Intraoperative Monitoring Fundamentals - Five Day Course

Presenting a unique learning experience integrating both lecture and extensive hands-on workshops. The first two days of the course will focus on the essential fundamental principles of evoked potentials with an emphasis in the upper and lower extremity somatosensory techniques. Basic instrumentation concepts will also be presented to assist in developing an understanding of the equipment used and how the signals acquired are processed and displayed. This is followed by three days of lecture and hands-on training designed to integrate these fundamental concepts into the OR and learn the concepts to function as an Intraoperative Monitoring Specialist.

Topics covered include: Overview of Intraoperative Monitoring, Introduction to the Operating Room, Instrumentation Concepts, Neuroanatomy and Neurophysiology Related to Monitoring, Anesthesia concepts, Spinal Surgery Instrumentation, Spinal Cord Monitoring utilizing TCeMEP and SSEP, Nerve Root Monitoring with EMG, Cranial Nerve and EEG Monitoring, and hands-on workshops so each student has the opportunity to practice the skills taught in class.

INTRODUCTION TO EVOKED POTENTIALS AND INSTRUMENTATION The course begins with an introduction to Evoked Potentials then followed by lectures on near-field vs far-field recording methods, stimulus types and characteristics, calibration, polarity, amplification (recording gain, display gain, sensitivity), and filters. The averaging process will be explained in detail. You will learn how the analysis time, number of points, dwell time and sampling rate determine horizontal resolution and how to calculate each. Vertical resolution and the number of voltage levels expressed as bit capacity will be explained. You will gain an understanding of the signal-to-noise ratio and its effect on the resolution of the signal. You will gain a working knowledge of EP terminology.

UPPER EXTREMITY SOMATOSENSORY EVOKED POTENTIAL – UE SSEP We follow this with an introduction of the Upper Extremity SSEP followed by anatomy and physiology of the Upper Extremity Somatosensory System, electrode placement, instrument parameters, montage construction, and peak identification. This series of lectures is followed by an extensive hands-on workshop where each participant will have the opportunity to function as a technologist and a patient. The workshop is followed by lectures discussing waveform measurements, criteria for abnormality, and troubleshooting techniques.

LOWER EXTREMITY SOMATOSENSORY EVOKED POTENTIAL – LE SSEP Anatomy and physiology of the lower extremity somatosensory system, electrode placement, instrument parameters, montage construction, and peak identification. This series of lectures is followed by an extensive hands-on workshop where each participant will have the opportunity to function as a technologist and a patient. The workshop is followed by lectures discussing waveform measurements, criteria for abnormality, and troubleshooting techniques.

BRAINSTEM AUDITORY EVOKED POTENTIALS – BAEP Anatomy and physiology of the Brainstem Auditory System, electrode placement, instrument parameters, montage construction, and peak identification. This series of lectures is followed by hands-on workshop where each participant will have the opportunity to function as a technologist and a patient. The workshop is followed by lectures discussing waveform measurements, criteria for abnormality, and troubleshooting techniques.

OVERVIEW OF BASIC INTRAOPERATIVE MONITORING The course begins with a brief overview to include a historical perspective, philosophy, modalities, and applications of Basic Intraoperative Monitoring. Discussion will also focus on who records and who interprets the data, professional societies, IOM credentials, and CPT codes and billing guidelines.

INTRODUCTION TO THE OPERATING ROOM Students will learn the goal of intraoperative moniotring, basic terminology, aseptic and sterile techniques, operating room conduct for monitoring specialists, attire, roles, responsibilities, and communication of OR team members. Topics also covered include cautery use and safety, patient positioning, and Universal / Standard Precautions.

INSTRUMENTATION CONCEPTS Students will become acquainted with the recording equipment by learning gain/sensitivity, filters, principles of differential amplification, polarity, near-field/far field recording methods & potential nomenclature, analog-to-digital conversion specifically horizontal ( sampling rate, dwell time, aliasing ) and vertical ( bit capacity ) resolution. You will learn the different types of stimulation used for SEP, TCeMEP, EMG, Auditory Evoked Potentials.

NEUROANATOMY and NEUROPHYSIOLOGY RELATED TO MONITORING You will learn the brain and brainstem structures, anatomy of the vertebral column, auditory pathway, motor and sensory pathways of the spinal cord, muscles and nerve root innervation, and peripheral nerves associated with monitoring and cranial nerves. Also you will learn basic cell anatomy and function.

ANESTHESIA A basic understanding of anesthesia is mandatory for the monitoring specialist. You will gain an understanding of induction, maintenance, and emergence. You will learn about the role and perspective of the anesthesia specialist, trade and brand names of the more common anesthetic agents, methods of delivery, sedation issues, neuromuscular blockade, MAC, and narcotics. You will also learn how the BIS monitor is used and indications for and interpretation of cerebral oximetry. Students will also learn the physiological variables monitored by the anesthesia specialist and how these can effect monitoring.

SPINAL INSTRUMENTATION Students will be introduced to the concepts of deformity correction including rotation, distraction, decompression, and spinal fusion. Also addressed will be the advantages & disadvantages, risk to neural structures, and the instrumentation / hardware used to correct spinal deformities such as; pedicle screws, anterior interbody cages, and posterior lumbar cages.

SPINAL CORD MONITORING – TCeMEP The sensory and motor pathways must be monitored to adequately protect the spinal cord. Somatosensory Evoked Potentials (SSEP) and Transcranial Electrical Motor Evoked Potentials (TCeMEP) will be presented. Transcranial electrical motor evoked potentials will cover patient set-up, anatomy of the voluntary motor pathway, neurophysiology of the corticospinal tract, stimulation parameters, recording and anesthesia protocols, alarm criteria, special considerations, risk factors, safety considerations and informed consent. TCeMEP case studies will highlight the conclusion of this most important component of IOM.

SPINAL CORD MONITORING – SSEP Somatosensory Evoked Potentials will include response generators, anesthetic considerations, patient hook-up, muscles to monitor, contraindications and risks, advantages and interpretation, and clinically significant changes. Discussion will include how to monitor the more challenging patients like those with cerebral palsy, peripheral neuropathy, or those with pre-operative baseline abnormalities.

SPINAL NERVE ROOT MONITORING – EMG Indications for spontaneous (free-run) and Triggered EMG will be presented and discussion will focus on how to determine spinal level appropriate for monitoring. Patient hook-up and indications for EMG monitoring such as pedicle screw cases are discussed and demonstrated.

CRANIAL NERVE MONITORING Protection of the auditory and cranial nerves is an integral component of monitoring for skull base surgeries. You will learn the indications for Brainstem Auditory Evoked Potentials and EMG monitoring, responses, patient hook-up, anesthetic considerations, risks and contraindications, and clinically significant changes.

EEG MONITORING Monitoring EEG during carotid endarterectomy surgery has become the standard of care at most facilities. Topics include patient preparation and hook-up, anesthetic considerations, and clinically significant changes.

HANDS-ON WORKSHOPS Hands-on workshops are designed to teach you how to properly identify placement sites for stimulating and recording electrodes. Also facilitate understanding of stimulation methods, apppropriate montages, obligate waveforms, instrument parameters and recording techniques to adequately perform intraoperative monitoring.