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Avantaje ale abordării multimodale în monitorizarea intraoperatorie neurofiziologică a tumorilor intracraniene și medulare

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23.10. 2022

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Ovidiu C. Banea

Neurofiziologie Clinică, MD, PhD

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NEUROTOC Spain

MION Synapse Informal Group Romania

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Sumar

    • GON LON, multimodal or RISK?

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    • Motor evoked Potentials monitoring
    • Continous monitoring of motor cranial nerves
    • Spinal cord multimodal monitoring (previous lectures (Dr Filip and session IONM)
    • Video

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GON LON?

Occipitocervical fixation C0-T2, Multimodal versus RISK

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  • Data before surgery:
    • Patient female ≈ 30 year-old, with EDS
    • Artrodesis C0-T2
    • What do we do?

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Proc:

Médula Anclada

Cirujano:

Dr XY

Hospital:

Teknon

Fecha:

21/10/2022 (08:00 - 17:00)

Paciente:

ZZZ

Obs:

Fusión C0-T2 ARTRODESIS OCCIPITO-CERVICAL O ATLAS-AXIS

Máquina:

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RISK versus KNOWLEDGE

“Who does what in the operating room?

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Who is entitled to take medical responsibility fo IONM?

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Neurosurgical societies have to be very cautious in defining IONM techniques”

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Francesco Sala,

Verona 2015

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Occipitocervical fixation C0-T2, Multimodal versus RISK

Review the anatomy, understanding the risk

Always ask to see the patient medical history and if possible

Clinical Neurophysiology preoperative examination (EMG, NCS, PEM, PESS)

Look or ask for neurological examination,

if possible describe previous to surgery in your note.

NOW is the time for the planning of surgery IONM (MION) protocol.

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Occipitocervical fixation C0-T2, Multimodal versus RISK REVIEW

  • Cervical plexus = network of nerves formed by the anterior rami of spinal nerves C1 – C5 that gives off both motor (deep) and sensory (superficial) branches.

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  • Branches from the loop between C2 and C3:
    • Lesser occipital nerve (formed by C2)
    • Great auricular nerve (formed by C2 and C3)
    • Transverse cervical nerve (formed by C2 and C3)
  • Branches from the loop between C3 and C4:
    • Supraclavicular nerves (formed by C3 and C4)

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  • As highlighted in the names of those four sensory branches, a mnemonic to memorize the names can be derived from the bolded letters. Thus the mnemonic for the sensory branches is Let's Go To Sleep.

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https://www.kenhub.com/en/library/anatomy/cervical-plexus

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Occipitocervical fixation C0-T2, Multimodal versus RISK REVIEW

  • Motor branches of the cervical plexus form:
    • Ansa cervicalis (C1-C3) Synonyms: Ansa nervi hypoglossi, which is a nerve loop innervating the infrahyoid muscles in the anterior cervical triangle.
    • Phrenic nerve (C3-C5) which supplies the diaphragm and the pericardium of the heart. Additional muscular branches are also given off to provide innervation to several prevertebral, sternocleidomastoid and trapezius muscles. C3/C4

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  • Ansa cervicalis (mnemonic: Susan Saw Game Of Thrones)
    • Sternohyoid nerve (C1 – C3)
    • Sternothyroid nerve (C1 – C3)
    • Geniohyoid nerve (via hypoglossal nerve) (C1)
    • Omohyoid nerve (C1 – C3)
    • Thyrohyoid nerve (via hypoglossal nerve) (C1)

https://www.kenhub.com/en/library/anatomy/cervical-plexus

HOPA MITICĂ

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Clinical Neurophysiology Preoperative TESTS and PLANNING

Potenciales evocados motores

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CMCT 9,6ms para el lado derecho y 9,8ms para el lado izquierdo (ADM)

CMCT 14,9ms para el lado derecho y 14,7ms para el lado izquierdo (AH)

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PLANNING

23 muscles (UL and LL) is that necessary?

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MEP

SSEP

TRIGGER EMG

NERVE ROOT

PEDICLE SCREW

EEG

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Clinical Neurophysiology Preoperative TESTS and PLANNING

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MEP

SSEP

TRIGGER EMG

NERVE ROOT

PEDICLE SCREW

EEG

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STOP!

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Clinical Neurophysiology Preoperative TESTS and PLANNING

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MEP plus RAW EMG

SSEP

TRIGGER EMG

NERVE ROOT

PEDICLE SCREW

EEG

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BRAINSTEM AND CRANIAL NERVES (PPT ASNER 2021)

CoMEP

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SHORT TRAIN 3 to 5 stimuli with 0.5 ms duration each. ISI 2ms, Train repetition rate of 2 Hz. Intensity up to 120 mA

Montaj

C3 (+) vs Cz (-) for right muscles from left hemisphere

C4 (+) vs Cz (-) for left muscles from right hemisphere

90 ms after the train we delivered a single pulse over same stimulating montage !!!

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COMEP

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VIDEOS

C1/C2 INTERBODY BILATERAL FUSION PIF HERE

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A TRAIN HERE

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NEW REFLEX FOR MION Pentru prima data online ASNER, OCT 2022 HERE

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CoMEP

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SHORT TRAIN 3 to 5 stimuli with 0.5 ms duration each. ISI 2ms, Train repetition rate of 2 Hz

Intensity up to 120 mA

Montaj

C3 (+) vs Cz (-) for right muscles from left hemisphere

C4 (+) vs Cz (-) for left muscles from right hemisphere

90 ms after the train we delivered a single pulse over same stimulating montage !!!

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Mulțumesc!