intraoperative neurophysiologic monitoring for sacroiliac fusion
DESCRIPTION
Intraoperative Neurophysiologic Monitoring for Sacroiliac Fusion. Hallie Loy bs CNIM. Anatomy of the Pelvis. Typical SI Fusion Patient…. Symptoms:. Low back pain Buttock and hip pain Ipsilateral LE weakness LE numbness and tingling Trouble sleeping Leg instability Problems sitting. - PowerPoint PPT PresentationTRANSCRIPT
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INTRAOPERATIVE
NEUROPHYSIOLO
GIC
MONITORING FO
R
SACROILIAC FU
SION
H A L L I E L
O Y BS C
N I M
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ANATOMY OF THE PELVIS
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TYPICAL SI FUSION PATIENT…
S Y M P T O M S :• Low back pain• Buttock and hip pain• Ipsilateral LE
weakness• LE numbness and
tingling• Trouble sleeping• Leg instability• Problems sitting
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SI JOINT AS A CAUSE OF PAIN:
25% of all low back pain is caused by Sacroiliac joint disease.
The incidence of SI joint degeneration in post-lumbar fusion surgery is 75% at 5 years post-op.
SI joint is a pain generator in low back pain of 43% post- lumbar and lumbar-sacral fusion patients.
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• Clinical tests• Imaging studies
(x-ray. CT scan, MRI)
• SI joint injections of a local anesthetic
DIAGNOSIS…
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• Physical therapy
• Chiropractic manipulations
• Pain medication
• Injection therapy
OTHER TREATMENT OPTIONS
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SI FUSION SURGERY
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WHY DO WE MONITOR SI FUSIONS?
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IATROGENIC NERVE INJURY RATES HAVE BEEN REPORTED TO BE AS LOW AS 1% AND AS HIGH AS 18%.
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Movement Nerve Root Segments
Hip flexion L2/3Hip extension L4/5Hip adduction L2/3Hip abduction L4/5Knee extension L3/4Knee flexion L5/S1Ankle Dorsiflexion L4/5Great toe extension L5Ankle plantarflexion S1/2
Lower Limbs MyotomesLower Limb
Dermatomes
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HOW DO WE MONITO
R SI
FUSIONS? SSEP
EMG SE-EMG
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SSEPStimulation:Uppers: Ulnar
NerveLowers:
Posterior Tibila Nerve
Low FreqFilter (Hz)
High FreqFilter (Hz)
Amp
(μV)
Typical latencies
(ms)
Stim.Intensity
(mA)
StimDuration
(ms)
Stim.Rate (Hz)
SEP mediannerve cortical
30 250-1000 0.5-5 17-23 20-35 0.2-0.5 1.3-
4.7
SEP mediannerve subcortical
30 500-1000 0.5-3 11-16 20-35 0.2-0.5 1.3-
4.7
SEP tibialnerve cortical
30 250-1000 0.5-5 35-45 25-50 0.2-1 1.3-
4.7
SEP tibialnerve subcortical
30 500-1000 0-3 27-35 25-50 0.2-1 1.3-
4.7
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Alarm Criteria:- Amplitude
decrease of 50%
- Latency increase of 10%
SSEP
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EXAMPLES OF CHANGES
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Patient had LUE amplitude decrease of greater than 50% due to a positional issue.
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Needle electrodes used in the following muscles:
• L5- Tibialis Anterior
• S1- Gastrocnemius
• S2- Anal Sphincter
EMG
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Alarm Criteria:• Any
burst/firing from nerves on the side the surgeon is working.
FREE RUN EMG
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Stimulation probe used to stimulate either the guide wire/pin or the drill bit to insure a safe distance between the drill bit and the neural structures.
SE-EMG
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Alarm Criteria:• Response
<8 mA with an absolute minimum of 6 mA
SE-EMG
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• LE numbness
• LE weakness• Incontinenc
e• Foot drop
IN THE CASE OF NERVE INJURY
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QUESTIONS?
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REFERENCES
- "Minimally Invasive Sacroiliac Joint Surgery." MIS Sacroiliac Joint Fusion Surgery. SI-BONE, n.d. Web. 08 Apr. 2013.
- Moed, B.R. (2008). Monitoring neural function during pelvic surgery. In M.R. Nuwer (Ed.), Intraoperative Monitoring of Neural Function Handbook of Clinical Neurophysiology (vol. 8, pp. 752-763). Elsevier B. V.
- Moore MD, M.R. (2012, January ). The Sacroiliac Joint: A Forgotten Pain Generator. The SI-BONE Sentinel, 1-2.