Intraoperative Neurophysiologic Monitoring

手术目的：
 what is intraoperative neurophysiological
monitoring?
1. Intraoperative neurophysiologic
monitoring (IONM) is a technique that is
directly aimed at reducing the risk of
neurological deficits after operations
2. IONM is a technique that makes use of
recordings of electrical potentials from the
nervous system during surgical
operations.
1. The use of IONM offers a possibility to
detect injuries before they become so
severe they cause deficits after the
operation.
2. Introduction of IONM has reduced the
risk of debilitating deficits such as muscle
weakness, paralysis, hearing loss, and
other loss of normal body functions.
Evoked potential [pə'tenʃ(ə)l] monitoring includes

• somatosensory evoked potentials (SSEP),

• brainstem auditory evoked potentials
(BAEP),
• motor evoked potentials (MEP),
• visual evoked potentials (VEP).
1. SKULL BASE SURGERY
• One of the first application of intraoperation
neurophysiology was monitoring facial
nerve function during acoustic neuroma
resection ,
• a technique actually pioneered in the late
19th which came into widespread use
during the 1980s.
BEAP

MEP

• The rates of anatomic and functional facial nerve

preservation could be significantly increased by
using intraoperative facial nerve monitorin ．
• The prognosis is obviously improved by IFNM in
the patients with acoustic neuromas
• Similar technique can be used to monitor
other cranial motor nerves by appropriat
placement of recording electrodes.
• Some techniques for monitoring sensory
nerves such as:
visual evoked potential which are an
obviously means of monitoring optic nerve
function, are notoriously unstable under
anesthesia.
auditory brain stem respones(ABR)
ABR can evaluate precisely
cochlear ['kɔkliə] nerve function.
 Case Study
•
A patient with a medium-sized vestibular schwannoma expressed a strong
desire that her hearing and facial function be preserved after surgery. Her
surgeons suggested a suboccipital approach to the mass lesion.
• The seventh and eighth cranial nerves were continuously monitored using
facial EMG and the auditory brainstem response (ABR). Following the
craniotomy, surgeons used a device to retract the cerebellum in order to
facilitate access to the tumor. The ABR deteriorated immediately,
characterized by a rapid reduction in wave V amplitude and a shift in the
absolute latency of nearly one millisecond . This dramatic change in auditory
function was immediately reported by the audiologist in an effort to minimize
permanent auditory nerve injury. The retractor was removed and then
repositioned. The ABR gradually improved to near-baseline morphology and
absolute values.
• The schwannoma was successfully resected, and postoperatively the patient
was found to have hearing levels equal to the preoperative findings.
2. SPINAL CORD SURGERY
• SSEP has been the standard of
intraoperative monitoring, with excellent
ability to assess dorsal column and lateral
sensory tract function; it probably also can
detect changes in function of anterior motor
tracts by stimulating mixed sensorimotor
peripheral nerves.
•MEPs were developed to better the motor
neurophysiological pathways.
 Technique
• MEPs are elicited by either electrical or magnetic stimulation
of the motor cortex or the spinal cord. Recordings are
obtained either as neurogenic potentials in the distal spinal
cord or peripheral nerve,
• Electrical stimulation also can be applied directly over the
spinal cord when a laminectomy affords exposure proximal
to the lesion in question. Distal neurogenic potentials then
can be recorded.

• Its use in combination with SSEP appears to improve the

accuracy of monitoring spinal cord function.
3. ANEURYMS SURGERY
• Treatment of cerebral aneurysms carries
risks of ischemia to structure downstream
from the aneurysm.

• The risk is particulary high for aneurysm of

the posterior communicating or perforators
supplying critical brain stem and thalamic
structures
• Electroencephalogram (EEG) and SEP can
be recorded from the same scalp electrodes
by directing the signals to separate
amplifiers with approriate filter settings.
• Scalp EEG can also be used to monitor
cerebral function during carotid or other
vascular surgery
• The EEG is used to titrate the level of barbiturate
to obtain a burst-suppression pattern ,in which
periodes of soelectricity alternate with higher-
amplitude bursts.
• A burst ratio of about 20% burst activity is
adequate,more than this proviodes no further
cerebral protective effect and will make it more
difficult to extubate the patient after the procedure.
• For anterior cerebral or anterior communicating
artery anuerysm ,posterior tibial nerve SEP should
be used since the lower extremity somatosensory
area is in the distal anterior cerebral artery.
• For posterior communicating or basilar artery
aneurysms,both upper and lower extremity SEP
should be recorded since occlusion of perforating
arteries into the brain stem or thalamus can affect
either or both of these pathways.
The End

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