INTRAOPERATIVE

NERVE MONITORING

PRESENTER AMULYA
MODERATOR DR.SHAJI THOMAS
INTRODUCTION

Intraoperative nerve monitoring

Principle
Nerve connected to muscle , stimulated by point probe causes impulses to travel
through muscle that manifests itself qualitatively and quantitatively via an EMG
connected to an electrode attached to muscle
AIM

Reduce intraoperative surgical morbidity

Aiding dissection in previously operated fields
Allow focussed rehabilitation in the event of iatrogenic nerve damage
Prevents longterm nerve damage related sequalae
Serves as additive knowledge to anatomy and excellent surgical technique
HISTORY

1898 Fedor Krause from Berlin - Monopolar stimulation to check function of facial
nerve after acoustic nerve neurectomy
Stimulated facial nerve and visually noted contractions of facial region

1960 - Breakthrough.. Flisberg and Lindholm introduced to thyroid surgery

Parsons and Hilger facial nerve stimulators - parotid and ear surgeries
MAIN FIELDS WHERE IT IS USED

Thyroid surgeries - vagus and RLN are monitored

Parotidectomy - Facial nerve
Skull base , Posterior cranial fossa surgeries
Thyroid gland surgeries

Incidence of vocal cord paralysis after thyroid surgery - 3%

Bilateral vocal cord paralysis - 0.1 - 1.3%
Intraoperative visual identification of RLN gold standard
But visual identification of intact nerve doesnot imply intact function
Number of mechanisms of neural injury donot produce visual alteration of nerve
Mechanisms of RLN injury
Traction (71%) > Thermal (17%) > compression(4.2%) >
clamping>ligature>entrapment>suction related >transection
Majority of traction injuries - At Ligament of Berry
 Intraoperative nerve monitoring

INTERMITTENT CONTINUOUS
Most common Recent advancement
INTRAOPERATIVE NEUROMONITORING TECHNIQUE
Physiology of nerve and basis of IONM

RLN - Mixed motor and sensory nerve

Motor component - intrinsic muscles of larynx - Normal VC movement

Stimulated nerve fibres - Compound action potential CAP (sum of impulses of nerve fibres)
CAP traverses through nerve - waveform - recordable by placing electrodes at muscle end plates
Recorded as EMG potentials or CMAPs
PARTS OF MONITORING SYSTEM

1.Monitor
2.Interface connector box
3.Endotracheal tube with surface electrodes - recording side
4.Stimulator probes - stimulation side
- Nerve stimulator probes
- Continuous vagal stimulator probe
EQUIPMENT SET UP
Stimulation side

Monopolar /Bipolar probes

Ground electrode -usually placed on patient’s shoulder or sternum
Recording side
Low pressure cuffed silicone endotracheal tube - two integrated stainless steel contact
electrodes on each side that monitor vocal cord emg activity
Electrodes should make good contact with luminal surface of vocal cords
Correct positioning - direct laryngoscopy
NIM - Nerve Integrity Monitor
Response system for laryngeal nerve monitoring

This nerve monitoring device transforms

laryngeal muscle activity into
audible and visual electromyographic signals
When vagus or RLN is stimulated
Intubation

Anaesthesia
Short acting neuromuscular blocking agent at induction

Monitor tube placement

Patient positioning - shoulder roll with head extended
Repeat laryngoscopy to verify the location of tube
Surgical field initial tests

Before beginning of case

Stimulator probe should be tested on infrahyoidal and sternocleidomastoid muscle
Confirms pulse generator and probe are working properly and lack of paralytic agent
Standard steps of RLN monitoring in IONM

1. Stimulation of ipsilateral vagus before RLN dissection - V1

2.Stimulation of RLN at the first point where it is found in TEG - R1
3.Stimulation of RLN at its most proximal point after dissection is over - R2
4.Vagus stimulation after bleeding control is complete at the surgical field
Most appropriate test for post op vocal cord function - V2
5.Vocal cord examination with post op laryngoscopy - L2
Initial signal from vagus nerve before identification of RLN
To confirm overall system function - vagus nerve identified and stimulated
● Crucial step to know that monitoring is working efficiently
● Normal pathway of RLN is elicited
● Stimulated directly by dissecting 1-2 cm carotid sheath and applying electrode
directly
● INMSG recommends baseline response of > 500uV with stimulation current of 1-2
mA with detectable laryngeal twitch
RLN is identified - tracheooesophageal groove in proximity to inferior thyroid artery
Nerve is mapped and stimulated using EMG signal
Most important principle : visual identification of nerve and satisfactory electrical emg
response
Amplitude and Latency - EMG
Change - Amplitude decrease > 50 %
Latency increase > 10%
Impending neuropraxia
Interpretation of signal

Intactness of V1-R1-R2-V2 - ensures nerve is intact

Loss of signal
If the EMG amplitude of the vocal cord < 100 μV by stimulation of the nerve
with a current above the threshold level
and/or the absence of an audible warning tone, is defined as signal loss
Signal INTERPRETATION TROUBLE SHOOTING

No signal at V1 Equipment failure/technical error Manual palpation of post cricoid

Check for ET tube placement
Status of muscle relaxants

No signal at R1 Nerve not correctly identified Rule out stimulation or recording side
(with intact V1) problems

Loss of signal at Suggests nerve insult Check for C/L nerve stimulation
R2 Manual stimulation of post cricoid twitch
(with normal V1 if present suggests recording error
and R1

Loss at V2 Rule out nerve insult not detected at R2 If LOS at R2 is true positive rule out
pressure over RLN due to
hematoma ,collection
False positive tests (LOS with intact vocal False negative tests( Good EMG with
cord mobility) post VCP)

Endotracheal tube displacement Stimulation applied to nerve segment

distal to site of nerve injury

Blood or fascia preventing good contact Delayed neuropraxia

netween stimulating probe and nerve

Paralytic agent

Neuropraxia with early recovery

Inadequate stimulating probe current

Continuous IONM

Real time monitoring

Removes risk due to temporal gap and spatial gap
It involves Automatic periodic stimulation of vagus nerve
and assessment of EMG changes during surgery
 Visual identification Intermittent IONM Continuous IONM
without IONM

Identification of LOS - + +

Avoidance of bilateral - + +
VCP in presence of intact
RLN anatomy

Identification of - limited _
intraoperative recovery of
RLN function

Minimization of traction - + +
related RLN

Real time monitoring over - - +

entire RLN

Detailed emg _ _ +
documentation
Applications

1.Mapping and identification of RLN - Redo surgeries,infiltrative thyroid ca

2.Prognostication of RLN function
3. Challenging anatomic variations
4.Surgical decision making and lower rate of bilateral vocal cord palsy
2015 American Thyroid Association guidelines
IONM nerve monitoring as an adjunct to facilitate nerve identification and to conform
neural function
AHNS guidelines for management of invasive DTC suggests considering use of IONM
In all cases of thyroid cancer surgery
German association of endocrine surgery and INMSG recommend routine use of IONM
in all cases of thyroid and parathyroid surgery
All eligible databases from 1980 to 2017
Meta-analysis was performed to evaluate the effect of IONM on RLN injury.
34 studies included in the analysis.
Overall analysis found a significant decrease in total injury (RR=0.68, 95%CI: 0.55 to
0.83),
transient injury (RR=0.71, 95%CI: 0.57 to 0.88), and permanent injury (RD=−0.0026,
95%CI: −0.0039 to −0.0012) with IONM.
Subgroup analysis found IONM played a preventive role of total, transient and
permanent injury in patients undergoing bilateral thyroidectomy.
INTRAOPERATIVE FACIAL NERVE MONITORING

Facial nerve monitoring is of interest in Otology,skull base surgery,Head and Neck surgery and
Neurologic surgery
It is routinely used - Vestibular schwannoma surgery
Facial nerve monitoring goals
Nerve localization
Detection of neural trauma
Assessmnet of neural integrity
INTRAOP METHODOLOGY
Short acting Neuromuscular blocking agents
Instruments
Recording ,grounding electrodes
Stimulator probes
EMG assembly
Four electrodes are placed - frontalis
Orbicularis oculi
Orbicularis oris
Mentalis muscle
Ground electrodes over sternum
 128 parotidectomies
47 without IONM 81 with IONM
End point HB at 1 and 6 months ( Facial palsy HB 3 or higher)

15 ( 8 transient,7 permanent) 19(12 transient,7 permanent)

Significant differences between two groups were only found with regard to reoperations
65 cases with IONM - 4 cases of mild temporary paralysis and no permanent post
operative paralysis of facial nerve
Avg operating time duration was 1.8 hr

44 cases control group - 9 cases of mild temporary paralysis 2 cases permanent

Avg operating time 3 hrs
conclusion

Excellent adjunct but not a replacement

Especially useful in difficult cases and tricky post treatment fields
Lesser operative times, easier access to nerve
Data still raw,need more studies
Judicious use in difficult cases, needs usage in all cases to gain familiarity
In India cost ….
THANK YOU