The TRACE registry (Trans-Radial Approach in Central and northErn Greece).

OBJECTIVE: We examined trans-radial approach (TRA) use in coronary angiographies (CAs) as well as in percutaneous coronary interventions (PCIs) in specific regions of Greece, its distribution in public and private catheterization laboratories (CLs) and its preference by operators. Reliable data regarding the use of TRA are not available in Greece. METHODS: The study was performed in northern and central Greece, which constitutes 35.32% of the national population. This study focused on the years 2004, 2009 and 2013. RESULTS: There are 12 CLs. CAs performed using TRA were 0.43% in 2004, 12.28% in 2009 and 39.81% in 2013, whereas PCIs performed using TRA were 0.38%, 9.20% and 39.48%, respectively. Operators familiar with TRA, but who performed TRA electively, were 13.33% in 2004, 60.38% in 2009 and 42.37% in 2013. However, operators performing TRA routinely were 2.2%, 5.66%, and 49.15%, respectively. In 2013, there was a 3.76% decrease in CAs and 4.51% decrease in PCIs compared to 2009; in private CLs, there was a 29.63% decrease in CAs and 34.72% decrease in PCIs performed, which was contradictory to the 27.27% increase observed in CAs and 29.83% increase in PCIs in public CLs. CONCLUSIONS: This is the first study to reveal the volumes and trends in interventions performed via TRA across central and northern Greece. TRA has gained a reputation among operators in both public and private CLs. Due to the financial crisis in Greece, catheterizations have been diminished, whereas private CLs have lost a great amount of their turnover.

Quantitative estimation of the recurrent laryngeal nerve irritation by employing spontaneous intraoperative electromyographic monitoring during anterior cervical discectomy and fusion.

STUDY DESIGN: Prospective, clinical study. OBJECTIVE: The objective of our study was to evaluate the role of laryngeal intraoperative electromyography (IEMG) in predicting the development of postoperative recurrent laryngeal nerve (RLN) palsy in patients undergoing anterior cervical discectomy and fusion (ACDF). We also attempted to develop a method to quantify the total IEMG irritation of the RLN. SUMMARY OF BACKGROUND DATA: RLN injury has been recognized as the most common ACDF-associated neurologic injury. It has been postulated, that the employment of laryngeal IEMG may identify the operative events leading to RLN injury and subsequent postoperative palsy. METHODS: Laryngeal IEMG monitoring was performed in 298 patients undergoing ACDF. Preexistent baseline EMG activity, amplitude, and duration of IEMG activity were recorded. The total amount of RLN irritation was expressed as an Irritation Score (IS) applying a specially designed mathematical equation incorporating the amplitude, the duration, and the presence of any baseline EMG irritation. The relationship of IEMG activity with parameters such as the number of operative levels, the duration of the procedure, the presence of any previous neck surgeries, and the type of the used retractor was examined. RESULTS: IEMG activity was recorded in 14.4% of our patients. Postoperative RLN injury occurred in 2.3% of our patients. The sensitivity of IEMG was 100%, the specificity 87%, the positive predictive value 16%, and its negative predictive value 97%. The calculated IS ranged between 0.28 and 3.47 (mean IS: 2.09). Significantly increased IEMG activity was found in patients with previous surgical intervention, patients undergoing multilevel procedures, long-lasting procedures, and cases in which self-retained retractors were used. Likewise, significantly increased IS were observed in patients with previous surgeries and in cases where self-retained retractors were used. CONCLUSIONS: Our study indicates that laryngeal IEMG is a high-sensitivity modality that can provide real-time information and can potentially minimize the risk of operative RLN injury.

Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury.

BACKGROUND CONTEXT: Somatosensory evoked potential (SSEP) is used to monitor integrity of the brain, spinal cord, and nerve roots during spinal surgery. It records the electrical potentials from the scalp after electrical stimulation of the peripheral nerves of the upper or lower limbs. The standard monitoring modality in lumbosacral spine surgery includes lower-limb SSEP and electromyography (EMG). Upper-limb SSEP monitoring has also been used to detect and prevent brachial plexopathy and peripheral nerve injury in thoracic and lumbosacral spine surgeries. We routinely monitor lower-limb SSEP and EMG in lumbosacral spine procedures at our institution. However, a few patients experienced postoperative numbness and/or pain in their ulnar distribution with uneventful lower-limb SSEP and EMG. PURPOSE: We hypothesized that the postoperative upper extremity paresis in lumbosacral surgeries may result from compression and/or stretch of the brachial plexus and/or ulnar nerve while the patients were in prone position. Using upper-limb SSEP, we investigated whether we observe any significant change in the SSEP, and if so, whether we can prevent or reduce frequency of postoperative upper extremity deficits. STUDY DESIGN/SETTING: In this prospective study, we monitored upper-limb SSEP, in addition to lower-limb SSEP and EMG, in 230 elective, posterior lumbosacral spinal procedures. All operations were performed by a group of four neurosurgeons. PATIENT SAMPLE: One hundred and thirty-one female and 99 male with an age range of 28 to 86 years between January 2004 and December 2005 were studied. OUTCOME MEASURES: Amplitude and latency of upper-limb or ulnar SSEP were continuously compared with those of the baseline. A greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant. METHODS: After intubation, patients were positioned prone on Jackson or Andrews spinal table. Anesthesia was maintained with inhalant gas (desflurane or sevoflurane) and propofol infusion with and without minimal infusion of narcotics (fentanyl, sufentanyl, or remifentanil). Intraoperative neurophysiologic monitoring of upper-limb or ulnar SSEP was achieved by continuously recording cortical and subcortical responses after alternate stimulation of the ulnar nerve at the wrist. In our institutional protocol, a greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant to alert the operating surgeons. When significant changes occurred, the surgeon was immediately notified. Also, reevaluation of vital signs, depth of anesthesia, and patient's position, and technical troubleshootings were subsequently followed. RESULTS: We observed a greater than or equal to 50% decrease in amplitude of ulnar SSEP in 10 patients without significant changes in lower-limb SSEP (peroneal or posterior tibial nerve SSEP) or EMG during surgery. Eight patients had changes in unilateral limbs, and two patients had changes in bilateral limbs. Two patients with significant changes in unilateral limbs showed changes twice. The mean SSEP amplitude for the 14 changes was 29.2+/-3.1% (mean+/-SEM, standard error of mean) of the baseline value at the average surgical time of 60+/-1.5 minutes. With repositioning of the arms, the amplitudes were immediately restored with the average of 70.2+/-7.1% (n=14) of the baseline value. The mean amplitude of upper-limb SSEP was 73.4+/-8.7% (n=12) of the baseline at wound closure. The average surgical time was 154+/-29.2 minutes per case for the 10 patients. There was no documented postoperative upper extremity paresis in all 230 patients. CONCLUSIONS: The present study demonstrates that upper-limb SSEP monitoring could detect position-related ulnar neuropathy in 5.2% of the patients undergoing lumbosacral spine surgery.

New non-invasive sonographic modality for intracranial pressure/volume monitoring.

INTRODUCTION: The wide use of intracranial pressure and cerebral perfusion pressure monitoring has improved the management of patients with severe head injuries. The rare but worrying complications associated with the application of such monitoring makes the idea of a non-invasive method of monitoring very attractive. MATERIALS AND METHODS: A new non-invasive ultrasonographic technology was used to measure cerebral perfusion pressure in 27 normal volunteers. The average monitoring time was 45.3+/-0.2 min, and the average perfusion pressure recorded was 77.4+/-0.3 mmHg. No complications were reported during the procedure, which was performed while the subjects were in regular ward beds. CONCLUSION: The non-invasive character of this method could extend the use of cerebral perfusion pressure measurement to several other neurosurgical entities, such as hydrocephalus, pseudotumor cerebri, chronic headache, and spinal cord injuries.