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INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING FOR SACROILIAC FUSION HALLIE LOY BS CNIM.

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Presentation on theme: "INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING FOR SACROILIAC FUSION HALLIE LOY BS CNIM."— Presentation transcript:

1 INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING FOR SACROILIAC FUSION HALLIE LOY BS CNIM

2 ANATOMY OF THE PELVIS

3 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

4 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.

5 Clinical tests Imaging studies (x-ray. CT scan, MRI) SI joint injections of a local anesthetic DIAGNOSIS…

6 Physical therapy Chiropractic manipulations Pain medication Injection therapy OTHER TREATMENT OPTIONS

7 SI FUSION SURGERY

8

9 SI FUSION VIDEO

10 WHY DO WE MONITOR SI FUSIONS?

11 IATROGENIC NERVE INJURY RATES HAVE BEEN REPORTED TO BE AS LOW AS 1% AND AS HIGH AS 18%.

12 MovementNerve Root Segments Hip flexionL2/3 Hip extensionL4/5 Hip adductionL2/3 Hip abductionL4/5 Knee extensionL3/4 Knee flexionL5/S1 Ankle DorsiflexionL4/5 Great toe extension L5 Ankle plantarflexion S1/2 Lower Limbs Myotomes Lower Limb Dermatomes

13 HOW DO WE MONITOR SI FUSIONS?  SSEP  EMG  SE-EMG

14 SSEP Stimulation: Uppers: Ulnar Nerve Lowers: Posterior Tibila Nerve Low Freq Filter (Hz) High Freq Filter (Hz) Amp (μV) Typical latencies (ms) Stim. Intensity (mA) Stim Duration (ms) Stim. Rate (Hz) SEP median nerve cortical SEP median nerve subcortical SEP tibial nerve cortical SEP tibial nerve subcortical

15 Alarm Criteria: -Amplitude decrease of 50% -Latency increase of 10% SSEP

16 EXAMPLES OF CHANGES

17 Patient had LUE amplitude decrease of greater than 50% due to a positional issue.

18 Needle electrodes used in the following muscles: L5- Tibialis Anterior S1- Gastrocnemius S2- Anal Sphincter EMG

19 Alarm Criteria: Any burst/firing from nerves on the side the surgeon is working. FREE RUN EMG

20 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

21 Alarm Criteria: Response <8 mA with an absolute minimum of 6 mA SE-EMG

22 LE numbness LE weakness Incontinence Foot drop IN THE CASE OF NERVE INJURY

23 QUESTIONS?

24 REFERENCES -"Minimally Invasive Sacroiliac Joint Surgery." MIS Sacroiliac Joint Fusion Surgery. SI-BONE, n.d. Web. 08 Apr 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 ). Elsevier B. V. -Moore MD, M.R. (2012, January ). The Sacroiliac Joint: A Forgotten Pain Generator. The SI-BONE Sentinel, 1-2.


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