I was fortunate to be able to attend the 7th Leipzig Practical Course on Neuro-
monitoring in Leipzig, Germany March 13-16. Leaving good weather in Philly, I arrived in Frankfurt with piles of snow and hundreds sleeping on cots in the airport from cancelled flights the night before. Even the normally punctual German trains were delayed on the way to Leipzig. But once I got there the next few days were educational and fun.
Leipzig is known for books and Bach. The Leipzig Book Fair was going on in parallel making hotels hard to come by. This Fair is a massive event for publishers, writers, readers, and publications and builds upon Leipzig’s centuries-old history in publishing.
My trip happened on short notice and due to the Fair I didn’t have a hotel for the first night. I lucked out and found a room…the last one…in the Kosmos Hotel. I like to stay in alternative places when possible as I see too many hotels where you know what your room looks like before you open the door. The Kosmos was very much alternative; a bed, a chair, a bathroom in the hall…and that’s about it. But that’s all I needed as I was out “paying homage to Bach” for much of the evening with Rudi Matmueller the founder of Inomed and Michael Malcharek who was running the course.
Inomed is a pretty cool German company that makes intraoperative monitoring equipment. They aren’t in the U.S. yet, but look for them soon.
Leipzig is the home of Bach and I found a few hours to tour the Bach Museum. Though small, it is very well done. Once you go through it, you feel like you knew Bach and you knew the Leipzig he knew. A highlight for me was the “orchestra wall” that lets you raise the volume of individual instruments of that era in a Bach orchestral piece so you can hear how it contributes to the overall sound. I often think of multimodal neuromonitoring as an orchestra score for the brain. Several instruments from Bach’s time as well as some of his original musical scores are on display and you learn how they deciphered who wrote what due to the inks and writing styles. This museum is in contrast to the Haus Der Musik in Vienna that I toured a few years ago. Most musicians of these times eventually lived in Vienna so that museum is larger and covers the works of many musicians.
Back to the reason I was there…the Leipzig meeting is one of the few focusing on neuromonitoring and was first organized by Dr. Michael Malcharek, a neuro- anesthesiologist in Leipzig. He has had encouragement and support from colleagues and vendors including Rudi Matmueller, the president of Inomed.
The meeting covered the use of raw and processed EEG, evoked potentials during surgery, and intensive care monitoring. As the name implies it is a very practical course providing hands-on experience using the monitoring modalities (furnished by various vendors) as well as a visit to an OR where monitoring is taking place. I gave a workshop on multimodal neuromonitoring in the ICU and enjoyed many discussions with attendees during the frequent social functions.
I ran into friends I hadn’t seen in a while like Michael Dinkel who has been recording intraoperative evoked potentials for most of his career. I also ran into Gerhard Schneider who I knew when he was “just a kid” running around the ORs in Munich with Professor Kochs. Drs. Schneider, Malcharek, Dinkel and a few others have helped to maintain a focus on neuromonitoring at a national level in Germany in a time when other topics are getting the spotlight.
My career has kept me focused on critical care for the past decade and a lot has developed in intraoperative monitoring that has passed me by. This course provided a glimpse of some of the new techniques. In an evening symposium Maja Rogic talked about some fascinating work on recording motor evoked potentials from the cricothyroid muscles in order to better map the speech areas of the brain . She did some of this work with Vedran Deletis, an old friend of mine who I hoped would be there. They stick recording needles into the cricothyroid muscles through the skin. Ouch. Then they stimulate transcranially (C3-Cz, see A below) to elicit a response. The interesting thing is that you can’t get a motor evoked potential from a single stimulation in anesthetized patients like you can in awake patients.
To elicit MEPs, a short train of stimuli must be used to build up an excitatory postsynaptic potential and reach a firing threshold of the target motoneurons. The diagram below shows the path of the stimulation from the primary motor cortex, down the corticobulbar pathways, vagal nucleus, vagal nerve, and superior laryngeal nerve to the cricothyroid muscles. The response is shown as the superposition of four single MEPs from cricothyroid muscle.
So where does broccoli (from the title) fit in? Maja has also been working on food recognition…something I have no trouble with. She did some interesting experiments in this area and presented the work for the first time at this symposium. But since it’s so new, she asked that I not include it in this blog until the publication is accepted. So you have to wait for the broccoli.