Intraoperative EMGs

[Rehabs of Steel]

One of my PM&R attendings did an intraoperative EMG yesterday. He had mentioned it could become standard of care for some neurosurgical/ortho cases. This is my first time seeing/hearing about this. Are there many physiatrists doing intraoperative EMGs? Any other thoughts on this area?

---

Members don't see this ad.

 

[olafa]

One of my PM&R attendings did an intraoperative EMG yesterday. He had mentioned it could become standard of care for some neurosurgical/ortho cases. This is my first time seeing/hearing about this. Are there many physiatrists doing intraoperative EMGs? Any other thoughts on this area?

i have seen SSEP's - it that what you are referring to? The cases I have seen are done by a Phd/ technician not the physiatrist- physician

to do EMG you need the voluntary contraction to look at motor unit potentials and when a patient is under anesthesia, well not very helpful.

 

[axm397]

I think you are referring to intraoperative monitoring. There's usually a tech placing the electrodes and setting it up - and a physician (neuro or PM&R typically) monitoring the waveforms. Typically used for spine surgery - but also for other surgeries going near nerves - can detect intraoperative injuries to the nerve early - which may allow for correction of the injury if caught early.

 

[Finally M3]

There are some people doing remote monitoring, but reimbursement is a question though.

 

[RUOkie]

Most IOP is done by a technician and then monitored by the neurosurgeon and the tech. There are exceptions where a PM&R/Neuro is there but typically that is just for brachial plexus surgeries and the like. Our local NS uses IOP for all pedicle screw insertions, but the reimbursement is poor at best for us to be standby in the OR. I would only do it as a favor to my biggest referral source (it is unlikely he would ask!)

 

[Rehabs of Steel]

Thanks for everyone's comments!

 

[Ludicolo]

Actually, intraop monitoring with SSEPs, and more recently TcMEPs, has become standard of care for a number of spine surgeries, esp scoliosis surgeries. Needle EMG monitoring is sometimes used in spinal or peripheral nerve surgeries, also w/ facial nerve surgeries – the sudden onset of a neurotonic discharge quickly lets the surgeon know that they’re touching something they probably shouldn’t be touching. BAERs are often used in acoustic neuroma cases. Lots of technical factors to consider and control for – temperature, ambient electrical noise, anesthetic agents, patient positioning, etc.

I think IOM is mostly done by techs/neurologists, although I know of a few physiatrists who do this in addition to their regular practice. I’m not one of them. I did a fair amount of IOM during my training, and from an intellectual standpoint I thought it was very cool. And I understand the need for it. But from a productivity/reimbursement/patient contact standpoint, I think my time is better spent doing outpatient clinics/conventional EMGs.

 

[Nico47]

As fate would have it, I have in my hand the following AANEM monograph:

Peripheral Nerve Stimulation and Monitoring During Operative Procedures
by Brian A. Crum, MD and Jeffrey A. Strommen, MD

It talks about techniques, pitfalls (those ORs are chilly!), and common uses of IOM.

The major sections discuss ulnar entrapment at the elbow, median at the wrist, brachial plexus reconstruction, fascicle selection for biopsy, and nerve tumor localization.

Key points are: IOM is useful for determining functional continuity of axons, which is not possible by visual inspection alone, and when a cut needs to be made it's nice to be certain by NCS that the surgeon's in the right place.