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Improving Treatment with Neuromonitoring During Spinal Surgery
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Posted on: 01/12/2011
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For complex spinal surgeries that could potentially damage the spinal cord, spinal nerve roots, or blood vessels to these areas, surgeons use intraoperative monitoring (IOM) devices. These tools make it possible to check the patient and make sure everything is alright and no neurologic damage has occurred.
Monitoring neurologic function (motor control and sensory input) isn't required with all spinal surgeries. The most common uses are for correction of spinal deformities (e.g., scoliosis) and removal of spinal cord tumors.
As with any new technology, as intraoperative monitoring (IOM) has developed, there has been a call for protocols and a standard of care. Research to show what works best should help guide the use of IOM. The goals are to improve patient care and reduce the number of complications and problems.
As such, it's helpful for surgeons to have evidence-based guidelines. This review of the literature (studies already published on the topic) helps pull together what we know so far in an attempt to define a standard of care (SOC) for intraoperative neuromonitoring.
One of the problems with defining a standard of care is that each patient is unique and each procedure has its own twists and turns. Added to that are the differences in training among surgical personnel and ways to monitor these devices. There are no standard to dictate what is "proper" training and monitoring. There also isn't a standard for who is qualified to read and interpret the tests.
A court of law wants a standard that it can judge each case by (despite any differences from patient to patient and in various surgical situations). Toward this end, the Scoliosis Research Society approved intraoperative monitoring in 2009.
They stated IOM is not just an investigational tool but a valuable way to detect problems early. Preventing loss of blood supply to the spinal cord or paralysis is both a medical and a legal problem. From a medico-legal perspective, having a standard of care for intraoperative monitoring is essential.
From the studies that have been done so far, we see that physicians aren't the only ones who can monitor neurologic intraoperative devices with accuracy. Many nonphysician technicians and professionals have already proven their skill, ability, and experience with neuromonitoring.
In fact, the whole field of neuromonitoring was pioneered by nonphysician clinical professionals. But they must have proof of training or certification as required by the American Board of Neurophysiologic Monitoring. And recertification is required every 10 years.
Another area of concern has been the reading and interpretation of test results via internet connections. The technician isn't in the operating room with the surgeon providing real-time (instant) feedback. He or she can't see the patient and is often monitoring more than one person at a time. Is that safe? What if the internet connection fails or there is some computer glitch?
There are also automated monitoring systems that are not managed by a live person. Although these have been approved by the FDA, some experts question whether it is safe to apply electrical stimulation to the brain and trust a machine's interpretation of it?
Can we afford to take chances with someone's life or put them at risk of permanent paralysis and disability? These are the kinds of questions that must be considered when establishing a standard of care for everyone who is undergoing complex spinal surgery with neuromonitoring. And that's why the American Society of Neurophysiological Monitoring recommends all monitoring be done by a trained and certified technical professional.
The author concludes by saying that all parties concerned (physicians, lawyers, neurophysiologic monitoring professionals, hospital administrators) must come together to formulate a standard of care that is in the best interest of the patient. Certification requirements for the staff carrying out the tests should result in specialty licensing as the bottom-line. It is not the medical degree that should be relied upon when it comes to neuromonitoring.
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References:
John P. Dormans, MD, FACS. Establishing a Standard of Care for Neuromonitoring During Spinal Deformity Surgery. In Spine. December 1, 2010. Vol. 35. No. 25. Pp. 2180-2185.
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