W J Mills1, J R Chapman, L R Robinson, J C Slimp. 1. Department of Orthopaedic Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle 98104, USA.
Abstract
OBJECTIVES: To assess the role of intraoperative somatosensory evoked potential (SSEP) monitoring of the radial and median nerves in preventing iatrogenic nerve injury during closed, locked intramedullary (IM) nailing of the humerus. DESIGN: Prospective clinical study. SETTING: Pacific Northwest Level One trauma center and Southern California military medical center. PATIENTS: Thirteen patients with indications for surgical stabilization of fractures of the humeral diaphysis and either unknown neurologic status of the affected limb or anticipated difficult reduction maneuvers due to fracture complexity or displacement. INTERVENTION: Closed, antegrade or retrograde locked IM nailing of the humerus was attempted while intraoperative monitoring of the radial and median nerves with SSEP was performed. MAIN OUTCOME MEASUREMENTS: Intraoperative radial and median nerve SSEP changes during closed fracture manipulation, guide rod insertion, reaming, and humeral nail placement. RESULTS: Baseline recordings were obtained in twelve of thirteen patients for both the radial and median nerves. An absence of radial nerve signal in one patient with a closed head injury prompted an open procedure, revealing entrapment of the radial nerve in the fracture. Intraoperative SSEP changes were observed in two of the twelve remaining patients during fracture manipulation and distal interlocking. The signal amplitude returned after discontinuation of manipulation and traction, and alteration of the interlocking maneuver. No neurologic deficits were noted in these two patients. CONCLUSIONS: Intraoperative radial nerve SSEP monitoring appears to reliably reflect the status of the radial nerve in those patients with a humerus fracture. In three of eleven patients, intraoperative signal changes prompted a change in surgical plan. In no patient did there appear to be evidence of iatrogenic nerve injury.
OBJECTIVES: To assess the role of intraoperative somatosensory evoked potential (SSEP) monitoring of the radial and median nerves in preventing iatrogenic nerve injury during closed, locked intramedullary (IM) nailing of the humerus. DESIGN: Prospective clinical study. SETTING: Pacific Northwest Level One trauma center and Southern California military medical center. PATIENTS: Thirteen patients with indications for surgical stabilization of fractures of the humeral diaphysis and either unknown neurologic status of the affected limb or anticipated difficult reduction maneuvers due to fracture complexity or displacement. INTERVENTION: Closed, antegrade or retrograde locked IM nailing of the humerus was attempted while intraoperative monitoring of the radial and median nerves with SSEP was performed. MAIN OUTCOME MEASUREMENTS: Intraoperative radial and median nerve SSEP changes during closed fracture manipulation, guide rod insertion, reaming, and humeral nail placement. RESULTS: Baseline recordings were obtained in twelve of thirteen patients for both the radial and median nerves. An absence of radial nerve signal in one patient with a closed head injury prompted an open procedure, revealing entrapment of the radial nerve in the fracture. Intraoperative SSEP changes were observed in two of the twelve remaining patients during fracture manipulation and distal interlocking. The signal amplitude returned after discontinuation of manipulation and traction, and alteration of the interlocking maneuver. No neurologic deficits were noted in these two patients. CONCLUSIONS: Intraoperative radial nerve SSEP monitoring appears to reliably reflect the status of the radial nerve in those patients with a humerus fracture. In three of eleven patients, intraoperative signal changes prompted a change in surgical plan. In no patient did there appear to be evidence of iatrogenic nerve injury.
Authors: Zirka H Anastasian; Brian Ramnath; Ricardo J Komotar; Jeffrey N Bruce; Michael B Sisti; Edward J Gallo; Ronald G Emerson; Eric J Heyer Journal: Anesth Analg Date: 2009-09 Impact factor: 5.108