Intraoperative neuromonitoring for spinal surgery. A case of hemiparesis following posterior laminectomy and fusion with loss of intraoperative SSEP signals

1. Intraoperative Neuromonitoring in a case of Cervical stenosis with posterior decompression
Upper Chesapeake Medical Center Spine conference
8/18/17

2. 63 year old man
cc: LBP
HPI: Sx for 14 years. Rx with PT, chiropractor, massage, epidural
steroid injections, .
In the last 2-3 months c/o difficulty walking, loss of balance,
numb/pain thumb, IF, MF and radial hands. “Legs do not work
right”. Feet burning.
PMH: L knee scope, HTN, chol
Meds: amlodipine besylate, losartan , K
SH: civil servant, married, grown children
Exam: ataxia, waddling gait, B foot slap, L ankle 3-4 beats of
unsustained clonus, R no clonus, negative Hoffmans, full painless
ROM neck, 5/5 motor U and LE, no sens.
MRI lumbar spine : mild DDD, stenosis L3L5

4. RL

8. c2c3

9. c3c4

10. c4c5

11. c5c6

12. c6c7

13. PROBLEM LIST:
1. Severe ataxia
2. C6 radiculopathy
3. Stenosis C4C5>C3C4>C5C6
4. C4C5 spondylolisthesis
5. Myelomalacia C5C6

16. • Stagnara wake up test
• SSEP: somatosensory evoked potentials
• tcMEP: transcranial motor evoked potentials
• nMEP: neurogenic MEP spinal cord
• sEMG: spontaneous EMG
• tEMG: triggered EMG

18. MAP<60

23. Amplitude 50%
Latency 10%

24. : poor signals RLE
ost flip no change, prone position
nutes after laminectomy B 90% loss of signals
eturned while closing
.6L, EBL: 200cc, U/O: 250cc, op time: 3h20min

35. RR: 0/5 R motor, normal face, L
• RR: 0/5 R motor upper and
lower, normal face, L 4/5
motor upper and lower
RR: 0/5 R motor, normal face, L 4/5 motor

37. C4C5

38. 6weeks postop

39. thanks