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May 2001
Volume 65 |
Number 5
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SUBSPECIALTY NEWS
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| Neurologic
Surgery: A Logical Choice for Anesthesiologists |
Michael E.
Mahla, M.D.
Society of Neurosurgical Anesthesia and Critical Care
Much like other subspecialty societies, the Society of Neurosurgical
Anesthesia and Critical Care (SNACC) is beginning to tackle the
questions surrounding the definition of a consultant in neurosurgical
anesthesiology. This process initially involved defining the curricular
content of the required primary rotation in neuroanesthesia in
the core residency program. It is now focusing on fellowship training
curriculum and content. What unique and special competencies and
services can a neuroanesthesiologist provide to patients having
surgery that risks the structure and function of the central and
peripheral nervous systems?
Neuroanesthesiologists are becoming recognized as the logical
choice to head medical direction for neurologic monitoring services
to patients undergoing surgery that places the nervous system
at risk, such as scoliosis repair or thoracic aneurysm repair.
This concept regarding the role of anesthesiologists in nonanesthesia
monitoring is similarly embraced by the Society of Cardiovascular
Anesthesiologists with respect to transesophageal echocardiography.
Currently, there are several SNACC members in the United States
and internationally who are entirely responsible for the provision
of neurologic monitoring at their respective institutions. Indeed,
these same SNACC members are performing much of the current and
important research in neurologic monitoring.
This initiative will require significant changes in neuroanesthesia
training programs. Fellows training in neuroanesthesia will need
significant exposure (at least six months) to neurologic monitoring
modalities including auditory and somatosensory-evoked responses,
motor-evoked responses, evoked and spontaneous electromyography,
electroencephalography, transcranial Doppler ultrasound and other
methods for cerebral blood flow measurement. They will also need
training in basic neuroanatomy and neurophysiology to provide
a solid basic science foundation necessary for understanding and
interpreting these responses. Also, current practitioners, if
interested in gaining skills in this area, will need equivalent
exposure and training.
As the specialty of neurologic surgery continues to advance,
requirements for intensive neurologic monitoring both in the operating
room and the intensive care unit will likely expand. Complex spinal
surgery and intracranial neurovascular surgery already utilize
extensive monitoring at many centers. 1,
2 Recently, a patient at the University
of Florida was spared a major neurologic deficit following clipping
of a basilar apex aneurysm. During surgery, one of several clips
placed to control this complex, multilobed aneurysm put pressure
on a small atheroma in one of the exiting posterior cerebral arteries.
The problem was not visible under the operating microscope, but
a persistent unilateral loss of the cortical somatosensory evoked
a response following temporary occlusion of the basilar artery,
which alerted the surgeon and anesthesiologist to the problem
and prompted re-exploration and induced hypertension that would
not have otherwise occurred. Even less complex cases performed
in community hospitals are increasingly using neurologic monitoring.
Within the next decade, clinical intraoperative monitoring of
motor pathways, with its incumbent anesthetic requirements, is
likely to become much more common, especially at larger private
and university hospitals.
Currently, neurologic monitoring is provided for the most part
by nonanesthesiologists. 3 While these
models work well, I believe that anesthesiologists could do a
better job. Many of these physician providers rely on technicians
to perform the monitoring and are not physically present in the
operating room. In this case, when a change in a monitored response
occurs, the technologist must contact the medical director who
must then verify the change. The medical director must then determine
what has happened surgically to make certain that the change makes
sense. He or she can then interact with the surgeon and anesthesiologist
to determine what is best to do at that point in time. Having
the anesthesiologist actually responsible for the monitoring reduces
the clinical response time to a change in the monitored response
to near zero. He or she can then in real time discuss work with
the surgeon to immediately implement appropriate surgical and
medical therapy.
The prospect for anesthesiologists becoming more involved with
neurologic monitoring is obviously very exciting, but there is
a potential problem that could defeat this initiative before it
even gets started. Anesthesiology reimbursement, particularly
from Medicare, has been undergoing many changes in recent years.
One of the most important issues to emerge from these changes
involves concurrent care. Can the anesthesiologist provide nonanesthesia
services at the same time he or she is supervising anesthesia
care by other providers (residents or nurse anesthetists)? Obviously,
if the anesthesiologist is providing direct care to a patient,
it would not be appropriate to supervise a neurologic monitoring
technologist in another location. That would be no better than
most current models. However, based on my nearly 20 years of experience,
I strongly feel that neuroanesthesiologists in the operating room
supervising two anesthetizing locations can readily supervise
neurologic monitoring without compromising care to either his
or her anesthetized patients or to the patient being monitored.
As more anesthesiologists become trained in neurologic monitoring,
it would be readily possible for the anesthesiologist to only
supervise monitoring in rooms where he /she is providing supervision
of the anesthetic.
SNACC is working hard with ASA to address issues relating to
neuroanesthesia. However, the importance of these issue extend
far beyond neurosurgical anesthesiology. Indeed, it extends to
the very definition of an anesthesiologist as a perioperative
medicine specialist. As anesthesiology moves into the 21st century,
neurologic monitoring, transesophageal echocardiography or those
skills involved with management of acute or chronic pain will
define the anesthesiologist's role. It will make him or her different
from other providers of anesthesia care, both in fact and in the
eyes of the public. The support of ASA in this issue is greatly
appreciated by all in SNACC.
References:
1. Nuwer MR, Dawson EG, Carlson LG, et al. Somatosensory
evoked potential spinal cord monitoring reduces neurologic deficits
after scoliosis surgery: Results of a large multicenter survery.
Electroencephalogr Clin Neurophysiol. 1995; 96(1):6-11.
2. Burke D, Nuwer MR, Daube J, et al. Intraoperative
monitoring. The International Federation of Clinical Neurophysiology.
Electroencephalogr Clin Neurophysiol Suppl. 1999; 52:133-148.
3. Nuwer JM, Nuwer MR. Neurophysiologic surgical
monitoring staffing patterns in the USA. Electroencephalogr Clin
Neurophysiol. 1997; 103(6):616-620.
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Michael
E. Mahla, M.D., is Associate Professor of Anesthesiology and
Neurosurgery, and Residency Program Director, University of
Florida College of Medicine, Gainesville, Florida. |
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