Intraoperative Neurophysiologic Monitoring (IONM, IOM)

Program Description:

On June 20, 2017, at 2:00 p.m. (ET), The TASA Group, in conjunction with neurology expert Dr. Lev Grinman, presented a free, one-hour interactive webinar presentation, Intraoperative Neurophysiologic Monitoring (IONM, IOM), for all legal professionals. During this presentation, Dr. Grinman discussed:

• The definition of IONM
• Why use IONM
• Supervising physician requirements
• What is monitored during IONM
• Surgeries utilizing IONM
• Complications of IONM
• What to look for in a legal case involving IONM

Intraoperative Neurophysiologic Monitoring (IONM, IOM) from The TASA Group, Inc. on Vimeo.

Dr. Lev Grinman is the chief medical officer of Medsurant Holdings, LLC which is currently the 3^rd largest provider of IONM services nationally.  He has monitored over 5,000 IONM cases during his career.  Dr. Grinman is a clinical instructor of neurology at Stony Brook University Hospital.  Dr. Grinman is board-certified in neurology and sleep medicine.

Transcript:

Rochelle: Good afternoon and welcome to today's presentation, "Intraoperative Neurophysiologic Monitoring or IONM or IOM." The information presented by the expert is not to be used as legal advice and does not indicate a working relationship with the expert. All materials obtained from this presentation are merely for educational purposes and should not be used in the court of law, sans the expert's consent, i.e., a business relationship where she or he is hired for your particular case. 

In today's webinar, Dr. Grinman will discuss what is IONM, why use IONM, supervising physician requirements, what is monitored during IONM, surgeries utilizing IONM, complications of IONM, and what to look for in legal cases. To give you a little background about our presenter, Dr. Lev Grinman is Chief Medical Officer at Medsurant Holdings, LLC, which is currently the third largest provider of IONM services nationally. He has monitored over 5,000 cases during his career. Dr. Grinman is a clinical instructor of Neurology at Stony Brook University Hospital. Dr. Grinman is board certified in Neurology and Sleep Medicine.

Attendees that require passcode, the word for today is Monitoring. During the Q&A session, we ask that you enter this passcode into the Q&A widget for CLE reporting purposes. The Q&A is located to the left of your screen. Please remember that if you're applying for CLE credit, you must log on to your computer as yourself and stay for the full 60-minute. You are also required to complete the survey at the end of your program. Please note that CLE credit cannot be given to those working together on a single computer. Tomorrow morning, you'll be sent out an email with a link to the archive recording of the webinar. The slides can be downloaded from the resource list at the widget at the bottom of your screen. Thank you all for attending today and Lev, the presentation is now turned over to you.

Dr. Grinman: Thank you so much. Welcome, everybody. As mentioned, my name is Dr. Lev Grinman. I am a specialist in the field of intraoperative monitoring. I'm the Chief Medical Officer of a company that just does intraoperative monitoring. Nationally, we perform over 30,000 procedures currently per year. 

So what exactly is IONM or intraoperative neurophysiologic monitoring? It's actually a fairly niche field, our subspecialty within neurophysiology. However, it is a field that has a lot of implications as it is very broadly used by neurosurgeons and spine surgeons. Spine surgeons could be orthopedic spine surgeons or neurosurgeons specializing in the spine, probably hundreds of thousands of procedures every year in the U.S. are being monitored with IONM.

So in short, IOM or IONM is the monitoring of nervous system structures and pathways during surgery. As I've mentioned, it is most commonly used for procedures involving the spine and the brain. There are several procedures which you can utilize in both the spine and the brain and I'll explain why. Occasionally, IOM can also be used for surgeries that involve the vascular structures such as carotid endarterectomy and abdominal aortic aneurysms. The reason that's important for example in the carotid endarterectomy, what happens is you clamp off the carotid artery which is one of the two main vessels giving the blood supply to the brain and then you clean it out, you clean out any plaque that's in there. So hypothetically, it's possible that in some patients when you clamp off that large vessel, you can have a lack of oxygen to the brain. The reason you shouldn't get that is that the back of the brain should be able to supply blood as well and those people do just fine. However, in a small portion of patients when you clamp off that carotid, they may end up with a stroke, and so it's important to be able to monitor.

So why do surgeons use IOM? They use it to minimize neurologic damage during surgery. The main concept of IONM is that, and I'll show you a couple of pictures of what the data actually looks like. But what we're able to do is to monitor certain neurological pathways such as sensory pathways or motor pathways that travel all the way from the brain down to your toes and the other way around. And so that if you're able to see a change in sensory data or motor data which is pretty easy to obtain, there's a very good chance that if you catch it early enough that the surgeon can change their approach or ask the anesthesiologist to raise the blood pressure and thus preventing any permanent type of damage to the nervous system.

Surgeons also use IOM to find certain neural structures in the surgical field. It may not be perfectly obvious what is the nerve and what is not when there's a tumor, for example, sitting in a large cavity and eating up a lot of different structures. So by stimulating the area or by hopefully stimulating the nerve, you're able to tell that if you get a proper response, you know that you are what it is and then you're not gonna cut it. And, of course, if you're not cutting it, then you're gonna avoid potentially significant postoperative impairments.

Surgeons also use IOM not for just practical reasons but in this day and age, it's widely recognized that using it minimizes or sometimes eliminate, not eliminate, but thus minimize the surgeon's medical-legal risk. Why? One, IONM has been around for many years now and over the last several years, it has become the standard of care for certain procedures. And if the surgeon is not using it, he can be held liable because he can't prove that he was doing everything correctly during surgery. And so surgeons know that they have to utilize IOM even if they may not personally be [audio glitch 00:07:19]. And so IOM in known to improve clinical outcomes and it can lower, as we spoke, as I spoke, it lowers the risk of permanent neurological injury.

So furthermore, when a surgeon uses IOM, it can help that surgeon to defend what they were doing. If they were working in a routine fashion and the patient woke up with a deficit, they can then go back and say, "Look, I had data that was collected by the intraoperative monitoring staff that showed that the sensory nerves were working fine, that the motor nerves were working fine, that none of the nerve roots were being irritated, yet the patient woke up with a deficit." And they can say, "I did everything right," and that certainly helps them.

And furthermore, occasionally, the surgeon can actually shift the blame to the team that performs the IONM. If the people who are doing the IONM are not doing it properly or are not notifying the surgeon of a change that is significant and has occurred, they are responsible for not reporting that data. And that could be the difference between a patient who comes out of surgery okay or sometimes paralyzed. 

So I spoke about IOM generally but let's get into a little bit more detail as to how is IOM actually performed and I will start with who performs IOM. There's typically two people involved. Number one, there's almost always a technologist who is certified in neurophysiologic intraoperative monitoring. They have a special degree. They have to take a test for CNIM degree. Occasionally, these technologists go on to actually have a doctorate in intraoperative monitoring. That's called the DABNM that's less common but some do have it.

And a lot of times, these technologists come from other healthcare related fields, they were previously chiropractors or the allergist or even for medical graduates. And that's what draws them into this field. The technologist should be credentialed to perform services at the facility where they monitor. So IOM is unique in the sense that many times, the IOM is performed by a person who is not actually employed by the facility where the service or the surgery is taking place. The surgeon may request their services and they may come in and they do the procedure to help the surgeon but they're actually not paid by the surgeon, which is illegal, and they're not paid by the facility. And so even though they are not technically a vendor but they're not an employee of the facility, they should be credentialed with the hospital so the hospital knows who they are and that they have access to the patient's confidential information.

The technologist is often supervised in real-time, and it has to be real-time, by a physician and this trend started less than 10 years ago but it is now a requirement by Medicare and all other insurances that followed suit to have the technologists supervised by a physician. And this physician can be in the operating room with the technologist or more frequently with the help of technology nowadays, physicians can actually be outside of the operating room connected remotely through a secure connection to the technologist's laptop. And if I go back for a second to the first slide, you can see that this is a laptop that a technologist would have with them. There would be certain equipment that would be hooked up or with the sensors that then go in the patient's body, and this is what they're gonna see, and the physician should be able to see the exact same thing as they are. 

So as far as the physician is concerned, who are these physicians that can monitor the surgery? The physician should be board certified or at least board eligible in either neurology which is the most common field and that is my primary specialty. Occasionally, these physicians can be from the subspecialty of Physical Medicine and Rehabilitation. However, a lot of hospitals these days are frowning upon that that they think that neurologists are the most qualified. But certainly, there are a lot of PM&R doctors who still monitor cases.

Occasionally, a hospital will allow a physician who is not either a neurologist or PM&R doc to monitor surgery, but very often, they will ask them to have specialized training in neurophysiology. So what I've seen is, for example, anesthesiologist who also have taken a fellowship in neurophysiology and sometimes intraoperative monitoring, have a degree in it and thus, are able to monitor cases. Finally, some states will even allow audiologists to supervise intraoperative monitoring cases. And there's more of a historical reason for this.

Audiologists were the ones to pioneer the field of intraoperative monitoring. Audiologists were familiar with the inner workings in the inner ear and the nerves going to the inner ear and they took that and sort of translated that into how it can be used in other parts of the nervous system and that's why audiologist will sometimes get specialized training in IONM and certain states, and this is a state-specific thing, will allow audiologist to supervise remotely. It's sort of similar to a function of a nurse practitioner or physician's assistant in medical practice where physicians must still oversee their work but they can operate independently.

A couple of other points about a supervising physician and IONM. The physician should be licensed in the state where the procedure takes place. So one doctor may be able to monitor cases in a lot of different hospitals that are brought out across the country. For example, I myself am licensed in about 14 states right now and the reason for that is that so I can monitor these cases. Even though I may be sitting in New York and the patient is in California, in order for me to be able to see the data, I am considered to be their physician. So, therefore, I have to be licensed in the state where the procedure is taking place.

Again, the physician just as a technologist does not have to be employed by the facility or the hospital where the procedure is taking place. Many hospitals are not requiring physicians to get credentials through their credentialing office to be allowed to monitor cases. Again, if you're able to see HIPAA secure confidential information, and you're logging in and you're basically, you're aware of what's going on in an operating room in the hospital even though you're not sitting and put there, but, of course, you're getting all of this information, you should be credentialed at that facility.

One last point is that the technologist and supervising physician should be able to communicate at all times. Most of the communications is via in some sort of internet chat programs. There are chat programs build into most intraoperative softwares that are unique to certain vendors, put out software that a company may prefer, and in those programs, we'll often have a chat window where the doctor and technologist can communicate. Very often, there will also be another chat program such as Skype for Office that is HIPAA compliant where you can have comments going back and forth. Very rarely, the physician will actually call into the operating room. And some states such as Oklahoma require for certain insurances for doctors to be able to physically clear what's going on in the operating room. And also sometimes you will communicate via telephone either with the technologist or the surgeon if there is some sort of urgent matter that can't be taken care of via chat program. And what's important is that this has to take place in real time. 

Physicians who do intraoperative monitoring, some of these physicians do it full time, some of them do it part-time, some of them are employed full time by intraoperative monitoring companies, others may be contractors who see patients in the office, and a certain amount of time during their day through intraoperative monitoring. Nonetheless, that should not matter how you practice outside of IOM. You should not be seeing any patients while you are monitoring an IOM patient. And I think that's a medical-legal liability for you to be seeing patients and monitoring patients at the same time because obviously, you're not able to put all of your attention to where it needs to be, and that's the IOM case.

As a matter of fact, some payers such as Medicare have specific guidelines stating how many patients can be monitored or billed at once with a clear speculation that you can only bill for time in which you were spending on their case performing intraoperative monitoring. Very quickly, this is basically just an illustration of the nervous system and I wanted to bring this up because I'm going to be speaking in a little bit more detail about the inner workings of IOM, I'm not gonna bore you and give you too many details but I think if you do have cases with IOM, you should have a basic idea to what we're talking about.

Obviously, on top, we have the brain that then connects to the brain stem and that then continue down at the spinal cord. At the level of the spinal cord, every so often, you have levels where spinal nerves come out of spinal cords and then these nerves interconnect with each other to form bigger nerves that then travel to the upper part of the body, the torso, and obviously the arms and the hands. The reason I mentioned these spinal nerves or nerve roots is that they can be at risk during certain types of surgeries where you're working next to or on the spinal cord.

Finally, as the spinal cord travels down, it actually ends at a lumbar level, so sort of lower back at around L2, lumbar vertebrae 2, where it continues down as these big strands [SP] that are called the cauda equina. Cauda equina is actually a Latin term that means a horse's tail, that kind of look like a horse's tail. And this cauda equina, these nerves, these individual nerves then connect and form bigger nerves again and that then travels to the lower part of the body such as the legs, etc.

So what exactly do we monitor during intraoperative monitoring? There are several modalities that are almost always monitored and there are some modalities that are monitored less frequently because they are more specific to certain types of surgeries but not others. So I would say the most commonly monitored modality is something called the somatosensory evoked potentials or SSEP. You can think of it basically as main sensory pathway going from your body up to the spinal cord into to your brain. For example, if I were to move somebody's foot up and down, there would be a signal that would be generated at the level of the foot that would then travel up the leg which then travels up to the posterior part of the spinal cord and then it goes up to the brainstem and then all the way up to the top part of the brain and that would allow the brain to know what's going on lower down.

The second modality that I think is very important is motor evoked potentials. Basically, it's the opposite of sensory. Sensory signals go from down, they go up to the brain, motor potentials go from the brain down to your body. And so normally, if a person wants to walk, the brain will tell the legs to start moving. We can manipulate that in surgery by actually sending a current through the skull and thus stimulates the motor cortex which sits at the top of the brain and that signal will then travel to the arms, it will travel to the legs, and we'll be able to see how well that pathway works. It sounds pretty crude but it actually works quite well and it's a fairly safe procedure. The downside of it is that the patients will move or jump a little bit even when they're anesthetized and so the surgeon will usually be the ones to ask to run a trial of motor evoked potentials. And for surgeries where the spinal cord is at risk, it's generally recommended that both somatosensory evoked potentials and motor evoked potentials be monitored.

EMG is also a very commonly used modality. EMG allows you to see muscle activity by putting electrodes or needles into specific muscles and then see why that's important, for example, if you're working, you're doing a certain type of neck procedures like ACDF and the surgeon is working next to the nerve root. If that root is irritated during surgery, that irritation will be seen as little spikes in the EMG channel because the muscles innervated by that nerve will be receiving information telling us that they should be doing something, and so you'll be able to tell if the nerve root is irritated. The same principle applies to cranial nerves which are nerves that come out of the brain stem and innervate the face. And also EMG is very useful for surgeons who are trying to determine the location of nerve tissue or when they're doing surgeries involving pedicle screws in the lower back where they want to make sure that the screws are not touching any of the nerve roots which would be very painful when the patient comes out of surgery, and it could also lead to some degree of paralysis.

A few other modalities just to mention, one is, EEG. Of course, EEG monitors brain wave activity. It is most useful for surgeries indirectly involving brain structures. It can only measure brain activity. So you would use it for tumor surgeries, aneurysms, cerebral aneurysms, and I'll mention that a little bit more, and for carotid endarterectomy. Some companies and some people will use EEG for most of their cases where they can use it to gauge the depth of anesthesia.

Auditory evoked potentials are used for auditory pathways and that's useful for, for example, acoustic neuroma surgeries. Visual evoked potentials are used for monitoring nerves that innervate the eye and that could be useful for procedures where you're operating on the pituitary. The approach to pituitary is usually through the front of the head and so those nerves can be irritated occasionally. And there are a couple of other less utilized modalities that I'm not going to speak of because it's not used that often.

An important concept that needs to be sort of addressed, I think. The intraoperative monitoring team is usually the one that's the most versed in which modality should be used and how they should be used. And they're gonna drive the surgeon and say, "We think that since, for example, you're working on the spinal cord, you should be using the somatosensory pathway monitoring or SSEPs, motor evoked potentials, and maybe EMG." However, the surgeon always has the final word on what modalities will be monitored. For some reasons, some surgeons may say, "You know what? I don't believe motor evoked potentials are useful or I don't think EMG is useful, and I'm only choosing to do somatosensory evoked potentials." And that is okay. We don't argue with the surgeon, we only recommend, we document what we've recommended and the surgeon gets to take what they want.

Just to let you know, as you saw previously, there was a picture of a laptop in the operating room. This could be a laptop that...and this is just to show you the different attachments that can be used to hook the patient up. And there are gonna be leads that come out of these structures out of these attachments, so basically, very often, the patient will have something placed on their head and there's gonna be some sensors or stimulating electrodes that are placed peripherally on the hands, or around the hands, and also in and around the foot level. This is just to give you a very general idea, this is what I see when I monitor surgery. The waveforms up on top is what I would see for sensory monitoring and the squiggles on the bottom is what I see when I do motor-monitoring. Those are motor evoked potentials. And so when these squiggles disappear or start to change, gets smaller, that's when we start worrying and try to figure out what happens during surgery and notify the surgeon as necessary.

At this time, I wanted to see if there are any questions.

Rochelle: Yes, there are. If all the attendees can enter in the passcode for today which is monitoring and you can also enter in any questions that you have for Dr. Grinman. Our first question is, how can it be that a nerve root is completely severed in a discectomy or foraminectomy yet the IOM does not detect a problem? How could it be missed if monitored? And this attorney is looking to it for a case.

Dr. Grinman: Sure. That's actually a very good question. Very often, if you completely sever the nerve, while you're severing the nerve, you technically should be seeing some EMG activity, there's probably gonna be some kind of burst or high-level activity. However, it may be very brief. If the nerve is completely cut off, the signals are gonna stop going to the muscle. Basically, you've now disconnected that nerve from the rest of the nervous system and if the nerve is completely severed, you may not see any EMG activity going forward. And that's an important point because...and that's exactly what your question is, you think, well, you're damaging the nerve, you're going to be seeing EMG activities. Not necessarily, the nerve is completely gone, then you may not be seeing much after the first couple of seconds.

Rochelle: Next question, are neurosurgeons required to do neural monitoring when doing an ACDF in a complex surgical case?

Dr. Grinman: So there's nothing that the surgeon is required to do anything. However, it is the standard of care to do neural monitoring for an ACDF. That's a procedure that is done at a fairly tight space where the spinal cord is at risk and the nerve roots are at risk. So I would say most surgeons do have those procedures monitored. I mean, nothing is required but again, that's something that most surgeons prefer to have better outcomes and, again, for medical-legal reasons.

Rochelle: Next question, is IONM also used for anterior spinal surgery?

Dr. Grinman: Yes. So IONM is used for different...and I'll go into that a little bit. IONM is used for both anterior and posterior surgeries. So for example, the last question was about an ACDF or anterior cervical discectomy and fusion, that is an anterior approach. So in that case, even though it's mostly the sensory pathways that are gonna be affected, in the anterior approach, you could also affect the...I'm sorry, it's both the motor and the sensory pathways that are affected during an ACDF and so it's actually very important because there's a higher chance of damaging the motor track in an anterior surgery. And in a posterior surgery, again, I think in any surgery where the spinal cord is at risk, you should be using IONM, and again, that could be for both anterior and posterior.

Rochelle: Next question, can IONM also be used as a diagnostic tool? If so, how?

Dr. Grinman: That's a good question. It's not meant to be a diagnostic tool and that's actually a very important point that we make. IONM is used to compare a patient's baseline to their own data during the procedure. So what that means is the patients...we gather a baseline that usually takes place before the surgeon cuts the patient. Sometimes that's even done before the patient is intubated. And what's more is that data can be collected before positioning and after positioning. And that's important too because if the data changes and you flip the patient over, that can let the surgeon know that the patient is gonna be at risk for some kind of compression the entire surgery. 

But to get back to your question more specifically is I don't really care as the monitorist, I don't care if the patient has, for example, diabetic peripheral neuropathy. If I get signals and those signals are reliable, that to me is most important. And then if there's changes to the data compared to baseline, that's when I know there may be a problem. We're not trying to diagnose conditions so it's not technically diagnostics but it is very useful. 

Rochelle: Next question, since the risk of IONM is infection, is it not recommended for patients allergic to antibiotics?

Dr. Grinman: Not that I'm aware of. Usually, everything is supposed to be done...IONM is a fairly non-invasive procedure in the sense that yes, you could be using needles but everything is supposed to be sterilized and so the risk of infection is quite small. And I have not seen that as a contraindication in such patients. 

Rochelle: Does IONM play a role in preventing or detecting the onset of compartment syndromes during prolonged surgery? 

Dr. Grinman: Potentially in the compartment syndrome, that's not something we typically think about but I guess if compartment syndrome were to form during surgery and the compartment syndrome were to put pressure on the actual nerves that you may be able to see a change. I think due to the timeline of how compartment syndromes form, IONM is probably not as useful as it would be for procedures we are directly affecting the nerves with the surgical approach or etc.

Rochelle: Next question, if there is a remote oversight, does the technician has a responsibility to communicate changes to the surgeons as an instruction from oversight?

Dr. Grinman: So technically, I think the final responsibility rests on the physician who's supervising the technologist. Classically, it used to be just a few years ago that those physicians were involved in oversight. And so most of the technologists who have been doing this for several years are very comfortable notifying the surgeons themselves if there's any changes in data. Technically though, the physician and the technologist have to agree that there is a change and that the change is significant. It's always gonna be the technologist who tells the surgeon what's happening. What I've seen in medical-legal cases is that both the technologist and the physician can be held liable if something goes wrong. But I think that ultimately, the main responsibility lies in the physician or rests on the physician because they're responsible for the supervision. 

Rochelle: Next question, how often has IOM confirmed the mistakes made by the surgeon? 

Dr. Grinman: I don't have specific numbers as to how often it can confirm a mistake but certainly...or if there is some sort of injury to, for example, the spinal cord itself during surgery, it's very likely that you're gonna see a change. So the reason we use IONM is that it's specific and sensitive. You're gonna be able to catch mistakes or you're gonna be able to catch problems with the nervous system fairly frequently. Typically, more often than not, we noticed a change that may not be clinically significant but sometimes it is. And so I think that it is very useful in doing changes and I think those changes do occur frequently if something is going wrong meaning that the nervous system is specifically affected or if the spinal cord is being affected. 

Rochelle: And our last question...I'm sorry?

Dr. Grinman: Sorry, just one more thing. One last thing, in IONM, we don't like thinking of it as catching a mistake that a surgeon is making, we like to think of it as being part of the surgical team and helping the surgeon to avoid mistakes. But certainly, yes, IONM can show that something went wrong. 

Rochelle: Thank you. And our last question, does an EMG require standard of care in a discectomy/foraminectomy regarding the EMG? If nerve root is totally severed, will that ascend of muscle activity be seen intraoperatively? 

Dr. Grinman: Not necessarily. I mean, usually, EMG, if nerve roots are potentially affected by surgery such as what you're mentioning, then EMG typically, I would say, is the standard of care. Again, if there's irritation of the nerve root, you're gonna see activity on EMG. And similar to what I already answered with the previous question, if you completely sever a nerve because no information is gonna be getting to the muscle, if the nerve is completely gone, you're not gonna be able to see any issue. You may be able to see a change in the somatosensory evoked potentials and motor evoked potentials but in a complete resection or dissection of a nerve, the dissection, you may not see significant EMG activity at all. 

Rochelle: Thank you, Dr. Grinman, you can continue on with the presentation.

Dr. Grinman: Okay, very good. So a couple of the questions were about specific procedures and so actually, this part of the talk is going to be about the types of surgeries that commonly utilize IOM and which modalities are commonly used. 

Rochelle: And these are just some main examples, there are other procedures that involve the spinal cord that also utilize IOM. I'm just mentioning the ones that are most commonly seen and are most prevalent. But talking about the cervical spine or the level of the neck, if the approach is done at the level of the neck and at the anterior that you should be monitoring the sensory evoked potentials, motor evoked potentials and EMG. And again, it could be useful for both anterior and posterior cervical fusions or anterior approach and posterior approach in the neck.

In the thoracic spine, it could be very useful for either cord compression or scoliosis corrections. Scoliosis correction was actually one of the first surgeries where intraoperative monitoring was utilized and for good reasons, there's a lot of stretching of the nerves and also of the blood vessels that occurs when you correct scoliosis. Scoliosis is kind of like an S-shape of the spine and in order to fix that, you put in rods through the main [SP] rods, and then change the curve of the spine into a more straight orientation. And again, that significant movement alters the blood supply to the nerves and it affects the nerves directly. And that's why it's very important to use in those procedures.

Finally, as I mentioned, in the thoracic level, if you have cord compression such as metastatic tumors of the spine or if there's a trauma that affects the thoracic cord, you're also gonna want to use IOM. What's important to note though is that in the thoracic spine, the EMG is not very useful, it doesn't have a very high degree of specificity and so we typically don't use EMG at the mid level or the thoracic level, we only use SSEP and MEP. 

Finally, IOM is commonly used in the lumbosacral spine. And as I mentioned earlier, the spinal cord ends at the level of about L2 and so a lot of these procedures occur lower than the spinal cord and so the spinal cord is technically not at risk for a lot of these procedures. However, there are instances especially in a tethered cord surgery where the surgeon is going to be cutting sort of the adhesive part of the cord or the cauda equina and you're gonna be able to, by stimulating the nerve tissue, you're gonna be able to ensure that you're not cutting anything that supplies actual motor innervation or sensory innervation to the patient. And also with some for the commonly done procedures in the lower spine, surgeons will be using screws to stabilize the hardware and they very often test the screws to make sure that they're not hitting these nerve roots exiting at that level and that is very useful for them. And again, this could be used both in the anterior and posteriors procedures.

I wanted to give special attention to carotid endarterectomy. It is the standard of care to use intraoperative monitoring in CEA surgery. Classically, you use the SSEPs and EEGs to monitor any change that occur after you clamp that carotid artery. Recently, some researchers come out showing that motor evoked potentials can also be useful in the surgery and we have some facilities that also utilize MEPs but almost always you want to utilize at least SSEP and EEG.

Then surgeries within the actual brain or within the actual parenchyma of the brain, one of the most important ones where we use monitoring is cerebral aneurysm clipping and sometimes coiling, it can be useful as well and it's certainly most important for clipping. When the surgeon clips the aneurysms, they want to make sure that the blood supply is then not compromised to the rest of the brain and so we will also perform trials with MEP and the continuous SSEPs, and also EEG can be used to show any changes that occur after they clip. 

There are certainly other types of brain surgery where IOM is very useful especially if critical structures required for motor function or sensory or especially language are being compromised, they're potentially compromised. If there's a brain tumor that's taking up a lot of the space and it's next to the motor cortex, if you cut into that area, you can leave the patient partially paralyzed. And so it's important to have the ability to see where the surgeon is going.

And also, you can use mapping and that you stimulate certain parts of the brain to see what kind of response the patient has, whether they're still able to move parts of their body or continue talking. And in some of these surgeries, patients actually have to wait so that you can test to see how their functions changes or does not change hopefully with stimulation of certain areas before you cut there. IOM is very useful for caustic neuromas.

We've talked a little bit about cranial nerves. One of the cranial nerves is cranial nerve VIII. If there's a tumor growing on it, that's called an acoustic neuroma or classically known as a schwannoma. Therefore, you want to be monitoring SSEPs, ABRs, or the auditory brainstem responses, and some of the cranial nerves. Some of the larger acoustic neuromas can actually sort of eat up cranial nerve VII as well. And so one of the biggest risks of acoustic neuroma surgery is the patient may wake up with full or partial paralysis of their face and ones on the side where the surgery has taken place.

And so the hope of the surgery and the hope of doing intraoperative monitoring is that you're gonna spare cranial nerve VII while you may or may not be able to save carnal nerve VIII while you're cutting the tumor. And finally, IOMs can be used for a couple for other procedures within the brain or next to the brain such as vascular decompression when you're trying to treat trigeminal neuralgia, pituitary tumors, resections, and also epilepsy surgery. When you're potentially affecting certain important structures in the brain, you want to know what you're cutting before you do.

Briefly, I want to talk about, so say if you're an attorney or you're a physician and you want to understand what happens during surgery, what does the intraoperative monitoring can do? Almost always, the physician and technologist will put together a report. It's usually fairly standard across the industry. It's usually one report that's generated. The top part of the report is almost always written by a technologist, where they will mention what modalities will be monitored and what they themselves saw during the surgery, whether any changes occurred. At the bottom, the physician will write an interpretation saying, "Based on the changes that were observed, what pathways may have been affected." Obviously, 99% of the time, everything is gonna be okay and they're gonna say, "Nothing seems to be affected." But when there are changes, the job of the physician is to say, "Well, what kind of deficit may a patient wake up with?" Of course, clinical correlation is always necessary post-operatively. Thus, just because the change is seen during surgery doesn't mean the patient is gonna wake up with a deficit. 

Occasionally, the reports are written. Technologists will write their own report. A physician will write a completely separate report. Typically, it will not be more than one page and it will describe what they thought during surgery along with their interpretation. Many reports also include waveform screenshots basically showing the intermittent data throughout the case, and also what the flow of the data or say the somatosensory data showed during the case. It also will very often show you the event log. The event log is what the window where the technologist makes notes during the procedure basically saying, "This is what we're monitoring, this is what the surgeon is doing at this time, when an incision is made, when certain parts of the procedure are taking place, and also to mention the vital signs during the procedure. And sometimes, there is also...and this may not be part of the report, a chat log that I spoke about and that is the communication window between the technologist and the physician that's supervising.

Some of the complications of IOM, this is important to mention because this is what people will then complain about after surgery. Occasionally, you may have tongue lacerations and this occurs almost always secondary to motor evoked potentials because we're extending a fairly high current through the patient's scalp. Not only are the arms and the legs is gonna be affected and they're gonna jump, but the patient is also gonna bite down really hard. It's involuntary and this occurs simply from the MEP and that's why you need a soft bite block and it should be soft and that is placed by the anesthesiologist. Occasionally, those will get dislodged. 

Fortunately, some of these lacerations...I mean, most of these lacerations will heal but they can be pretty painful. Of course, patients can wake up with sore muscles. You could have electrical burns in the area of where the leads were placed. This is so rare that sometimes you can have some sort of short circuit where more current is coming through than it's supposed to but it is a fairly rare event but it can happen. Seizures can hypothetically occur especially with the use of motor evoked potentials because you're sending a fairly high amount of dose. And some patients especially those that are predisposed to seizures may have one. Again, it's very rare. And if they do occur, they can be stopped fairly quickly.

Some patients, of course, may have an allergic reaction to adhesives and that can be true of other procedures as well but since we are using adhesives, if the person is allergic to it, they may develop some sort of skin reaction. And finally, it's possible that the IOM could interfere with certain implantable devices such as pacemakers or certain devices implanted in the brain, and so if you're able to turn off an implanted device usually, for example, pacemakers, the cardiologist will come in and turn the pacemaker off. Otherwise, there is a small risk of the currents that's going through, sometime interfering with the device. Again, it's rare but can happen. 

So what are some of the red flags in surgery? When you're reviewing a report, you're reviewing a procedure that didn't go well. Number one, the surgeon does not act properly when a change is reported. The surgeon may have been told, "Look, we lost the motors, we lost the sensory data as soon as you put in that implants," or just something specific. And the surgeon has the option of taking the implants out or changing what they were doing or continuing on with the surgery. If a surgeon believes that what you're telling them that is not necessarily correlated from what they're currently doing, then they say, "No, I don't really believe it," and continue doing what they were doing and the patient may wake up with a deficit. And so if the surgeon was told that they're doing something that's affecting the data and they didn't make the corrective actions, most of the time, that's their fault and that's when you've been very clearly show that the surgeon wasn't doing what they were supposed to even with the use of IOM.

Another red flag could be when looking back, the intraoperative monitoring team does not report a change to the surgeon in a timely manner. Something happens, something changed, they did troubleshooting, it wasn't anything technical, but they didn't tell the surgeon. That's the problem on the IONM side and may not be a problem on the surgeon side because it may be something that the surgeon just cannot see but only the data can see.

Certainly, wrong modalities can be used during IOM surgery. Of course, you want to make sure that you're capturing the most important information and the most amount of information that can be useful for that specific type of surgery. So, again, if you're doing an ACDF and you're not monitoring motor evoked potentials, you may potentially miss a significant motor deficit that occurs after the surgery is over that could have been prevented. And also if you're doing EMG, you want to make sure you're monitoring the muscle groups that are gonna be affected by the nerve roots exiting at a specific level in the spine.

Another thing to look out for is data that's not continuously being recorded or trials of certain tests are not being done often enough. And, for example, this can be true of MEPs. A surgeon may not like doing MEPs frequently because of patient movement, however, MEPs really should be repeated after every step of the surgery, after every piece of hardware is placed or removed. Technically, the surgeons should ask for an MEP trial or should be offered an MEP trial and that should be documented. And the utility obviously is very limited if you do an MEP at the beginning of surgery and then you do it all the way at the end of surgery and you have a loss of data and you don't know where the change occurred and then everybody is confused. So you want to do it frequently enough, you're catching potential problem.

So again, if you're reviewing a legal case, you want to make sure that the proper modalities were being utilized and that's where an expert can help tell you what should have been utilized and how it is utilized. Were the trials done frequently enough as I already spoke, and also the expert will be able to tell you that changes indeed occurred and when they occurred during surgery. And then based on the chat logs and the event logs, you should be able to see if the changes that occurred, was a surgeon notified? And then if the surgeon was notified, how did the surgeon respond to the change in data, were corrective steps taken, was the wakeup performed? A wakeup is basically when a patient is under anesthesia, if something happens but the surgeon is not sure exactly what caused the change in data, they can choose to have anesthesia wake the patient up and ask them to move their arms and legs and make sure that nothing was damaged and that could be very important. 

Finally, you want to make sure that the physician who is monitoring the case remotely wasn't supervising 20 cases or 30 cases or 40 cases at once which can happen. And that is a big problem. Again, the more cases you monitor at once, the less attention you can pay to a particular case. 

A couple of more things, when you're examining IONM data, you always want to ask for the "raw" data files that contain all of the information relevant to the case that then an expert witness can review. So you may be provided with a report from a company or the hospital that performed the IONM and that may have some snapshots of the data but it doesn't have it continuously. It only has years of time when the data was taken. So it's very important to be able to scroll through the actual files and almost look through in real time to see when exactly changes occurred and what the sequence of events was.

So most experts such as myself would have access to specific software such as Cadwell which is a popular one to be able to load a file from the surgery and actually look through the entire procedure. As I said, printouts may not be sufficient, screenshots may not be sufficient, because the change could have occurred very quickly and they may not have been captured, and the raw data may contain the event window which I already spoke about but sometimes it's not included in the report. It is a very important part of the documentation.

So if you're an attorney who's on a case that involves IONM, you want to ask for all existing reports: IONM report, the surgical report, and the anesthesiologist report. Sometimes changes can occur or damages in the nervous system can occur because of changes in blood pressure, so you want to see what the blood pressure was throughout the day. There could be changes that are secondary to specific types of anesthesia. And so, again, you want to have the perspective, you want to see what the anesthesiologist was seeing during the case.

You want to get all of the chat logs that were taken or used during the case and, again, be aware that technologists maybe using more than one chat program meaning they may be communicating with the physician within the actual Cadwell for example, but also speaking to them on a different chat program. So you'll be able to get more information that way by asking for all of the chats, not just...you know, there isn't just one, it could be two. And as I said, you want to obtain the anesthesiologist's flow sheets because you want to see what the blood pressure changes were, if there was any loss of blood, and what the anesthesia was. All these things could impact the data and are part of the whole narrative.

If you're using an expert witness or thinking of getting an expert witness for IONM, realize that IONM is a very niche field within neurology or within neurophysiology. Very few neurologists have proficiency in IONM. There could be somebody who does IONM regularly and has done a lot of cases because most neurologists does not have the right skill set. They may be able to read SSEPs individually or ABRs individually. They may not understand how to read them as it relates to surgery.

A couple of last things, the IONM team is there to gather data and report the data. The IONM team as I'd already mentioned cannot dictate to the surgeon what modalities to use and what's important. They can't tell the surgeon what the surgical course can be. The job of the intraoperative team is to say, "We have a team," to let the surgeon know and then the surgeon has to decide on their own, how they want to proceed. It's not my job as an IONM physician or neurologist to tell the surgeon they need to take hardware out or they need to give the patient blood, to raise their blood pressure, or something else. We just tell the surgeon what's going on in real-time and then the surgeon can ask why that data may be significant but, again, we can't tell them what to do. It rests on their shoulders. 

Be aware of remote physicians who monitor many cases per day. So if you have somebody who's monitoring 10 cases at once, they're just not doing a good job, and that's bad medicine and reliability. IONM should not be done by the surgical team itself, it's a specialized thing so it shouldn't just be done by the surgeon. Looking at it occasionally, it should be done by certified technologists supervised by a trained physician. So if you're not using a technologist and you're not using a physician, that could be a problem for the surgeon. Finally, I wanted to see if we have any more questions. 

Rochelle: Sure. If all the attendees can enter the passcode which is Monitoring. Question, what is the risk of turning off the pacemaker during surgery? Is this a decision made by the cardiologist? 

Dr. Grinman: Yes, it's typically a decision made by both the surgeon and the cardiologist. I don't think the risk to the patient is high by turning it off or having any kind of adverse cardiac events. Very often, surgeons do request that a cardiologist come in and evaluate the patient before surgery takes place. Sometimes surgeons may not even call a cardiologist, they may just say, "You know what, I don't want to take any chances, let's not perform motor evoked potentials so as not to cause any problems with the pacemaker." But I think the right thing to do is to turn it off and if you get a cardiologist and it has to be...usually, the cardiologist [inaudible 00:59:51] you with that. 

Rochelle: Next question, what type of experts should review the raw data?

Dr. Grinman: Again, it should be an expert who is well-versed in IONM, somebody who sees and monitors many cases a year and is very well-versed in this particular field. 

Rochelle: Next question, is billing fraud a problem with IONM?

Dr. Grinman: Yes. It certainly is a problem or it can be a problem just as it can be in any other medical fields or subspecialty. There could be different types of problems with billing. IONM, and this can be a whole different conversation. IONM is typically built out of network which creates a whole different way of getting reimbursed by the insurance company. The issues that may arise are billing, using the wrong CPT codes to bill for things that did need to be monitored or occasionally, billing for something that wasn't performed. Another problem that is arising more frequently is because the Medicare guidelines dictate that we shouldn't be monitoring more than one or two cases at once or you shouldn't be billing from more than one or two cases at once for Medicare patients.

If somebody is monitoring multiple Medicare cases, then the billers have to know what insurances are being involved at any particular time so that they're not overbilling for services. In some private insurance such as United Healthcare have followed suit and they are also asking the physicians in practices not to bill from more than one case at a time. 

Rochelle: Are events, chat logs stored post-procedure so that they could be captured in an audit trail? If not, how can these be discovered? 

Dr. Grinman: I'm sorry, Rochelle. Let me just finish with my other thought. 

Rochelle: Awesome.

Dr. Grinman: One of the other things that I've seen with inappropriate billing is that some companies will bill too much meaning they will put thousands of dollars. They will value certain parameters that they think they were thousands of dollars and they're simply not so they will overbill the insurance companies and sometimes they will overbill the patient and that I think is also fraud in that you're not supposed to be overbilling. If a typical case reimburses a few thousand dollars, you shouldn't be billing a $100,000. And Rochelle, I'm sorry, what was the next question?

Rochelle: That's okay. Are events and chat logs stored post-procedure so they can be captured in its audit trail? If not, how can these be discovered?

Dr. Grinman: So I hope I understood the question, but basically, these are saved on a computer, on the laptop that the technologist uses. Most practices will also then...then it will be saved as part of the medical record in the EMR. Obviously, the chat log is turned off once the surgery is over and the technologist will usually stay behind to see if the patient is moving well after the anesthesia wears off. But you are supposed to be able to get any chat logs that are available from the practice that performed the IONM. They should be able to provide you those.

Rochelle: And our last question, can IONM be used for evaluation of an epidural abscess caused by a cord compression? 

Dr. Grinman: So it's not really used for evaluation but it can certainly be useful for a surgery where an epidural abscess is being drained or removed. Because it's putting pressure on the spinal cord, it allows you to see what's going on when...A, you're able to see what the patient's baseline is, and then if any changes occur during the surgery and hopefully there may be improvement if it's not a longstanding issue. So it's not necessarily used as a diagnostic tool to say whether or not somebody has an epidural abscess. You're going into the OR or knowing that there is one and then it can be useful in helping the surgery guide the surgeon. 

Rochelle: Thanks so much, Lev.

Dr. Grinman: My pleasure.

Rochelle: In addition to being your best source for testifying and consulting experts for the past 60 years, TASA also offers: e-Discovery and forensic solutions, free, interactive webinars, day-in-the-life videos, research reports on expert witnesses including the Challenge History Report 2.0, Professional Sanction Search, and Expert Profile 360. Please remember that if you're applying for CLE credit, you must attend for the full 60 minutes of the presentation. You're also required to complete the survey at the end of the program. I want to take this opportunity to thank everyone for attending and most especially Dr. Lev Grinman for his time and effort in creating this presentation.

If you would like to speak with Lev or if you would like to speak with a TASA representative regarding expert witness for a case that you're working on, please contact TASA at 1-800-523-2319. One of my colleagues will be following up with you regarding your feedback on today's presentation. Thank you all for attending. This concludes our program for today.