Spinal Cord Monitoring

Details

Title

Spinal Cord Monitoring

Type

Stage Two

Module code

HPS257

Requirement

Optional

Module objective

By the end of this module the Clinical Scientist in HSST will be able to apply their expert knowledge of the principles, instrumentation, methodology, clinical application, and risks and benefits of spinal cord monitoring in adults and children. Their knowledge will include the clinical indications for monitoring, selection of equipment and techniques, interpretation of monitoring information and communication with the multidisciplinary team.

They will also have expert knowledge of management systems for the integration, dispersal, storage and access of results.

The Clinical Scientist in HSST will be expected to perform a range of technical, clinical and communication skills and consider the needs and views of the patients and their families undergoing procedures requiring spinal cord monitoring, treating patients and their families with kindness and compassion. They will be required to critically evaluate their own response to both normal and complex situations, consistently using the professional attributes and insights required of a Consultant. They will be aware of developments in technology that may be translated to and enhance neurological monitoring and will identify opportunities to innovate to improve patient safety and clinical services.

Stage 2 HSST education and training is designed to ensure the Clinical Scientist in HSST is learning and working at the cutting edge of science. Where necessary, given the speed at which science and technology develops, those delivering training and the Clinical Scientist in HSST together are expected to identify emerging developments that may be outside those specifically detailed in the Stage 2 modules and gain the knowledge and skills to take them forwards.

Knowledge and understanding

By the end of this module the Clinical Scientist in HSST will be able to analyse, synthesise, evaluate and critically apply their expert knowledge of spinal cord monitoring. This will include the design and application of appropriate neurophysiological measurement techniques to monitor the functional integrity of the sensory and motor spinal cord and peripheral neural structures during orthopaedic and neurosurgery in and around the spine, including:

Underpinning science:

• clinical and functional anatomy, physiology and pathophysiology relevant to spinal cord surgery and monitoring, including embryology and development;
• pharmacology and therapeutics relevant to spinal cord surgery and monitoring.

Clinical considerations:

• protecting patients of paediatric age and vulnerable adults from maltreatment, abuse, neglect, or exploitation (safeguarding);
• informed consent in adults and children;
• clinical investigations relevant to spinal cord surgery;
• surgical procedures undertaken in spinal deformity correction and other spinal surgery requiring neurophysiological monitoring;
• risks and mechanisms of neurological injury associated with surgical procedures;
• current guidelines for performance of intraoperative neurophysiological monitoring techniques;
• current local policies and procedures on individual responsibilities of members of the monitoring team and advised action relating to adverse events;
• the importance of performing all neurophysiological procedures in accordance with recognised guidelines.

Technical and clinical monitoring:

• important technical considerations such as:
  • electrode characteristics
  • filter settings
  • amplifier characteristics
  • the principles of computerised signal averaging and artefact rejection
  • how to recognise and correct of common artefacts during recordings
  • regular system calibration for stimulators and recorders
  • the effects of anaesthesia and systemic factors on the nervous system
  • the effects of anaesthesia and systemic factors on the recorded neurophysiological potentials
• formulating a plan with surgical and anaesthetic staff to monitor and map the neurological structures at risk during spinal and orthopaedic surgery, and devise a strategy for timely and effective feedback;
• pathophysiology of conditions where neurophysiology recordings are indicated during spinal deformity surgery, including:
  • scoliosis
  • kyphosis
  • spondylolisthesis
  • thoracic/lumbar fusion/decompression/correction.

Indications for and limitations of:

Somatosensory evoked potentials (SEPs):

• upper limb SEPs, including:
  • the use of upper limb SEPs as a means to monitor the cervical nerve roots and cord during surgery in and around the cervical region
  • the significance of using appropriate stimulus and recording sites
  • the use of upper limb SEPs as a means of a control for surgery below the level of the cervical region
  • the significance of a significant change in neurophysiological potentials amplitude and latency during surgery
  • the effects of neurological disease on upper limb SEP potentials
• lower limb SEPs, including:
  • the use of lower limb SEPs as a means to monitor the lumbar roots during surgery in and around the lumbar region
  • the significance of using appropriate stimulus and recording sites
  • the use of lower limb SEPs as a means to monitor the lumbar and thoracic cord during surgical procedures that put these structures at risk
  • the significance of a significant change in neurophysiological potentials amplitude and latency during spinal surgery
  • the effects of neurological disease on lower limb SEP potentials
• epidural recordings, including:
  • the use and safety of epidural potentials to record spinal sensory potentials during surgery
  • the significance of a significant change in recorded potential during surgery.

Transcranial motor evoked potentials (Tc-MEPs):

• stimulus parameters, including:
  • the selection of cortical derivations to optimise the MEP of interest
  • the selection of stimulus parameters to optimise the MEP of interest
• peripheral recordings, including:
  • the use of MEPs after transcranial electrical stimulation to monitor nerve root function
  • the significance of muscle recording site selection
  • the use of MEPs after transcranial electrical stimulation to monitor the integrity of the cervical, thoracic and lumbar spinal cord
  • the significance of a significant change in recorded motor potential during surgery
  • the effects of neurological disease on MEPs.
• D-waves, including:
  • the significance of a significant change in recorded potential during surgery
  • the use and safety of epidural potentials to record spinal motor potentials during surgery
  • the effects of spinal cord disease on D-waves.

Free-running electromyography (EMG), including:

• the significance of muscle recording site selection;
• the significance of a significant change in EMG discharges during spinal surgery;
• the effects of neuromuscular blockade on the recorded potentials.

Pedicle screw stimulation, including:

• the significance of muscle recording site selection;
• the significance of the site of stimulus delivery;
• the significance of a reduced stimulus intensity to evoke a muscle response;
• the effects of neuromuscular blockade on the recorded potentials.

Minimally invasive surgery, including:

• the significance of muscle recording site selection;
• the significance of the site of stimulus delivery;
• the effects of neuromuscular blockade on the recorded potentials;
• the intraoperative neurophysiological correlates of certain clinical conditions, such as neurological, neurosurgical and orthopaedic disorders;
• optimising the diagnostic value of intraoperative monitoring during spinal procedures;
• the sensitivity and specificity of a range of methods of neurophysiological monitoring of the spinal cord to predict impending neural injury;
• monitoring the outcome of spinal surgery, including the patient perspective.

Professional practice:

• adapt current tests, develop, validate and implement novel investigations to better to facilitate diagnosis and management within current ethical and governance frameworks;
• consistently work to high standards of clinical practice, applying knowledge and evidence, evidence-based decision making and evaluating the impact of those decisions;
• monitor, evaluate and maintain personal clinical practice standards and the standards of the service they lead;
• balance data confidentiality, security and protection, and the sharing of data with relevant stakeholders, including patients, to ensure high-quality patient- centred care;
• explain the principles and relevance of the novel procedures to patients at an appropriate level of complexity and involve patients in the development process appropriately;
• support conclusions drawn from evidence with reasoned argument;
• appreciate the impact of new evidence on patients and carers;
• facilitate effective and empathic communication with respect to the evidence base underpinning vascular science;
• act in accordance with the principles and practice of patient-centred care, regularly reflecting on personal practice and revising judgements and changing behaviour in light of new evidence;
• critically assess and evaluate personal and team-related performance in the context of evidence-based patient care, identify areas of good practice and make improvements where necessary;
• seek feedback from patients on their own and the team’s performance and adapt practice accordingly.

Advances in scientific and clinical practice:

• identify opportunities for innovative approaches to the development, delivery and evaluation of new clinical services;
• present these new developments in a concise and appropriate manner to the multidisciplinary team, including healthcare management, in order to influence and progress their implementation;
• keep up to date with scientific research in Neurophysiological Science;
• adopt a mindset that actively seeks creative solutions to problems through engagement with individual creativity, approaches and techniques;
• work with and encourage others to find creative solutions to problems through engagement with group creativity approaches and techniques;
• be positive and confident about developing ideas and putting them into action;
• actively seek out opportunities for collaborative discussions and research, being open to new developments, attending conferences and keeping up to date with the literature;
• adopt a forward-looking, progressive approach and be receptive to new ideas, looking out for emerging technologies;
• promote a sustainable, engrained culture of innovation in an individual, department and/or organisation;
• ensure clinical and scientist colleagues are kept up to date with novel techniques used within the service;
• ensure patients fully understand any procedure that is undertaken;
• continue to monitor any safety issues relating to a novel procedure introduced to the diagnostic or follow-up service.

Leading scientific services:

• critically review the literature and disseminate findings and scientific data and make recommendations for future activity;
• ensure clinical and scientist colleagues are kept up to date with new and novel techniques used within the service;
• work with patients and parents to develop and update patient information materials appropriate to service requirements;
• share data on clinical practice standards with service users and managers to encourage dialogue and debate;
• be committed to, support and lead continuous improvement of neurophysiological scientific services, with particular reference to auditing practice, evidence-based practice, innovation, and the introduction and use of new and improved technologies;
• reflect on the challenges of applying research to practice in relation to all areas of practice and suggest improvements, building on a critique of available evidence.

Technical and clinical skills

By the end of this module the Clinical Scientist in HSST will have a critical understanding of current evidence and its application to the performance and mastery of a range of technical skills and will:

• perform upper limb SEPs in theatre during surgery in and around the cervical region;
• perform upper limb control SEPs in theatre during surgery in and around the thoracic and/or lumbar region;
• design, develop, implement and evaluate appropriate recording techniques for the sensory spinal cord pathways;
• perform upper limb MEPs in theatre during surgery in and around the cervical region;
• perform upper limb control MEPs in theatre during surgery in and around the thoracic and/or lumbar region;
• design and develop appropriate stimulating and recording techniques for the motor spinal cord pathways;
• utilise epidural recording techniques for the monitoring of the sensory and motor spinal pathways;
• perform free-running EMG of selected muscle groups to evaluate root perform free-running EMG of selected muscle groups to evaluate root
• perform pedicle stimulation techniques to ensure integrity of the bone;
• interpret neurophysiological recordings acquired during surgery;
• communicate significant neurophysiological changes to the anaesthetic and surgical teams;
• reflect on the challenges of applying research to practice in relation to the use of spinal cord monitoring in clinical practice and suggest improvements, building on a critique of available evidence;
• promote the importance of innovation in spinal cord monitoring.

By the end of this module Clinical Scientist in HSST will be expected to critically reflect and apply in practice a range of clinical and communication skills with respect to monitoring the function of the spinal cord during surgery in and around the spinal cord. They will communicate effectively with patients, relevant clinicians and other healthcare professionals and will:

• take a relevant focused history, when appropriate in collaboration with the supervising clinician;
• perform the appropriate investigations, taking into account pathologic and non-pathologic contraindications and risks that affect the intraoperative neurophysiological recordings;
• take a holistic approach to spinal cord monitoring and provide an accurate and comprehensive assessment of the patient’s clinical problem;
• analyse all the recorded neurophysiological data during the surgical procedure;
• discuss the effects of anaesthesia on the neurophysiological recordings with the anaesthetic team to determine the optimal regimen;
• provide a clinical interpretation of the neurophysiological data, placing the results in the context of patient history, clinical examination and surgical procedure;
• produce a clear and informative clinical report;
• advise and communicate effectively with patients, relevant clinicians and the public, and other healthcare professionals working within the multidisciplinary team;
• adapt current tests and develop novel intraoperative recording techniques to better facilitate monitoring and mapping of the spinal cord during surgery;
• consistently work to high standards of clinical practice, applying knowledge and evidence, making decisions and evaluating the impact of those decisions;
• monitor, evaluate and maintain clinical practice standards;
• balance data confidentiality, security and protection, and the sharing of data with relevant stakeholders, including patients, to ensure high-quality patient- centred care;
• critically review the literature and disseminate findings and scientific data and make recommendations for future activity;
• ensure clinical and scientist colleagues are kept up to date with new and novel techniques used within the service;
• work with patients and parents to develop and update patient information materials appropriate to service requirements;
• share data on clinical practice standards with service users and managers to encourage dialogue and debate;
• support and contribute to the development of multidisciplinary clinical team working and work with the team to determine scientific service priorities;communicate effectively with the anaesthetic and surgical teams any significant changes in the neurophysiological recordings and their underlying pathophysiology;
• be committed to and support continuous improvement of neurophysiological services, with particular reference to auditing practice, evidence-based
• practice, innovation, new and improved technologies;critically reflect on the challenges of applying research to practice in relation to these areas of practice and suggest improvements, building on a critique of available evidence.