Spinal Cord Monitoring

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Monitoring during neurosurgery

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Presentation transcript:

Spinal Cord Monitoring Dr. M. Fennelly Consultant Anaesthetist The Royal National Orthopaedic Hospital

Why do I want to know about this?!!

How? Stagnara ‘Wake up test’ Ankle clonus test Neurophysiological -Evoked potentials

Intra-operative physiological monitoring Spinal cord (Scoliosis) Sciatic/ Femoral nerve (THR) Brachial plexus Pedicle screws Vascular surgery Parotid surgery

Concept of monitoring

Mechanisms of Injury …… …….Indirect mechanical

Mechanisms of Injury …… L4 L5 Direct mechanical

aorta Segmental a. Anterior spinal a. Radicular a.

Reduced cord perfusion Mechanisms of injury Ischaemic cord injury Compression + Distraction Oedema Hypotension = Reduced cord perfusion

( To posterior tibial nerve, peroneal nerve Somatosensory Evoked Potentials Epidural spinal somatosensory evoked potential Cortical somatosensory evoked potentials C2 somatosensory potentials ( To posterior tibial nerve, peroneal nerve stimulation)

Preoperative electrode placement Out of surgical field Anterior approach surgery Spinally injured Spondylolisthesis Brachial plexus exploration

Relaxation unimportant Anaesthetic considerations for SSEP Relatively forgiving Relaxation unimportant

Effects of local anaesthetics and opiates on S.S.E.P. Loughnan, Fennelly et al. Anaesthesia and analgesia 1995

S.S.E.P. or M.E.P. ?

M.E.P. Motor end-plate

WHY ? Dissociation of SEP and MEP Earlier prediction of damage Specific pathway monitoring

M.E.P. Problems Anaesthetic Stimulus patterns

Anaesthesia Nitrous oxide Isoflurane Muscle relaxation Propofol infusion Fentanyl Alfentanil Remifentanil

Factors affecting E.P.s Hypoxia Hypotension Carbon dioxide Temperature Nerve integrity Anaesthetic agents Side

Interpretation What is a significant change? Latency Amplitude  50% Other parameters N.B. Must monitor minimum 20 minutes after final correction

Action Exclude technical failure Exclude anaesthetic change Release correction / distraction (Decompress)

How long have you got ? Aortic cross clamp 30 minutes

Why is the S.M.E.P. more sensitive to anaesthetic agents Than the S.S.E.P. ?  Synapses in pathway 

History at RNOH... Sensory nerve conduction in the human spinal cord: epidural recordings made during scoliosis surgery. Jones SJ. Edgar MA. Ransford AO. Journal of Neurology, Neurosurgery & Psychiatry. 45(5):446-51, 1982 May. Spinal cord monitoring in scoliosis surgery. Experience with 1168 cases. Forbes HJ.Allen PW. Waller CS.Jones SJ.Edgar MA.Webb PJ.Ransford AO. Journal of Bone & Joint Surgery - British Volume. 73(3):487-91, 1991 May. Temporal summation--the key to motor evoked potential spinal cord monitoring in humans. Taylor BA. Fennelly ME. Taylor A. Farrell J. Journal of Neurology, Neurosurgery & Psychiatry. 56(1):104-6, 1993