“Patient Transparent” Intraoperative Neurophysiological

Monitoring in Minimally Invasive Spine Surgery (MISS)

• Chief, Neurospine Surgery, California Spine Institute

• Founding Chairman – President, the American Academy of Minimally
Invasive Spinal Surgery (AAMISMS).
• Immediate past President of the International Society for Minimally
Intervention in Spine Surgery (ISMISS)
• Internationally recognized pioneer and leader in minimally invasive
spinal surgery (MISS).
• Interests:
– Promoting interdisciplinary, inter-specialty and international education
– Research and Development in MIST
– Contribution in surgical informatics development of a “digital technological
convergence and control system” for DOR (digital OR)
– Authored and co-authored numerous peer reviewed articles, chapters
and textbooks, and appointed to editorial boards and an Editor-in-Chief
for medical, surgical, and research journals.
• Enjoys the practice of martial arts (Grand Master, Martial Arts Hall of Fame and
Martial Arts Legend Award)and its philosophy, playing Chinese classical musical
instruments, collecting Asian Art, tennis, skiing, traveling and social
John C Chiu, MD, DSc, FRCS (US) networking.
• Contact Information: www.spinecenter.com

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 Society for Progress and Innovations
for the Near East:
Updates and Cadaveric Bio-skills Workshop
Beirut, Lebanon
June 23 – 26, 2010

“Patient Transparent”
Intraoperative
Neurophysiological Monitoring in
Minimally Invasive Spine
Surgery (MISS)

John C Chiu, MD, DSc, FRCS (US)

Chief, Neurospine Surgery
California Spine Institute
Thousand Oaks, California, USA

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 Introduction

• Trend of spinal surgery is toward less or

minimally invasive spine surgery (MISS)
• MISS aims at being less traumatic, with less
morbidity and improved surgical outcome
• The obvious challenge of MISS is limited
visualization and exposure of the relevant
anatomy in spite of fluoroscopy and endoscopy
to work with, and potentially placing the
relevant neural structures at increased risk
of trauma
• INTRAOPERATIVE NEUROPHYSIOLOGICAL
MONITORING (IOM) of neural structure,
direct visualization with fluoroscopy and
endoscopy creates safer endoscopic MISS
procedures
• Spontaneous EMG monitoring, at times SSEP
and MEP can provide the surgeon with useful
feedback to avoid neural trauma during MISS
• Intra-operative surface
EEG/neurophysiological monitoring optimizes
the anesthesia for MISS

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 Introduction

• Different neural structures may be at

risk during different stages of various
spinal procedures
• In cases of pedicle screw placement, it
can be monitored with triggered EMG, a
longer probe can be used for stimulation,
often through an expandable retractor
• Therefore, various customized
intraoperative neurophysiological
monitoring (IOM) instruments have
been developed specifically for less or
MISS to avoid neural trauma
• e.g. Synthes Oracle systems, NuVasive
and Spineology ProMap™ active EMG
neuro monitoring probe for EMG IOM
are designed to alert the surgeon for
instrument placement and to prevent neural
trauma
• The real time IOM allows a surgeon to
immediately intervene and correct
potential irreversible neural damage

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 Types of Intraoperative
Neurophysiological Monitoring
(IOM)

For neurological complication avoidance!

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 Spontaneous Electromyography
(sEMG)

• Spontaneous EMG (sEMG) or

Free-run EMG
– Most frequently used for
endoscopic MISS related to EMG output
microdecompression, of
herniated disc, spinal nerve Surgical Site
EMG Recording
and stenosis decompression
– Continuous recording of muscle
activity
– Mechanical or thermal nerve
irritation causes EMG activity
• Triggered or Evoked EMG
(tEMG)
Injury
– Electrical stimulation through a EMG Recording
probe can activate nerve fibers
in the surgical field causing a
muscle response
– Used to identify nerve
structures
– Used to test pedicle screws

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Myotomal Distribution of Spinal Nerve for Neuro-
monitoring

Root Muscle Nerve

C-3, C-4 trapezius CN XI
C-5, (C-6) deltoid axillary
C-5, C-6 biceps brachii musculocutaneous
C-6, C-7 triceps radial
(C-8), T-1 abductor pollicis brevis Median
C-8, (T-1) abductor digiti minimi Ulnar
C-8, (T-1) adductor pollicis Ulnar
C-8, (T-1) first dorsal interosseus Ulnar
T-7–12 external oblique
T-7–12 rectus abdominis
L-2, L-3, (L-4) iliacus lumbar plexus
(L-2), L-3, L-4 vastus lateralis/medialis Femoral
(L-2), L-3, L-4 rectus femoris Femoral
(L-4), L-5, (S-1) semitendinosus/membranosus Sciatic
L-4, L-5 tibialis anterior Peroneal
L-5, (S-1) extensor hallucis peroneal
L-5, (S-1) extensor digitorum brevis peroneal
(L-5), S-1 gastrocnemius lateral tibial
S-1, (S-2) gastrocnemius medial tibial
S-1, S-2 abductor hallucis tibial
S-3, S-4, S-5 external anal sphincter pudendal
S-3, S-4, S-5 external urethral sphincter pudendal

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Types of Mechanically Activated Spontaneous
(sEMG)

• Spike Train: Repetitive series of spikes. Can

be caused by stretching or compression of the
nerve, heating or cooling

• Neurotonic Discharge: High frequency spike

train discharge. Associated with nerve injury Spike Train
and post-op deficit

• Burst: High amplitude multiphasic complex

transient. Bumping or cutting of nerve (cannot
distinguish)

• Random Irregular: May indicate light

anesthesia. No correlation to post-op deficit
Neurotonic Discharge

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Spontaneous Electromyography (sEMG)
IMPORTANT sEMG CLINICAL CORRELATION
AND APPLICATION IN MISS
1. Spike or burst activity indicates brief direct or indirect
contact to a nerve and can assist the surgeon in
navigating the instruments away from a particular
trajectory
2. Spikes and bursts can also inform the surgeon of the
instruments in proximity to the nerve root
3. During MISS, sEMG trains are of clinical significance, and
the surgeon is typically notified if these occur
4. Trains are continuous, repetitive EMG firing often caused
by continuous force applied to the nerve root
5. Trains of higher frequency and/or amplitude tend to
represent significant nerve fiber recruitment caused by
excessive force on the nerve and are likely to indicate a
high probability of nerve injury if a relevant manipulation
is sustained
6. These alerts a MISS surgeon for immediate corrective
action or intervention to prevent irreversible neural
trauma

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 Pedicle Screw Stimulation

Needle anode in the skin or

muscle.

Alternate shoulder site can

also be used.

• A breach in the pedicle allows current to reach the nerve

root at a lower threshold
• Simple K-wire or active EMG neuro monitoring probe
can be utilized to detect contact to the nerve
• To prevent neural trauma

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Criteria for Pedicle Screw Thresholds

Threshold: > 10mA Good Value: Pedicle is intact

Threshold: > 8-10 mA Borderline Value: The pedicle wall and screw
position should be re-examined.

Risk of breach is about 1/350

Threshold: > 6-8mA Cautionary Value: Possible breach or crack in
pedicle wall. The pedicle wall should be re-
examined and re-positioning of the screw
should be considered.

Threshold: < 6 mA-3mA Poor Value: A Breached Pedicle is highly

probable. Screw re-positioning or permanent
screw removal may be necessary.

Threshold: ≤ 3 mA Severe Value: Direct nerve root contact is

highly probable.

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Somatosensory Evoked Potentials
(SSEP)

• Spinal cord electrophysiological

monitoring techniques arose in
the 1970s, when SSEPs were
described for monitoring the
spinal cord during surgical
deformity correction for scoliosis
• Measure of dorsal column
sensory pathways
• Useful for
– Spinal cord monitoring
– Detecting limb positioning
problems
– Monitoring cortical perfusion
– Mapping sensory-motor cortical
areas
• Alerts a surgeon for correction
or intervention to prevent
irreversible neural trauma

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 SSEP Pathways

Median
Nerve

SSEPs are mediated through the dorsal

columns in the spinal cord

Posterior Tibial

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Left Posterior Tibial Nerve (LPTN) – SSEP

C3’-C4’
Cortex

Cz’-Fpz
Cortex

Cs3-Fpz
Brainstem

LPF
Peripheral Nerve

0 100 mS

Surgical Site

Injury Intervention
Initiated

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Pre-op baseline PTN, SN, EMG & SSEP
Response

Left Posterior Tibial Nerve Right Posterior Tibial Nerve EMG

Left Saphenous Nerve Right Saphenous Nerve EEG

Monitoring Notes

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Thoracic cord injury

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Upper cervical cord injury

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Motor Evoked Potentials (MEP)

• Over the past 3 decades, MEPs have emerged

as an extremely valuable and efficacious
tool in IOM
• By the early 1990s, transcranial electrical
stimulation was popularized as a method to
monitor the corticospinal tracts
• MEPs have become the gold standard for IOM
of the motor tracts
• The major drawback of MEP monitoring is
inability to perform continuous monitoring
• Anesthetic inhalants decrease the efficacy
• Transcranial MEPs are the only “true motor
tract” (separate blood supply) evoked potential

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 Transcranial Motor Evoked
Potentials (TCMEP)

TCMEP Epidural D-Wave

Electrical
stimulation of Muscle MEPs 20 mS
motor cortex
through the
scalp

Record
descending
spinal cord
potential (D-
Wave)

Record limb 100 mS

muscle
potentials

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TCMEP Changes During Lumbar Instrumentation

Baseline Rod Placement After Rod Removal

L Hand

L Leg

R Hand

R Leg

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Surface EEG Monitoring – BIS
System
• Another important IOM:
surface EEG - BIS (Bispectral
Index) (Aspect Medical Systems,
Newton, MA, USA) monitoring
during MISS
• Optimizes the depth of
anesthesia
• BIS Index measures the level of
consciousness of the patient and
helps to decrease the amount
of anesthetic medications used,
up to 40% less
• Optimal IV conscious sedation
with BIS Index range of 60-80

BIS index for anesthesia

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Clinical Application

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EMG Monitoring – Stimulation of K-
wire
Response observed only on Vastus Medalis

NERVE ROOT:

Adductor Longus

Vastus Medialis

Tibialis Anterior

Gastrocnemius

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EMG Monitoring – Stimulation of K-wire
Response observed on ALL channels (muscles) resulting from
movement of K-wire only

NERVE ROOT:

Adductor Longus

Vastus Medialis

Tibialis Anterior

No Change in
Gastrocnemius Stimulation intensity
only movement of
location of K-wire

Simple K-wire or active EMG neuro monitoring probe can

be utilized to detect contact to the nerve
To prevent neural trauma

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 Case Illustration I
Endoscopic Microdecompressive MISS for Lumbar
Herniated Disc and Stenosis L4-L5

• 61 year old female with

degenerative herniated lumbar
discs and lumbar stenosis L4-5
with significant low back and leg
pain and neurogenic
claudication
• Under IV Conscious sedation
and local anesthesia
• Underwent endoscopic
microdiscectomy and inter
spinal process decompression
with an interspinous process
spacer insertion
• IOM and BIS monitoring IOM Pre-op Baseline
throughout her lumbar surgery

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 Case Illustration I

IOM - EMG During Endoscopic Lumbar Discectomy

Neurotonic discharge changes in tracing, during placement of interspinous process spacer for
distraction/decompression of Stenosis L4-L5 caused by retraction of Cauda Equina

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 Case Illustration I

Post Lumbar Surgery PTN, MN & EMG

IOM tracing RPTN returned to

pre-spinal stenosis distraction
status

RPTN return to baseline.

Patient awoke with no
deficit.

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Endoscopic Lumbar MISS Surgery

• In lumbosacral spinal procedures, the focus

on preservation of neurological function
shifts to the nerve root level, as only the
thecal sac and nerve roots are encountered
below the level of the conus medullaris
• Endoscopic microdecompressive
lumbar discectomies can be
accomplished with simple sEMG IOM
probe to prevent neural trauma
• Used concurrently, sEMG and SSEP
monitoring are complimentary in
preventing nerve root injury during lumbar
spine surgery
• During surgery for release of a rare
condition - tethered spinal cord, careful
dissection and identification of the
lumbosacral nerve roots by stimulation of
various structures should be performed
prior to relieving the tethering structure

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 Lumbar Endoscopic MISS Case
Illustration I
With sEMG IOM monitoring, successful endoscopic microdecompression for extruded
herniated L4-5 disc

• 26 yo “Extreme
Athlete”, Motorcycle,
Rally car X-games
gold medalist
• Severe posttraumatic
L4-5 disc herniation
• Excellent relief from
outpatient
endoscopic MISS
• Return to rally car
racing in two weeks

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 Lumbar Endoscopic MISS Case
Illustration II
With sEMG IOM monitoring, successful endoscopic microdecompression for large
extruded herniated L5-S1 disc

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 Lumbar Endoscopic MISS Case
Illustration III
With sEMG IOM monitoring, successful endoscopic microdecompression for large
extruded post traumatic herniated L4-5 disc

• Young grocery store

manager
• One week post
successful SMART
endoscopic lumbar
L4-5 discectomy
aided by sEMG IOM

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Cervical and Thoracic MISS Surgery

• During microdecompressive cervical

and thoracic discectomies and
decompression of nerve root spinal
procedures, nerve root/EMG
monitoring is critically important to
avoid trauma to spinal nerve
• Endoscopic microdecompressive
cervical and thoracic
discectomies can be
accomplished with simple sEMG
IOM probe to prevent neural
trauma
• If the spinal cord is involved during
procedures in the cervical and
thoracic spine, preservation of spinal
cord integrity is clearly of paramount
importance
• As mentioned in the modalities
section, the use of SSEPs and MEPs
in combination is of great value in
providing a global assessment of
spinal cord function

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Cervical Endoscopic MISS Case
Illustration IV
With sEMG IOM monitoring,
81 yo NS Professor
underwent successful
endoscopic cervical
discectomy, developed
transient extreme
bradycardia (30) detected
and monitored on the large
intra-op screen, of
SurgMatix system and
treated with atropine. Did well.
Discharged in 1 hour.

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 Cervical Endoscopic MISS Case
Illustration V
With sEMG IOM monitoring English rock star had successful endoscopic cervical C3-4 discectomy for C3-4 disc herniation

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 Thoracic Endoscopic MISS Case
Illustration VI
With sEMG IOM monitoring successful endoscopic thoracic MISS

T7 herniated disc

27yr old F-22 fighter

pilot suffered
severe T7 herniated
disc symptoms as a
result of
tremendous G-
Force

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Discussion and Comment
• An advanced technologically driven
MISS requires various less invasive
surgical instruments and advanced
complex technology than the usual
traditional spinal surgery
• The MISS spine surgeon has only limited
and restricted visualization of the surgical
field
• MISS has to depend on the preoperative
interpretation of pathology in relationship
to X-Rays, MRI, CT, 3D CT imaging studies
for pre surgical planning
• Intra-operatively C-Arm fluoroscopic
imaging, and endoscopic visualization on
real time basis facilitates the MISS
• It is aided by intraoperative
neurophysiological monitoring
especially with sEMG and other relevant
neuro-monitoring modalities in order to
avoid significant neurological complications

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 Discussion and Comment
• SurgMatix® Is a “digital surgical
technology convergence and OR
control system”, involving
monitoring and recording of all wave
form and imaging data, including
sEMG, Pre-Operative, Intra-
Operative and Post-Operative
phases of MISS

• Real time sEMG IOM integrates

with all patient related
medical/surgical information creates a
“patient centric” and “patient
transparent” DOR in order to
facilitate a safer MISS

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 Discussion and Comment
SurgMatix intraoperative monitoring screen displays real time wave form,
imaging, vital signs, sEMG, BIS, IOM information to facilitate MISS surgery

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 Conclusion:

• Utilization of intraoperative
neurophysiological monitoring, IOM
prevents neurological injury and
provides a safer MISS
• A thorough familiarity with the
various modalities available for
IOM - including especially sEMG,
and tEMG besides SSEPs, MEPs, is
a must for a endoscopic MISS
surgeon
• Knowledge MISS technique,
benefits and limitations of each
monitoring modality helps to
maximize the value of IOM
during MISS procedures
• An interdisciplinary approach to
IOM facilitates the optimization of
MISS technique and in preventing
neural trauma

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 Hope you enjoyed this presentation!

“‫ﻣﻤﻨﻮﻥ‬ ‫”ﻣﺮﺳﯽ ﺧﻴﻠﯽ‬

“Arigato”

“Danke schön”

“Thank you” “Cám ón”

“Gracias”
“Merci”

John C. Chiu, M.D., FRSC (US), D.Sc.

California Spine Institute

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