Types of IONM  Continuous or signalled  INITIATION  UE: median or ulnar  LE: post tib nerve or peroneal nerve  RECORDING   Transcranial somatosensory cortex  Can use with NM blockade (not sensitive to anesthesia)  Advantages  Reliable, unaffected by anesthetics  Disadvantages  Nerve roots not checked  Delay due to summation  Tests  Dorsal Columns  Loss if:  Impacts dorsal column  Motor EvokedContinue reading “Neuromonitoring “

Autonomic Dysreflexia  

Timing: after a T6 or higherr lesion  Loss of supraspinal control of Sympathetic NS  Sinus Bradycardia – most common arrhythmia following SCI  Orthostatic and Supine Hypotension – lack of sympathetic tone  Autonomic Dysreflexia – unchecked visceral stimulation (lesions higher than T6)  Sympathetic dysregulation (stimulus in abdomen)  Autonomic dysreflexia is defined as an increase in systolic blood pressureContinue reading “Autonomic Dysreflexia  “

VA Injury  

RF  Anteriorly C7  Laterally C3-6  Posterior C1-2  Aberrant pathology  Anatomy  V1  Extraosseous  Subclavian, anterior to C7 TP, entry to C6 transverrse foramen  V2  Within transverse foamina of C6-C1  Risk during lateral mass  V3  Superior to arch of atlas to foramen magnum  Vulnerable during lateral exposure and C1 laminectomy (don’t go 1cm past midline at arch  V4  Intradural extension fromContinue reading “VA Injury  “

RLN Palsy  

RF  Right side approach  Revision  Anterior C5  Multilevel  OR time  Prolonged retractor in the tracheoesphageal junction  Signs and Symptoms  Aspiration  Dysphasia  Dysphonia  Management  Observation  SLP consult  Thickened fluid diet  6 weeks no improvement – ENT consult   Teflon injections to vocal cords  Revision  Confirm palsy from ENT consult preop  If so, use that side for revision 

Esophageal Injury  

RF  Revision  Distoted anatomy  Zenkerrs  Tumou  Infection  Symptoms  Neck pain  Dysphagia  Odynophagia  Discharge  Subcutaenous emphysema  Dx Injuy  Intraop  Withdraw NG, inject methylene blue  Post op  Endoscope  Barium swallow  Management  Intraop  Call Gen surg  Irigate contaminated field  Feeds by NG  Post op  Endoscope  Gen surg   

SS Infection  

Backgound  .7% – 16%  Sstaph aurreus  DDx  ASD  Inadequate decompression  Seroma  hematooma  Risk Factors  Patients >70  ASA  DM CV malignance  Steroid  Revision  COPD  Prior infection  Preop hospitaloin 1 week  Prior rads  Obessity smoking nutriional ETTOH  Transufion, sstaged, levels fused, OR traffic, ssurgery >3, blood loss >1 

Neurologic Insult Intraop  

SSEP  Continuous (bottom up)  Not sensitive to   Perfusion  Halothanes  50% amplitude, 10% latency  Looks at dorsal columns, so it is inaccurate; most insults are anterior cord  MEP  Evoked (so delayed vs insult) (up to down)  Sensitive to   Perfusion  Halothane  50% amplitude, 10% latency  EMG  Evoked 8 is no breach  Management  Notify  Intraop pause  Anesthesia  NM  CallContinue reading “Neurologic Insult Intraop  “

Airway after ACDF 

Symaptoms  Swallowing difficulty  Fullness  Neck mass  Strridor  Causes  Hematoma  Risk factors  Surgical   >3 bodies  C2-4  Blood losss >300  OR time 5 hours  Patient  Obesity  OSA  Pulmonary disease  Myelopathy  Revision  Anesthetic  Multiple attempts  Need for fiberoptic  Management  Assess need for airway, inform anesthesia/ ENT  Urgent intubation  OR for hematoma evacuation and hemostasis