02 Janik Spinal Cord Monitoring Color

Janik, Daniel, MD Spinal Cord Injury CRASH 2010
SPINAL CORD MONITORING

Implications for the Anesthesiologist
Daniel Janik, MD
Associate Professor
University of Colorado Denver
Overview
• Why we monitor
• What type of cases are monitored
• What are the monitoring modalities commonly
employed and what we are looking for
• How do the monitoring modalities work
• Impact of anesthesia on monitoring
• What should you do in the OR
• Summary
Why We Monitor
• Surgery of the spine involves the risk of
ischemia or traumatic injury from:
Positioning
Surgical interventions/manipulations
-Parenchyma damage
-Vascular occlusion/disruption
Anesthetic interventions (hypotension)
• Monitoring can and does make a difference
Why We Monitor
• Risk of neurologic morbidity:
Anterior cervical discectomy – 0.46%
Scoliosis correction – 0.25-3.2%
Intramedullary spinal cord tumor resection
– 23.8-65.4%
• Estimated 50-80% reduction in morbidity with
monitoring
Costa P, Bruno A, Bonzanino M, et al. Spinal Cord 45:86, 2007
Why We Monitor
Opportunities for Injury

Why We Monitor
Why We Monitor - Ischemia

Why We Monitor - Positioning
Why We Monitor
• Study by Scoliosis Research Society and
European Spinal Deformities Society:
51,263 cases (scoliosis, kyphosis, fractures,
spondylolisthesis)
Overall injury incidence 0.55% (historical
average incidence 0.7-4%)
Incidence of false-negatives 0.063%
(1:1500)
Nuwer MR, Dawson EG, Carlson LG, et al. Electroencephalography & Clinical
Neurophysiology 96:6, 1995
Why We Monitor
• The Scoliosis Research Society position:
“Neurophysiologic monitoring can assist in
the early detection of complications and
possibly prevent post-operative morbidity in
patients undergoing operations on the spine”
• Makes monitoring a de facto standard of care
during axial skeleton and spinal cord
operations
Scoliosis Research Society: Position statement on somatosensory evoked potential
monitoring of neurologic spinal cord function during surgery, in. Park Ridge,
Illinois, September, 1992
Why We Monitor
• Combined monitoring modalities

(somatosensory evoked potentials, motor
evoked potentials, electromyography) has
higher sensitivity and higher positive/negative
predictive value than single modality
techniques.
Hyun SJ, Rhim SC, Kang JK, Hong SH, Park BR. Spinal Cord 2009 Aug;47(8):616-22
What Type Of Cases Do We Monitor?
• Neurosurgical:
Spinal cord tumors
Spinal cord vascular malformations
Tethered cord
• Orthopedic:
Cervical stenosis, fractures, herniated disks
Thoracic fractures, herniated disks
Lumbar fractures requiring hardware
Scoliosis
Spondylolisthesis
Cases We Monitor - Scoliosis
Cases We Monitor – Cervical Disk

Cases We Monitor – Cervical Subluxation
Janik, Daniel, MD
Cases We Monitor
Spinal Cord Injury CRASH 2010
Thoracic Compression Fracture

Janik, Daniel, MD
Cases We Monitor
Lumbar Spondylolisthesis
Janik, Daniel, MD
Cases We Monitor - Tumors
Monitoring Modalities Commonly
Employed in Spine Surgery
• Electromyography (EMG)
Free-run
Stimulated
• Somatosensory Evoked Potentials (SSEP)
• Motor Evoked Potentials (MEP)
Transcranial electric stimulation (most common)
Transcranial magnetic stimulation
Monitoring Modalities - EMG

• Accomplished through the use of either
needle electrodes placed into, or skin surface
electrodes placed over, muscles innervated by
nerves at risk during surgery
• Muscles chosen depends on specific nerves at
risk
• Irritation or stimulation of nerve trunk or root
produces compound muscle action potential
(CMAP) or motor unit potential (MUP) firing
• Requires functional neuromuscular junction
Motor Unit Potentials

EMG – Neurotonic Discharge
(Multiple MUPs)
• Free-run EMG used for:

warning of irritation of nerves/roots
• Stimulated EMG used for:
identification of nerves/roots
confirmation of correct pedicle screw placement
(no neural impingement)

Jameson LC, Janik DJ, Sloan TB Anesthesiology Clinics 2007, 25;605-630
Monitoring Modalities – EMG
Improper Pedicle Screw Placement

Monitoring Modalities – EMG
Opportunities for Nerve Root Damage

Somatosensory Evoked Potentials

• Assesses the functional continuity of the
peripheral nerve, spinal cord, and brain
• Acquired by stimulating a mixed function nerve
and recording the response along the neural tract
to the cerebral cortex
• Response requires multiple stimuli (250-1000),
amplification, filtering, and averaging
• In arm, incoming volley of neural activity is
primarily from proprioception and vibration –
posterior columns
• In leg, same pathways but also includes some
contribution from anterolateral spinocerebellar
tracts*
SSEP
Jameson LC, Sloan TB. Anesthesiology Clinics 2006, 24;777-791


• Small response, buried in background
electrical activity of EEG, EMG, and EKG
• Follow recordings for changes in latency (time
from stimulus to appearance of response) and
amplitude
• Latency is measure of speed of conduction
• Amplitude is measure of number of neurons
responding
• Magnitude and localization of changes
determines significance
Miller’s Anesthesia 2005


• Responses affected by anything that
depresses/slows neural activity/conduction:
Ischemia – compression; hypotension;
hypoxemia
Hypothermia
Anesthetics causing metabolic suppression
(cortical responses primarily)
• Responses are not affected by:
Neuromuscular blockade
Motor Evoked Potentials

• Used to assess the functional continuity of the
corticospinal tracts
• Stimulation of the motor cortex (magnetic or
electric energy) activates pyramidal cells →
waves travel down axons to summate at
anterior horn cells → peripheral nerve
response → compound muscle action
potential (CMAP) produced
• Measure onset time and amplitude of CMAP
Janik, Daniel, MD
Lotto ML, Banoub M, Schubert A. J Neurosurg Anesthesiol 2004; 16:32-42


• Sensitive to:
Spinal cord perfusion
Previous neurologic damage
Volatile anesthetics (dose-dependent)
Bolus doses of opiates and hypnotics
Janik, Daniel, MD
Response to Hypotension
Hyun SJ, Rhim SC, Kang JK, et al. Spinal Cord 2009, 47;616-22
Motor Evoked Potentials (and SSEP)
Ischemia Caused by Spine Distraction
Costa P, Bruno A, Bonzanino M. Spinal Cord 2007; 45:86-91

Separate Blood Supply Dictates
Differential Monitoring
Posterior
Sensory Spinal
Arteries
Anterior
Motor Spinal
Artery
What We Are Looking For

• Significant changes requiring alert are:
SSEP (from baseline)
- Amplitude reduction of > 50%
- Latency increase of > 2 mSec
MEP (from baseline)
- Amplitude reduction of > 50%
- Threshold increase of > 100V
- Change in waveform morphology
Janik, Daniel, MD
Impact of Anesthesia on
Monitoring
• In general, volatile anesthetics suppress the
SSEP and MEP
Decrease amplitude, Increase latency (lower and
slower), especially MEP
• In general, intravenous anesthetics suppress
SSEP and MEP but to much lesser extent
Again – lower and slower
Etomidate and Ketamine are notable exceptions
and may augment amplitude
Opiates and Dexmedetomidine have no effect
Janik, Daniel, MD
Impact of Anesthesia - SSEP
Comparison of Isoflurane and Thiopental

Impact of Anesthesia - SSEP

Sloan TB, Heyer EJ. J Clin Neurophysiol 2002; 19(5):430-443
Suppressed Cortical Response Preserved Cervical Response

Janik, Daniel, MD Impact of Anesthesia - SSEP
Amplification Effect of Etomidate

Impact of Anesthesia - MEP
Effect of Bolus of Propofol

Impact of Anesthesia on Monitoring

Impact of Anesthesia on Monitoring
The Signal Acquisition May Be Difficult

What Should I Do In The Operating
Room
• Know the monitoring modalities commonly
employed in the type of surgery planned (talk to
surgeon and monitoring team; anticipate based
on experience)
• Choose anesthetic technique that will optimize
the monitoring data acquired maximizing the
quality of information flowing to surgeon who
makes decisions
Avoid muscle relaxants if using EMG
TIVA is best overall for SSEP and MEP
Volatile up to 1 MAC acceptable if not using MEP
Cottrell’s Neuroanesthesia 2010 (In Press)

What Should I Do In The Operating Room?
Choice of Anesthetic
Room
Room
• Maintain a stable anesthetic level during
critical portions of the procedure
Avoid large bolus dosing of anesthetic drugs
Avoid changing technique during procedure
(TIVA→Gas)
• Maintain patient’s homeostasis:
Normothermia
Normal blood pressure (MABP= 70-90mmHg)
Adequate hemoglobin level
Adequate oxygen level (need I say?)
What If The Signals Go Bad?

• If related to anesthesia drugs:
Lower concentration of volatile agents if used
Switch to TIVA if necessary
• If related to surgical maneuver:
Surgeon will make their appropriate response
Correct hypotension (if present)
Increase MABP, even if “normal”
Correct anemia (if present)
Correct hypoxemia (if present)
What If The Signals Go Bad

• These anesthesia interventions can
significantly change the patient outcome for
the better
• Opportunity to make a “save” – change a true
positive change to a false positive (signals
looked bad but patient awakens neurologically
intact or with only a transient deficit)
Anesthetic Techniques I Use

• In spine surgery EMG is frequently used in
conjunction with SSEPs and/or MEPs
• If SSEP & EMG case:
Hypnotic of choice for induction
NMB of choice for intubation, then no more for duration
of case
Load with opiate – 0.5-1mcg/kg sufentanil followed by
0.3-0.5mcg/kg/hr infusion (or equivalent dose of your opiate
of choice
Maintain with ½-1 MAC volatile agent of choice if signals
adequate; otherwise, use TIVA (see next slide)
Anesthetic Techniques I Use
• If MEPs are used (with or without SSEP), then

TIVA is preferable:
Propofol induction with 05.-1mg/kg Ketamine included
If baseline recordings desired prior to positioning → SUX for
intubation (if not contraindicated by pre-existing disease);
otherwise may use NMB of choice then no more for duration of
case
Load with opiate – 0.5-1mcg/kg sufentanil followed by 0.3-
0.5mcg/kg/hr infusion (or equivalent dose of your opiate of
choice)
Maintain with Propofol/Ketamine infusion (0.5mg Ketamine
per cc of standard strength Propofol) run at 100-300mcg/kg/min
Propofol. Remove Ketamine 1 hr prior to emergence
Summary
• Monitoring modalities employed will vary based
on surgical procedure and tissue at risk
• Monitoring does improve outcome
• Choice of anesthetic technique can have a
significant impact on the ability to acquire signals
and the quality of those signals
• Patient management can have a profound effect
on ultimate neurologic outcome
• Maintain communication with surgical and
monitoring teams especially during critical
portions of the case
THE END

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Janik, Daniel, MD Spinal Cord Injury CRASH 2010

SPINAL CORD MONITORING

Opportunities for Injury

Why We Monitor - Ischemia

• Combined monitoring modalities

Cases We Monitor – Cervical Disk

Thoracic Compression Fracture

Employed in Spine Surgery

Monitoring Modalities - EMG

Motor Unit Potentials

Monitoring Modalities - EMG

• Free-run EMG used for:

Monitoring Modalities - EMG

Improper Pedicle Screw Placement

Opportunities for Nerve Root Damage

Somatosensory Evoked Potentials

Jameson LC, Sloan TB. Anesthesiology Clinics 2006, 24;777-791

Somatosensory Evoked Potentials

Miller’s Anesthesia 2005

Somatosensory Evoked Potentials

Motor Evoked Potentials

Lotto ML, Banoub M, Schubert A. J Neurosurg Anesthesiol 2004; 16:32-42

Motor Evoked Potentials

Ischemia Caused by Spine Distraction

Costa P, Bruno A, Bonzanino M. Spinal Cord 2007; 45:86-91

What We Are Looking For

Comparison of Isoflurane and Thiopental

Impact of Anesthesia - SSEP

Suppressed Cortical Response Preserved Cervical Response

Amplification Effect of Etomidate

Effect of Bolus of Propofol

Impact of Anesthesia on Monitoring

The Signal Acquisition May Be Difficult

Cottrell’s Neuroanesthesia 2010 (In Press)

What If The Signals Go Bad?

What If The Signals Go Bad

Anesthetic Techniques I Use

• If MEPs are used (with or without SSEP), then

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