Dr.

Tuan Tu Quoc Le ChoRay Hospital,Viet Nam

Monitoring scoliosis surgery The last several years there have been some major advances in spinal cord monitoring  There are some scoliosis patients that have had spinal surgery that have unexplainted lower limb postoperative deficits


What is Scoliosis?


A normal spine, when viewed from behind, appears straight. However, a spine affected by scoliosis shows evidence of a lateral, or sideways, curvature, and a rotation of the back bones (vertebrae), giving the appearance that the person is leaning to one side. Scoliosis is defined as a curvature of the spine measuring 10 degrees or greater on x-ray. Scoliosis is a type of spinal deformity and should not be confused with poor posture.

Scoliosis


Consists of abnormal vertebral column curvature in the coronal plane Four common types of curve patterns seen in scoliosis are:
   

thoracic - 90 % of the curves occur on the right side. lumbar - 70 % of the curves occur on the left side. thoracolumbar 80 % of the curves occur on the right side. double major - curves that occur on the right and left side.

Most often scoliosis is idiopathic

Determination of the Cobb angle from a radiograph. Angles are measured from the intersections of lines drawn perpendicular to the disk spaces above and below the curvature.

Treatment of Scoliosis


observation and repeated examinations Observation and repeated examinations may be necessary to determine if the spine is continuing to curve. Progression of the curve depends upon the amount of skeletal growth, or the skeletal maturity of the child. Curve progression slows down or stops after the child reaches puberty. bracing Bracing may be used when the curve measures between 25 to 40 degrees on an x-ray, but skeletal growth remains. The type of brace and the amount of time spent in the brace will depend on your child's condition.

Treatment of Scoliosis


Surgery


Surgery may be recommended when the curve measures 50 degrees or more on an xray and bracing is not successful in slowing down the progression of the curve.  Surgery ought to be reserved for patients >10 years, who failed conservative management of sitting, with good nutrition and other factor s (Banta et al., 1998).

Scoliosis surgery


The most frequent indication:

Posterior spinal fusion and instrumentation  Anterior spinal release  Or both


Scoliosis surgery at UCLA medical center



Posterior spinal fusion and instrumentation



Scoliosis correction basically involves straightening with bilateral metallic rods anchored to vertebral processes of the prone patients exposed spine  The anchors consist of pedicle screws and sublaminar hooks or wire

Scoliosis surgery(cont.)


A properly directed pedicle screw passes through the pedicles center into the vertebral body without breaking through the pedicle wall into the spinal canal or foramina Sublaminar hooks and wire enter the spinal canal To straighten the spine,anchor pairs along the rod are strategically forced apart(distracted) or push together (compressed) along with any necessary rod rotation before rigidly fixing attachments Laminae are then decorticate and cancellous bone fragments spread over them to promote subsequent osseous fusion

Neurological complications of scoliosis surgery

Neurological complications occur in 15% of cases.  Risk factors include combined anterior and posterior surgery, severe rigid curves and kyphosis. Occasional radiculopathy occurs when roots are damaged as a result of the placement of hardware. Feared complications are paraparesis and paraplegia.  Mechanical injury to the spinal cord can happen in several ways.


Neurological complications of scoliosis surgery



Simple trauma or external cord compression can occur with some hardware passed through the epidural space.
 

In a normal spinal anatomy: the cord lies in the middle of the canal. In the scoliosis patient: the cord often lies along the concave side of the canal. Therefore the spinal cord takes a short cut along that concave edge, and it would not be as long as a comparable spinal cord in a normal person. When the spinal column is partially straightened, the relatively shorter spinal cord has difficulty accommodating itself in the relatively longer spinal column. It is stretched.
o Modern segmental instrumentation has less of a problem than

Harrington rods.

Neurological complications of scoliosis surgery



Ischemic spinal cord injury is a devastating complication, especially when it involves an anterior spinal cord thrombosis. That produces a central cord syndrome.
 

Some such injuries traverse the entire cord width, producing paraplegia. Other injuries are partial, with damage especially to deeper cord tracts including the lateral corticospinal motor pathway. It may relatively spare the posterior columns and anterior corticospinal tracts, which may be impaired in function only in the initial days or hours. The mid-thoracic level is the most common level for such impairment, because that is a watershed vascular region lying halfway between the rostral and caudal feeding arteries.

Neurological complications of scoliosis surgery



Ischemic cord injury can have a variety of contributing factors.



One commonly cited cause is compression of the major lumbar radicular artery, known as the artery of Adamkiewicz.
o That is the major caudal feeding vessel for cord perfusion.

It lies at an upper lumbar level. It can be compressed mechanically by placement of hardware or by spinal column straightening and rotation.


Another possibility is compression or stretching of the anterior spinal artery itself.

Neurological complications of scoliosis surgery



Finally, the mechanical spinal column rotations and straightening can compress minor radicular feeding arteries that occur at each spinal level.

The exact cause of ischemic injury is difficult to determine for individual patients. It is a recognized and feared complication of scoliosis correction surgery. Ischemic damage may be more likely:
 

when blood pressures are low because a partially compressed vessel is more at risk for thrombosis. An interesting additional factor toward ischemic complications is atherosclerosis. Myers reported 37 cases of visual loss after spinal scoliosis correction surgery that occurred from ischemic optic neuropathy, retinal artery occlusion, or cerebral ischemia (Myers et al., 1997).

Neurological complications of scoliosis surgery

 

Delayed onset paraparesis or paraplegia occurs in a small portion of patients during the hours or days after scoliosis correction surgery. There are several theories about the underlying etiology of these injuries.


One theory is the eventual decompensation of a stretched spinal cord or vessel, which goes on to damage axons mechanically or thrombose the compromised vessel. Another is the relatively hypercoagulable state immediately after surgery, which can lead preferentially to thrombosis of inflamed or compressed vessels. Other known coagulation complications are pulmonary emboli that occur in up to 20% of patients, a rate that varies among clinical series (Cain et al., 1995; Wood et al., 1997; Dearborn et al., 1999). Good postoperative volume support and clinical monitoring are considered highly desirable to reduce the contribution of hypovolemia and hypotension to postoperative thromboses (Bradford et al., 1999).

Monitoring techniques


The objective of performing IOM during procedures involving decompression and instrumentation of the cervical, thoracic, and lumbosacral spine :
detect insults to the central and peripheral nervous systems  the subsequent prevention of iatrogenic neurological injury.


Monitoring techniques


There are many different monitoring modalities:



  

Somatosensory evoked potentials (SEPs) Dermatomal sensory evoked potentials (DSEPs) Motor evoked potentials (MEPs) Free-run and stimulus evoked electromyography (EMG). Each of these modalities has its advantages and disadvantages as it relates to which segment of the spinal cord it assays or whether it monitors cord versus single nerve root function.

The selection of the modality(ies) to be used during these procedures is based on the nature of the procedure & the potential and systems at risk for injury

Setting up for Scoliosis



What is needed for Scoliosis surgery.

Monitoring of sensory fibers in spinal cord  Monitoring of motor fibers in spinal cord  Monitoring for wall breakdown and pedicle screw misplacement


Modalities of Scoliosis in UCLA



Include:
  

Somatosensory evoked potentials (SEPs) Motor evoked potentials (MEPs) Free-run and stimulus evoked electromyography (EMG and stimulating EMG).

SEP monitoring of Scoliosis



Somatosensory evoked potentials (SEPs)

Lower limb SEPS(tibial stimulation): at the ankle  Upper limb SEPS(median/ulnar stimulation): at the wrist used as a kind controls( detect systemic or anesthetic related changes) To avoid the chance that bilateral simultaneous lower limb testing might mask unilateral cord compromise, the testing of each side separately, using alternating stimulation and asynchromous parallel averaging ,is unanimously recommend.


SEP monitoring of Scoliosis



Rate and intensity  Needle electrodes can be used for nerve stimulation.
o Two are placed along the course of the nerve. o This allows for secure location, and avoids the problems of slippage or

drying of the conductive paste during long cases. o It also avoids changes in skin resistance that can occur over many hours of long cases.


Intensity to cause a 1-2 movement(# 20mA),prior to initiation of neuromuscular blockade Stimulate at 5.1/s/nerve, adjust rate as need
o Faster stimulation would have been helpful to produce EPs quicker in

the operating room. However, faster stimulation generally produces lower amplitude EPs, making monitoring more difficult. o Slower stimulation can produce larger EPs, but slows the speed of creating new EP tracings.

Marc R. Nuwer(ed). Handbook of clinical neurophysiology,volume 8: Intraoperative monitoring of neuron function, Elsevier, 2008, pp 182

SEP monitoring of Scoliosis(cont.) Filters 30 and 3,000Hz, notch filter off  Time-consuming average:


Require about 300 trials to produce a welldefined EP tracing suitable for measurement and comparision to baseline  300-500 sweep average(American Society of Neurophysiologic Monitoring:ASNM,2005)


SEP monitoring of Scoliosis(cont.)



None specifically base montage recommendations on derivations signal-to-noise(SNR) and its profound effect on reproducibility and the rapidity of feedback Signal to noise ratio & feedback rapidity


For reliable interpretation,SEPs must be averaged to reproducibility, defined as < 20-30% random trial to trial amplitude variation & convincing waveform superimposition in successive trials Since SNR has a power nonlinear relationship to the necessary averaging time, even modest gains substantially accelerate feedback, so that one should strive to maximize SNR and reject low SNR techniques

SEP monitoring of Scoliosis(cont.)



Derivations of SEP monitoring in OR differ from standard derivation of SEP in laboratory

  

Derivation need not be standardize because patients are their own controls Amplitude change is the primary criterion SNR is critical

Highest SNR derivation(=use the derivation showing fastest reproducubility) should be selected for monitoring, and this can vary between patients and sides.It is simple for upper limb SEPs, but more complex for lower limb SEPs; in either case should include decussation assement

SEP monitoring of Scoliosis(cont.)



Recording
  

Recording at multiple sites above the level of surgery is helpful Near-field scalp recording channels: are less affected by background muscle & movement artifact. Far-field potentials recorded from the cervical channel: are less affected by changes in anesthetic concentrations. Upper limb SEPS:
o Montage:  CSp5 -Forehead(ussually MF)  Left side : C 4 -MF, C 4-C 3  Right side: C 3-MF, C 3-C 4

Sites


Lower limb SEPS:

o Montage:  Cz -forehead(MF), CSp5-MF  Left side : C 3-C 4  Right side: C 4-C 3

SEP monitoring of Scoliosis(cont.)



Lower limb SEPS:

compare 

latency & amplitude of P37 P37 is highly variable , commonly maximal at CPz(Cz), but may be better at:
o Cz or Pz (David B.MacDonald) o C1 and C2 or C3 and C4 (M.R.Nuwer)

The P37 is generated at the primary somatosensory cortex.

 

It may show up at the midline or off-center, paradoxically, on the side of the leg stimulated. It may have a doubled negative peak, which sometimes leads to peak-picking errors by inexperienced users. When encountering the doubled peak morphology, a user might sometimes choose the first, and at other times choose the second

Phenomenon of paradoxical localization.

Notice how the positive peak generated in one hemisphere can show up best at the scalp vertex as in (A), or on the scalp overlying the other hemisphere as in (B).

Normal stable SEPs.

Normal stable SEPs.

SEP monitoring of Scoliosis(cont.)



Change intraoperative criteria for alarm

Mild Latency o Amplitude 5% 25% Moderate Severe 10% 50% 20% 70%

SEP monitoring of Scoliosis(cont.)



Lower limb SEPs:



The primary measurements are the P37 peaks amplitude and latency. Secondary measurements are the amplitude and latency for the cervical peak. Latencies should stay within about 510% of baseline values, for example, 34 ms of normal variation for a 37-ms P37 peak. Amplitudes should stay within 50% of baseline values. Some users raise alarms at 30% decrease of the P37, since such a degree of amplitude drop is uncommon among welldefined P37 peaks.

SEP monitoring of Scoliosis(cont.)

 Lower


limb SEPs:

These latencies and amplitudes usually are chosen after the patient has been under anesthesia for 20 min, since there is a period of gradual amplitude loss and minor latency increase due solely to the anesthetic itself. That effect takes 2030 min to take effect after induction. Even during that time period, though, monitoring needs to watch for early deterioration due to positioning on the table or problems related to intubation.

SEP monitoring of Scoliosis(cont.)

 Lower


limb SEPs:

Anesthetic effect is distinguished from clinical pathway impairment by observing the cervical peaks, since they are relatively steady despite anesthesia. It is the P37 cortical peak that is affected more greatly by the onset of anesthetic.

SEP monitoring of Scoliosis(cont.)



Interpretation of changes: alarms & considerations



A 50% drop in recorded potentials is generally considered to be sufficient for raising an alarm  Latency increases greater than 510% also are cause for alarm.
o Latency measures need to take into account

temperature effects. o Amplitude measures need to take into account anesthetic effects especially for cortical potentials.

SEP monitoring of Scoliosis



What will we do when changes occur?



 

Surgical cause:direct cord trauma, excessive traction, blunt trauma, excessive compression, stretching of the cord from spinal distraction, vascular insufficiency from compression, Systemic factors: hypotension,hypoxia Technical problem: o electrode disconect, equipment malfunction o Impedance checks and review of raw input data can assure the recording system s integrity

MEP monitoring of Scoliosis



No standardized MEP monitoring approach or guideline currently exists  TES activates the corticospinal system, and recording are made from the spinal cord(D wave) or peripheral muscle.

MEP monitoring of Scoliosis



Epidural recording:


D wave is relatively immune to anesthesia (because no sysnapse are involves),doesnt require omission of neuromuscular blockade D wave has rapid reproducibilidy due to high SNR and high stability

Muscle recording (CMAP recordings, muscle MEP ):



No averaging is require owing to very high SNRs, so that feedback can be instantaneous.

Epidural recording:


CMAP recordings:
 It

D wave can produce false results during scoliosis surgery: an up to 75% decrease/increase of D wave has been found in a number of patients despite unchange muscle MEPs and neurologic outcome (Ulkatan et al,2006)

incorperates alpha motor neurons and assesses the corticospinal tract from brain to individual limbs or even specific muscles relevant to the level of surgery excellent correlation with early postoperative motor outcome

MEP monitoring of Scoliosis



Stimulating electrodes


4 limbs : place at C3 and C4

o To diminish TES artifact by increasing the distance

from the scalp SEP recording electrodes through which TES current reachs the headbox
 MEP stimulating electrodes: placed 1-2cm anterior C3,C4  CP scalp SEPelectrodes: are slightly posterior to C sites

Volt may be set : 300-400 Volts , then we increase slowly until get best response we will set baseline, then press button STORE.

International 10-20 system

IOM of Scoliosis


If the critical window for intervention is just 15 min, then the monitoring and surgical teams should act within that window to identify and correct any problems and to optimize clinical factors such as blood pressure. After that time window, the risk of long-term injury climbs. A complete loss of signals with complete recovery within 15 min is of concern, but usually is associated with no postoperative deficits. This rule applies especially when both SEP and MEP are monitored.

IOM of Scoliosis


On the other hand, very slow partial recovery over hours has a much higher risk of postoperative neurological deficits. Of course, a complete loss with no recovery has a high degree of prediction of postoperative neurological deficits.

EMG Technique in scoliosis



Background
There have many well-document case of patients with acute radiculopathy from spine surgery despite normal MEP & SEP monitoring.  EMG is more sensitive than SEPs,DSEPs for detecting nerve root dysfunction


o Provides immediate results without averaging o Can be monitored from multiple channels

simultaneously o Giving instantanneous feedback to the surgeon during critical phases of the procedure

EMG Technique in scoliosis Nerve root monitoring using free running EMG  Pedicle Screw Stimulation: Stimulustriggered EMG monitoring to verify correct placement of pedicle screws


Free running EMG Technique in scoliosis

 Nerve

root monitoring using free running EMG:

 Continuous

free running EMG is monitored from muscles innervated by nerve roots considerd to be at risk for injury during surgery  Blunt mechanical trauma to nerve roots causes a depolarization that will be conducted down the nerve,across the neuromuscular junction and evok identifiable MUPs in the monitored muscles

Free running EMG Technique

o Minor nerve root manipulation: a short

burst of MUPs o More severe mechanical nerve injury or retraction: Neurotonic discharge o Very serve nerve injury: repetitive grouped MUPs,myokymic discharges  The loudspeaker on IOM machine can be used to provide the surgeon with an inmediately audible warning of potenitial nerve root injury.

EMG activity from nerve root injury. (A) Minor nerve root manipulation: a short burst of MUPs,(B,C) More severe mechanical nerve injury or retraction: Neurotonic discharge (D) Very serve nerve injury: repetitive grouped MUPs,myokymic discharges

Nerve roots at risk T7-12 L1-2 L2-4 L4-5 S1-2 S3-5

Appropriate muscle for EMG monitoring External oblique and rectus abdominus Iliacus Vastus medialis Tibialis anterior Medial gastronemius Anal and urethral sphincter

Muscles suitable for IOM of thoracicolumbrosacral nerve root segments during lumbar fusion

Pedicle Screw Stimulation

With increasing frequency, pedicle screws are being used in entirety of the thoracic spine for procedures including the correction of spinal deformities and spinal fixation for thoracolumbar spine  With an increase in utilization of instrumentation, particularly pedicle screws, comes an increase in potential morbidity with the placement of these devices to the spinal cord, spinal nerve roots, and thoracic vasculature.


Pedicle Screw Stimulation(cont.)



This morbidity may occur for a variety of reasons.

1. 2.

3.

The pedicle size, particularly diameter, is smaller in the thoracic spine than in the lumbosacral spine. Probably the most problematic is the variation in medial and rostral angulation that is encountered in the thoracic pedicles (Krag et al.,1988; Vaccaro et al.,1995b) Major vascular structures,the esophagus are at risk for screw placement that may breach the anterior cortex of the vertebral body (Vaccaro et al., 1995a).

Pedicle Screw Stimulation(cont.)



Stimulus- triggered EMG monitoring to verify correct placement of pedicle screws



Holes are drilled blindly through the narrow pedicles into the vertebral body to facilitate pedicle screw placement. Cadaver studies: 20% of screws are misdirected, lying outside the bony pedicle wall Clinical studies: detected 5-10% cases with postoperative syndroms from irritation or injury to the adjacent nerve roots by misplaced pedicle screw

Pedicle Screw Stimulation(cont.)



can be used to quickly verify correct placement of pedicle screws in real time during surgery
o Holes or crews that are correctly positioned within the

pedicle the pedicle wall are separate from the adjacent nerve roots by a bony layer with high impedance to the passage of electrical current o Holes or crews that has perforated the bony pedicle wall will lie directly against adjacent nerve roots.Direct electrical stimulation of such misplaced holes or screws activates the adjacent nerve roots,evoking CMAP respones in muscle from the approciate myotomes

Pedicle Screw Stimulation(cont.) Stimulate pedicle screw or instrumentation tool  Record Evoked EMG  Types of stimulation


Screw stimulation  Continuous stimulation  Fixed stimulation



Perform testing manually or automatically

Pedicle Screw Stimulation Protocol

1.Continuous stimulation of pedicle probe, tap 2.Fixed stim at 7mA with pedicle feeler 3.Continuous stimulation of screw driver 4.Screw stimulation of placed screw

Stimulus threshod Probability of screw malposition >8mA 0.31% 4-8mA 17.4% <4mA 54.2% <2.8mA 100%

Stimulus threshod& pedicle screw malposition(confirm by palpaltion and/or radiographs) for 4,587 screws)(from Raynor et al,2005)

Pedicle Screw Stimulation(cont.)



Technique in UCLA:
o Use a monopolar stimulating electrode with a remote

anode needle electrode placed in the surgical wound and stimulus-trigger EMG recording made from approciate muscle. o test the hole before the screw is put in. A probe with a metal ball tip is run up and down the sides of the hole by the surgeon while run 20 milliamperes into the ball tip.
 No EMG response is good.  An EMG response suggests that the wall of the hole is cracked

into the spinal space or root space.A misplaced hole should be redirected and then retest before it is intrumented

o test the pedicle screws as they are advanced in the pedicle

and vertebral body

Neurotonic discharge associated with nerve root manipulation using surgical instrument. Note that activity from contralateral root is quiet during this period.

Stimulus- triggered EMG monitoring of Scoliosis(cont.)

EMG Technique in scoliosis(cont.)

Stimulus-triggered EMG for detecting pedicular wall breach

EMG TECHNIQUE IN SCOLIOSIS(CONT.)

Principles of stimulation of a pedicle screw with electrical impulses. Toleikis JR. Neurophysiological monitoring during pedicle screw placement. In: Deletis V, Shils JL, eds. Neurophysiology in Neurosurgery. Amsterdam: Elsevier; 2002:231264

EMG TECHNIQUE IN SCOLIOSIS(CONT.)

Illustration of different current paths that will steel stimulus current from the nerve root. Toleikis JR. Neurophysiological monitoring during pedicle screw placement. In: Deletis V, Shils JL, eds. Neurophysiology in Neurosurgery. Amsterdam: Elsevier; 2002:231264

Anesthesia


Ron Leppanen( ASNM meeting 2007)

    

Nitrous oxide: 50% Isoflurane: none or less 0.2-0.5% Propofol: <200g/kg/ph Pentanyl No muscle relaxant Pre-position: TIVA with propopol at 5-10mg/kg/h+ opiods or Sevoflurane 0.5-2% sometimes with Nitrous oxide Post-position anethesia for surgery: TIVA and propopol occasionally reached 12mg/kg/h

MacDonald(2005)
 

Limitations and problems with monitoring

  

Does monitoring predict all deficits? No, monitoring may miss some significant deficits. Nearly all major persistent deficits are recognized. But:
 

Some root injuries would be missed when the spinal cord itself is monitored. Some delayed deficits have clinical onset hours after surgery, and monitoring only determines the state of the spinal cord at the moment of monitoring. A few major deficits may still be undetected despite the best available monitoring.

Limitations and problems with monitoring



In some cases monitoring raises false alarms. In the survey, this occurred in 12% of monitored cases.
Some of those were true positive cases where deficits were totally prevented.  Others were really false alarms due to technical causes. Those remain an annoyance to surgical procedures.


Limitations and problems with monitoring



Problems with transcranial electrical MEP include the need for total intravenous anesthetic, or at least only small amounts of inhalation anesthetic.


Some anesthesiologists feel uncomfortable with those restrictions, and in some patients higher levels of inhalation anesthetic must be used. In those cases, MEP may be impractical. Likewise, MEP requires reduced, controlled amounts of neuromuscular junction blockade. Occasionally, the patient might move on the table. At the time of stimulation, the movements are noticeable but cannot be tolerated during delicate interventions.

Conclusions


A variety of techniques are available to monitor thespinal cord during scoliosis surgery. They offer the opportunity of alarms for high-risk situations. Scoliosis correction surgery has an inherent risk of spinal cord injury. Monitoring is associated with substantial reductions in postoperative neurological deficits in scoliosis surgery, though it does not prevent all deficits. When monitoring does raise an alarm, a variety of possible interventions are available for consideration.

THANK YOU FOR YOUR ATTENTION