1 1,5,6 Reference 1. Chappell AS et al. Pain Pract 2011;11(1): Chappell AS et al. Pain 2009;146(3): Frakes EP et al. Curr Med Res O

Transcription

1 니혼고텐 제 2 회대한수술중신경계감시연구회심포지움대한수술중신경계감시연구회대한수술중신경생리감시연구회 제 2 회 대한수술중신경계감시연구회 심포지움 ( 금 ) 서울아산병원내구내아산생명과학연구원지하대강당 대한수술중신경계감시연구회

2 1 1,5,6 Reference 1. Chappell AS et al. Pain Pract 2011;11(1): Chappell AS et al. Pain 2009;146(3): Frakes EP et al. Curr Med Res Opin 2011;27(12): Bymaster FP, et al. Curr Pharm Des. 2005;11(12): Woolf CJ. Pain Mar;152(3 Suppl):S Baron R. Nat Clin Pract Neurol Feb;2(2): 심발타 (주성분 : 둘록세틴) 원료의약품 명칭 및 분량 심발타 30mg 중 주성분 둘록세틴 30mg, 심발타 60mg 중 주성분 둘록세틴 60mg 효능 효과 주요 우울장애의 치료, 범불안장애의 치료, 당뇨병성 말초 신경병증성 통증의 치료, 섬유근육통의 치료, 비스테로이드성 소염진통제(NSAIDs)에 반응이 적절하지 않은 골관절 염 통증의 치료 용법.용량 이 약은 식사와 관계없이 투여할 수 있다. 1) 주요 우울장애: 1일 1회 60mg, 최대 1일 60mg 2) 범불안장애: 1일 1회 60mg, 최대 1일 120mg 1)~2)에서 일부 환자에는 약물에 적응할 수 있도록 1주일 동안 1일 1회 30mg으로 투여를 시작하여 1일 1회 60mg으로 증량할 수 도 있다. 3) 당뇨병성 말초 신경병증성 통증: 1일 1회 60mg, 최대 1일 120mg 3)에서 당뇨병의 합병증으로 종종 신장애 환자의 경우에는 저용량으로 시작하여 점차적으로 증량할 것을 고려한다. 4) 섬유근육통: 1일 1회 60mg, 최대 1일 60mg 5) 비스테로이드성 소염진통제(NSAIDs)에 반응이 적절하지 않은 골관절염통증: 1일 1회 60mg, 최대 1일 60mg 4)~5)에서 환자가 약물에 적응할 수 있도록 1주일 동안 1일 1회 30mg으로 투여를 시작하여 1일 1회 60mg으로 증량한다. 60mg에 반응을 보이지 않는 환자에게 1일 60mg 초과용량 투여는 추가적인 유익성이 없으며, 더 높은 이상 반응 발현율과 연 관된다. 사용상의 주의사항 중 경고 1) 자살 성향 및 우울증 치료제: 주요 우울장애나 다른 정신과적 질환을 가진 소아, 청소년 및 젊은 성인(18~24세)에 대한 단기간의 연구에서 우울증 치료제가 위약에 비해 자살 충동과 행동(자살 성향)의 위험도를 증가시킨다는 보고가 있다. 2) 세로토닌 증후군 사 용상의 주의사항 중 금기 1) 이 약의 주성분 또는 첨가제에 대해 과민증을 나타낼 경우 2) MAO 저해제와 병용투여 할 경우 3) 간질환 환자 4) 투석이 필요한 말기 신질환 환자 또는 중증의 신장애 환자(크레아티닌 청소율 < 30 ml/min) 5) 조절되지 않는 협우각 녹내장환자 6) 조절되지 않는 고혈압 환자 7) 과당 불내성(fructose intolerance), 포도당-갈락토스(glucose-galactose) 흡수장애, 또는 수크로스 이소말타아제 결핍증 등의 유전적인 질환을 가진 환자 제조원 계약 제조원 : Eli Lilly Netherlands BV Grootslag 1-5, NL-3991 RAHouten 수탁제조원 : Eli Lilly and Company, Lilly Technology Center Indianapolis, Indiana, 수입원 :한국릴리(서울특별시 중구 후암로 98 STX남산타워 4층) Tel ( ) 공동판매원 : 서울특별시 중구 동호로 330 CJ제일제당센터 11, 12층 CJ헬스케어 제품에 대한 자세한 내용은 제품 설명서 원본을 참고하시기 바랍니다. I 한국릴리 유한회사 I 서울특별시 중구 후암로 98 STX남산타워 4층 우) 대표전화번호 : I CJ 헬스케어 I 서울특별시 중구 동호로 330 CJ제일제당센터 11, 12층 CJ헬스케어 대표전화번호 : Oct 2016

3 제 2 회 대한수술중신경계감시연구회 심포지움 ( 금 ) 서울아산병원내구내아산생명과학연구원지하대강당 대한수술중신경계감시연구회

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5 제 2 회대한수술중신경계감시연구회심포지움 일시 : 2015 년 6 월 5 일 ( 금 ) 12:30~18:00 장소 : 서울아산병원내구내아산생명과학연구원지하대강당 Program 12:30-12:50 Registration 12:50-13:00 Opening remark 김주한 ( 한양의대 ) Symposium I 좌장 : 김주한 ( 한양의대 ) / 김창환 ( 인하의대 ) 13:00-13:30 Monitoring during vertebral column surgery 류한욱 ( 전북의대 ) 3 13:30-14:10 Monitoring during spinal cord surgery Vedran Deletis 17 (St. Luke s Roosevelt Hospital, USA) 14:10-14:40 Monitoring of spinal roots and pedicle screw evaluation 김기원 ( 서울의대 ) 44 14:40-15:20 Monitoring during lumbosacral surgery and selective dorsal rhizotomy Vedran Deletis 46 (St. Luke s Roosevelt Hospital, USA) 15:20-15:40 Coffee break Symposium II 좌장 : 박동식 ( 한림의대 ) / 박수철 ( 연세의대 ) 15:40-16:10 Anesthetic considerations 이지현 ( 서울의대 ) 67 16:10-16:40 Interpretation & reporting of neurophysiologic data 서대원 ( 성균관의대 ) 82 16:40-17:30 Case discussions 17:30-17:50 <Emerging issue> Monitoring devices without neurophysiologist: Is it trustworthy? 박윤길 ( 연세의대 ) 97 17:50-18:00 Closing

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7 제 2 회대한수술중신경계감시연구회심포지움 Symposium I 좌장 : 김주한 ( 한양의대 ) 김창환 ( 인하의대 )

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9 제 2 회대한수술중신경계감시연구회심포지움 Vertebral Column Surgery 류한욱 전북의대전북대학교병원신경과 Vetebral Column anatomy SEP technique MEP technique 대한수술중신경계감시연구회 3

10 제 2 회대한수술중신경계감시연구회심포지움 Spinal cord blood supply Anterior spinal artery Anterior horn Central gray matter Ventral portions of dorsal horns and corticospinal tracts Posterior spinal artery Dorsal column Superficial dorsal horn gray matter Outer rim of the cord D.B. MacDonald Clinical Neurophysiology 124 (2013) Radicular overlap and anatomic variation of muscle innervation Risk of vertebral column op Spinal cord Nerve root Brachial plexus Peripheral nerve Vertebral column disorders Scoliosis Abnormal vertebral column curvature in the coronal plane Cervical spondylosis Degenerative process consisting of boney spur formation with disc degeneration and prolapse Spinal fractures Trauma, pathologic fractures Vertebral column tumors Primary or metastatic tumors Ossification of the post. Longitudinal ligament (OPLL) Spinal canal narrowing due to calcification and ossification of the post. Longitudinal ligament 4 Symposium I

11 류한욱 Monitoring during vertebral column surgery Surgical procedures and IOM Posterior spinal fusion and instrumentation Anterior spinal release Anterior cervical discectomy and fusion Decompressive laminectomy Reduction and fixation Spinal tumor resection Surgical procedures and IOM Injury of mechnism Compression Traction Ischemia May injure the spinal cord Detection of spinal system Corticospinal system Position & vibration (Dorsal column) Bulbocarvernosus reflex F-wave, H-wave Limited detection Pain & temperature (spinothalamic system) Many other descending, ascending and intrinsic spinal cord system Surgical procedure Positioning Decompression Reduction maneuvers (including traction) Reconstruction 대한수술중신경계감시연구회 5

12 제 2 회대한수술중신경계감시연구회심포지움 Surgical procedure Positioning 1.8% of patients undergoing ant. Cervical spine surgery had evidence of impending neurological injury secondary to positiong Brachial plexopathy Peripheral nerve injuries (ulnar groove) Decompression Usually requires removal of bone and ligamentous structures Assess the physiologic integrity of the spinal cord and nerve roots during the surgical compression More than 20% recovery in signal amplitude at the conclusion of the operation was associated with favorable neurological outcome Surgical procedure Reduction Reduction maneuvers such as distraction can cause neural injury either by causing a traction injury or by compressing the neural structures Spinal deformity secondary to fracture dislocation are at risk for cord ischemia following spinal distraction Distraction might reduce blood vessel caliber and decrease spinal cord blood volume Reconstruction Placement of hardware such as screws, plates and cages to stabilize spine has a potential risk of injury to spinal cord or roots Both triggered and spontaneous EMG has been used to monitor Intraoperative neuromonitoring consideration First applied modality of SEP Halved paraplegia risk during scoliosis surgery (Nuwer et al., 1995) Spinal cord compromise threatening paralysis might affect the full transverse extent of the cord causing SEP deterioration MEP + SEP Anatomical separation of corticospinal and dorsal column tract Distinct blood supply 6 Symposium I

13 류한욱 Monitoring during vertebral column surgery Somatosensory Evoked Potentials International Federation of Clinical Neurophysiology (IFCN 1999) American Clinical Neurophysiology Society (ACNS ) American Society of Neurophysiologic Monitoring (ASNM 2005) No universally standardized SEP monitoring criteria Upper limb SEPs median nerve stimulation Surgery risk C7~C8 cord ulnar nerve stimulation Lower limb SEPs tibial nerve at the ankle Alternative peroneal nerve at the knee Separately testing using alternating stimulation To avoid simultaneous stimulation mask unilateral cord compromise MEDIAL NERVE SEP Electrode position 대한수술중신경계감시연구회 7

14 제 2 회대한수술중신경계감시연구회심포지움 SEP in Intraoperative neuromonitoring Averaging ASNM: 300~500 sweeps ACNS 200~1000 sweeps IFCN no recommendation nonoptimized cortical and subcortical SEP Need of rapid surgical feedback Reliable interpretation of SEP (Less than 20~30% random trial variation) SNR optimized derivation 50~100 sweeps (generally less than 200) MacDonald Clin Neurophysiol SEP Stimulating and Recording Parameters Stimulation Upper extremity Lower extremity Nerve stimulated Median or Ulnar Posterior tibial Frequency (Hz) 2~5 2~5 Intensity (ma) 15~35 30~60 Duration (msec) 100~ ~300 Number of averages 250~ ~750 Recording Filter (Hz) LFF HFF 1,000~3,000 1,000~3,000 Time base (msec) 40~50 75~150 Neurophysiologic IOM 2 nd SEP waveforms Upper SEP waves N20 - near field potential by primary somatosensory cortex N18 far field potential by medial lemniscus to thalamus P14 far field potential by cuneate nucleus N13 - near field potential by cervical spine N9 (EP) - near field potential by brachial plexus Lower SEP waves P37 - near field potential by primary somatosensory cortex N34 - far field potential by medial lemniscus to thalamus P31 - far field potential by gracilis nucleus N22 near field potential by lumbar spine 8 Symposium I

15 류한욱 Monitoring during vertebral column surgery Cortical potentials Upper limb derivations Negative N20 generated by the contr. Post-central scalp Positive P22 potential by frontal scalp Stimulation one side while simultaneous recording CPc and Cpi (Decussation assessment) Input 1 should be CPc for normal decussation and Cpi for non-decussation Frontal Input 2 (FPz or Fz) boosts signal amplitude because of P22 CPc-Fpz or CPc-Fz (but may have frontal EEG noise) CPc-CPi or CPc-CPz Normal decussation CPc-FPz, CPc-CPi and CPc-CPz Non-decussation Cpi-FPz, Cpi-CPc and Cpi-CPz MacDonald Clin Neurophysiol. Median somatosensory evoked potential intraoperative monitoring: recommendation based on signal-to-noise ratio analysis Median SEP decussation test Cortical potentials Lower limb derivations Positive P37 generated by leg sensory cortex of the contralateral hemisphere Highly variable potential s scalp field Commonly maximal near CPz but may be maximal at Cz or Pz With normal decussation, its field spreads over the ipsilateral scalp to the stimulated nerve while a simultaneous negative N37 arises over the contralateral scalp Left stimulation(decussation): Cz-CP4, CPz-CP4, Pz-CP4, CP1-CP4, CP3-CP4, Cz-FPz, CPz-FPz, Pz-FPz, Pz-FPz, CP1-FPz, CP3-FPz and Cz-Pz Non-decussation: Cz-CP3, CPz-CP3, Pz-CP3, CP2-CP3, CP4-CP3, Cz-FPz, CPz- FPz, Pz-FPz, CP2-FPz, CP4-FPz and Cz-Pz Traditional method: CPz-CPc, Cpi-CPc, CPz-FPz and Cpi-FPz for normal decussation Traditional method: CPz-Cpi, CPc-Cpi, CPz-FPz and Cpi-FPz for nondecussation D.B. MacDonald Clinical Neurophysiology 115 (2004) 대한수술중신경계감시연구회 9

16 제 2 회대한수술중신경계감시연구회심포지움 Tibial SEP decussation test Optimal P37 monitoring derivations for 74 tibial nerves of 37 patients Input 1 Input 2 CPc Cpi* Pz FPz Cz CPz Pz icpi Cpi *Non-decussation, CPc and Cpi, CP4 or CP3 contralateral and ipsilateral to the stimulated nerve; icpi, CP2 or CP1 intermediate centroparietal ipsilateral D.B. MacDonald Clinical Neurophysiology 116 (2005) Subcortical potentials Upper limb Subcortical P14-N18 complex is recorded Input 1: CPi (for normal decussation) Input 2: Epc (to aviod cervical cord potential contamination) : mastoid C5S-FPz (combines the cervical N13 and inverted P14) Lower limb Subcortical P31-N35 complex is recorded FPz-C5S is used but due to small signal and high noise, inconsistent for reliably effective monitoring Lesser sensitivity to anesthesia but not be standard potential 10 Symposium I

17 류한욱 Monitoring during vertebral column surgery Peripheral potentials Lower limb monitoring: PF (popliteal fossa) Upper limb monitoring: EP (Erb s point) CF (Cubital fossa) CF is better choice because of containing little noise than EP Provide determining supramaximal stimulus Detect distal limb ischemia or pressure Technical control may be ruled out Need of Motor evoked potential Consistently show good correlation to early postoperative motor outcome in expert hands Typically provide an earlier warning than SEP so that intervention can be initiated more quickly Directly test motor pathways Do have supporting evidence for improved outcome during related intramedullary spinal cord tumor and descending aortic surgery D.B. MacDonald J Clin Monit Comput. 20(2006) Motor evoked potentials Spinal D-waves Single pulse TES (transcranial electrical stimulation) can monitor D (direct wave) wave in the spinal epidural or subdural space The bipolar recording electrode must be inserted into the epidural space Advantage of D-wave Relatively immune to anesthesia No relation with neuromuscular blockade High stability and rapid reproducibility due to high SNR Excellent correlation to long-term motor outcome for intramedullary spinal cord tumor and cerebral tumor surgery Limitation of D-wave Invasive and cannot be used for anterior precedures Not clearly lateralized Excludes lower motor neuron Becomes to small to record at lumbosacral cord False results during scoliosis surgery Ulkatan S Clinical Neurophysiology 117 (2006) D.B. MacDonald Clinical Neurophysiology 124 (2013) 대한수술중신경계감시연구회 11

18 제 2 회대한수술중신경계감시연구회심포지움 Motor evoked potentials Muscle potentials Pulse train TES evokes muscle MEPs Possible to assesses corticospinal system and lower motor neurons Good correlation with early postoperative outcome More sensitive for spinal cord compromise than SEP More sensitive to anesthesia than SEP (TIVA appears optimal) Stimulus parameters 3~8 retangular pulses 1~5 millisecond interstimulus interval (ISI) Commonly started 5 pulses with 4 msec ISI for spine surgery M3-Mz and M4-Mz are used for initial decussation assessment Right MEP: M1-M2 or M3-M4 Delitis V. Clinical Neurophysiology 112 (2001) D.B. MacDonald Clinical Neurophysiology 124 (2013) Single D-wave and pulse train muscle MEP 12 Symposium I

19 류한욱 Monitoring during vertebral column surgery Pathologic changes of EP Distal nerve disturbances EP decrement of the affected limb due to peripheral nerve conduction may suggest distal limb ischemia or pressure Proximal nerve or plexus disturbances EP decrement of the affected limb without affecting peripheral SEPs may occur in the arms during spine surgery due to shoulder malpositioning Repositioning may help prevent postoperative neuropathy or brachial plexopathy Radiculopathy NIOM do not identify isolate root conduction failure or injury due to radicular overlap Dermatomal SEP might identify individual sensory root dysfunction but is unreliable Discrete motor root infury may not be apparent in muscle MEPs However, when the injured root supplies a major part of the recorded muscle s innervation, obvioius abrupt step reduction of MEP amplitude may be seen Multiple muscle to monitor MEPs is reasonable D.B. MacDonald Clinical Neurophysiology 124 (2013) Pathologic changes of EP Spinal cord compromise May produce abrupt bilateral or unilateral MEP loss and/or tibial cortical SEP amplitude decrement Focal evoked potential decrements can be seen to spread which further indicate pathologic change than systemic effect Four patterns of evoked potential decrement MEP only MEP followed by SEP Simultaneous MEP/SEP SEP only (rare) Warning criteria Traditional warning criteria 50% decrease in amplitude and 10% increase in latency Latency prolongation is the hallmark of demyelination (chronic process) Acute axonal conduction failure or neuronal failure predominantly reduces signal amplitude SEP consideration Poor reproducibility (>30% amplitude variation) compromises the identification of true amplitude changes Good reproducibility (20~30% variation) is essential to identify true more than 50% SEP amplitude decrements Exellent repoducibility (<20% variation) lesser degrees of true SEP amplitude decrement may be significant MacDonald DB Clin Neurophysiol.l 2004;115(3): 대한수술중신경계감시연구회 13

20 제 2 회대한수술중신경계감시연구회심포지움 Warning criteria MEP consideration No significant noise distortion but show trial-to-trial variation due to inherent fluctuations of lower motor neuron excitability High sensitivity so that pathologic decrements tend to overestimate the degree of corticospinal system compromise Variable warning criteria of MEP in spinal surgery Only disapperance of previously consistent muscle MEP is significant Very marked attenuation (80%) of amplitude is significant Greater than 100V MEP threshold elevation or transformation from long duration polyphasic to short duration biphasic potentials may be meaningful sign D.B. MacDonald J Clin Monit Comput. 20(2006) D.B. MacDonald Clinical Neurophysiology 124 (2013) Systemic factors Hypothermia & Anesthesia Mild-to-moderate hypothermia prolongs latency but has less effect on amplitude Intensional deep hypothermia obliterates both potentials Anesthetic increments can reduce amplitude However stable anethesia may produce unexplained potential fade (falling cortical SEP amplitudes, muscle MEP fading or increasing stimulus requirements) Hypotension Mean arterial pressure < 60mmHg can cause ischemia and restoring BP may be followed by potential restoration Anesthetic Fade Lyon. J Neurosurg Anesthesiol 2005;17: Symposium I

21 류한욱 Monitoring during vertebral column surgery R/O Systemic effects Systemic effects are generalized and tend to be gradual Produce approximately parallel four-limb changes Gradual changes evolving over many minutes or hours are likely to be systemic Careful bolus anesthesic injection is recommended May produce relatively abrupt generalized evoked potential decrements 213 consecutive patients who underwent INM during thoracolumbar spine surgery Intraoperative MEP Sensivity: 100% Specificity: 23.7% Intraoperative SEP Sensitivy: 28.6% Specifity: 94.7% Combined INM with EMG and SEPs is helpful Gunnarsson et al 대한수술중신경계감시연구회 15

22 제 2 회대한수술중신경계감시연구회심포지움 Monitoring screen 16 Symposium I

23 제 2 회대한수술중신경계감시연구회심포지움 Intraoperative monitoring during spinal cord surgery Vedran Deletis Institute for Neurology and Neurosurgery, St. Luke s-roosevelt Hospital, New York, USA 대한수술중신경계감시연구회 17

24 제 2 회대한수술중신경계감시연구회심포지움 18 Symposium I

25 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 19

26 제 2 회대한수술중신경계감시연구회심포지움 20 Symposium I

27 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 21

28 제 2 회대한수술중신경계감시연구회심포지움 22 Symposium I

29 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 23

30 제 2 회대한수술중신경계감시연구회심포지움 24 Symposium I

31 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 25

32 제 2 회대한수술중신경계감시연구회심포지움 26 Symposium I

33 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 27

34 제 2 회대한수술중신경계감시연구회심포지움 28 Symposium I

35 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 29

36 제 2 회대한수술중신경계감시연구회심포지움 30 Symposium I

37 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 31

38 제 2 회대한수술중신경계감시연구회심포지움 32 Symposium I

39 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 33

40 제 2 회대한수술중신경계감시연구회심포지움 34 Symposium I

41 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 35

42 제 2 회대한수술중신경계감시연구회심포지움 36 Symposium I

43 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 37

44 제 2 회대한수술중신경계감시연구회심포지움 38 Symposium I

45 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 39

46 제 2 회대한수술중신경계감시연구회심포지움 40 Symposium I

47 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 41

48 제 2 회대한수술중신경계감시연구회심포지움 42 Symposium I

49 Vedran Deletis Intraoperative monitoring during spinal cord surgery 대한수술중신경계감시연구회 43

50 제 2 회대한수술중신경계감시연구회심포지움 Monitoring of spinal roots and pedicle screw evaluation 김기원 서울의대서울대학교병원재활의학과 수술중척수의신경생리감시는척추체의유합및교정수술, 심장및대동맥등의심혈관수술, 또는척수내 / 외척추종양수술에서매우중요하다. 감각유발전위검사및운동유발전위검사가주로수술중감시에이용되어왔고, 각각척수후기둥및피질척수로의기능을평가할수있다. 최근에는척수후기둥또는피질척수로를확인하는데척수매핑 (spinal cord mapping) 의활용이개발되었고, 유발근전도등을함께사용하여수술중신경손상을최소화할수있다. 1 특히, 척수수술에서 D-wave의임상적유용성은널리입증되어있으나임상에서의활용은부족하다고할수있다. 2 운동유발전위의유의한변화기준에대해서다양한지표가제안되었으나이에대해서는아직논란의여지가있고, 진단및수술에따른고려가필요하다. 3-5 이러한다양한수술중감시방법들은필요에따라다양하게조합되어사용될수있으며, 적절한해석을필요로한다. 6 References 1. Yanni DS, Ulkatan S, Deletis V, Barrenechea IJ, Sen C, Perin NI. Utility of neurophysiological monitoring using dorsal column mapping in intramedullary spinal cord surgery. Journal of neurosurgery Spine 2010;12: Yamamoto T, Katayama Y, Nagaoka T, Kobayashi K, Fukaya C. Intraoperative monitoring of the corticospinal motor evoked potential (D-wave): clinical index for postoperative motor function and functional recovery. Neurologia medico-chirurgica 2004;44:170-80; discussion Ito Z, Imagama S, Sakai Y, et al. A new criterion for the alarm point for compound muscle action potentials. Journal of neurosurgery Spine 2012;17: Calancie B, Molano MR. Alarm criteria for motor-evoked potentials: what s wrong with the presence-or-absence approach? Spine 2008;33: Nelson EG, Hinojosa R. Age-related histopathologic changes in the human cochlea. Otolaryn- 44 Symposium I

51 김기원 Monitoring of spinal roots and pedicle screw evaluation gology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2005;133: Deletis V, Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clinical neurophysiology: official journal of the International Federation of Clinical Neurophysiology 2008;119: 대한수술중신경계감시연구회 45

52 제 2 회대한수술중신경계감시연구회심포지움 Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy Vedran Deletis Institute for Neurology and Neurosurgery, St. Luke s-roosevelt Hospital, New York, USA 46 Symposium I

53 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 47

54 제 2 회대한수술중신경계감시연구회심포지움 48 Symposium I

55 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 49

56 제 2 회대한수술중신경계감시연구회심포지움 50 Symposium I

57 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 51

58 제 2 회대한수술중신경계감시연구회심포지움 52 Symposium I

59 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 53

60 제 2 회대한수술중신경계감시연구회심포지움 54 Symposium I

61 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 55

62 제 2 회대한수술중신경계감시연구회심포지움 56 Symposium I

63 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 57

64 제 2 회대한수술중신경계감시연구회심포지움 58 Symposium I

65 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 59

66 제 2 회대한수술중신경계감시연구회심포지움 60 Symposium I

67 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 61

68 제 2 회대한수술중신경계감시연구회심포지움 62 Symposium I

69 Vedran Deletis Intraoperative monitoring during lumbosacral surgery and selective dorsal rhyzotomy 대한수술중신경계감시연구회 63

70

71 제 2 회대한수술중신경계감시연구회심포지움 Symposium II 좌장 : 박동식 ( 한림의대 ) 박수철 ( 연세의대 )

72

73 제 2 회대한수술중신경계감시연구회심포지움 Anesthetic consideration during intraoperative neurophysiologic monitoring 이지현 Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea Issues of intraoperative Neurophysiologic Monitoring Multimodal monitoring technique Ex. Combined monitoring of SSEP and tcmep YOUR LOGO Intraoperative Neurophysiologic Monitoring Electromyography Motor nerve conduction studies Somatosensory evoked potentials Motor evoked potentials Brainstem auditory evoked potentials electroencephalography YOUR LOGO 대한수술중신경계감시연구회 67

74 제 2 회대한수술중신경계감시연구회심포지움 General Anesthesia Hypnosis Analgesia Paralysis Stability of the autonomous nerve system JAMA. 2011;305(10):1050 YOUR LOGO Stage of Anesthesia Induction : Intravenous anesthetics - propofol, barbiturate : Volatile agent (maximal dose) : Neuromuscular blocking agent to facilitate tracheal intubation Maintenance : Volatile agents Minimum Alveolar Concentration (MAC) : Total intravenous anesthesia - Target effect site concentration (Ce) : Balanced anesthesia low dose volatile agents with low dose IV anesthetics Emergence : Discontinue all anesthetics : Reverse the effect of NMA YOUR LOGO Effect of Anesthetic Agents inhalational anesthetics YOUR LOGO 68 Symposium II

75 이지현 Anesthetic consideration during intraoperative neurophysiologic monitoring Volatile agents Mechanism of Action (+) control of GABA receptor (-) control of excitatory NMDA receptor /nach receptor synaptic transmission Enhancement of muscle relaxation MEP (0.2MAC) > cortical SSEP ( MAC) >>> subcortical SSEP Isoflurane> Sevoflurane, Desflurane >Halothane YOUR LOGO N2O Adjuvant agent Decrease in its usage Potentiate the depressant effects of volatile agent Cortical SSEP >>> subcortical SSEP (more profound than other inhalation anesthetics at equipotent dose) MEP > 9% decrease in amplitude during single pulse tcmep at 60% N2O Recommended dose : < 50% N2O Neurosurgery 1989;24:253-6., Br J Anaesth 1999;82: YOUR LOGO Effect of Anesthetic Agents intravenous anesthetics YOUR LOGO 대한수술중신경계감시연구회 69

76 제 2 회대한수술중신경계감시연구회심포지움 Propofol N-methyl-d-aspartate receptor antagonists A dose-dependent reduction in SSEP and MEP amplitude without effect on latency Well-studied PK-PD modeling in adult easy to titrate Produce a more stable neurophysiological environment for monitoring cf. children // propofol infusion syndrome No analgesic properties combined with opioid Neurosurgery 29: , 1991, Br J Anaesth 91: , 2003, J Neurosurg 96: , 2002 YOUR LOGO YOUR LOGO Opioids Fentanyl, remifentanil, alfentanil, sufentanil Little effect on SSEP and MEP monitoring Bolus >> continuous infusion Context sensitive half time YOUR LOGO 70 Symposium II

77 이지현 Anesthetic consideration during intraoperative neurophysiologic monitoring Midazolam Induction dose : 0.2 mg/kg suppression of cortical SSEP Even low dose (0.05 mg/kg) cause a prolonged, marked depression in MEP recording poor induction agent when MEP recording is planned YOUR LOGO Barbiturate Thiopental sodium Common induction agent amplitude, latency in SSEP (for about 10 min.. ) Induction bolus may abolish myogenic MEP for min It is not known if multi-pulse stimulation can overcome this suppression Not recommended when MEP is planned Anesth Analg 1988;67: ,Spine (Phila Pa 1976) 1993;18: YOUR LOGO Ketamine Enhance cortical SSEP amplitude within 2-10 min after bolus administration Little effect on MEP Hypnotic and analgesic effect Can decrease the use of other anesthetics good for obtain EP response Limitation.. - IICP, hypertension, excessive secretion, halluciation.. YOUR LOGO 대한수술중신경계감시연구회 71

78 제 2 회대한수술중신경계감시연구회심포지움 Dexmedetomidine Alpha-2 receptor agonist mcg/kg/hr little effect on SSEP recording Bolus may decrease the response of MEP (recovery within 30 min) Limitation - Age limitation (<18 yr) - bradycardia, hypertension followed by hypotension.. Expecially in children Anesthesiology 2008; 109:417-25, Anesthesiology 2007;106:393-6 YOUR LOGO Neuromuscular blocking agents No effect on SSEP// abolish MEP response YOUR LOGO Nerve stimulation test For effective MEP monitoring T1 response >10-20% of baseline presence of 2 of 4 twitches of TOF YOUR LOGO 72 Symposium II

79 이지현 Anesthetic consideration during intraoperative neurophysiologic monitoring YOUR LOGO YOUR LOGO YOUR LOGO 대한수술중신경계감시연구회 73

80 제 2 회대한수술중신경계감시연구회심포지움 YOUR LOGO YOUR LOGO YOUR LOGO 74 Symposium II

81 이지현 Anesthetic consideration during intraoperative neurophysiologic monitoring Sugammadex The rocuronium molecule is bound within sugammadex's lipophilic core Recurarisation, a phenomenon of recurrence of neuromuscular block, may occur Rocuronium, vecuronium, pancuronium 16 mg/kg sugammadex, 3 minutes after intubating dose of ROC A median time to recovery of the T4/T1 ratio to 0.9 is 1.5 min YOUR LOGO After reversal, a significant increase in TCeMEPs amplitude was observed, but with great variability in muscle response. YOUR LOGO YOUR LOGO 대한수술중신경계감시연구회 75

82 제 2 회대한수술중신경계감시연구회심포지움 Effect of Various Anesthetic Agents on Evoked Responses YOUR LOGO Nonpharmacologic factor YOUR LOGO Clinical Practice in Anesthesia for Evoked Potential Monitoring YOUR LOGO 76 Symposium II

83 이지현 Anesthetic consideration during intraoperative neurophysiologic monitoring In adult patients.. Some anesthesiologists often prefer to use low dose of volatile anesthetics YOUR LOGO..Anesthesia: PPF + FTN + N2O, tcmep monitoring.. HAL SEVO 0.5MAC ISO 1 hr HAL SEVO 1MAC ISO J Neurosurg Anesthesiol 2006;18: YOUR LOGO 0.5 MAC of desflurane + low dose propofol or opioid vs. Total intravenous anesthesia (propofol +opioid) 156 adult patients undergoing spinal surgery P = and 0.44 P = 0.15 and 0.82 J Clin Monit Comput (2015) 29:77 85 YOUR LOGO 대한수술중신경계감시연구회 77

84 제 2 회대한수술중신경계감시연구회심포지움 Limitation.. Retrospective observational study The choice of anesthesia was not random TIVA for patients with preexisting neurological or vascular compromise The amplitudes of TIVA group would be lower than DES group J Clin Monit Comput (2015) 29:77 85 YOUR LOGO In pediatric patients.. Low dose volatile agent + other drugs TIVA Reduced use of PPF Off-label use of PPF (<3yr) Difficult to control effect site concentration Delayed awakening Difficult to obtain MEP PPF-infusion syndrome YOUR LOGO TCI for children YOUR LOGO 78 Symposium II

85 이지현 Anesthetic consideration during intraoperative neurophysiologic monitoring Alternatives of PPF-opioid regimen Use of Dexmedetomidine and Ketamine infusions during Scoliosis Repair Surgery with Somatosensory and Motor-Evoked Potential Monitoring: A Case Report AANA J Dec;78(6): YOUR LOGO Planning the anesthetic approach EPs that are sensitive to Volatile agents EPs that are relatively insensitive to Volatile agents EPs that are insensitive Neuromuscular agents EPs that are sensitive Neuromuscular agents Cortical SSEP Cortical AEPs Volatile<0.5 MAC DES or SEVO Not affected by IV agents NMB may quality of EP Transcranial MEPs Limit use of volatile agents and NMBs TIVA requires careful titration of propofol Monitor acid base and electrolytes Epidural and perispinals SSEPs and MEPs Subcortial SSEPs BAEPs Both volatile and IV agents safe Pedicle screw stimulation, spinal reflex testing, motor cranial nerve (e.g. facial nerve) Volatile agents may be used Avoid NMBs YOUR LOGO Caution!! YOUR LOGO 대한수술중신경계감시연구회 79

86 제 2 회대한수술중신경계감시연구회심포지움 Monitoring during neurosurgery ECG Invasive arterial blood pressure Central venous pressure Pulse oximetry Body temperature Bispectral index YOUR LOGO Regional tissue oxygen saturation (rso2) Near-infrared spectroscopy technique Cerebral and extra-cerebral tissue oxygen saturation YOUR LOGO YOUR LOGO 80 Symposium II

87 이지현 Anesthetic consideration during intraoperative neurophysiologic monitoring 29 adult patients Median nerve SSEP testing INVOS monitor Decrease in rso2 < 10% from baseline or rso2 < 50% correlated with any reduction in SSEP amplitude indicate cerebral ischemia YOUR LOGO YOUR LOGO Summary Regardless whether inhalational anesthetics or intravenous anesthetics are used during spine operations where SSEPs and MEPs are being monitored, it is important to attempt to maintain constant (steady-state) concentrations of anesthetics. Bolus administration or acute changes in inhalational anesthetics can result in marked alterations in evoked potentials, which must be distinguished from potential neuronal injury. YOUR LOGO 대한수술중신경계감시연구회 81

88 제 2 회대한수술중신경계감시연구회심포지움 Interpretation & reporting of neurophysiologic data 서대원 성균관의대삼성서울병원신경과 배경 INM 방법 INM 판독내용 INM 판독증례들 내용 배경 INM 방법 INM 판독내용 INM 판독증례들 내용 82 Symposium II

89 서대원 Interpretation & reporting of neurophysiologic data SMC INM cases 1,600 1,400 1,200 1, 합계 ,010 1,075 1,043 1,246 1,572 Growth in volume of INM cases Number of cases (in thousands) U.S INM cases Nuwer MR Neurology 2013 대한수술중신경감시연구회 대한수술중신경계감시연구회 83

90 제 2 회대한수술중신경계감시연구회심포지움 대한수술중신경계감시연구회 대한수술중신경계감시연구회 대한수술중신경계감시연구회수신회 Korean Society of Intraoperative Neurophysiologic monitoring KSIN 한국신경모니터링연구회 84 Symposium II

91 서대원 Interpretation & reporting of neurophysiologic data 검사자의교육 시행단계 관심 : 어떤것일까? 시행하는데문제는없을까? 동기 : 어떻게배워야하나? 우리스승은왜안배워줬을까? 의욕 : 어떻게하면많이할수있을까? 우리병원에서안하시는분은? 욕심 : 어떻게하면쉽게잘할수있을까? 우리병원잘할수있는분야은? 불안 : 앞으로안정적으로발전할수있을까? 안정적으로확대할수있는가? 대한수술중신경계감시연구회 85

92 제 2 회대한수술중신경계감시연구회심포지움 86 Symposium II

93 서대원 Interpretation & reporting of neurophysiologic data 배경 INM 방법 INM 판독내용 INM 판독증례들 내용 Guidelines on Evoked Potentials Standards for EP Equipment Amplifier, Averager, Display, Writeout, Standards for EP Recording Electrical safety, Filtering, Polarity, Calibration Option Standards for Documentation and Interpretation of Results Name, ID, A/S Date, #, Tech name or initials Stimulation pattern, polarity, field/check size, full/partial field, intensity, frequency, stimulation site, masking Recording averaging number, time base, voltage calibration Channel (Input 1-input 2) Guidelines on SL AEP Stimulation Polarity :(R), (C), (R and C) clicks Rate : 5~200/s (8~10/s) Stimulus Intensities: 40~120 db pespl. Contralat. masking white noise at 60 dbspl Recording Band pass: 10~30 to 2,500~3,000 Hz (-3 db) Impedances: < 5 KW Analysis time: ms from stimulus onset No of Trials: 1K~4K individual trials Guidelines on SL SSEP Montage Channel 1: Cz - Ai or Mi; Channel 2: Cz - Ac or Mc Stimulation Impedance < 5KW Ground electrode on the stimulated limb monophasic rectangular pulses (pulse width: 100~300us, stim. rate: 3~5Hz) Recording standard EEG disk electrodes < 5 KW (collodion is more stable than EEG paste) Passband: appr. 30~3,000Hz (-6 db/oct) Re. Standards Analysis for VEP time: 40 ms for MNSEP and 60 ms for PTSEP Guidelines for Writing Clinical EP Reports 대한수술중신경계감시연구회 87

94 제 2 회대한수술중신경계감시연구회심포지움 SEP Methods Recording Sites: cortical CPz, CP3/4 cord epidural/subc Others Kz, 5 uv, 10 ms/d, Recording cortical Cord Stimulation Sites transcut median, post tibial epidural cord Others repeated 10-50mA, 0.2ms, 5.9/s (threhols) Stimulation MEP Methods Stimulation Location Type Others transcranial direct cortical epidural single repeated 500V, 15 ma, 0.3 msec, 30-50Hz (threshold) Stimulation APB ADQ Cord Recording Location spinal epidural distal muscle D-wave CMAP Others Kz, 100 uv, 2 ms/d, no averaging Recording TA AH Stimulation Parameters emplyoing rectangular biphasic pulse Pulse polarity Pulse interval 20msec (50Hz.) Intensity (ma) +15 Pulse intensity -15 Pulse duration 0.3msec Train duration 5sec. 88 Symposium II

95 서대원 Interpretation & reporting of neurophysiologic data 자극시고려사항 자극부위경두개 (transcranial) 피질 (direct cortical) 신경 (direct peripheral) 자극목적 추적감시파형추적감시기능평가주변신경조직확인정체불명조직이신경인지확인신경계기능이유지되고있는지확인 Stimulation Parameter DCS MEP Pulse 0.3 msec 0.05 (0.5endeav) pos-nega pos biphasic mono square-wave SW Intensity 1-15mA V Freq (IPI) 50Hz(20msec) 500Hz (2msec) Train duration 5-10sec 10msec 대한수술중신경계감시연구회 89

96 제 2 회대한수술중신경계감시연구회심포지움 판독시행의장단점 부담 오류 검사후피곤 의료사고책임 장점 복습 자료제시 연구의중심 공통적인발전 향후 INM 주체역할 INM Precision Efficiency 효율적융통성 원리적 엄격성 Experience 배경 INM 방법 내용 INM 판독내용 INM 판독증례들 90 Symposium II

97 서대원 Interpretation & reporting of neurophysiologic data Guidelines for Writing Clinical Evoked Potential Reports Identification Technical results Description Normal Latency, amplitude, hemispheric dff, topography Interpretation Impression normal or abnormal (severity) technically inadequate for interpretation showing a pattern of unknown clinical significance technically inadequate results Clinical relevance 판독내용의구성 1. 정보 2. 방법 3. 결과 4. 결론 환자, 수술, 마취, 검사자검사시간, 종류, 자극, 기록검사별결과값또는그래프이상소견등급화임상적연관성 1. 기본정보 환자정보 수술정보 마취정보 검사정보 대한수술중신경계감시연구회 91

98 제 2 회대한수술중신경계감시연구회심포지움 기본정보 환자환자명 : 이OO, 성별 / 연령 : F/65, I.D: 수술전진단 : Glioma Lt. temporal 수술명 : Craniotomy tumor remove 집도의 : Dr. 남00 수술방 : B07 마취마취의 : Dr. 이00 마취법 : propofol: 4.0 μg /kg/min remifentanyl: 1.5~2.5 μg /kg/min veccuronium: 0.5 μg /kg/min (TOF: 2/4) 검사검사의 : Dr. 서대원생리사 : 박00/ 김00 2. 검사방법 검사시간 검사종류 검사별 자극방법 ( 운동역치 ) 기록방법 검사방법 일시날짜 ; 감시시작 ; 11:00 감시종료 ; 15:44 기록시작 ; 11:47:39 기록종료 ; 15:34:19 종류추적감시 EP 체성감각유발전위, 운동유발전위 EMG 자유근전도 ( 근육명 ) 검사 SSEP 기능평가 EMG 유발근전도 ( 측면전파반음, 신경 ) MEP EMG 자극 median ; 15 ma, 0.3 msec, 5.1 Hz post tib ; 20 ma, 0.3 msec, 5.1 Hz 기록 three cortical and one cervical recordings 자극 transcranial, 400 V, 5 pulses/train motor threshold: 200 V 기록상지 ; ADQ, APB, 하지 ; TA, AH 자극 5 ma,0.3 msec, single 기록 frontalis, OOC, OOR, mentalis 92 Symposium II

99 서대원 Interpretation & reporting of neurophysiologic data 3. 검사결과 관찰한파형 관찰한내용 추적감시 기능평가 ( 평가시점, 평가내용 ) 이상여부외과확인 결과치보여주기 검사결과 1. 체성감각유발전위 (somatosensory evoked potentials) 좌측정중신경 ; N20 과 N13 의유의한진폭감소는관찰되지않음. 우측정중신경 ; N20 과 N13 의유의한진폭감소는관찰되지않음. 좌측후경골신경 : P40 과 N30 의유의한진폭감소는관찰되지않음. 우측후경골신경 ; P40 과 N30 의유의한진폭감소는관찰되지않음. 2. 운동유발전위 (motor evoked potentials) 좌측 MEP 우측상하지에서추적한 CMAP 의유의한차이관찰되지않음. 우측 MEP 좌측상하지에서관찰된 CMAP 의유의한차이관찰된지않음. 3. 자유근전도 (free running EMG) 안면에서추적한자유근전도에서일시적긴장파형 (tonic discharge) 관찰됨. 외과집도의에게알림. 상하지에서추적한자유근전도에서특이소견없었음. 4. 유발근전도 (triggered EMG); 수술중시행한안면신경상분지자극시상부와하부안면근에서유발근전도파형관찰됨. 미세감압술후유발근전도소실됨. 수술중시행한안면신경하분지자극시하부안면근에서만근전도관찰됨. 4. 검사결론 검사에대한해석 체성감각유발전위, 운동유발전위, 자유근전도추적감시에서수술도중과종료때유의한변화는관찰되지않음. 유발근전도기능평가에서관찰되었던측면전파방응은미세감압술후소실됨. 대한수술중신경계감시연구회 93

100 제 2 회대한수술중신경계감시연구회심포지움 [ 참고 ] 환자 : 김00 (M/48, SMC No.: ) 전진단 : Lt. MCAB and A-com aneurysm 수술명 : Craniotomy, aneurysm clipping 집도의 : Dr. 김종수 수술방 : B12 마취의 : Dr. 정익수 propofol: 4.0 μg /kg/min Remifentanyl: 1.5 ~ 2.5 μg /kg/min vecuronium: 0.5 μg /kg/min (TOF: ¼) 검사자 : 전문의 Dr. 서대원, 임상생리기사 : 박상구 [ 감시 ] 날짜 ; 시작 ; 11:57 종료 ; 16:09 [ 기록 ] 시작 ; 13:02:50 종료 ; 16:06:52 [ 방법 ] 체성감각유발전위자극 median nerve ; 15 ma, 0.3 msec, 5.1 Hz post tibials nerve ; 20 ma, 0.3 msec, 5.1 Hz 기록 four channels three cortical and one cervical recordings 운동유발전위 자극 transcranial electrical; 400 Volts, single, 5 pulses/train 운동역치는 200 Volt 였음. 기록 arm; ADQ, APB, leg; TA, AH [ 결과 ] 1. 체성감각유발전위 (somatosensory evoked potentials) 추적감시 좌측정중신경 ; 피질 (N20, P23) 와피질하전위 (N13, P16) 의유의한진폭감소는관찰되지않음. 우측정중신경 ; 피질 (N20, P23) 와피질하전위 (N13, P16) 의유의한진폭감소는관찰되지않음. 좌측후경골신경 : 피질 (P40, N45) 피질하전위 (N30, P35) 의유의한진폭감소는관찰되지않음. 우측후경골신경 ; 피질 (P40, N45) 피질하전위 (N30, P35) 의유의한진폭감소는관찰되지않음. 2. 운동유발전위 (motor evoked potentials) 수술중신경계감시보고서 복합근육활동전위 (CMAP) 의유의한진폭변화는관찰되지않음. [ 결론 ] 수술중신경계감시의유의한이상소견은관찰되지않음. Data 94 Symposium II

101 서대원 Interpretation & reporting of neurophysiologic data 배경 INM 방법 INM 판독내용 내용 INM 판독증례들 판독의실수 정확한판독 자세한판독 보호적판독 여운적판독 대한수술중신경계감시연구회 95

102 제 2 회대한수술중신경계감시연구회심포지움 Functional surgery Vascular surgery Tumor surgery Spine surgery Intraoperative Neurophysiology Monitoring Mapping TCD EEG EP NCV EMG ENS Report Information Methods Results Interpretation 96 Symposium II

103 제 2 회대한수술중신경계감시연구회심포지움 Monitoring devices without neurophysiologist: Is it trustworthy? 박윤길 연세의대강남세브란스병원재활의학과 Standard of Care Credentialing of neuromonitoring personnel Off-site remote monitoring Automated surgeon-controlled device Anesthesia on Standard of Care Others Credentialing of personnel American Board of Neurophysiologic Monitoring (ABNM) Diplomate certification Master degree in physical/life science or healthcare field Min. 3 yr neuromonitoring experience (300 cases) Written and oral exam. American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET) Certification of neurophysiologic intraoperative monitoring Bachelor degree in any field 150 cases Written exam without oral test 대한수술중신경계감시연구회 97

104 제 2 회대한수술중신경계감시연구회심포지움 Off-site remote monitoring 얼마나정확히신경학적변화를해석할수있는가 동시에여러개의감시가가능한상태인지 원격연결이끊어졌을때어떻게대처할지 의료사고에따른법적문제와책임 Surgeon-controlled device Automated, surgeon-directed monitoring system No trained professional to interpret data 수술집중을방해 수술자에게전적인책임 FDA 미승인상태 Qualification American Association of Neuromuscular & Electrodiagnostic Medicine, AANEM 1 IOM team 은외과의, 마취과의, 임상신경생리전문의 (clinical neurophysiologist), 그리고기사 (technologist) 로 구성되어야하며임상신경전문의는별도의임상신경생리 training 을받은사람이어야한다. 2 임상신경생리전문의의자격요건은신경과나재활의학 전공의과정을마친사람 98 Symposium II

105 박윤길 Monitoring devices without neurophysiologist: Is it trustworthy? Qualification American Academy of Neurology Professional Association (AANPA) 보험청구원칙 on-line real time 이나수술장근처에있는 physician 의 supervision 하에 technician 에의해시행할수있으나수술외 과의와마취의는 supervising physician 의역할을할수없다. 검사보고는외과의사나마취과의사에의해시행되지않아 야한다. 또한수술에참여하는외과의사또는마취과의사는 IOM 뿐아니라수술중신경생리검사에해당하는다른 procedure 에대해서도보험청구를할수없다. 수술중신경계감시임상진료지침대한신경과학회정도관리위원회, 대한임상신경생리학회, 대한수술중신경계감시연구회 EP, EMG, EEG, NCS, TCD 등과같은개별검사 기법에대한전문적인수련을한신경과혹은 재활의학과전문의사 마취가완료되면전극을설치하고일차기준 파형을측정 기준파형과비교를하여신경계기능변화를 판단 국내행위정위 유발전위, 표면 ( 침 ) 근전도, 뇌파추적감시 신경과또는재활의학과전문의 의사단독 종류와방법결정 수술자및마취의사와협의 기록전극, 자극전극부착 유발전위유도및감시 수술과정조정및수술후신경계손상확인 보고서작성 의사보조인력 검사보고서사본보관 대한수술중신경계감시연구회 99

106 제 2 회대한수술중신경계감시연구회심포지움 Monitoring devices without neurophysiologist NIM-spine TM 신의료기술신청 (2010 년 ) 척추수술용으로만든기계이기때문에크기가작아수술실내공간을적게사용. 척추수술에필요한침근전도와운동유발전위기능만을가지고있어수술집도의직접판독할수있다고제안 신경외과전문의 기존수술중신경생리검사와큰차이가없음 수술에집중하면서모니터나음향으로들리는신경반응의변화에즉각대응하기어려움 수술중작은자극에대해서도신경반응이나타나고세밀한관찰이필요하며다양한신경생리의변화에대한이해와지식이필요함 Thyroid operation & IOM Recurrent laryngeal nerve (RLN) Recording electrodes vocal cord surface electrodes, vocal cord needle electrodes, postcricoid paddle electrodes Stimulation electrodes monopolar and bipolar neural stimulators Monitoring systems Audio-only Visual display of the waveform and audio tones. 100 Symposium II

107 박윤길 Monitoring devices without neurophysiologist: Is it trustworthy? 대한수술중신경계감시연구회 101

108 제 2 회대한수술중신경계감시연구회심포지움 좌측 RLN 자극 -> 우측에도상당한크기의 stimulation artifact 파형이있음. Negative predictive value % Positive predictive value (Audio-only system) % - Randolph GW et al. Laryngoscope Symposium II

109 제 2 회대한수술중신경계감시연구회심포지움 인쇄일 2015 년 6 월 2 일인쇄발행일 2015 년 6 월 5 일발행 발행처 대한수술중신경계감시연구회서울시동작구보라매로 5 길 20 보라매병원진리관 4 층 Tel Fax daelimkoo@gmail.com 인쇄처 서울시중구수표로 6길 ( 충무로3가 ) 동성빌딩 Tel Fax jinlk@chol.com Homepage.

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