Communication and collaboration in spine neuromonitoring: time to expect more, a lot more, from the neurophysiologists

Abstract

T his commentary is addressed to surgeons who order intraoperative neuromonitoring (IONM). In the US, and in some other countries, a certified technologist is commonly supervised by an expert neurophysiologist physician. 40 US neurophysiologist physicians are often positioned off-site while monitoring several or many cases simultaneously. 41 As an example of a contrary view that is also held elsewhere in the world, a leading Canadian authority argues, "The vast majority of those involved in IONM in Canada believe, for best practice, the IONM expert should be in the operating room (OR) doing the neurophysiology" (personal communication, David Houlden, University of Ottawa, 2016). Similarly, the joint guidelines between the Italian Neurosurgical and Clinical Neurophysiology Societies clearly state that the supervising physician should be in the OR or available in-house whenever summoned to the OR. This model is quite popular in other European countries (such as Germany), but other models exist. In Spain, only clinical neurophysiologists are present in the OR and they perform IONM without the support of certified technologists. Keeping these dissonant approaches in mind, we will: 1) review scholarship that indicates that improved collaboration in the OR is associated with better patient outcomes; 2) demonstrate how IONM injury prevention is predicated on trust-based communication of test results; and 3) propose practical IONM solutions that might better achieve the trusted "expert in the OR" vision.

Intraoperative neuromonitoring alerts in a pediatric deformity center

“…According to Skinner and Sala, surgeons should no longer accept "remote" monitoring as it is practiced in the United States. 10 Our model is consistent with that used in Canada and Europe, and it is a more cost-effective model for any hospital that requires neuromonitoring for its surgical procedures.…”

“…Neuromonitoring alerts were determined by the aforementioned criteria and then categorized utilizing Bradford Hill causality guidelines; Skinner and Sala determined that using causality guidelines can help determine a true-positive change based on the causal relationship between the intervention and recovery of the evoked response. 10 Therefore, a true-positive change was defined as a decrease in amplitude of response based on the alert criteria, correlated with a surgical event, which either recovered with intervention or which remained at closing and correlated with a postoperative neurological impairment seen upon the patient's emergence from anesthesia. A false-positive change was defined as a loss of amplitude that did not return at closing, yet the patient emerged from anesthesia with no new neurological impairment.…”

“…4 Motor function may be monitored using TceMEPs, but TceMEP monitoring is sensitive to inhalation agents. 10 Therefore, a TIVA anesthetic protocol is an optimal choice for maintaining sedation throughout the procedure. 4,10 Also, TceMEP monitoring appears to be more beneficial in detecting a change in spinal cord perfusion to the motor tracts that results from surgical manipulation.…”

“…10 Therefore, a TIVA anesthetic protocol is an optimal choice for maintaining sedation throughout the procedure. 4,10 Also, TceMEP monitoring appears to be more beneficial in detecting a change in spinal cord perfusion to the motor tracts that results from surgical manipulation. The most logical explanation for this finding can be supported by the vascular anatomy of the spinal cord.…”

Editorial. Intraoperative neuromonitoring: gold standard or fool’s gold?

“…The authors should be applauded for this accomplishment. 6,7 Crew resource management is a system of communication developed by NASA, after the collision of two Boeing 747s on a foggy runway in the Canary Islands in 1977, to address stressful and at times emergency situations that may arise in the cockpit. An investigation of…”