Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals. / Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos.

The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.

[Recommendations on neurophysiological studies during the COVID-19 pandemic]. / Recomendaciones sobre estudios neurofisiológicos en tiempos de pandemia de COVID-19.

At the end of January, the current outbreak of COVID-19 coronavirus disease was declared an important international public health emergency. In Spain, since the government declared the state of alarm on 14 March 2020, doctors responsible for carrying out neurophysiological tests have been performing them without any consensus criterion or clear safety guidelines for doctors, technicians or patients. The following recommendations, based on current knowledge of the disease and therefore liable to change in the future, are proposed when the pandemic appears to have entered a process of decreasing virulence and, with it, the strict containment measures established to date. However, in view of the possibility of a second wave of the pandemic, it seems necessary to establish basic and minimum recommendations to respect the patient's right to appropriate care, similar to that provided prior to the pandemic, and to maintain minimum safety standards for the patients themselves and for the doctors, technicians and health personnel carrying out these tests. These recommendations concern the constitution of a priority based on the reason for consultation, the establishment of calls to check the patient's clinical situation before going to the outpatient department and the rules for carrying out neurophysiological tests, which are generally based on the preservation of hospital circuits, respect for and observation of the known barriers to contagion of this disease, and the use of disposable material. These recommendations are of particular interest, especially given the uncertainty of not knowing the evolution of the SARS-CoV-2 infection in the coming weeks or months.

TITLE: Recomendaciones sobre estudios neurofisiológicos en tiempos de pandemia de COVID-19.A finales de enero, la Organización Mundial de la Salud declaró el brote actual de la enfermedad por coronavirus COVID-19 como emergencia de salud pública de importancia internacional. En España, desde que el 14 de marzo de 2020 el Gobierno decretase el estado de alarma, los médicos encargados de las pruebas neurofisiológicas las hemos estado realizando sin tener un criterio consensuado ni unas pautas adecuadas de seguridad claras para los facultativos, los técnicos ni los pacientes. Las siguientes recomendaciones, basadas en el actual conocimiento de la enfermedad y, por tanto, susceptibles de variaciones en el futuro, se proponen cuando la pandemia parece que ha entrado en un proceso de disminución de la virulencia y, con ello, las medidas estrictas de confinamiento hasta ahora mantenidas; sin embargo, ante la posibilidad de una segunda oleada de rebrotes de la pandemia, parece necesario establecer unas recomendaciones básicas y de mínimos para respetar el derecho del paciente a una atención adecuada, similar a la previa a la pandemia, y mantener unos mínimos de seguridad para los propios pacientes y los médicos, técnicos y personal sanitario que realizan estas pruebas. Se trata de recomendaciones sobre el establecimiento de una prioridad basándose en el motivo de consulta, el establecimiento de llamadas de comprobación de la situación clínica del paciente antes de acudir a la consulta externa y las normas de ejecución de las pruebas neurofisiológicas, que se basan, en general, en la preservación de circuitos hospitalarios, el respeto y el cuidado de las barreras de contagio conocidas de esta enfermedad, y la utilización de material desechable. Estas recomendaciones son de especial interés, sobre todo por la incertidumbre de no saber la evolución de la infección por el SARS-CoV-2 en las próximas semanas o meses.

[Intraoperative neurophysiological monitoring in Spain: its beginnings, current situation and future prospects]. / Monitorizacion neurofisiologica intraoperatoria en España: inicios, situacion actual y perspectivas de futuro.

Intraoperative neurophysiological monitoring (IONM) is nowadays another tool within the operating room that seeks to avoid neurological sequels derived from the surgical act. The Spanish Neurophysiological Intra-Surgical Monitoring Association (AMINE) in collaboration with the Spanish Society of Clinical Neurophysiology (SENFC), and the IONM Working Group of the SENFC has been collecting data in order to know the current situation of the IONM in Spain by hospitals, autonomous communities including the autonomous cities of Ceuta and Melilla, the opinions of the specialists in clinical neurophysiology involved in this topic and further forecasts regarding IONM. The data was gathered from November 2015 to May 2016 through telephone contact and/or email with specialists in clinical neurophysiology of the public National Health System, and through a computerized survey that also includes private healthcare centers. With the data obtained, from the perspective of AMINE and the SENFC we consider that nowadays the field of medicine covered by IONM is considerably large and it is foreseen that it will continue to grow. Therefore, a greater number of specialists in Clinical Neurophysiology will be required, as well as the need for specific training within the specialty that involves increasing the training period of MIRs based on competencies due to the increase in techniques/procedures, as well as its complexity.

TITLE: Monitorizacion neurofisiologica intraoperatoria en España: inicios, situacion actual y perspectivas de futuro.La monitorizacion neurofisiologica intraoperatoria (MNIO) es hoy en dia una herramienta mas dentro del quirofano que busca evitar secuelas neurologicas derivadas del acto quirurgico. Nuestro objetivo, desde la Asociacion de Monitorizacion Intraquirurgica Neurofisiologica Española (AMINE), en colaboracion con la Sociedad Española de Neurofisiologia Clinica (SENFC) y el Grupo de Trabajo de MNIO de la SENFC, ha sido recopilar datos para conocer la situacion actual de la MNIO en España por hospitales, comunidades autonomas y ciudades autonomas de Ceuta y Melilla, las opiniones de los especialistas en neurofisiologia clinica involucrados en este tema y las perspectivas de futuro. La recopilacion de los datos se ha realizado durante el periodo de noviembre de 2015 a mayo de 2016 mediante contacto telefonico o correo electronico con especialistas de neurofisiologia clinica del Sistema Nacional de Salud, y mediante una encuesta via informatica en la que tambien participaron algunos centros sanitarios privados. Con los datos obtenidos consideramos desde la perspectiva de la AMINE y la SENFC que el campo de la medicina que abarca la MNIO en estos momentos es muy amplio y seguira creciendo. Por eso, se precisa un mayor numero de especialistas en neurofisiologia clinica, asi como una mayor formacion especifica dentro de la especialidad, que implica incrementar el periodo formativo actual de los medicos internos residentes en funcion a competencias debido al incremento de las tecnicas/procedimientos, asi como su complejidad.

[Elevated incidence of cognitive impairment in patients with asymptomatic carotid stenosis]. / Elevada incidencia de deterioro cognitivo en pacientes con estenosis carotidea asintomatica.

INTRODUCTION: Stroke is one of the main causes of mortality and functional disability in developed countries. Carotid stenosis (CS) is considered the reason for 20-30% of strokes. However, the studies that have gone into depth on the cognitive status of these patients are limited. AIM: To investigate the cognitive performance of CS patients and its relationship with clinical variables (carotid obstruction, lifestyle). PATIENTS AND METHODS: 33 CS patients were evaluated using a broad neuropsychological protocol, and were divided into two groups: symptomatic CS and asymptomatic CS. RESULTS: 50-57% of CS patients showed deficits in processing speed and visual memory (immediate recall). 41.9% showed altered performance in semantic fluency, whereas the percentage was 30% in digits subtest. The percentage of altered performance was 20-27% in verbal memory (learning curve, delayed recall) and visual memory (delayed recall). No significant differences were found between the symptomatic CS and asymptomatic CS groups. Cognitive performance correlated significantly with lifestyle scale factors, but not with the percentage of carotid obstruction. CONCLUSION: A high percentage of CS patients showed a clinically altered performance in different cognitive domains, regardless of suffering vascular neurological symptoms (symptomatic vs asymptomatic CS). A close relationship was found between lifestyle and cognitive status of CS patients.

TITLE: Elevada incidencia de deterioro cognitivo en pacientes con estenosis carotidea asintomatica.Introduccion. Los ictus se situan como una de las principales causas de mortalidad e incapacidad funcional en los paises desarrollados. La estenosis carotidea (EC) se considera la causa del 20-30% de los ictus. No obstante, los estudios que han profundizado en el estado cognitivo de estos pacientes son escasos. Objetivo. Estudiar el rendimiento cognitivo de pacientes con EC y su relacion con variables clinicas (obstruccion de la carotida, estilo de vida). Pacientes y metodos. Se evaluo a 33 pacientes con EC mediante un protocolo neuropsicologico amplio, distribuidos en dos grupos: EC sintomatica y EC asintomatica. Resultados. Un 50-57% de los pacientes con EC presento una ejecucion alterada en velocidad de procesamiento y memoria visual (recuerdo inmediato). Un 41,9% rindio de forma alterada en fluidez semantica, mientras que en el subtest de digitos el porcentaje fue del 30%. En la memoria verbal (curva de aprendizaje, recuerdo demorado) y la memoria visual (recuerdo demorado), el porcentaje de alterados fue del 20-27%. No se encontraron diferencias significativas entre los grupos de EC asintomatica y EC sintomatica. El rendimiento cognitivo correlaciono significativamente con los factores de la escala de estilo de vida, pero no con el porcentaje de obstruccion de la carotida. Conclusion. Un elevado porcentaje de los pacientes con EC presento un rendimiento clinicamente alterado en diferentes dominios cognitivos, con independencia de que hubieran experimentado o no sintomatologia neurologica vascular (EC asintomatica frente a sintomatica). Se encontro una estrecha relacion entre el estilo de vida y el estado cognitivo de los pacientes con EC.

Intraoperative neurophysiological monitoring in peripheral nerve surgery: Technical description and experience in a centre.

INTRODUCTION: Intraoperative neurophysiological monitoring has experienced a spectacular development in the past 20 years, particularly in the fields of neurosurgery and spine surgery. it has become a useful, almost indispensable, tool in preventing nerve damage during surgery. The aim of this article is to describe the intraoperative technique and analyze its results in the field of peripheral nerve surgery. OBJECTIVE: To describe the usefulness of a technique in peripheral nerve surgery, the technique used and the experience in a centre. PATIENTS AND METHODS: A retrospective study was conducted on 30 cases of peripheral nerve surgery performed in this centre from 2009 to 2013, using the intraoperative monitoring technique. RESULTS: Of the total of 13 peripheral nerve tumors recorded, there were 11 excellent results and 2 good results, one temporary hypoesthesia and one with almost complete sensory, except for motor, recovery. Traumatic injury was recorded in 17 cases, of which 6 required performing a graft, and the remaining 11 cases only neurolysis was performed, with complete motor and sensory recovery. CONCLUSIONS: Intraoperative neurophysiological monitoring is a useful tool in the secondary surgery of peripheral nerve injury and the intraneural tumor pathology.

[Intraoperative neurophysiological monitoring of the spinal cord: our experience]. / Monitorización neurofisiológica intraoperatoria de la médula espinal: nuestra experiencia.

INTRODUCTION: The main objective of intraoperative monitoring of the spinal cord is to detect any neurological damage that may occur (and which would otherwise go unnoticed) while it is still reversible. AIM: To retrospectively evaluate the effectiveness of neurophysiological monitoring in spine and spinal cord surgery since the time such procedures were first implemented within our centre. PATIENTS AND METHODS: The patients were divided into three groups, according to their pathologies. They were clinically evaluated with the McCormick scale before surgery, on discharge from hospital and at six months after the operation. Neurophysiological monitoring was performed with motor evoked potentials, somatosensory potentials and screw stimulation, when appropriate. RESULTS: The sample finally consisted of 49 subjects, with a mean age of 51 +/- 19.4 years. Distribution by groups was 53.1% spinal cord tumours, 22.4% traumatic injuries to the spinal cord and 24.5% bone/disc pathologies. During surgery potentials improved in 4.08% of patients, in 63.26% they remained intact, 20.41% were alerted by the neurophysiologist with intact potentials, 10.2% suffered a transitory decline and in one case there was permanent loss. All the patients who were submitted to a follow-up at six months displayed a clinical status that was the same or better than the one before their operation. CONCLUSIONS: Neurophysiological monitoring is a valuable tool that prevented, in 30.61% of our patients, damage that could otherwise have occurred. From the clinical point of view, its high predictive value is also worth highlighting.

[Anesthetic and physiologic implications of neurophysiologic monitoring with evoked potentials during spinal surgery]. / Implicaciones anestésicas y fisiológicas de la monitorización neurofisiológica intraoperatoria con potenciales evocados en la cirugía vertebral y medular.

Neurophysiologic monitoring with somatosensory and motor evoked potentials in spinal surgery is now widely applied in order to reduce the risk of neural injury and facilitate intraoperative decision making. Most anesthetics affect such monitoring by altering both somatosensory and motor evoked responses and these effects may place constraints on the choice of anesthetic. Intraoperative management includes maintaining stable physiologic conditions, which involves adjusting hemodynamic parameters, maintaining normal blood flow to promote proper oxygen exchange, ensuring proper ventilation, and avoiding variations in temperature. Close collaboration between the anesthetist, the surgeon, and the neurophysiologist will ensure the success of intraoperative monitoring and make it possible to avoid neural injury by making timely changes in the surgical approach.