Medical/Legal Expert Witness
Neuromonitoring is typically employed during surgical procedures which carry a high risk of new postoperative neurological deficits. Inevitably, some of these procedures will have bad outcomes, which may range from relatively focal pain, numbness, or weakness through total paralysis and loss of sensation below the level of the injury; for high cervical procedures, this can involve all four limbs and even dependence on a ventilator for breathing. Not surprisingly, cases resulting in new deficits often become the subject of medical/legal actions, and questions arise as to whether neuromonitoring contributed to the outcome.
Issues relating to neuromonitoring may affect the deliberations in a specific legal proceeding in a wide variety of ways, as can be seen from the following (partial) list:
- Failure to utilize neuromonitoring in cases where it is indicated and appropriate techniques are available
- Failure to utilize appropriate monitoring techniques for a given case
- Technical errors in instrumentation
- Failure to recognize significant changes in monitored signals
- Failure to communicate intraoperative changes to the surgeon in a timely fashion
- Failure of the surgeon to take appropriate action when notified of signal changes
- Use of anesthetic techniques which compromise the ability to monitor appropriately
- Inadequately trained or skilled personnal performing neuromonitoring
- Online “supervision” performed for the purpose of billing professional fees by physicians with inadequate knowledge or experience in neuromonitoring
Inservice Training in Specific Neuromonitoring Techniques
I offer inservice training in all types of intraoperative monitoring; for example, cranial nerve monitoring for acoustic neuroma or other skull base tumors, selective dorsal rhizotomy for spasticity secondary to cerebral palsy, cortical and subcortical mapping during resection of tumors near the sensorimotor region, peripheral nerve explorations, as well as monitoring during cardiovascular and interventional radiology procedures. I can provide a thorough grounding in the basic principles of instrumentation, electronics, and digital signal processing, areas which are often poorly understood, leading to erroneous or artifact-contaminated intraoperative recordings. I can also advise on staffing or equipment needs, supervision requirements, and virtually any aspect of intraoperative monitoring.
In addition to training neuromonitoring personnel, I also can provide educational sessions for surgeons on new technological developments and current literature regarding techniques specifically applicable to specific types of surgical procedures, Similarly, I can provide guidance to anesthesiologists on optimal regimens, which vary dramatically for different surgical procedures. Please contact me for information concerning any of your training needs.
As an example of how, I have worked with established neuromonitoring groups, here is a description of the training I offered in transcranial motor evoked potentials after the first transcranial stimulator was approved by the FDA in 2002. I can create a similar program for any other area of neuromonitoring, customized to each client’s specific background experience and needs.
TcMEP techniques are rapidly evolving and involve the application of high currents and voltages in order to stimulate the brain through the intact scalp. It is now generally acknowledged that tcMEP represents a major advance in monitoring the function of the motor pathways of the brain and spinal cord, and has the potential for significantly reducing the incidence of post-operative paralysis.
Like any powerful tool, tcMEP monitoring is safest and most effective when used by appropriately trained professionals who have the knowledge to utilize the technique to its maximum effect. However, since the FDA has only recently (2002) approved devices for transcranial stimulation, many monitoring practitioners have not had the opportunity to gain this experience. An effective way to get started immediately in tcMEP monitoring is to engage my consulting services.
The most rapid and effective way to incorporate new techniques into an existing monitoring practice is through intensive in-house training, rather than attendance at lecture-format conferences. Thus, my consulting services combine didactic lectures, hands-on demonstrations, and monitoring actual surgical cases at your hospital, with your personnel and equipment, and interfacing with your surgeons, anesthesiologists, and other OR personnel.
For example, for groups wishing to add tcMEP to their existing practice, I provide in-house consultation and training in the use of multipulse electrical stimulators for transcranial motor evoked potential monitoring during surgery. This training is intended for groups who are already experienced in intraoperative monitoring using SEP, EMG, EEG, or other techniques and who wish to add tcMEP to their monitoring capability. I have extensive experience in tcMEP; I was one of the first people in the US to use the Digitimer D185 under a research protocol in the late 90's prior to its obtaining FDA approval, and have used it, and subsequently the CV-2 and TCS-1 from Cadwell, in hundreds of cases.
Generally, I visit for 2 or 3 days. During the first day, I help interface the high voltage multipulse stimulator with your existing monitoring equipment, create appropriate protocols, and test the entire system to ensure that the stimulator is correctly connected and integrated with your equipment. I also train your IOM staff in the use of the transcranial stimulation, anatomy and physiology of tcMEP, indications for tcMEP monitoring, risks and patient safety issues, troubleshooting, identification of normal and abnormal tcMEP responses, anesthesia considerations, applications to specific surgical procedures, etc. It is also useful to meet with and/or give formal presentations to the anesthesiologists and surgeons who will be involved and make sure they understand the utility of tcMEP and their role in its successful use in the OR.
On the second and/or third days, we go into your OR and I assist in setting up and monitoring tcMEP during appropriate surgical case(s). I will help your staff in electrode placement, equipment setup, obtaining baseline recordings, and interpreting tcMEP data obtained during the case(s). The goal is to bring your staff to the point where they will be ready to begin using tcMEP independently.