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Cervical Surgical Procedures
1. While brachial plexus injury due to traction or over tightening of the shoulders during cervical procedures isn't common it is important to guard against this possibility. Utilizing SomatoSensensory Evoked Potentials (SSEPs) with stimulating electrodes place either at the ulnar or median nerve we can help prevent neurological damage to the plexus. TransCranial Motor Evoked Potentials (TcMEP) can similarly detect any possible injury and are can be utilized as a secondary means of corroboration.
2. During exposure special care should be taken while entering the pretracheal fascia to avoid recurrent laryngeal nerve (RLN) palsy. Injuries can be prevented, via ElectroMyographical (EMG) monitoring of the bilateral RLNs. Utilizing a 4 channel recording electrode on the endotracheal tube, that is strategically placed by the anesthesia team. These electrodes can detect possible injury due to traction.
3. Once exposure is complete and decompression begins, attention is shifted, to prevention of nerve root and spinal cord injury. EMG monitoring is utilized, to guard against nerve root damage. Subdermal recording electrodes are placed in the specific dermatonal zones which correlate to the spinal levels being operated on.The spinal cord is monitored via SSEP and TcMEP monitoring. This is most important during interbody (graft) placement and subdural tumor resection, but it is imperative to establish a preincision baseline as well as to utilize a continuous monitoring approach during the entirety of the case to establish a real time assessment of the integrity of the cord. It is important to note that monitoring the ascending (sensory) and descending (motor) tracts of the spinal cord is essential. This ensures the integrity of both the dorsal and ventral side of the cord. The motor tract is monitored by stimulation of the primary motor cortex with subdemal needle electrodes and recording at upper limb and lower limb bilateral muscle groups. Typically we record at level specific muscles and add the abductor pullucis brevis and the abductor hallucis to ensure complete coverage. Monitoring the sensory tract employs stimulation at the ulnar/median nerves for upper limb and at the tibial nerve for lower limb.
4. Direct nerve stimulation utilizing a monopolar hand held probe can be utilized to verify nerve root integrity at any point during the procedure.
ACDF's/PCDF's and all Cervical Procedures:
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Jane Faber, New York
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Jane Faber, New York
Jane Faber, New York
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