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What is Neuromonitoring and Why is it Important to Patient Safety?

Posted: Sep 23, 2016 10:48:43 AM
 
Host: Bill Boggs (15:30)

Panel: Dr. TV Seshan (Founder of Neuro Alert), Rose Auerbach (Neurophysiological Technologist), Dr. Joseph Annichiarico (Physiatrist of Physical Medicine and Rehabilitation), and Dr. Ezriel Kornel (Brain and Spine Surgeon Assistant Clinical Professor at Weill Cornell Medical College)

Transcripts to follow:

Bill Boggs, Host:
Hi, I'm Bill Boggs. Today, I'd like to introduce you to a crucial technical procedure, which is becoming the standard of care in operating rooms and continues to gain popularity among surgeons and patients alike. Intraoperative neurophysiological monitoring, also known as neural monitoring, is a simple, minimally invasive and cost-effective tool designed to detect, treat, and prevent potential damage to the nervous system during high-risk medical procedures such as brain, nerve, and spine surgery.
 
Now, here's how it works: a certified monitoring technician assigned to the case is using a unique software program to detect potential injuries that may go unnoticed during that operation. As a result the operating surgeons obtain the instant feedback that they need to avert or reverse injuries. Neuromonitoring has proven to reduce the occurrence of neurological damages during surgery from 4 percent down to .05 percent. Simply put, it ensures patient safety and reduces the physicians' liability while preventing medical errors and bringing down skyrocketing health care costs. 
 
Therefore the significance of monitoring is undeniable so we think it's essential that more people become aware of intraoperative monitoring and develop a better understanding of this important procedure, its impact on patient safety, and patient outcomes so we've assembled a panel of medical experts and experienced technicians who are here to share their insights with you into this important development.
 
Okay so here's our panel; we have with us Dr. TV Seshan, he is board certified in physical medicine and rehabilitation. He is also the founder and clinical director of Neuro Alert--that's a fast-growing, physician-owned, health care organization in Westchester, New York providing monitoring services for hospitals and surgeons. Throughout his long and distinguished career in medicine Dr. Seshan has firmly established himself as a pioneer in intraoperative neuromonitoring.
 
Ms. Rose Auerbach is a neurophysiological technologist, Dr. Annichiarico is board certified in physical medicine and rehabilitation,  and Dr. Ezriel Kornel is a brain and spine surgeon assistant clinical professor of neurosurgery at Weill Cornell Medical College. Thank you very much for being here.
 
Dr. Seshan let's begin with you. Can you please explain to us how you got into the neuromonitoring and essentially what prompted you to devote so much of your time and your own personal resources to this procedure?
 
Dr. TV Seshan, Founder of Neuro Alert:
Thank you. In 1982, I was asked by one of the attending orthopedic surgeons at Westchester Medical Center to come and monitor a complex spine case called scoliosis correction, and that's how I got into this particular field. I was trained by a professor at New York Medical College Dr. Audrey Randolph, and I was able to monitor complex spine cases, initially, and then went on to develop methods of monitoring other types of cases where the nervous system was at risk. So, slowly I developed a process and a teaching method to instruct other physicians as well as technologists over the years.
 
Bill Boggs, Host:
How has it evolved and change from that initial day when you were first there--you know, experiencing it for the first time and as you've grown as somebody who's training others--how has a whole practice evolved?
 
Dr. TV Seshan, Founder of Neuro Alert:
The practice has evolved considerably, mostly from advances in technology, specifically computer technology where the equipment is readily available on a commercial basis, off-the-shelf items. We are now able to take the equipment into the operating room because they're extremely portable as opposed to in the old days where the machines were pretty big and heavy. 
 
Bill Boggs, Host: 
Everything is reduced.
 
Dr. TV Seshan, Founder of Neuro Alert:
That's right. So now the equipment is the size of a laptop, pretty much, and therefore we are able to transport this equipement to any hospital that requires this kind of service.
 
Bill Boggs, Host: 
Is this something that the patient requests or the physician requests or either/or?
 
Dr. TV Seshan, Founder of Neuro Alert: 
Usually the surgeon who is operating is the one who requests this particular service.
 
Bill Boggs, Host: 
Right. Let me shift down to Dr. Annichiarico. From your experience how does neuromonitoring influence patient outcomes?
 
Dr. Joseph Annichiarico, Physiatrist of General Physical Medecine & Rehabilitation: 
Well the early studies done in the eighties show that you're able to actually monitor the nervous system with electrical impulses, and any change during the surgery would affect these electrical impulses. With the technologist there and a physician remotely connected, they can convey this information directly to the surgeon and make any changes. Even something as simple as changes in blood pressure could be detected through this monitoring. So the outcomes as you mentioned earlier have reduced any damages or any patient injuries dramatically.
 
Bill Boggs, Host: 
Can you describe the the monitoring--you know for the layman watching, or not a doctor watching, who's unfamiliar with this--describe how the process is actually working?
 
Dr. Joseph Annichiarico, Physiatrist of General Physical Medecine & Rehabilitation: 
Sure. The technologist meets the patient prior to the surgery, usually in the waiting area, and as the patient is brought into the operating room, electrodes are placed. Some are pasted right on the skin, and some, after the patient goes to sleep, are put under the skin and those electrodes are then connected to the monitoring equipment where electrical signals--small doses of electrical currents are provided to the patient and recorded through the peripheral nerves.
 
Bill Boggs, Host: 
What does the person who's actually doing the monitoring--the trained technician--what is he looking for?
 
Dr. TV Seshan, Founder of Neuro Alert: 
The technician is first establishing a baseline nervous system function for that particular patient. After establishing the baseline, which is basically a numeric value, of the time it takes for the impulse to go from one place to the other.
 
Bill Boggs, Host: 
Let me shift over to Ms. Auerbach. You are somebody who does monitor this, correct?
 
Ms. Rose Auerbach, Neurophysiological Technologist:
Yes.
 
Bill Boggs, Host: 
Explain what you are doing. You're there on the front line--looking for what?
 
Ms. Rose Auerbach, Neurophysiological Technologist:
Right. I'm in operating room the entire time of the surgery. I start out by placing the electrodes on my patient, and I record my baseline responses so that way I can compare back to them for the entire case. I'm just continuously monitoring throughout the entire procedure, comparing back to the baseline responses to see if there's any significant changes, and if there are then I alert the surgeon immediately.
 
Bill Boggs, Host:
What would you see that would indicate that there is a problem? Just give me one exhibit A. Hopefully it doesn't happen but what's an example--something like 'this is the way the patient would be protected?'
 
Ms. Rose Auerbach, Neurophysiological Technologist:
An example of this is something we monitor called sensory pathways.  We stimulate the nerve, and then we record it from the scalp--from the brain--so when we see a change in amplitude--so we start with our baseline amplitude of the signal. If that drops by fifty percent then we know that there's a significant change from that patient's baseline.
 
Bill Boggs, Host:
Then what would happen?
 
Ms. Rose Auerbach, Neurophysiological Technologist:
Then I would tell the surgeon immediately if I saw that, and then a surgeon could interpret that.
 
Bill Boggs, Host:
Let me--let's take this situation where that would happen. If we were not monitoring, and you're the surgeon, how would you know that was going on--that problem has occurred?
 
Dr. Ezriel Kornel, Brain and Surgeon Assistant Clinical Professor:
That's a great question that I want to get to. One simple example is that when we operate on the spine, we put people in a prone position where they're lying on their chest and abdomen, their arms are stretched out in front of them and there can be pressure on the nerves in the axilla, and so those patients are in that position for a fairly long period of time, and there could be undue pressure on those nerves, and when they're recording that--if they see a change in the amplitude, we know that the arms need to be shifted a little bit. So what we're offering is that the anesthesiologist can actually shift the arm a little bit, and it makes a big difference because if we don't do that, sometimes the patient wakes up and they've got tingling in their hands that can last for days or weeks even--and they can even have weakness for a period of time from hours to days. So if we can monitor that and see that there's a change occurring and reposition them, then we avoid that problem and that's just sort of the icing on the cake because we monitor--from what we do, there are three areas in which it's important for us. 
 
One is where we're doing brain surgery, such as if we're operating on a tumor at the base of the brain, we want to see that we're not damaging any of the nerves that are coming out of the brainstem. We do monitoring of those nerves, and we can tell if we are affecting those nerves and it can be very difficult to tell just by looking. So it's very useful to get this information from that perspective.
 
Then, when we're operating on the spinal cord for instance, if you've got a herniated disc in your neck, you're not seeing the spinal cord. You're operating above the spinal cord, so you don't know if maybe what you're doing could potentially be bringing undue pressure on the spinal cord. So if you're being told that there is now a change in the signal, you have to check what you're doing there. Could be other reasons; it could be that the blood pressure has changed or that the anesthesia is affecting the patient, but it tells us, "Look and see. Make sure that what we're doing is not causing undue pressure in the spinal cord." And it's rare that it does happen, that we put pressure on the spinal cord, but it's great when it happens to know if we can change whatever we're doing. Maybe there's a little piece of tissue that's under hanging that we haven't seen that we can now find and pull out.
 
And then the others when we're doing surgery on, most often, on the lumbar spine--and nowadays we do more minimally invasive surgery. So we're not exposing all the nerves in the lower back. We're trying to limit tissue exposure, so we're putting in a lot of hardware. We put screws into the spine; we put cages into the spine, and that's around the nerves. So we want to make sure that we're not injuring those nerves even though we can't see them. And we have ways, using radiology techniques, we have now, and intraoperative cat-scans that we use, but it's great when we have a team like Neuro Alert there--they can tell us, "oh, that particular nerve is firing; it's being irritated," so we can see, maybe we need to change the trajectory of the screw a millimeter or two.
 
Bill Boggs, Host:
Have you been using this your entire career?
 
Dr. Ezriel Kornel, Brain and Surgeon Assistant Clinical Professor:
No, I've been using it now for the past about five years.
 
Bill Boggs, Host:
And how would you say your own personal--when you walk into the operating room now, you know, that you have this tool--how are things different for you, just psychologically, as the man who's gotta operate on the brain or the spine or whatever?
 
Dr. Ezriel Kornel, Brain and Surgeon Assistant Clinical Professor:
It gives me a lot more confidence that what I'm doing is not going to harm the patient. When the patient wakes up, I'm not going to find the patient has a weak foot or has numbness in their leg. Or god forbid can't move their legs. It gives me a lot of confidence that I know during the surgery they've got all the information that I need to make sure the operation goes well.
 
Bill Boggs, Host:
Good, well this has been a thorough discussion. Is there's anything you'd like to add on it, you know to the now rapidly becoming informed viewer, about Neuro Alert?
 
Dr. TV Seshan, Founder of Neuro Alert:
There are a couple things that I would like to say. The expertise of people like Dr. Annichiarico and people like Rose here is extremely helpful and they work as a team along with the anesthesiologist and the surgeons and the neurosurgeons in the operating room and that team effort is what really helps the patient overall. We don't operate in a vacuum. We communicate constantly and that communication helps the surgeon in terms of navigation, in terms of preventing any, you know, potentially, any permanent damage, and we found that teamwork is what gets it done in the end.
 
Bill Boggs, Host:
Rose, last thing here, when you're actually monitoring, are you communicating with the physicians? Is anybody overseeing you, or are you pretty much in charge of the monitoring.
 
Ms. Rose Auerbach, Neurophysiological Technologist:
No I'm overseen the whole time by a remote position.
 
Bill Boggs, Host:
You are overseen by another physician that's the technician and then another doctor as a backup?
 
Ms. Rose Auerbach, Neurophysiological Technologist:
Yes.
 
Dr. TV Seshan, Founder of Neuro Alert:
It could be Dr. Annichiarico remotely viewing Rose's screen.
 
Bill Boggs, Host:
You've been in that situation?
 
Dr. Joseph Annichiarico, Physiatrist of General Physical Medecine & Rehabilitation: 
That's primarily what I do at this point, yes. As you were saying, I connect to her screen immediately when she gets in the operating room all the way through the end of the procedure and you have constant chats going on the laptop. We can pick up the phone as well.
 
Bill Boggs, Host:
Good so you know this has been really interesting. I came into the program knowing not much more than what I read on the script. And I hope you've learned as much as I have, so let me say bye. Thank you very much for the panel.
 
Let me see if I can draw a conclusion here. So why is neuromonitoring so important? Patient safety during complex surgery has always been one of the great concerns to any surgeon. Oftentimes, major medical operations place the nervous system at risk, as we've learned today, that explains why we've seen increased demand in the healthcare market for this useful diagnostic and navigational tool. When it comes to influencing patient outcomes, the role, the impact, and the significance of neuromonitoring is undeniable as an increasing number of health care organizations and surgeons of all specialities are starting to incorporate neuromonitoring into surgical procedures. Thank you very much.
 
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