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The scientific practice of neuromonitoring
takes place in the surgical suite (OR). It aims to 1) reduce the
risk to the patient of iatrogenic damage to the nervous system,
and/or 2) provide functional guidance to the surgeon. To accomplish
this, a specially trained member of the surgical team, for example
a neurophysiologist, obtains and
co-interprets triggered and spontaneous electrophysiologic signals from the
patient as their surgery proceeds. Patients who benefit from
neuromonitoring are those undergoing surgeries which involve the nervous system or
which pose risk to it. Neuromonitoring is also known as surgical
neurophysiology, intraoperative neurologic monitoring, or simply
intraoperative monitoring. Acronyms include IOM and IONM.
Licensure – Certification – Credentialing
In the US, IONM licensure has not been legislated at the state
or federal level. Issues of licensure are discussed in ASET's 68
page White Paper on Occupation
Regulation. Worldwide, there are at least two private
certifications available: the technologist level CNIM and the
professional level D.ABNM. Though not governmentally regulated,
certain health care facilities have internal regulations pertaining
to neuromonitoring certifications. The more fundamental issue is
that demand for trained intraoperative neurophysiologists continues
to be greater than their number (2007).
Certification for Neurophysiological Intraoperative Monitoring
(Technologist Certification)
The CNIM [1] is awarded by
the American Board of Electroencephalographic and Evoked Potential
Technicians [2]. As of 2007-02,
minimum requirements include 1) a B.A., B.S. or another health care
credential, and 2) an experience base of 100 surgeries. ABRET has
scheduled for 2008 major changes to these requirements. The $350,
250 question, 4 hour multiple choice written exam is offered twice
a year.
Diplomat of the American Board of Neurophysiologic Monitoring
(Professional Board Certification)
The D.ABNM [3] is awarded by
the American Board of Neurophysiological Monitoring [4]. As of January 1, 2011 the minimum
requirements include: 1) a doctorate in a health science related
field, Most have an MD, PhD, AuD, ScD or a DC. 2) an
experience base of 300 surgeries that spans at least 3 years of
primary responsibility, and 3) two surgeon-signed attestation
forms. The exam includes a written portion, which must be passed
first, and an oral portion. The $600, 250 question, 4 hour written
exam is offered twice a year, as is the $800 oral exam. As of
2007-02, there are 104 D.ABNM certified individuals.
Methods
Neuromonitoring employs various electrophysiologic modalities,
such as extracellular single unit and local field recordings, SSEP, TCeMEP, EEG, EMG, and ABR. For a given surgery,
the set of modalities used in depends on which neural structures
are at risk.
In general, a trained neurophysiologist or technologists
attaches a computer system to the patient using stimulating and
recording electrodes. Interactive software running on
the system carries out 2 tasks. The system 1) selectively activates
stimulating electrodes with appropriate timing, and 2)
processes and displays the electrophysiologic signals as they are
picked up by the recording electrodes.
See video of the equipment used [5]
The neurophysiologist can thus observe and document the
electrophysiologic signals in realtime in the operating during the
surgery. The signals change according to a various factors,
including anesthesia, tissue temperature, surgical stage, and
tissue stresses. Various factors exert their influence on the
signals with various tissue-dependent timecourses. Differentiating
the signal changes along these lines – with particular
attention paid to stresses – is the joint task of the surgical
triad: surgeon, anesthesiologist, and neurophysiologist.
Transcranial Doppler Imaging is becoming more widely used to
detect vascular emboli.
TCDI can be used in tandem with EEG during vascular
surgery.
IONM techniques have significantly reduced the rates of morbidity and mortality without introducing additional risks.
By doing so, ONM techniques reduce health care costs.
Surgical
Procedures
Patients benefit from neuromonitoring during certain surgical
procedures, namely any surgery where there is risk to the CNS or to a peripheral nerve. Most
neuromonitoring is utilized by spine surgeons or neurosurgeons, but
vascular, orthopedic, otolarygologists and urology surgeons have
all utlized neuromonitoring as well.
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