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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 30250-10000.5-517-2320-350.2-0.51.3-4.7 SEP median nerve subcortical 30500-10000.5-311-1620-350.2-0.51.3-4.7 SEP tibial nerve cortical 30250-10000.5-535-4525-500.2-11.3-4.7 SEP tibial nerve subcortical 30500-10000-327-3525-500.2-11.3-4.7

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. 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.


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