permanent paralysis.

    To avoid this possibility, researchers from Syracuse developed and tested a new intraoperative neuromonitoring method that they hoped could decrease the risk that a malpositioned pedicle screw might breach the spinal canal. The researchers separate their detailed findings into two companion articles in the Journal of Neurosurgery: Spine, the first describing the method itself and the second demonstrating how information gained from the neuromonitoring procedure can affect the surgical protocol.

    New Intraoperative Neuromonitoring Method

    Intraoperative neuromonitoring is fairly new. Although it has been in use at major university/academic centers for roughly the past 20 years, it is only now starting to be used in smaller community hospitals. The general idea is to perform intraoperative neuromonitoring testing intermittently during surgeries that directly place the brain and/or spinal cord at risk and watch for any changes in test results that might reflect a loss or worsening of nerve function due to technical issues such as placing a bone graft against the spinal cord or overstraightening the spine in a patient with scoliosis. Early detection of such a change can give the surgeon time to "undo" whatever action led to the change in test results, thereby avoiding new problems or symptoms.

    There are currently two intraoperative neuromonitoring tests of brain and spinal cord function that are used widely in thoracic spine surgery: somatosensory evoked potential testing, which focuses on function of the spinal cord's sensory pathways, and motor evoked potential testing, which focuses on function of the spinal cord's motor pathways. Although both tests provide valuable information to the surgeon, neither one can detect bone screws that are placed too close to the spinal cord, except for the rare instance in which a screw actually penetrates the cordundefinedat which point permanent damage may already have been done.

    The new intraoperative neuromonitoring procedure described in the companion papers involves two steps: 1) initiation of electrical stimulation (4-pulse trains) passing within the trajectory track planned for the pedicle screw; and 2) measurement of electromyographic (EMG) responses to the stimulation from the patient's leg muscles.

    The neuromonitoring results are based on tests conducted during thoracic spine surgeries performed in 71 patients at Upstate University Hospital and Crouse Hospital in Syracuse, NY. During these operations, 802 screws were placed in vertebrae to anchor spinal rods. The authors describe how during this type of operation, the surgeon creates a pathway, or track, in the center of the pedicle by using a pedicle finder (similar to an awl). The surgeon then inserts a probe into the pedicle track to "feel" for any defect that might indicate a present or potential breach in the side of the pedicle nearest the spinal canal (the medial wall). These steps are integral parts of the operation: if no defect is found, the surgeon normally inserts the screw, whereas if a defect is found, the surgeon can revise the track if it seems necessary. For the purposes of the present study, before placing the pedicle screw in the track, the surgeon inserted a second ball-tip probe capable of delivering electrical stimulation to navigate the pedicle track, paying attention specifically to the medial wall of the track.

    Brief, low-intensity pulses of electricity (repetitive stimulus trains at intensities up to 20 mA) were delivered through the ball-tip while the surgeon moved the probe along the pedicle's walls. If the dense bone of the pedicle wall was intact, it provided insulation from the electrical current, rendering the stimulation inert. Conversely, if there was a defect in the wall facing the spinal cord, motor nerve fibers in the spinal cord were activated. This activation was confirmed by measuring electromyographic (EMG) activity from leg muscles whose nerves were acted upon by these spinal cord motor nerve fibers.

    The researchers sought a particular stimulation thresholdundefinedthe minimum stimulus intensity needed to cause an EMG response from the leg during electrical stimulation of the pedicle track. In theory, the lower the stimulus intensity, the higher the probability that a pedicle wall breach has occurred near the spinal cord; identification of a low stimulus threshold thus serves as a caution against placing a screw along that pedicle track.

    Testing the New Method

    To provide a comparison, the researchers stimulated the pedicle screw itself, once inserted, and assessed EMG responses to this stimulation from leg muscles as well as from intercostal and abdominal muscles. Postoperative computed tomography (CT) scans were later examined and compared with intraoperative EMG recordings by multiple reviewers who were blinded to (kept unaware of) patient identities and intraoperative test results. This was done to determine how well intraoperative neuromonitoring of pedicle track thresholds could predict which screws once inserted would veer too far medially and thereby encroach upon the spinal cord.

    The researchers report that postoperatively 32 pedicle screws were found to have breached the spinal canal to an extent (2 or more millimeters) that is clinically relevant and should be avoided. This medial malpositioning of all 32 pedicle screws had been predicted intraoperatively, prior to screw insertion, by EMG responses of leg muscles to the 4-pulse train stimulation delivered within the pedicle tracks.

    In contrast, electrical stimulation of the screw after placement did not always elicit a response from the targeted muscles, even when the spinal canal had been breached. As expected, neither somatosensory nor motor evoked potential testing was effective in detecting signs of screw malpositioning, confirming that these "standard-of-care" tests were ineffective for detecting and/or preventing this type of surgical risk.

    By applying a receiver operating characteristic analysis, the researchers found that their new method of pedicle-track 4-pulse stimulation and leg muscle responses proved most effective when a combination of 10-mA (lower threshold cutoff) and 15-mA (upper threshold cutoff) stimulation intensities was used. In this study, a 10-mA threshold had an 88% chance of detecting a clinically relevant medial breach (2 or more millimeters) by an implanted screw and a 15-mA threshold increased that chance to 100% accuracy.

    Providing Feedback to the Surgeon

    The second paper on the new neuromonitoring method covers the role of feedback during surgery. Although the study was prospective, blinded, and randomized, under specific conditions some blinding was discarded.

    During Phase 1, which covered the first 65 cases, as a rule no neuromonitoring feedback was given to the surgeon during the operation. Exceptions to this rule, however, were made in cases in which muscle responses to pedicle-track stimulation indicated a breach of the medial pedicle wall that would result in direct physical contact between screw and spinal cord. This was indicated by leg muscle responses to a stimulation intensity of 4 mA or less. When this occurred, "break-the-blind" feedback was relayed to the surgeon. During Phase 2, "planned feedback" was provided to the surgeon in 50% of the remaining pedicle tracks. Here too, break-the-blind feedback was relayed to the surgeon in cases randomized to no planned feedback if the leg muscle response was highly predictive of a breach that could lead to endangerment of the spinal cord.

    The researchers broke the blind for 29 pedicle tracks. Based on this information, the surgeon revised the pedicle track before the screw was ever placed. The researchers say it's conceivable that any one of these 29 screws could have caused permanent neural injury had its malpositioning not been prevented by this new form of intraoperative testing.

    Feedback to the surgeon and consequent revision of pedicle tracks "led to a significant reduction in the numbers of screws with clinically relevant medial malpositioning." Among the pedicle tracks for which feedback to the surgeon was provided and surgical revision of the track was performed, there was no instance of clinically relevant medial encroachment on the spinal canal.

    Summary Findings

    For the researchers, the success of the new neuromonitoring method was verified by the high chances of detecting a clinically relevant medial breach (2 mm or more) before screw placement: 88% using a 10-mA stimulation threshold and 100% using a 15-mA threshold. The rates of false positives associated with this neuromonitoring method were 10% when the alarm threshold selected was 10 mA and 26% when it was 15 mA. These values demonstrate that this new neuromonitoring method represents a considerable improvement over other methods of detecting medial screw malpositioning used today, such as screw stimulation and monitoring of somatosensory and motor evoked potentials.

    With this NIH-funded prospective, randomized, and blinded clinical studyundefineda first in the field of neuromonitoringundefinedthese researchers have proved that use of their novel real-time intraoperative test can significantly reduce the incidence of pedicle screws placed too close to the spinal cord during thoracic spine surgery, thereby making the surgical procedure safer for patients undergoing this surgery.

    ###


    Calancie B, Donohue ML, Harris CB, Canute GW, Singla A, Wilcoxen KG, Moquin RR: Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 1: Methods and alarm criteria. Clinical article. J Neurosurg Spine, published ahead of print April 1, 2014. DOI: 10.3171/2014.2.SPINE13648

    Calancie B, Donohue ML, Moquin RR: Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2: The role of feedback. Clinical article. J Neurosurg Spine, published ahead of print April 1, 2014. DOI: 10.3171/2014.2.SPINE13649

    Disclosure: This study was supported by a grant from the National Institutes of Health to B. Calancie (R01 NS063055). Digitimer Ltd. (Welwyn Garden City, UK) designed and provided the researchers with a current:voltage adapter for recording voltage pulses calibrated to the intensity of current pulses being delivered. Dr. Moquin reports a consultant relationship with K2M.

    The authors hail from the following institutions: SUNY Upstate Medical University (Drs. Calancie, Donohue, and Singla, and Ms. Wilcoxen), Syracuse Orthopedic Specialists (Dr. Harris), and Crouse Neurosciences (Drs. Canute and Moquin), all of which are located in Syracuse, New York.

    For additional information, please contact:
    Ms. Jo Ann M. Eliason, Communications Manager
    Journal of Neurosurgery Publishing Group
    One Morton Drive, Suite 200
    Charlottesville, VA 22903
    Email: jaeliason@thejns.org
    Telephone 434-962-1425
    Fax 434-924-2702

    The Journal of Neurosurgery: Spine is a monthly peer-reviewed journal focused on neurosurgical approaches to treatment of diseases and disorders of the spine. It contains a variety of articles, including descriptions of preclinical and clinical research as well as case reports and technical notes. The Journal of Neurosurgery: Spine is one of four monthly journals published by the JNS Publishing Group, the scholarly journal division of the American Association of Neurological Surgeons. Other peer-reviewed journals published by the JNS Publishing Group each month include the Journal of Neurosurgery, Neurosurgical Focus, and the Journal of Neurosurgery: Pediatrics. All four journals can be accessed at http://www.thejns.org.

    Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 8,300 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system including the brain, spinal column, spinal cord, and peripheral nerves. For more information, visit http://www.AANS.org.

    The three techniques to start thoracic pedicle screw placement evaluated in this study: straight-forward, funnel, and in-out-in.
    Brown et al. Scoliosis 2010 5:14   doi:10.1186/1748-7161-5-14


  • 11 Nov 2013 10:59 AM | Neuro News (Administrator)

    IONM - Medico-Legal Research:

    Intraoperative neural monitoring (IONM), utilizing somatosensory evoked potentials (SEP) and electromyography (EMG), was introduced to cervical spine surgery in the late 1980's. However, as SEP only provided physiological data regarding the posterior cord, new motor deficits were observed utilizing SEP alone. This prompted the development of motor evoked potential monitoring (MEP) which facilitated real-time assessment of the anterior/anterolateral spinal cord. Although all three modalities, SEP, EMG, and MEP, are routinely available for IONM of cervical spine procedures, MEP are not yet routinely employed. The purpose of this review is to emphasize that MEP should now routinely accompany SEP and EMG when performing IONM of cervical spine surgery. Interestingly, one of the most common reasons for malpractice suits involving the cervical spine, is quadriparesis/quadriplegia following a single level anterior cervical diskectomy and fusion (ACDF). Previously, typical allegations in these suits included; negligent surgery, lack of informed consent, failure to diagnose/treat, and failure to brace. Added to this list, perhaps, as the 5 th most reason for a suit will be failure to monitor with MEP. This review documents the value of MEP monitoring in addition to SEP and EMG monitoring in cervical spine surgery. The addition of MEP0 should minimize major motor injuries, and more accurately and reliably detect impending anterior cord deterioration that may be missed with SEP monitoring alone.

    Keywords: Cervical surgery, electromyography, intraoperative monitoring, motor evoked potentials, neurological, somatosensory evoked potentials, spine surgery

    Read the full article:

    The need to add motor evoked potential monitoring to somatosensory and electromyographic monitoring in cervical spine surgery *

    * Epstein NE SURGICAL NEUROLOGY INTERNATIONAL SPINE: The need to add motor evoked potential monitoring to somatosensory and electromyographic monitoring in cervical spine surgery Surgical Neurology International, Year 2013, Volume 4, Issue 6 [p. 383-391] DOI: 10.4103/2152-7806.120782

    © 2013 Epstein; This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


  • 12 Sep 2013 9:06 AM | Neuro News (Administrator)


    Intraoperative nerve monitoring (IONM) has many applications in different surgical fields. In head and neck surgery, IONM has been used to perform surgery of the parotid, thyroid and parathyroid glands, preserving the facial and recurrent nerves. However, hypoglossal nerve neuromonitoring has not been addressed with such relevance.

    A retrospective review of surgeries performed on patients with special tongue and floor of mouth conditions was undertaken to examine the indications that prompted its use. Particular attention was given to the pathology, intraoperative findings and the final outcome of each patient.

    Four patients, aged between 6 years and 68 years, with complex oral tongue and floor of mouth lesions were reviewed. Three patients were male, aged 22 years and younger, and two of these patients had oral tongue cancers with previous surgery. Oral tongue and neck conditions are challenging since the functions of the hypoglossal nerve are put at risk. The use of IONM technology allowed us to preserve nerve functions, speech and swallowing.

    Although IONM of the hypoglossal nerve is not a common indication in tongue and floor of mouth lesions, under special conditions its application can be extrapolated to challenging surgical cases, like the ones described.


    The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

    Source:

    Carlos S Duque, Andres F Londoño, Adriana M Penagos, Diana P Urquijo and Juan P Dueñas

    World Journal of Surgical Oncology 2013, 11:225 doi:10.1186/1477-7819-11-225

    Published: 12 September 2013

  • 13 Jun 2013 11:31 AM | Neuro News (Administrator)
    Handbook of ICU EEG Monitoring A Book Review

    Editor: Suzette M. LaRoche, MD, Emory University School of Medicine

    Paperback ISBN: 9781936287390

    e-book ISBN: 9781617050787

    Demos Medical Publishing 2013

    Pages: 352

    Awarded FIVE STARS

    by the United Neurodiagnostic Professionals of America

    One of a kind: written by expert physicians for all practitioners involved in continuous EEG monitoring in the ICU. Technologists, nurses, neurologists, researchers, educators, managers and entrepreneurs benefit from this practical, clear and concise handbook. True to its title, this compact text easily fits into lab coat pockets for instant reference.

    Brand new, yet already highly-praised by the intensive care community, the Handbook of ICU EEG Monitoring accurately informs readers on all aspects of current cEEG technology. Each chapter introduces Key Points for focus and organization, facilitating quick absorption of complex material. Readers will be able to find all the answers to their questions faster than ever before! Here, eminent physicians and select accomplished specialists address the most important questions the industry faces today as cEEG case loads in ICU settings increase exponentially.

    Book Features:

    • Contains practical aspects of EEG testing in the critically ill not found in any other text
    • Convenient formatting of Key Points and outline for quick reading
    • Information is easy to read, grasp and retain
    • Just the right amount of of charts, graphs, EEG tracings, MRIs and neurological scales
    • Compiled by more than two dozen expert physicians and select specialists
    • Fits into lab coat pockets for quick and easy reference
    • Well-written and well-organized
    • Easy-to-follow, logical progression of text
    • Up-to-date, practical information written by top researchers in the field
    • Appropriate ACNS Guidelines
    • Standardized critical care terminology
    • 5 Sections: Technical Issues, Indications, Interpretations, Treatments and Additional Considerations

    Throughout, the Handbook of ICU EEG Monitoring contains neurological scales used in the ICU scoring system, graphs of EEG tracings, artifact patterns, references and recommendations for additional reading. Contained are many priceless pearls to help you unravel the mysteries of a most exciting and lucrative trend in health care. Reading this book guarantees you will impress anyone working in the ICU. Available in paperback or e-book format, the Handbook of ICU EEG Monitoring contains all the facts to help you overcome the tough challenges of this highly-profitable and emerging neurodiagnostic specialty. A good thing to have handy in your pocket. Be prepared for the challenges and opportunities ahead in ICU EEG monitoring.

    Read the Fully Detailed Book Review @ IONM.pro http://ionm.pro/2013/06/13/handbook-of-icu-eeg-monitoring-a-book-review/


    Copyright © 2013 – All Rights Reserved – United Neurodiagnostic Professionals of America (UNPA)

    Join the United Neurodiagnostic Professionals of America (UNPA) and become a member @ http://unpa.pro/Join

    UNPA – Your Professional Networking, News, and Consulting Sources: A service brought to its members by the United Neurodiagnostic Professionals of America


  • 04 May 2013 12:59 PM | Neuro News (Administrator)
    The xtreme lateral/ transpsoas approach is a new minimally invasive surgical access technique to achieve a discectomy and interbody fusion. This technique has been promoted as being made safe by the application of a specific intra-operative neurophysiological protocol involving direct stimulus and recording of lower extremity EMG responses. Despite this technique, we continued to see post-op nerve injuries, especially when working on the L4-5 level.

    We sought to improve the safety of this procedure by having a more sensitive measure of the compression of the femoral nerve. Knowing the anatomy of this nerve, the saphenous branch of the femoral nerve is a distal SENSORY continuation of the femoral nerve. By monitoring the “SSEP” of this nerve, we can, in theory, monitor the femoral nerve as it courses through the psoas muscle.

    When we reviewed the last 1.5 years of lateral approaches to the spine using this technique, we found that in 45 cases, we had NO femoral nerve injuries that were NOT detected using this technique. In one case, we had an attenuation of the SSEP on the approach side and the surgeon was alerted. Retractors were adjusted and return of the potentials were found. The patient woke up without issues. In 4 other cases, changes in the SSEP data persisted and 3 of the patients woke up with postoperative deficits.

    Please review the article and lecture to see if this technique may be helpful to improve your patient outcomes. Feel free to comment.

    http://unpa.pro/Saphenous_Nerve_SSEP_for_Lateral_Access_Lumbar_Surgery

    The Lecture: Saphenous Nerve Somatosensory Evoked Potentials for the Reduction of Femoral Nerve Injury during Lateral Access Surgery

    Justin Silverstein, MS, CNIM, Spine Medical Services,  Clinical Neurophysiology, Commack, NY

    To enjoy this presentation you must have Adobe Flash installed on your computer.
    The Adobe Flash download center is located at http://www.adobe.com/go/getflash.
    Please allow about 30 seconds for the full presentation to load on your computer.



  • 12 Mar 2013 4:35 PM | Neuro News (Administrator)

    Justin Silverstein, MS, CNIM, Spine Medical Services, Clinical Neurophysiology, Commack, NY

    The xtreme lateral/ transpsoas approach is a new minimally invasive surgical access technique to achieve a discectomy and interbody fusion. This technique has been promoted as being made safe by the application of a specific intra-operative neurophysiological protocol involving direct stimulus and recording of lower extremity EMG responses. Despite this technique, we continued to see post-op nerve injuries, especially when working on the L4-5 level.

    When reviewing the salient anatomy of the lumbar plexus at this level of the psoas muscle, we see the variable proximity of the fully formed femoral nerve and contributing branches. It is this nerve that is most at risk and injury may result in the most devastating postoperative complications.

    Read the entire article on our Surgical Neurophysiology & Neuromonitoring Group ℠ blog

    http://ionm.pro/2013/03/12/saphenous-nerve-somatosensory-evoked-potentials-technique-and-application-for-the-reduction-of-femoral-nerve-injury-during-lateral-access-surgery/


  • 04 Mar 2013 11:56 AM | Neuro News (Administrator)

    EMG and Evoked Potentials During Spine Surgery – Intraoperative Neuromonitoring Made Easy – A Guide

    EMG is an important clinical electrodiagnostic tool to assess function of neuromuscular tissue. It assesses spinal motor nerve roots and determines correct placement of hardware in surgical procedures, including cervical, thoracic, and lumbosacral spinal decompression, instrumentation, and fixation of spinal deformity. Evoked potentials provide information on vascular compromise of the spinal cord and nerves. Hence, concurrent recordings of EMG and evoked potentials can assess function integrity of the spinal cord and nerve more accurately. In this chapter, we will discuss application of EMG and evoked potentials in spinal surgery.*

    Many articles have been written on the subject yet none has captured the essence in such a concise and easy to understand format. This article will serve as a useful guide for the beginning and advanced clinical practitioner in intraoperative neurophysiological monitoring. In addition, an exhaustive list of reference articles provides easy access to the most important sources to reference for use in daily practice.

    Access the full length free article at the United Neurodiagnostic Professionals of America (UNPA) website

    Click here:

    EMG and Evoked Potentials During Spine Surgery – Intraoperative Neuromonitoring Made Easy – A Guide


  • 06 Feb 2013 3:22 PM | Neuro News (Administrator)


    Neuromonitoring Education Association:

    CNIM & IONM Practice Exams
    Version 1.1


    By Andrew A. Kopka, B.S., CNIM

    226 pages providing 970 practice exam questions with answer keys in addition to laminated EMG myotome and cranial nerve charts in a ring binder format

    Are you ready to sit for the CNIM exam? Does your organization need to measure prospective and current employees' depth of knowledge? Are you an intern, career-changer or do you simply need to review IONM concepts?  If you replied in the affirmative, Kopka's CNIM & IONM Practice Exams is a prime source to be added to your education system. The newest self-contained, supplemental learning module on the market, it helps to identify strengths and weaknesses through practice questions.

                                                    

    The scope, format and difficulty level match the actual CNIM exam administered by ABRET, the American Board of Registration of Electroencephalographic and Evoked Potential Technologists, serving as a guide through the certification and learning process.  With an abundance of diverse, challenging and, sometimes, conflicting information in circulation, this book provides clarity and profitability for managers and scholars alike.  The formula to success lies in the succinct and highly accurate reading list, saving you time and money.

    Learn to work well under the pressure of timed tests, gain confidence and study to pass the CNIM; provide your employees with the width and breadth of knowledge needed to excel in intra-operative neurophysiologic monitoring while creating a pathway for good learning techniques. Containing four CNIM Practice Exams, Math for the CNIM followed by a Math Practice Exam, as well as a Cranial Nerves Practice Exam, the questions fully incorporate the broad spectrum of information required for success. Whether you are benchmarking understanding, building a plan for continuing education or CNIM prep, the CNIM & IONM Practice Exams by Kopka will help build and organize your study program.

    A word from the author: "As many of you know, education in IONM is seldom available in formal training programs, residencies, and fellowships.  Many technologists, including myself, learn on the job and often have no formal curriculum to follow....The information is out there for individuals who are willing to search.  With that being said, what I believe is lacking are simple ways for students, technologists, neuromonitoring companies, hospitals and educational institutes to gauge depth of knowledge, gauge level of preparation for CNIM certification, and to quickly review IONM based information...With these exams, I hope to bridge some of these gaps".

    The CNIM & IONM Practice Exams' ring-binder format with hard laminated back and front covers is designed for easy, frequent use while preserving its content.  Blank answer sheets are provided for structure, user-friendliness and professional appearance.

    The book is available for purchase from the Neuromonitoring Education Association at Amazon for the price of $120.

    About the Author: Andrew A. Kopka, B.S., CNIM IS currently working in the capacity of lead IONM Technologist at the Department of Neuroscience of Saint Mary's Healthcare in Grand Rapids, Michigan.

    Copyright © 2013 – All Rights Reserved – United Neurodiagnostic Professionals of America (UNPA)

    Join the United Neurodiagnostic Professionals of America (UNPA) and become a member @ http://unpa.pro/Join

    UNPA – Your Professional Networking, News, and Consulting Sources: A service brought to its members by the United Neurodiagnostic Professionals of America


  • 01 Feb 2013 5:08 PM | Neuro News (Administrator)

    Basics of Billing & Coding Intraoperative NeuroMonitoring powered by GetBookee.org

     powered by GetBookee.org

    • Centers for Medicare and Medicaid Services www.cms.gov

    Disclaimer:

    The information contained is for entertainment purposes only. All contents and link-outs are generated and embedded from publicly available sources. The United Neurodiagnostic Professionals of America, its owners, and managers are not responsible for the embedded contents obtained through Getbookee.org. The following presentations are not to be considered a replacement for the Current Procedural Terminology (CPT) book or the International Classification of Diseases 9th Revision-Clinical Modification (ICD-9-CM) book. It is designed simply as a resource to help you obtain a better understanding of IONM coding. Always refer back to the full Current Procedural Terminology (CPT) book when coding. Current Procedural Terminology (CPT) is copyright 2012 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listing are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. International Classification of Diseases 9th Revision-Clinical Modification (ICD-9-CM) is copyright 2012 Ingenix. All Rights Reserved. Education Disclaimer: The information provided is general coding/billing information only – it is not legal advice; nor is it advice about how to code, complete or submit any particular claim for payment. It is always the provider’s responsibility to determine and submit appropriate codes, charges, modifiers and bills for services rendered. This coding and reimbursement information is subject to change without notice. Before filing any claims, providers should verify current requirements and policies with the payer.


  • 27 Nov 2012 6:04 PM | Neuro News (Administrator)


    Intraoperative Neurophysiologic Sensorimotor Mapping-A Review

    Mirela V. Simon*
    Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston

    Introduction
    The main goal of neurological surgery for supratentorial lesions remains maximal resection with preservation of function of the nearby eloquent cortical and subcortical structures. Many authors [1-9] have emphasized the positive impact of aggresive removal of gliomas on the survival rate and the quality of life in both adults and children. Others [10-12] have found a positive correlation between incomplete resection of an epileptic focus and poor seizure control outcome in epilepsy surgery.

    However, maximal resection of supratentorial lesions is in many circumstances difficult to achieve due to the close proximity of functionally normal eloquent cortex. Despite advanced neuroimaging techniques and sensitive microscopes, visual inspection has often suboptimal resolution for distinguishing between normal and abnormal tissue, especially in cases of distorted anatomy and infiltrative pathology. More so, abnormal brain tissue, as appreciated by visual inspection, can retain normal function [13-15]. Thus, functional cortical mapping is essential for safe resection of lesions in the vicinity of eloquent cortex. This usually entails a multimodality approach, including functional magnetic resonance imaging (fMRI), positron emission tomography (PET), diffusion tensor imaging (DTI) and neurophysiologic studies as well as co-registration techniques that optimally utilize all the available data [16,17].

    This article offers an overview of the neurophysiologic sensorimotor mapping. Probably one of the most important advantage this method has over the neuroimaging techniques is allowing live assessment of the cortical function and direct intraoperative feedback to the surgeon. Unlike fMRI, neurophysiologic techniques also allow subcortical mapping [18] and continuous monitoring of the sensorimotor pathways during the actual resection; also, its results are much less affected by the perilesional hemodynamic changes. Last, neurophysiologic mapping offers increased localizing specificity, when compared to other techniques [19,20].

    Sensorimotor neurophysiologic mapping consists of two parts: first, contralateral (to the craniotomy side) median somatosensory evoked potentials (SSEPs) phase reversal technique is employed with the attempt to localize the central sulcus (CS). Identification of the latter reveals to the surgeon and neurophysiologist the presumed location of the primary motor cortex. In the second part of the motor mapping, the surgeon stimulates the precentral regions, in order to identify the motor strip. Direct electrical stimulation is applied subdurally or epidurally and triggered muscle motor evoked responses (mMEPs) and/or evoked clinical responses are recorded and/or observed in the contralateral hemibody muscles in anesthetized or awake patients. Triggered responses at the lowest current amplitude will help delineate the primary motor cortex. Additionally, once the motor strip is identified, its continuous stimulation allows monitoring of the primary cortex and corticospinal tract throughout the resection. Similarly, recording of the thalamocortical SSEPs helps identification of the somatosensory cortex and monitoring of the large fiber sensory pathways during lesionectomy. Last, in awake patients, somatosensory cortex can be further delineated by eliciting sensory symptoms by electrical stimulation of the postcentral regions.

    Follow this link for full article view

    Neurosurgery Careers

    *Corresponding author: Mirela V Simon, WACC 739 G, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, Tel: 617 724-2655; Fax: 617 724-6513; E-mail: mvsimon@partners.org


    Citation: Simon MV (2011) Intraoperative Neurophysiologic Sensorimotor Mapping-A Review. J Neurol Neurophysiol S3. doi:10.4172/2155-9562.S3-002
    Copyright: © 2011 Simon MV. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.





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