Charles D. Yingling, Ph.D., FACNS

Surgery involving the brain, spinal cord, or peripheral nerves often carries a significant risk of damage to neural structures, resulting in new neurological deficits. Such damage can have devastating effects, including paralysis, chronic pain, loss of bowel/bladder control, or loss of sensation. In an ongoing effort to avoid or minimize such damage, the last 30 years have seen the development and growth of a new professional field, intraoperative neurophysiological monitoring, or neuromonitoring. Using state-of-the-art techniques to assess nervous system function during surgery, it is now possible to detect compromise of the nervous system in real time, allowing many potential problems to be reversed or avoided before it is too late and permanent damage has occurred.

I offer both inservice training in all aspects of neuromonitoring, and expert witness services for medical/legal actions involving neuromonitoring.
 

 

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Many of the techniques used in intraoperative monitoring are derived from similar tests routinely used in clinical diagnostic laboratories, which have been adapted for use in the operating room. Other techniques, such as transcranial motor evoked potentials (tcMEP) have been developed specifically to address issues that arise during surgery. In either case, application of these techniques in the electrically hostile and time-pressured environment of the OR requires specially trained personnel, with knowledge and experience in many fields, including neurophysiology, neuroanatomy, anesthesiology, and instrumentation, as well as an understanding of specific surgical procedures and the particular risks they entail.

There are still very few formal training programs in intraoperative monitoring, and practitioners have often migrated into this field from a variety of diverse backgrounds, including neurology, audiology, EEG technology, and neuroscience research. As of 2017, no states offer licensure specifically for neuromonitoring.

There are certifications available to practitioners at various levels, but there are generally no statutory requirements for pracitioners to hold such certification. This lack of regulatory consistency has led to widely varying models and standards of practice which may vary from state to state, region to region, and even from hospital to hospital within the same city.

As a result, many find themselves with gaps in their knowledge, and may feel comfortable with some techniques but less confident in the application of others. This is often true of relatively new techniques such as tcMEP and cortical or spinal mapping. I offer specialized consultation and in-house training to help monitoring teams gain familiarity and expertise with such techniques.

In addition, due to the relatively higher risk inherent in procedures during which neuromonitoring is utilized, there are inevitably a number of bad outcomes with new postoperative neurological deficits. In some of these cases, the neuromonitoring team correctly identified the problem during surgery, but there was no way to reverse the damage and the patient awoke with new deficits despite the best efforts of the entire surgical team. However, in other cases there was a breach of the standard of care by the monitoring team, contributing to the adverse outcome. This might involve use of inappropriate monitoring techniques or failure to recognize significant changes and report them to the surgeon in a timely fashion.

To help legal professionals navigate and understand this complex and often unfamiliar territory, I offer medical/legal expert witness services. My decades of experience give me the ability to review neuromonitoring and related medical records and determine whether the monitoring team failed to meet the relevant standard of care, or performed at an appropriate level. I can explain the techniques used, and the data collected during surgery, in a comprehensible manner that empowers counsel and is understandable by the typical jury.

As an example, one case involved a failure to recognize and inform the surgeon of a loss of responses transmitted through the spinal cord during revision of a failed thoracic fusion. This resulted in the patient’s lower extremities being paralyzed. As an expert for the plaintiff, I testified that the neuromonitoring team had been grossly incompetent, poorly trained, and lacking proper oversight, and demonstrated this in the courtroom. The jury awarded the injured patient over $20 million dollars.

In another case, I served as an expert for the defense. The monitoring team detected and reported a loss of spinal cord transmission, and improvised a technique to assist the surgeon in determining the exact location of the conduction block. Although the deficit unfortunately could not be reversed, I authored a report arguing that the performance of the monitoring team clearly met and exceeded the standard of care, and they were not found liable and dismissed from the case.

My legal work has been roughly evenly divided between plaintiff and defense. I approach each case from the same perspective: was the monitoring appropriate, correctly performed, and reported to the surgeon in a timely fashion?