Case Review 2016

Leah Solano

MVS 465

10 December 2015

CASE REVIEW: 10 NOVEMBER 2015

INTRODUCTION

• Two different changes in IONM signals, two different causes

• True change, by surgical manipulation

• Anesthetic change

• Anesthesia’s goals do not always coincide with our goals

PATIENT, SYMPTOMS & DIAGNOSIS

• Patient: 7 y.o. female

• Halo traction prior to surgery

• No neurological deficits at time of surgery

• Diagnosis: Congenital Scoliosis

PRE-OP X-RAY

PRE-OP X-RAY

• Surgeon: Dr. Farley

• Surgical treatment plan:

• Growing Rod Placement T3-

L4

• Smith-Peterson

Osteotomies with

allograft and autograft

• Intraoperative Monitoring Requested:

• UE and LE bilateral SSEPs

• MEP and spEMG

• Responses recorded from: bilateral APB-ADM, AB, IL, VL, BF, TA, GA, AH.

• *C3 electrode had to be placed nearer to Oz due to surgical site constraints and open wounds from halo

TREATMENT PLAN

BASELINE SSEPS

BASELINE SSEPS

BASELINE MEPS

FIRST CHANGE: LOSS OF MOTORS; MEP PRE-

DEROTATION

FIRST CHANGE: LOSS

OF MOTORS

FIRST CHANGE: LOSS OF MOTORS; SIGNAL RETURN

SECOND CHANGE: ANESTHETIC

• For the majority of the procedure, anesthesia consisted of Isoflurane (0.3 MAC),

Sufentanil, and Midazolam

• Near closing anesthetic regimen was changed to a combination of Isoflurane and Nitrous

Oxide at 1.3 MAC, Sufenta turned off

• Anesthesia’s goals: analgesia, amnesia, sedation, muscle relaxation, as well as a

timely wakeup

• Surgeon’s goals: Acquisition of reliable MEPs to ensure final surgical manipulations

would not cause spinal cord insult.

• Solution: Anesthesia changed the regimen back to Isoflurane at 0.4 MAC and

Sufentanil/Midazolam, and signals regained reliability.

SECOND CHANGE: ANESTHETIC

SECOND CHANGE: ANESTHETIC; SSEP LATENCY RETURN

Iso & N20

(1.3 MAC)

Iso (0.4 MAC) &

Sufenta/Midazolam

SECOND CHANGE: ANESTHETIC

REDUCTION IN MEP AMPLITUDE

SECOND CHANGE: ANESTHETIC; MEP AMPLITUDE

RETURN

CONCLUSION

• By closing, SSEPs and MEPs were stable and reliable, EMG quiet

• Patient woke able to move all extremities

Pre-op

Post-op