Intraoperative Monitoring of Neural Function

945 Pages·2008·79.537 MB·1-955\945

by  Marc R. Nuwer (Eds.)

Dedication
This book is dedicated to Jamie, Charles, Stephen, and Catherine. They shared time with this project to
allow me the opportunity to organize and create this book.
Acknowledgments
This work would not have been possible without the dedicated work of my assistants, Amy McGann, Sylvia
Fong, and Benjamin Caplan. Their organizational and editorial assistance greatly facilitated production of this
volume.
The book was initiated at the request of series editor, Jasper Daube. His helpful guidance was instrumental
inestablishingtheformatofthebook.Hismanyhelpfulsuggestionsgreatlyenhancedthecontentanddirections
for this work.
My own role and expertise in this field also was facilitated and enhanced by my UCLA colleague, James
Packwood PhD. Together we ventured into this field even when many others thought that recording reliable
evoked potentials in the operating room was unachievable, and when no other neurologist provided such a
service. I wish him well in his recent retirement after three decades of work in intraoperative monitoring at
UCLA.
I appreciate too the authors of the individual chapters in this volume. This is a very diverse set of experts.
Compilation of such knowledge into one volume has been an unprecedented undertaking for this field of
intraoperative monitoring.
Marc R. Nuwer
Volume Editor
Foreword
Clinical neurophysiology encompasses the application of a wide variety of electrophysiologic methods to the
analysis and recording of normal function, as well as to the diagnosis and treatment of diseases involving
the central nervous system, peripheral nervous system, autonomic nervous system, and muscles. The steady
increase in the growth of subspecialty knowledge and skill in neurology has led to the need for a compilation
ofthewholerangeofphysiologicmethodsappliedineachofthemajorcategoriesofneurologicdisease.While
some of the methods are applied to a single category of disease, most are useful in multiple clinical settings.
Each volume is designed to serve as the ultimate reference source for academic clinical neurophysiologists
and as a reference for specialists in the area. It will provide the information needed to fully understand the
physiologyandpathophysiologyofdisordersintheirpatients.Assuch,thesevolumeswillalsoserveasamajor
teaching text for trainees in each of the subspecialties.
TheHandbookvolumescoveralloftheclinicaldisordersservedbyclinicalneurophysiology,includingthe
muscle and neuromuscular junction diseases, epilepsy, surgical epilepsy, motor system disorders, peripheral
nerve disease, autonomic dysfunction, somatosensory system disorders, behavioral disorders, visual and
auditory system disorders, and monitoring neural function. Each will focus on the advances in one of these
major areas of clinical neurophysiology. Each volume will include critical discussion of new knowledge in
basic neurophysiology, and its application to different central nervous systems.
Eachvolumewillincludeanoverviewofthefield,followedbyasectionthatincludesadetaileddescriptionof
eachoftheCNPtechniquesused,andathirdsectiondiscussingelectrophysiologicfindingsinspecificsituations.
Thelatterwillincludehowtoevaluateeachalongwithacomparisonoftherelativecontributionofeachofthe
methods.Afinalsectionwilldiscussongoingresearchstudies,andanticipatedfutureadvances.
The application of clinical neurophysiology methods to monitoring in the operating room and in intensive
care has expanded rapidly over the past 10 years. This is seen in many research publications in neurosurgery,
orthopedic, vascular, otolaryngology and neurology, as well as the publication of books dedicated to nervous
system monitoring. The Accreditation Council of Graduate Medical Education has recently recognized
monitoring neural function during surgery as a subspecialty of neurology.
We are privileged tohave Marc Nuwer, a pioneer inthe development of monitoring neural function, as the
volume editor. He has done a superb job of assembling world leaders in the description of the methods and in
their application to a wide range of diseases and settings.
Thevolumedescribesamultiplicityofelectrophysiologicmethodsthatarebeingappliedtothemanytypes
ofsurgeryinwhichneuralstructuresareatriskforlossoffunction.Specialemphasisisonsurgicalprocedures
where function critical structures, like the spinal cord, can be preserved. Wherever possibly applicable, the
information presented focuses on evidence-based medicine; the specificity and sensitivity of each mode of
monitoring is provided when known, along with comparison of their relative values.
Jasper R. Daube, MD
Rochester, MN, USA
Franc¸ois Mauguie`re, MD
Lyon, France
Series Editors
Preface
‘‘The best way to deal with paraplegia is to prevent it from happening in the first place.’’ This is the goal of
intraoperative monitoring (IOM) and testing. The IOM mission now includes many techniques beyond spinal
cord monitoring. Analogous goals remain the mission across the many other IOM applications.
Inthepastthreedecades,IOMandtestinghasblossomedintoamajorareaofclinicalneurophysiology,now
widely used, and offering diverse techniques and applications. Most of the technology is familiar to clinical
neurophysiologistswhopracticeroutineoutpatienttesting.Applicationshavemadeinroadsintomanysurgical
subspecialties, as reflected in this volume’s Table of Contents. This volume presents the state of the art and
science, separated into several sections.
Section I reviews general issues of science and practice behind IOM. This includes an overview, some
history, and issues about staffing. Anatomy and physiology are complied as a convenient reference for users.
Effects of anesthetics are reviewed.
Section II presents the various techniques. Each chapter describes typical techniques, many with some
didactic examples. Descriptions are sufficiently detailed so that a new user would know how to stimulate
and record, and what changes to consider significant. The chapters also discuss the drawbacks or problems,
and how monitorists might cope with them.
Section III presents the applications to clinical disorders and situations. Each chapter reviews the relevant
literature. It discusses the clinical issues and any outcome studies for IOM and testing when used during a
particular surgical application.
Section IV digresses into the intensive care unit (ICU). Monitoring in surgery encouraged development of
monitoring for the immediate postoperative period in the ICU. Such monitoring also evolved to include uses
well beyond postoperative care. Chapters here include the search for nonconvulsive seizures in adults and
neonates.
Section V concludes the book with several related topics. Safety remains a concern for all monitoring, and
we adhere to the traditional medical dictum primum non nocere — above all, do no harm. Infrared and ultra-
sound monitoring techniques are reviewed in their own chapters. Another chapter describes techniques for
monitoring depth of anesthesia.
Wilder Penfield took neurophysiology to the operating room to localize motor and sensory cortex with
direct cortical stimulation.When hedidsointhe 1920s, Iwonderif hehadanyidea howmuchintraoperative
neurophysiology would grow over the next 80 years?
Marc R. Nuwer
Volume Editor
List of Contributors
Aglio, L.S. Department of Anesthesiology and Perioperative Medicine, Brigham and
Women’s Hospital, Harvard University, 75 Francis Street, Boston,
MA 02115, USA.
Ashram, Y.A. D ABNM, University of Alexandria, 507 El Horreya Ave., School of
Medicine, Fleming, Alexandria, Egypt.
Ball, B. Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905, USA.
Balzer, J.R. Departments of Neurological Surgery and Neuroscience, University of
Pittsburgh Medical Center, Suite B-400, 200 Lothrop Street, Pittsburgh,
PA 15213, USA.
Becker, D.P. DepartmentofSurgery/Neurosurgery,UniversityofCalifornia,LosAngeles,
CA 90095, USA.
Berenstein, A. Center for Endovascular Surgery and Intraoperative Neurophysiology,
Institute for Neurology and Neurosurgery, Roosevelt Hospital, New York,
NY 10019, USA.
Bishop, A.T. Mayo Clinic, Brachial Plexus Clinic, Rochester, MN 55905, USA.
Burke, D. Office of Research and Development, College of Health Sciences, Level 2,
Medical Foundation Building K-25, University of Sydney, Sydney, NSW
2006, Australia.
Canalis, R.F. Department of Surgery/Head and Neck Surgery, University of California,
Los Angeles, CA 90095, USA.
Cannestra, A.F. DepartmentofSurgery/Neurosurgery,UniversityofCalifornia,LosAngeles,
CA 90095, USA.
Cascino, G.D. Department of Neurology, Division of Epilepsy and EEG, Mayo Clinic, 200
First St. SW, Rochester, MN 55905, USA.
Claassen, J. Division of Critical Care Neurology and Comprehensive Epilepsy Center,
Department of Neurology, Columbia University, Neurological Institute,
Box 91, 710 W 168th Street, New York, NY 10032, USA.
Cozzens, J.W. Department of Neurosurgery, Feinberg School of Medicine, Northwestern
University, Evanston Hospital, Evanston, IL 60201, USA.
Crammond, D. Department of Neurological Surgery, University of Pittsburgh Medical
Center, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
xii LISTOFCONTRIBUTORS
Crum, B.A. Department of Neurology, W8A, Mayo Clinic College of Medicine, 200
First Street SW, Rochester, MN 55905, USA.
Daube, J.R. DepartmentofNeurology,E8B,MayoClinicCollegeofMedicine,200First
Street SW, Rochester, MN 55905, USA.
Deletis, V. Intraoperative Neurophysiology, Institute for Neurology and Neurosurgery,
Suite 11G-78, St. Luke’s Roosevelt Hospital, 1000 Tenth Avenue,
New York, NY 10019, USA.
De Vries, L.S. DepartmentofNeonatology,WilhelminaChildren’sHospital,UMC,POBox
85090, 3508 AB Utrecht, The Netherlands.
Dong, C.C.J. Department ofSurgery,VancouverGeneral Hospital,EEG Lab.,CP Ground
Floor, 855 W 12th Avenue, Vancouver, BC V5Z 1M9, Canada.
Duffau, H. DepartmentofNeurosurgery,HoˆpitalGuideChauliac,CHUdeMontpellier,
80 Avenue Augustin Fliche, 34295 Montpellier Cedex 5, France.
Edmonds, H.L. Cardiovascular Services, Surgical Monitoring Associates, Inc., 3712
Plymouth Road, Louisville, KY 40207, USA.
Eliashiv, D. Department of Clinical Neurophysiology, Cedars Sinai Hospital, 8700
Beverly Boulevard, South Tower, Los Angeles, CA 90048, USA.
Emerson, R.G. Department of Clinical Neurology, Columbia University College of
Physicians and Surgeons, New York, NY 10032, USA.
Engel, Jr., J. Department of Neurology, Geffen School of Medicine, UCLA, 710
Westwood Plaza, Suite 1250, Los Angeles, CA 90095, USA.
Fee, D. DepartmentofNeurology,UniversityofKentuckyChandlerMedicalCenter,
KY Clinic, Room L-445, Lexington, KY 40536, USA.
Fehlings, M.G. Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst Street,
Toronto, Ont. M5T 2S8, Canada.
Gonzalez, A.A. DepartmentofNeurology,KeckSchoolofMedicine,UniversityofSouthern
California, Healthcare Consultation Center II, 1520 San Pablo Street, Suite
3000, Los Angeles, CA 90033-4606, USA.
Gue´rit, J.-M. StressandCraniofacialPainClinic,CliniqueEdithCavell,Unite´d’Explorations
Electrophysiologiques du Syste`me Nerveux, CHIREC, Avenue Louise 390,
B-1050Brussels,Belgium.
Gugino, L.D. Department of Anesthesiology and Perioperative Medicine, Brigham and
Women’s Hospital, Harvard University, 75 Francis Street, Boston, MA
02115, USA.
Habeych, M. Department of Neurological Surgery, University of Pittsburgh Medical
Center, Suite B-400, 200 Lothrop St., Pittsburgh, PA 15213, USA.
Haghighi, S.S. Department of Clinical Neurodiagnostic, Sharp Memorial Hospital, 7901
Frost Street, San Diego, CA 92123, USA.
Hellstro¨m-Westas, L. NeonatalIntensiveCareUnit,DepartmentofPediatrics,UniversityHospital,
SE-22185 Lund, Sweden.
LISTOFCONTRIBUTORS xiii
Hemmerling, T.M. Department of Anesthesiology, Hoˆtel Dieu, 3840 St. Urbain, Montreal, PQ
H2W 1T8, Canada.
Hirsch, L.J. Comprehensive Epilepsy Center, Department of Neurology, Columbia
University, Neurological Institute, Box NI-135, 710 W 168th Street,
New York, NY 10032, USA.
Huang, T.C. Department of Otolaryngology, New York University School of Medicine,
550 First Avenue, NBV 5E5-10, New York, NY 10016, USA.
Huddleston, P.M. Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905, USA.
Husain, A.M. Duke University Medical Center, Box 3678, 202 Bell Building, Durham,
NC 27710, USA.
Ja¨ntti, V. Department of Clinical Neurophysiology, Tampere University Hospital,
P.O. Box 2000, FIN-33521 Tampere, Finland.
Jones, S. Department of Clinical Neurophysiology, The National Hospital for
Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
Journee, H.L. Department of Neurosurgery, University Medical Center Groningen, P.O.
Box 30.001, 9700 RB Groningen, The Netherlands.
Kelleher, M.O. Division of Neurosurgery and Spinal Program, Krembil Neuroscience
Center, University of Toronto, Toronto, Ont. M5T 2S8, Canada.
Kombos, T. Charite´-Universita¨tsmedizin Berlin, Campus Benjamin Franklin,
Hindenburgdamm 30, D-12200 Berlin, Germany.
Kothbauer, K.F. Division of Neurosurgery, Kantonsspital Luzern, CH-6000 Lucerne 16,
Switzerland.
Lalwani, A.K. Department of Otolaryngology, New York University School of Medicine,
550 First Avenue, NBV 5E5-10, New York, NY 10016, USA.
Legatt, A.D. DepartmentofNeurology,MontefioreMedicalCenter,111East210thStreet,
Bronx, NY 10467, USA.
Lo´pez, J.R. Department of Neurology and Neurological Sciences, Intraoperative
Neurophysiologic Monitoring Program, Stanford University School of
Medicine, 300 Pasteur Drive, Room A343, Stanford, CA 94305, USA.
MacDonald, D.B. Section of Clinical Neurophysiology, Department of Neurosciences, King
Faisal Specialist Hospital and Research Center, MBC 76, PO Box 3354,
Riyadh 11211, Saudi Arabia.
Mandir, A.S. Department of Neurology, Georgetown University, 3800 Reservoir Road
NW, Washington, DC 20007, USA.
Mashour, G.A. DepartmentofAnesthesiaandCriticalCare,MassachusettsGeneralHospital
and Harvard Medical School, Boston, MA 02114, USA.
Matthies, C. Section of Functional Neurosurgery, Department of Neurosurgery, Julius-
Maximilians-University of Wu¨rzburg, Josef-Schneider-Strasse 11, D-97080
Wu¨rzburg, Germany.
xiv LISTOFCONTRIBUTORS
Mendiratta, A. Department of Clinical Neurology, Columbia University College of
Physicians and Surgeons, New York, NY 10032, USA.
Minahan, R.E. Department of Neurology, Georgetown University, 3800 Reservoir Road
NW, Washington, DC 20007, USA.
Moed, B.R. Department of Orthopedic Surgery, Saint Louis University School of
Medicine, 3635 Vista Avenue, 7th Floor, Desloge Towers, St. Louis,
MO 63110, USA.
Møller, A.R. School ofBehavioral andBrain Sciences, UniversityofTexasat Dallas,GR
41, P.O. Box 830688, Richardson, TX 75083-0688, USA.
Neuloh, G. Neurochirurgische Universita¨tsklinik, D-53105 Bonn, Germany.
Niimi, Y. Center for Endovascular Surgery, Institute for Neurology and Neurosurgery,
RooseveltHospital,SuiteGG15,1000TenthAvenue,NewYork,NY10019,
USA.
Nuwer, M.R. Department of Neurology and Clinical Neurophysiology, UCLA School of
Medicine, Reed Research Building, Room 1-190, 710 Westwood Plaza,
Los Angeles, CA 90095, USA.
Packwood, J.W. Department of Clinical Neurophysiology, UCLA School of Medicine, Reed
Research Building, Room 1-194, 710 Westwood Plaza, Los Angeles, CA
90095,USA.Presentaddress:2718YandallDrive,Austin,TX78748,USA.
Quinonez, D. Department of Clinical Neurophysiology, Cedars Sinai Hospital, 8700
Beverly Boulevard, South Tower, Los Angeles, CA 90048, USA.
Rodi, Z. Division of Neurology, Institute of Clinical Neurophysiology, University
Medical Centre, Zalosˇka 7, SI-1525 Ljubljana, Slovenia.
Rose´n, I. Department of Clinical Neurophysiology, University Hospital, SE-22185
Lund, Sweden.
Rosow, C. Department of Anesthesia and Critical Care, Harvard Medical School, 55
Fruit Street, Boston, MA 02114, USA.
Royter, V. Department of Clinical Neurophysiology, Cedars Sinai Hospital, 8700
Beverly Boulevard, South Tower, Los Angeles, CA 90048, USA.
Rubinstein, E.H. Department of Anesthesiology, University of California, Los Angeles,
CA 90095-1778, USA.
Sabet, A. Department of Neurology, Gold Coast Hospital, Southport, Queensland,
Australia.
Sala, F. Department of Neurological Sciences and Vision, Section of Neurosurgery,
University Hospital, 37100 Verona, Italy.
Schrader, L.M. David Geffen School of Medicine, UCLA, 710 Westwood Plaza, Room
1-194, Los Angeles, CA 90095, USA. Present address: University of
Connecticut School of Medicine, 20 Old Stone Crossing, Hartford, CT
06117, USA.
Schramm, J. Neurochirurgische Universita¨tsklinik, D-53105 Bonn, Germany.
LISTOFCONTRIBUTORS xv
Sclabassi, R.J.
Department of Neurological Surgery, School of Medicine, University of
Pittsburgh Medical Center, Suite B-400, 200 Lothrop Street, Pittsburgh,
PA 15213, USA.
Shin, A.Y. Mayo Clinic, Brachial Plexus Clinic, Rochester, MN 55905, USA.
Slimp, J.C. Neuromonitoring Program, Department of Rehabilitation Medicine, Box
356490, University of Washington School of Medicine, Seattle, WA
98195, USA.
Sloan, T.B. Department of Anesthesiology, University of Colorado HSC, 4200 E. 9th
Avenue, Campus Box B113, Denver, CO 80262, USA.
Spinner, R.J. Mayo Clinic, Brachial Plexus Clinic, Gonda 8S, 200 First Street SW,
Rochester, MN 55905, USA.
Stead, M. Department of Neurology, Division of Epilepsy and EEG, Mayo Clinic, 200
First St. SW, Rochester, MN 55905, USA.
Stern, J.M. Department of Neurology, Geffen School of Medicine, UCLA, 710
Westwood Plaza, Suite 1250, Los Angeles, CA 90095, USA.
Strauss, C. Neurochirurgische Universita¨tsklinik, University Erlangen-Nu¨remberg,
Schwabachanlage 6, D-91054 Erlangen, Germany.
Strommen, J.A. Department of Physical Medicine and Rehabilitation, Mayo Clinic College
of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
Van Huffelen, A.C. Department of Clinical Neurophysiology (F.02.230), University Medical
Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
Vespa, P.M. Department of Neurosurgery and Neurology, David Geffen School of
Medicine, CHS 18-218, UCLA Medical Center, Los Angeles, CA 90095,
USA.
Vincent, F. Division of Neurosurgery and Spinal Program, Krembil Neuroscience
Center, University of Toronto, Toronto, Ont. M5T 2S8, Canada.
Vodusˇek, D.B. Division of Neurology, Institute of Clinical Neurophysiology, University
Medical Centre, Zalosˇka 7, SI-1525 Ljubljana, Slovenia.
Wang, H. Department of Hand Surgery, Huashan Hospital, Fudan University,
Shanghai, People’s Rep. of China, and Neurologic Surgery, Mayo Clinic,
Guggenheim 15-21B, 200 First Street SW, Rochester, MN 55905, USA.
Worrell, G.A. Department of Neurology, Division of Epilepsy and EEG, Mayo Clinic, 200
First St. SW, Rochester, MN 55905, USA.
Yingling, C.D. Stanford School of Medicine and Surgical Monitoring Services, 1001
Bridgeway #434, Sausalito, CA 94965, USA.
York, D. Department of Neuroscience, St. John’s Mercy Medical Center, St. Louis,
MO 63141, USA.
IntraoperativeMonitoringofNeuralFunction
HandbookofClinicalNeurophysiology,Vol.8
M.R.Nuwer(Ed.)
2 #2008ElsevierB.V.Allrightsreserved
CHAPTER 1
Overview and history
Marc R. Nuwer*
DepartmentofClinicalNeurophysiology,UCLASchoolofMedicine,LosAngeles,CA90095,USA
Over the past 30 years, neurophysiologic intraopera- duetoproblemswiththetechniqueitself,thedifficulty
tivemonitoring(IOM)hasgrownfromaninteresting ofobtaininggoodqualitytracingsfromsomepatients,
investigational procedure into a widely used method orasaresultofanestheticchanges.Truepositivecases
to protect patients from neurologic injury during (true predictions of postoperative deficits) also occur.
surgery. ThosearecaseswhereIOMraisesanalarm,anyavail-
IOM techniques include most neurophysiologic ableinterventionsareaccomplished,butthepatienthas
modalities commonlyused among outpatients.These neurologic injury anyway. Just because an alarm is
includeelectroencephalography(EEG),electromyog- raiseddoesnotnecessarilyallowforprompt,complete
raphy (EMG), evoked potentials (EPs), and nerve correction of the problem. False negative cases are
conduction velocity (NCV) testing of various types. those in which the patient suffers from a neurologic
IOM also includes some techniques not used in out- injury that was not predicted by IOM changes. False
patients, such as transcranial electrical motor EPs negativecasesarerare,butdooccur.Somearedueto
(tceMEPs). Most techniques are electrical. Some immediatepostoperativedeterioration.Othercasesare
other modalities, though, also have found some use aresultofinjuryinpathwaysnotmonitored.Occasion-
in surgery. The latter include oximetry and transcra- ally,theyareduetoerrorsbytheIOMteam,whofailed
nial Doppler (TCD). torecognizechangeswhentheyoccurred.
IOM helps in a number of ways. Most obviously,
it can warn the surgeon of a serious complication in 1.1. History of monitoring
time to intervene and correct the problem before it
becomes permanent. Second, it sometimes identifies Early intraoperative use of neurophysiology dates
a serious systemic problem that needs to be cor- back to epilepsy surgery during the first half of the
rected.Third,thesurgeoncanfeelcomfortableabout twentieth century. Penfield (Penfield and Boldrey,
the patient’s neurologic safety to that point in the 1937) used direct cortical stimulation to define the
case, and therefore go forward to provide a more homunculusofhumanmotorandsensorycortex.Soon
thorough procedure. Fourth, with IOM the surgeons thereafter, electrocorticography (ECoG) was used to
can feel more confident about a procedure’s safety, identify regions of epileptic discharges, slowing, or
allowing surgery on a high-risk patient who might lack of fast activity (Jasper, 1949; Marshall and
otherwise be turned away. Fifth, the patient and his Walker, 1949). These initial recordings were from
orherfamilycantakecomfortthattheveryrealneu- thesurfaceoftheexposedcortex,andlateracutedepth
rologic risks of surgery are lessened by IOM. electrode recordings were added. This set of techni-
IOMisnotaperfectprocedure.Falsepositivecases queshasevolvedinitsdetails,butremainsavaluable
(falsealarms)occurinaportionofcases.Inscoliosis, clinicaltoolinthesurgicaltreatmentofpatientswith
that rate is around 1% of procedures. In some other medicalrefractoryepilepsyeventoday.
types of procedures, the rate is higher. These may be The next clinical advances were not until several
decades later when routine EEG was carried out in
carotid endarterectomy (CEA) (Thompson, 1968;
*Correspondenceto:MarcR.Nuwer,M.D.,Ph.D.,Depart-
Wylie and Ehrenfeld, 1970; Sharbrough et al., 1973)
ment of Clinical Neurophysiology, UCLA School of
In the early days of CEA, many patients were kept
Medicine, Reed Research Building, Room 1-194,
710Westwood Plaza,LosAngeles,CA 90095,USA. awake during carotid clamping because of worries
Tel.: þ 1-310-206-3093; fax: þ 1-310-267-1157. aboutcorticalischemiaduringclamping.Betteralter-
E-mail: [email protected] (M.R. Nuwer). native ways were sought to evaluate for ischemia.