Neuromonitoring during spine surgery

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anbuitachi

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Just read about an old lawsuit (Vaccaro v. St. Vincent’s Med Ctr.) involving monitoring during spine surgery. Anesthesiologist was also sued for not stopping the surgery because monitoring couldnt get SSEP baselines. Expert anesthesiologist said its attending anesthesiologists resonspibility to stop the surgery b/c it had no SSEP. Case was a C4-5 decompression. Not sure what the outcome was... couldn't find it online.

What do you do at your practice? At my place, we let the surgeon decide for smaller cases. Obviously all bigger cases get neuromonitoring. Majority of cases here do get neuromonitoring but i do remember doing spine cases before without monitoring.
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anbuitachi said:
Just read about an old lawsuit (Vaccaro v. St. Vincent’s Med Ctr.) involving monitoring during spine surgery. Anesthesiologist was also sued for not stopping the surgery because monitoring couldnt get SSEP baselines. Expert anesthesiologist said its attending anesthesiologists resonspibility to stop the surgery b/c it had no SSEP. Case was a C4-5 decompression. Not sure what the outcome was... couldn't find it online.

What do you do at your practice? At my place, we let the surgeon decide for smaller cases. Obviously all bigger cases get neuromonitoring. Majority of cases here do get neuromonitoring but i do remember doing spine cases before without monitoring.
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Isnt a neurologist involved in reading the ssep. Where are they in all this?
 
anbuitachi said:
Just read about an old lawsuit (Vaccaro v. St. Vincent’s Med Ctr.) involving monitoring during spine surgery. Anesthesiologist was also sued for not stopping the surgery because monitoring couldnt get SSEP baselines. Expert anesthesiologist said its attending anesthesiologists resonspibility to stop the surgery b/c it had no SSEP. Case was a C4-5 decompression. Not sure what the outcome was... couldn't find it online.

What do you do at your practice? At my place, we let the surgeon decide for smaller cases. Obviously all bigger cases get neuromonitoring. Majority of cases here do get neuromonitoring but i do remember doing spine cases before without monitoring.
Click to expand...

i would be surprised if the anesthesiologist is culpable for anything regarding the neuromonitoring...
 
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Wow.

I always note what NM says to me, but I defer to the surgeon and to the neuromonitoring attending (usually a neurologist) what they request I/we do. If we're going to be held liable for neuromonitoring issues then we need to be paid for neuromonitoring every time, and we need an ability to control the surgical course.

This idea is a slippery slope too. Many cases could go either way on whether neuromonitoring is required. Are we to decide whether we do SSEPs/MEPs? How about for lumbar spine surgeries - do we require it then? Do we employ the NM techs (no!)? Does the surgeon harass us for the time taken for electrodes to placed, or when they inevitably malfunction?

Basically we should be left out of all this. You want a TIVA? No problem. You want the MAP pushed? Sure. But leave me out of all the rest - it's not worth the headache. I'll do the anesthetic, a NM tech and their attending do their part, and the surgeon can do their unnecessary/barely-indicated spine surgery. Done.
 
There's no way that you're liable for neuromonitoring. It's outside of our scope of practice to interpret it. If there's an issue, it's up the neuromonitor person and surgeon. If they want the pressure up or whatever, I'll do that, but that's where it ends. I don't decide if the surgeon can continue the case, etc...
 
I have never seen a neumonitoring done for any kind of procedure: surprizing practices are so different in this aspect
 
dhb said:
I have never seen a neumonitoring done for any kind of procedure: surprizing practices are so different in this aspect
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Where do you practice? It's become quite standard for a lot of back cases beyond a simple disc in my neck of the woods. I don't know if there's evidence behind it, but it's very widely used .
 
Neuromonitoring is commonly done but is not universally done for spine fusion surgery. Some of our old school surgeons never use it and have exactly the same results as those who do use it. Neuromonitoring is one of the major sources of "surprise out-of-network costs" that has America reeling right now. Although there is little doubt of its effectiveness in scoliosis surgery, the efficacy of neuromonitoring for pedicle screw surgery is controversial: one minimally invasive retrospective study demonstrated no difference (Intraoperative neurophysiological monitoring for minimally invasive 1- and 2-level transforaminal lumbar interbody fusion: does it improve patient ... - PubMed - NCBI) while another larger retrospective study (Intraoperative electromyographic monitoring to optimize safe lumbar pedicle screw placement - a retrospective analysis. - PubMed - NCBI) found a decreased incidence or re-operation when neuromonitoring was used. Surprisingly, there is a dearth of prospective studies given the extreme cost of neuromonitoring both personally to the patient and to the health care system.
 
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algosdoc said:
Neuromonitoring is commonly done but is not universally done for spine fusion surgery. Some of our old school surgeons never use it and have exactly the same results as those who do use it. Neuromonitoring is one of the major sources of "surprise out-of-network costs" that has America reeling right now. Although there is little doubt of its effectiveness in scoliosis surgery, the efficacy of neuromonitoring for pedicle screw surgery is controversial: one minimally invasive retrospective study demonstrated no difference (Intraoperative neurophysiological monitoring for minimally invasive 1- and 2-level transforaminal lumbar interbody fusion: does it improve patient ... - PubMed - NCBI) while another larger retrospective study (Intraoperative electromyographic monitoring to optimize safe lumbar pedicle screw placement - a retrospective analysis. - PubMed - NCBI) found a decreased incidence or re-operation when neuromonitoring was used. Surprisingly, there is a dearth of prospective studies given the extreme cost of neuromonitoring both personally to the patient and to the health care system.
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all well and good. But the neurosurgeon will get his a$$ sued if he does a case without it and there is a bad outcome. Especially if it is a case where monitoring is frequently used in the community.
 
There is absolutely no evidence neuromonitoring will protect in any way against litigation in cases of bad outcome. The neurosurgeon will get sued anyway. One of our neurosurgeons who no longer uses neuromonitoring after querying the tech about changes in waveforms with a pedicle screw probe on and off the patient. She stated there was no difference. He stopped using neuromonitoring that day and saves patients $30,000-90,000 per case.
 
algosdoc said:
There is absolutely no evidence neuromonitoring will protect in any way against litigation in cases of bad outcome. The neurosurgeon will get sued anyway. One of our neurosurgeons who no longer uses neuromonitoring after querying the tech about changes in waveforms with a pedicle screw probe on and off the patient. She stated there was no difference. He stopped using neuromonitoring that day and saves patients $30,000-90,000 per case.
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It’s insanely expensive and most likely unnecessary. Very surgeon dependent. The surgeons who have a stake in the NM companies are of course going to insist on using it.
 
chocomorsel said:
It’s insanely expensive and most likely unnecessary. Very surgeon dependent. The surgeons who have a stake in the NM companies are of course going to insist on using it.
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This is so not our lane. I don’t even know what procedure they are doing half the time. Discectomy, Lami, fusion.... it’s all the same to me. I just tube em and flip em. Telling the surgeon to use monitoring or not is like telling them what length of screw to use.....
 
dannyboy1 said:
This is so not our lane. I don’t even know what procedure they are doing half the time. Discectomy, Lami, fusion.... it’s all the same to me. I just tube em and flip em. Telling the surgeon to use monitoring or not is like telling them what length of screw to use.....
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When you learn about some of the shadiness and what it costs, and how these surgeons are getting a cut and rich off of some likely unnecessary s hit.. you get a bad taste in your mouth.

Obviously I didn’t t tell them to use or not use NM. I just chose not to participate in the shenanigans anymore.
 
chocomorsel said:
When you learn about some of the shadiness and what it costs, and how these surgeons are getting a cut and rich off of some likely unnecessary s hit.. you get a bad taste in your mouth.

Obviously I didn’t t tell them to use or not use NM. I just chose not to participate in the shenanigans anymore.
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It’s not like we are above doing unnecessary things for $. Unless you have never given “anesthesia” for cataracts.....
 
dannyboy1 said:
It’s not like we are above doing unnecessary things for $. Unless you have never given “anesthesia” for cataracts.....
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There's that, sure, and then there is charging 30-100K for neuromonitoring. Out of network. In the past, I made about $117 average per cataract. Now I am locums and probably make less per cataract.
Quite frankly, if someone was coming at my eye with a knife I certainly would like some anxiolysis. But that could easily be accomplished with PO Valium written by the surgeons. Guess the surgeons want quick, reliable drugs to pump out their cases so ask us to do it. Or they try to help us out. Or I don't really know why they ask for our help in this regard, but they do. I would totally be fine NOT providing that service if patients were getting exorbitant bills that they couldn't pay. Or to save the overall system money if we were ever to go the socialized healthcare route.
 
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we do neuromonitoring for scoliosis surgery mainly... patient doesn’t get a bill.
 
chocomorsel said:
Well that's nice for the patient. But somewhere in there, someone is paying for the NM services. Glad it's not the patient. Stick it to the insurance companies for all I care.
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yeah - i know, the taxpayer pays - but the techs are employees and get paid a wage you’d expect for a scientist, so the taxpayer gets a fair bit of bang for their buck
 
That expert testimony is somewhat confusing. Am I mistaken or is there still no large body of consensus evidence that neuromonitoring makes a definitive outcome difference for any of these cases?

It is disappointing that someone in our own field would attempt to make us responsible for whatever non-evidence based auxiliary monitoring du jour the surgeon has chosen.

Regarding whether a neurologist reads these during the case, I did a lot of spine for awhile and got to know the neuromonitoring folks fairly well, there was no neurologist involved in these during the cases at all. It was strictly them communicating with us and with the surgeons.
 
DM27 said:
Regarding whether a neurologist reads these during the case, I did a lot of spine for awhile and got to know the neuromonitoring folks fairly well, there was no neurologist involved in these during the cases at all. It was strictly them communicating with us and with the surgeons.
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That’s not the case at my shop. The techs are in constant contact with a neurologist during the case who is monitoring things remotely in real time.
 
DM27 said:
That expert testimony is somewhat confusing. Am I mistaken or is there still no large body of consensus evidence that neuromonitoring makes a definitive outcome difference for any of these cases?

It is disappointing that someone in our own field would attempt to make us responsible for whatever non-evidence based auxiliary monitoring du jour the surgeon has chosen.

Regarding whether a neurologist reads these during the case, I did a lot of spine for awhile and got to know the neuromonitoring folks fairly well, there was no neurologist involved in these during the cases at all. It was strictly them communicating with us and with the surgeons.
Click to expand...
See response #12
 
Even for scoliosis surgery I am not aware of any articles that demonstrated improved patient outcomes relating to neuromonitoring. I am aware of articles regarding why to do it, why it should be done, and articles where it resulted in change to the surgical plan intraop, but none where there was demonstrated outcome benefit.
 
SaltyDog said:
That’s not the case at my shop. The techs are in constant contact with a neurologist during the case who is monitoring things remotely in real time.
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That’s not the case where I work either. Tech, scribbles on screen, disc with surgeon. We tell them what we are changing, they tell us what they want.
It’s crazy to suggest that we are in any way responsible for anything to do with neuromonitoring. The decision to proceed or abort, wake up test, etc. is 100% on the surgeon. They want map 60 we make map 60. They want map 80, we make MAP 80. If you’re doing what they ask, and the **** hits the fan, and they charge on, that’s not your call.
 
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