Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring.

The American Society of Neurophysiological Monitoring (ASNM) was founded in 1989 as the American Society of Evoked Potential Monitoring. From the beginning, the Society has been made up of physicians, doctoral degree holders, Technologists, and all those interested in furthering the profession. The Society changed its name to the ASNM and held its first Annual Meeting in 1990. It remains the largest worldwide organization dedicated solely to the scientifically-based advancement of intraoperative neurophysiology. The primary goal of the ASNM is to assure the quality of patient care during procedures monitoring the nervous system. This goal is accomplished primarily through programs in education, advocacy of basic and clinical research, and publication of guidelines, among other endeavors. The ASNM is committed to the development of medically sound and clinically relevant guidelines for the performance of intraoperative neurophysiology. Guidelines are formulated based on exhaustive literature review, recruitment of expert opinion, and broad consensus among ASNM membership. Input is likewise sought from sister societies and related constituencies. Adherence to a literature-based, formalized process characterizes the construction of all ASNM guidelines. The guidelines covering the Professional Practice of intraoperative neurophysiological monitoring were initially published January 24th, 2013, and subsequently that document has undergone review and revision to accommodate broad inter- and intra-societal feedback. This current version of the ASNM Professional Practice Guideline was fully approved for publication according to ASNM bylaws on February 22nd, 2018, and thus overwrites and supersedes the initial guideline.

Recall and patient perceptions of hip precautions 6 weeks after total hip arthroplasty.

Background and purpose - There is a lack of evidence to support the role of hip precautions in preventing dislocation following total hip arthroplasty (THA). We report an exploratory study which assesses recall, adherence, and the impact of precautions on activities of daily living in the first 6 weeks postoperatively. Patients and methods - We designed a new questionnaire based on the education patients receive and refined by professionals within our multidisciplinary team. 129 patients underwent primary elective THA during the study period and received the questionnaire at 6 weeks postoperatively. Results - 97 (75%) patients responded before the 8th week postoperatively. Most of these (83 patients) could remember all the precautions. Of the 97 who responded only 22 claimed to adhere to all of the precautions. 48 admitted to putting their own underwear on without the use of aids or assistance, and 38 had started walking without an aid. Due to the precautions 67 avoided leaving the house at some point and 63 were unable to perform desired activities. 84 stated that their sleep was affected. There were no dislocations among the 97 patients who responded; however, there was 1 dislocation among the 32 non-responders. Interpretation - We found that most patients did not adhere to hip precaution advice. Precautions have a detrimental effect on patient activity and sleep. In view of the limited efficacy in reducing dislocation rate, we question the use of precautions in the primary arthroplasty setting.

Contemporaneous Evaluation of Intraoperative Ulnar and Median Nerve Somatosensory Evoked Potentials for Patient Positioning: A Review of Four Cases.

Somatosensory evoked potentials (SSEPs) are a valuable tool for assessing changes in peripheral nerve pathways caused by patient positioning during spinal surgeries. These changes, when left undiagnosed, may lead to postoperative neurological sequelae. Why an upper extremity SSEP attenuates due to positioning is not necessarily clear and can be multifactorial, affecting the peripheral nerves or elements of the brachial plexus. A conduction block can occur at any point along the course of the nerve secondary to entrapment, compression, and ischemia. These mechanisms of injury may be caused by extreme body habitus, the length of the procedure, or the patient's metabolic underpinnings. The goal of neuromonitoring for positional injury is to predict and prevent both peripheral nerve and brachial plexus injuries. Using ulnar and median nerve SSEPs contemporaneously may lead to better identification of compromised structures when an SSEP change to one or both of the nerves occurs. The investigators provide four case reports where intraoperative SSEP assessment of contemporaneous ulnar and median nerves prevented postoperative upper extremity neural deficits.

Rhythmic ictal nonclonic hand (RINCH) motions: a distinct contralateral sign in temporal lobe epilepsy.

PURPOSE: To describe a new ictal sign in temporal lobe seizures-rhythmic ictal nonclonic hand (RINCH) motions and to determine its lateralizing significance and other ictal manifestations associated with it. METHODS: We identified 15 patients with temporal lobe epilepsy who demonstrated RINCH motions and reviewed video-EEG recordings of all their seizures. We analyzed the epilepsy characteristics and all clinical features of recorded seizures, with particular attention to RINCH motions. RESULTS: RINCH motions were unilateral, rhythmic, nonclonic, nontremor hand motions. RINCH motions were usually followed by posturing, sometimes with some overlap. They involved the hand contralateral to the temporal lobe of seizure onset in 14 of 15 patients. CONCLUSIONS: RINCH motions are a distinct ictal sign that could be considered a specific type of automatism. They appear to be a lateralizing contralateral sign and are associated with dystonic posturing in temporal lobe epilepsy.