Intraoperative Neurophysiological Monitoring (IONM) for Patients With Pre Existing Heart Conditions
By Admin | May 04, 2021
A patient’s medical history is a critical component to providing them with the highest quality care. While the conditions a patient presents are at the forefront of their attention and the medical professional observing them, their preexisting conditions and comorbidities can also play a significant role in diagnosis and treatment. Accurately notating a patient’s history can provide life-saving information, especially when they are set to undergo surgery.
For one 67-year-old patient, pre existing conditions played a significant role in their treatment plan. In addition to testing positive for COVID-19, this patient also had a history of Congestive Heart Failure (CHF), Hypertension (HT/HTN), Diabetes Mellitus (DM), Atrial Fibrillation (AF/Afib), and obesity.
Pre Existing heart conditions can dramatically increase the risk of complications experienced during surgery. Given the number of conditions and the severity of this case, additional neuromonitoring measures helped ensure the patient's safety and provided the best chance at a quality outcome.
The patient’s immediate symptoms were progressive weakness in the lower extremities and an inability to walk. Upon further examination, an MRI scan of the patient’s thoracic and lumbar spine, multilevel disc protrusions, thecal sac indentation, synovial cyst at T7-8, severe lumbar spinal cord stenosis with squeezing of the thecal sac at L3-4, adhesive arachnoiditis at L4-5-S1 with clumping of nerve roots, and high-grade lumbosacral foraminal stenosis were all revealed.
A posterior lumbar fusion, posterior spinal fusion (L3- L4), decompression lumbar (L3-L4), and thoracic decompression at the T7-T8 level were required to treat this patient’s spinal conditions.
The surgical team for this set of procedures opted for Axis Neuromonitoring. Our expert team monitored upper and lower Somatosensory Evoked Potentials (SSEP), lower Motor Evoked Potential (MEP), triggered electromyography (t-EMG), nerve conduction velocity (NCV), lower Electromyography (EMG), and Train of Four (TOF).
“We work with top-of-the-line manufacturers and software companies to equip our technologists, and thus your surgeons, with the most advanced neuromonitoring systems available,” said Dr. Faisal R. Jahangiri of Axis Neuromonitoring in Richardson, Texas.
As surgery began, the patient’s bilateral upper SSEP baselines were both reproducible and reliable, and the lower SSEP of the posterior tibial nerve (PTN) and peroneal SSEP baselines were not reproducible or reliable. Lower MEP Foot-Abductor Hallucis (AH) response was lost during lumbar hardware placement but recovered after troubleshooting and double train implementation. AH responses remained stable throughout the procedure, but abnormal EMG activity in the left tibialis anterior (TA) occurred during decompression. This change in signals was reported to the surgeon quickly and efficiently thanks to the Axis Neuromonitoring team allowing the surgeon to loosen retraction, quieting down the EMG immediately. SSEPs improved from baseline at closing with repeating amplitudes.
The result? No neurological deficits were noted postoperatively by the surgical team or the patient. “Intraoperative monitoring services can significantly reduce postoperative complications. We understand that all surgical procedures carry risks. However, we aim to not only reduce that risk but to prevent additional surgeries, impairment, and frivolous litigation,” said Dr. Jahangiri.
Had neuromonitoring not been a part of this patient’s surgery, they could have suffered postoperative muscle weakness, numbness, severe pain, or foot drop. If changes in foot motor responses and abnormal spontaneous EMG were not identified on time by the intraoperative neuromonitoring technologist, it might have resulted in nerve root or spinal cord damage.