Intraoperative Neuromonitoring (IONM) is a rapidly-growing field that involves the monitoring of the central and peripheral nervous systems of patients undergoing surgical procedures such as orthopedic spinal correction (scoliosis treatment), cranial neurosurgery, and interventional radiologic procedures. Answer: No – CPT is very clear in that intraoperative monitoring (e.g., 95940, 95941) is included in the global surgical package for the surgeon and should not be separately reported. NERVE MONITORING Monitoring The routine use of facial nerve monitoring remains controversial. The New Standard of Care: Nerve Monitoring - ProPep Surgical Methods: We retrospectively evaluated the data of 273 patients who had primary thyroidectomy due to benign thyroid pathology between January 2012 and July 2017. International neural monitoring guidelines call for routine and systematic use of nerve-stimulating equipment in RLN dissection, but there are very limited published data on the value of nerve monitoring for NRLN identification. for primary, co- or assistant surgeon" As is the case with this patient, the lumbar spine is the most common location for this abnormality. During the test, one or more small needles (also called electrodes) are inserted through the skin into the muscle. Brain Stimulation publishes on the entire field of brain stimulation, including noninvasive and invasive techniques and technologies that alter brain function through the use of electrical, magnetic, radiowave, or focally targeted pharmacologic stimulation.. Clinical Uses 1. The company's website shows that Traxx provides a service called intraoperative neurophysiological monitoring, which evaluates the function of nerves during surgery. Nerve integrity monitoring system has become more routine and is most useful for recurrent tumors or difficult dissections. IONM has been clinically proven to reduce the patient’s risk of iatrogenic damage to the nervous system and provide functional guidance to the surgeon and surgical team. Discuss the monitoring plan and anesthetic techniques with the surgeon AND the neuromonitoring team prior to starting the case. NIM™ nerve monitoring electrodes are placed in the appropriate muscle locations in the patient for the procedure being performed. The intraoperative monitoring can identify even peripheral causes of nerve compression that will impact patients. After the introduction of the first commercial intraoperative neuromonitoring (IONM), the procedure became popular in the 1980s. Healthcare service providers [including hospitals, surgical centers, and ambulatory surgical centers (ASCs)] dcheadandneck.com/procedures/parotidectomy/facial-nerve-monitoring Bendini® is a computer-assisted NVM5 rod bending system used to bend rods to specific implant locations for spinal surgery applications. Additionally, some types of chemotherapy and radiation may produce nerve pain and nerve damage in certain individuals. Home > Neurology and Neurosurgery > Centers & Clinics > Intraoperative Neurophysiological Monitoring > Types of Intraoperative Monitoring Types of Intraoperative Neurophysiological Monitoring In order to preserve brain function during surgery, the neurosurgeon will use advanced intraoperative neurophysiological testing, such as: To test the muscle’s functional integrity, the associated nerve can be stimulated, which results in muscle contraction. Recurrent laryngeal nerve function should be monitored during thyroid surgery 1, either by direct observation of vocal cord function during surgery 2, which can be difficult, or by electromyography (EMG), during which electrodes are placed adjacent to the vocal cords to detect motion when the laryngeal nerves are stimulated.Electrodes can be secured to the outside of a … A typical method for nerve dissection is to make use of a small, tremendous hemostat or a nonlocking, smooth-jawed, right-angle dissector (McCabe facial nerve dissector) to softly elevate the parotid tissue within the pure aircraft simply superficial to every nerve. T. tzadqiel235 Guest. 2. Monitoring of serum lidocaine concentrations was not done routinely. Nerve Conduction Velocity (NCV) Testing What is a NCV test? I presented a large prospective study (1000 consecutive patients) at the 2013 annual meeting of the American College of Surgeons (10/17/13) entitled: Nerve Monitoring (NIMS) Increases Recurrent Laryngeal Nerve Injury During Failed Parathyroidectomy. Objective To determine whether IONM is a cost-effective intervention in the setting of … a technique used during surgery to monitor the condition of a patient's nervous system throughout the surgical procedure. The RLN is located on either side of the thyroid gland and serves several important functions, including control of vocal cord movement. Facial Nerve Monitoring Emily Z. Stucken, Kevin D. Brown, and Samuel H. Selesnick. This is known as intraoperative neurophysiologic monitoring (IONM). OCT can be used to detect neurodegeneration (the progressive death of nerve cells) in the retina, and its utility as a diagnostic and monitoring tool for … There are a number of ways to perform this monitoring. SSEP monitoring assess the signal that is sent to the brain and provides real-time feedback to the neuromonitorist. NVM5® Nerve Monitoring System Core to the NuVasive philosophy of facilitating reproducible outcomes in spine surgery is the procedural integration of neurophysiology and computer-assisted surgery technologies. The measured recording is a series of six to seven vertex positive waves of which I through V are evaluated. Electromyography is a procedure to continuously monitor and record the muscle’s electrical activity using needle electrodes. Learn more Information you need About NVM5 The NVM5 platform is a comprehensive set of intraoperative technologies specifically designed for spine … Based on more than 20 years of experience, the NIM-Response™ 3.0 and NIM-Neuro™ 3.0 nerve monitoring systems offer nerve monitoring technology. It includes both continuous monitoring of neural tissue as well as the localization of vital neural structures. The cost-effectiveness of this approach to total thyroidectomy has not been well studied. In recent years, the use of intraoperative nerve monitoring (IONM) has gained popularity amongst surgeons when operating on thyroid gland; however, its utilization in parathyroid surgery is not established. Nerve monitoring performed using different methods; Possibility of data extraction/calculation from the published results. "Medicare considers intraoperative monitoring part of the global surgical pkg. Acute abducens nerve palsy in a patient with the novel coronavirus disease (COVID-19) Falcone et al. Also called an electroneurography, EneG, or nerve conduction study, a nerve conduction velocity (NCV) test is a measurement of the speed of conduction of an electrical impulse through a nerve. nerve root avulsion; (5) identifying targets for nerve biopsy; and (6) monitoring and thereby preventing damage to intact nerves during surgery. By administering a couple of millilitres of local anaesthetic in this area the symptoms should disappear if the diagnosis is correct (otherwise the diagnosis is wrong). There is no examination (X-ray, ultrasound, MRI, scintigraphy) that can detect the nerve entrapment. What is an electromyography (EMG)? A peripheral nerve stimulator, also called the "train of four", is used to assess nerve function in patients receiving neuromuscular blocking agents (AKA paralytic medications). Satisfactory recovery from neuromuscular block has not occured until the train-of-four ratio is >0.9. Find out how to prevent or manage nerve problems during cancer treatment. The question of whether it should be used routinely was up for discussion at the American Thyroid Association 82nd Annual Meeting. For stimulation in spinal cord motor evoked potential (MEP) studies, the anode should be placed: rostral to cathode. At other facilities, neuromonitoring with anesthesia takes some negotiation. LONDON, Dec. 19, 2016 /PRNewswire/ -- The global nerve monitoring devices market size was valued at USD 1,001.4 million in 2014 and is expected to grow at a CAGR of 8.9% over the forecast period. Research finds exercise can help prevent muscle, nerve damage. This damage is called ischemia reperfusion injury, and it can affect surgery and trauma patients and soldiers injured on the battlefield. The research has found that pre-injury exercise has substantial benefits for preserving muscle and bone. Similar to testing current flow in a wire, nerve conduction velocity test ( NCV) is an electrical test, ordered by your doctor, used to detect abnormal nerve conditions. Seller: The University of Texas Health Science Center at San Antonio. The auditory brainstem response (ABR) is an auditory evoked potential extracted from ongoing electrical activity in the brain and recorded via electrodes placed on the scalp. Facial and cranial nerve monitoring: For nerve stimulation during surgeries involving the … The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. a technique used during surgery to monitor the condition of a patient's nervous system throughout the surgical procedure. Also called a myogram, an electromyography (EMG) measures muscle response or electrical activity in response to a nerve’s stimulation of the muscle. Intraoperative neurophysiological monitoring (IONM) or intraoperative neuromonitoring is the use of electrophysiological methods such as electroencephalography (EEG), electromyography (EMG), and evoked potentials to monitor the functional integrity of certain neural structures (e.g., nerves, spinal cord and parts of the brain) during surgery.The purpose of IONM is to reduce the risk to … Intravenous lidocaine had superior efficacy to morphine for renal colic and critical limb ischemia, superior efficacy to DHE for acute migraine, and equivalent efficacy to ketorolac for acute radicular lower back pain. Examples of “wrong pathway” monitoring Nerve Monitoring Endotracheal Tubes Dramatically Increase Vocal Cord Nerve Damage. a technique used during surgery to monitor the condition of a patient's nervous system throughout the surgical procedure. This International journal, Journal of Clinical Neuroscience publishes articles on clinical neurosurgery and neurology and the related neurosciences such as neuro-pathology, neuro-radiology, neuro-ophthalmology and neuro-physiology. If there is a change in nerve function, the NIM™ system may provide audible and visual warnings to help reduce the risk of nerve damage. OCT can be used to detect neurodegeneration (the progressive death of nerve cells) in the retina, and its utility as a diagnostic and monitoring tool for … In case of overlap between patient populations, authors and centres, the trial with the largest number … When certain delicate procedures are being performed on the spine or spinal cord, brain or an area rich with nerves, IOM is very valuable. Depending on the procedure, a variety of tests can be used to measure the nervous system function. Beck DL, Atkins JS Jr, Benecke JE Jr, Brackmann DE. Some controversy still remains with regard to the use of intraoperative recurrent laryngeal nerve monitoring. NMT can be blocked by neuromuscular blocking agents – drugs that cause transient muscle relaxation and prevent the patient from moving and breathing spontaneously. Ended On : November 23 2021, 04:00 PM. Monitoring can be established to prevent injury to the brain, spinal cord, cranial nerves and peripheral nerves throughout the body while undergoing surgery. Intraoperative neurophysiological monitoring is the continuous evaluation of a patient’s nervous system during surgery, especially procedures involving the brain and spinal cord. Learn about signs and symptoms of nerve changes. Recognize that the NIH has stated Facial Nerve monitoring is an effective and essential adjunct to reduce risk of facial palsy (Standard of Care) Recognize that RLN monitoring is still evolving and efficacy is modality dependent (Caution required) Identify the Laryngeal nerves Differentiate Vocal Cord anatomy and function During the test, one or more small needles (also called electrodes) are inserted through the skin into the muscle. The aim of nerve monitoring is to provide nerve location information to the surgeon during an operation. Neuropathy is our passion, and developing procedures, and testing outcomes is important to further the availability of treatments that actually help people who suffer from this debilitating disease. Win some, lose some. EMG. It is commonly seen used in critical care units. Objective: This study presents the effects of intraoperative nerve monitoring on RLN injuries in patients who underwent primary surgery for benign thyroid pathology. "For example, if we have the arm tucked too hard at the patient's side, the monitoring can indicate that we're irritating the ulnar nerve at the elbow," Dr. Nassr says. These electrodes are connected to the NIM™ system, which monitors EMG activity from muscles innervated by the affected nerve. Qualitative neuromuscular monitors, or peripheral nerve stimulators, provide an electrical stimulus to a motor nerve and the response of corresponding muscle subjectively evaluated. These electrodes are connected to the NIM™ system, which monitors EMG activity from muscles innervated by the affected nerve. The neurologistplaces needle electrodes into the muscle and monitors its spontaneous activity continuously. The purpose of IONM is to protect the nervous system. Brain Stimulation aims to be the premier journal for publication of original research in the field of neuromodulation. The suggested rate of stimulation for intraoperative posterior tibial nerve evoked potential monitoring is: d. 2 to 10 per second. NIM™ systems monitor EMG activity from multiple muscles. Intraoperative monitoring (IOM) is a technique used during surgery to monitor the condition of a patient’s nervous system throughout the surgical procedure. Intraoperative Monitoring (IOM) system that assists with implant placement and surgical technique by monitoring nerve and spinal cord activity throughout the surgical procedure. Guillain-Barré syndrome occurs when the immune system damages nerve cells, causing muscle weakness and occasional paralysis, ... a 30-year-old federal monitoring system. Neurocirugía en UPMC Nerve monitoring electrodes are placed in the appropriate muscle locations in the patient for the procedure being performed. It is also proven to improve the outcomes of spinal surgery. 412-647-3685 neuroinfo@upmc.edu. Thyroid Neuromonitoring. August 2020. IONM, the gold standard for identifying and managing at-risk nerves, plays an important role in protecting the recurrent laryngeal nerve (RLN) during thyroid surgery. Compression/trauma . Injury to the recurrent laryngeal nerve (RLN) is a well known, though less frequent, complication of parathyroid surgery. At some facilities, the neuromonitoring clinician tells the anesthesia team what they need, and anesthesia accommodates. Abstract. Neuromonitoring is a technology that allows the surgeon to assess spinal cord function during surgery through real-time feedback from individual nerve roots, motor tracts, and sensory tracts. MonitoringIdentification of the facial nerve. The facial nerve can be identified on the basis of spontaneous activation of the facial nerve monitor due to mechanical stimuli (eg, traction, compression, abrasion).Facial nerve mapping. ...Identification of injury risk. ...Prognostic assessment. ... Total reliance must not be placed on serum concentrations alone. 1,2 a technique used during surgery to monitor the condition of a patient's nervous system throughout the surgical procedure. These symptoms are similar to those caused by sciatica, however the term 'sciatica' is typically used to refer to conditions where the sciatic nerve is irritated or compressed, rather than being injured directly. be used in peripheral nerve procedures that pose a risk of injuries to nerves (Nuwer, 2008). IONM stands for IntraOperative Neurophysiological Monitoring. In addition, they use the most-advanced facial nerve monitoring technology. An epidural block affects nerve fibers that control muscle contractions inside the blood vessels. Intraoperative neurophysiological monitoring (IONM) or intraoperative neuromonitoring is the use of electrophysiological methods such as electroencephalography (EEG), electromyography (EMG), and evoked potentials to monitor the functional integrity of certain neural structures (e.g., nerves, spinal cord and parts of the brain) during surgery.The purpose of IONM is to reduce the risk to … Nerve monitoring is putting sensors in or on the patient that identify and monitor electrical signals conducted by nerves. Facial nerve monitoring parameters as a predictor of postoperative facial nerve outcomes after vestibular schwannoma resection. Intraoperative neurophysiological monitoring (IOM) allows assessment of nerve tissue function while the surgery is taking place. Depending on the procedure, a variety of tests can be used to measure nervous system function. Intraoperative neurophysiological monitoring (IONM) helps assess the integrity of neural structures and consciousness during surgical procedures. Medtronic NIM-Response 3.0 Nerve Monitoring System w/ Cart & Accessories. Serum Lithium Monitoring. The visible mass contains dysplastic spinal cord as well as meninges, nerve roots, and CSF. Objective: This study presents the effects of intraoperative nerve monitoring on RLN injuries in patients who underwent primary surgery for benign thyroid pathology. 26(4):728-32. . Intraoperative neurophysiological monitoring (IONM) or intraoperative neuromonitoring is the use of electrophysiological methods such as electroencephalography (EEG), electromyography (EMG), and evoked potentials to monitor the functional integrity of certain neural structures (e.g., nerves, spinal cord and parts of the brain) during surgery. Intraoperative facial nerve monitoring: prognostic aspects during acoustic tumor removal. Importance Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is used as a tool to decrease the rate of nerve injury, although study findings are divergent on IONM efficacy. Published quarterly—in March, June, September, and December—each issue offers state-of-the-art reviews on all types of anesthesia, including … The wires from the electrodes are then plugged into a machine that makes an audible beeping sound when the nerve is being agitated during the operation. The goal of monitoring is to alert the surgeon and anesthesiologist to impending injury in order to allow modification of management in time to prevent permanent damage. Keywords: neuromuscular monitoring, residual neuromuscular blockade, peripheral nerve stimulator, quantitative monitoring, sugammadex, calabadion Introduction Neuromuscular monitoring (NMT) is good guidance whenever there is a need to use neuromuscular blockade to significantly improve the quality of intubation and reduce airway … During the test, the nerve is stimulated, usually with surface electrode patches attached to the skin. Neuromuscular monitoring devices were introduced into clinical practice in the 1970s. Adjust the volume of the nerve monitor so that it can be heard above the ambient noise of the OR. The SSEP test monitors the nerve pathways that are responsible for feeling pressure, touch, temperature and pain. The peripapillary RNFL thickness is by far the most popular OCT parameter used for glaucoma diagnosis and monitoring progression. Monitoring of neuromuscular block. The technology is being used in several hospitals to improve patient comfort. It is usually ordered to diagnose or evaluate a nerve injury in a person who has weakness or numbness in the arms or legs. The patients were classified into two … Intraoperative neurophysiological monitoring is a procedure to continuously monitor the nervous system’s functional integrity during operations involving the brain and spinal cord. This review provides background on the equip-ment and techniques used for intraoperative periph-eral nerve and plexus monitoring and an interpre-tation of the findings obtained thereby. The complete removal of your tumor, combined with the preservation of the facial nerve, is a priority of the surgical team at Memorial Sloan Kettering. Overview Fingerprint Abstract Facial nerve monitoring has been increasingly routinely used as an intraoperative adjunctive method to help the head and neck surgeon to identify and minimize facial nerve injury during parotid surgery. Continuous intraoperative nerve monitoring (CIONM) uses a small vagal electrode to stimulate the vagus nerve at low level (1mA) stimulation every six seconds to provide a real-time uninterrupted nerve monitoring which offers an opportunity for detection of impending nerve injury and reversal of associated surgical maneuver to avoid permanent nerve injury. Sciatic nerve injury occurs due to trauma (pressure, stretching or cutting) to the nerve and can cause symptoms such as paresthesias, loss of muscle power and pain. SSEP monitoring assess the signal that is sent to the brain and provides real-time feedback to the neuromonitorist. Otol Neurotol. Regular blood sugar monitoring is the most important thing you can do to manage type 1 or type 2 diabetes. Incontinence treatment system, Pelvic floor stimulator, monitor, sensor, and/or trainer E0744 Neuromuscular stimulator for scoliosis The journal has a broad International perspective, and emphasises the advances occurring in Asia, the Pacific Rim region, Europe … This monthly journal offers comprehensive coverage of new techniques, important developments and innovative ideas in oral and maxillofacial surgery.Practice-applicable articles help develop the methods used to handle dentoalveolar surgery, facial injuries and deformities, TMJ disorders, oral cancer, jaw reconstruction, anesthesia and analgesia.The journal also … The ProPep® Nerve Monitoring System provides surgeons with real-time information regarding the location and function of these critical somatic nerves throughout the surgical procedure. BTW, Medicare will not pay for intraoperative nerve monitoring, but there is a number of private payors that will. All muscle relaxants should be reversed before prepping and draping. DISCLAIMER: This lot is sold AS-IS, WHERE IS. Injury to the facial nerve is one of the most feared and potentially devastating complications of otologic and neurotologic surgery. (2) Drafted 9/29/2016 Submitted for Review 10/12/2016 Submitted for Review 12/6/2016 NIM nerve monitoring electrodes are placed in the appropriate muscle locations in the patient for the procedure being performed. The facial nerve exits out of a small hole in the base of the skull, and then branches through the parotid gland to supply all the muscles of the face. A 1990 survey showed that most experienced otologists do … But a lot of the same conversations happen over and over. Anesthesiology Clinics presents procedurally focused articles that update you on the latest trends in patient management, keep you abreast of the newest advances, and provide a sound basis for choosing treatment options. Electromyography shows how well muscles respond to electrical signals transmitted by nearby nerves. Email: evivas@emory.edu. What is an electromyography (EMG)? Pediatric Neurology publishes timely peer-reviewed clinical and research articles covering all aspects of the developing nervous system.Pediatric Neurology features up-to-the-minute publication of the latest advances in the diagnosis, management, and treatment of pediatric neurologic disorders. Monitoring the condition of the nervous system helps prevent damage to the spinal cord, brain, or nerves . Keywords: ABR, acoustic neuroma, cranial nerve monitoring, electrophysiology, EMG, intraoperative cranial nerve monitoring, vestibular schwannoma. The NSS-2 BRIDGE is a percutaneous nerve field stimulator (PNFS) device system, that can be used as an aid to reduce the symptoms of opioid withdrawal, through application to branches of Cranial Nerves V, VII, IX, and X, as well as branches of the occipital nerves identified by transillumination. (Color-coded placement guides are included in the NIM™ software.) Nerve monitoring uses a special endotracheal tube with electrodes which detect movement of the vocal cords against them. Phone: 404-778-2178. The patients were classified into two … Our surgeons have extensive experience in using precise surgical techniques that help preserve the facial nerve. Neuromuscular transmission (NMT) is the transfer of an impulse between a nerve and a muscle in the neuromuscular junction. Technique 1. Hope this helps, Jennifer ENT CT . Nerve conduction studies check the transmission of electrical current through a nerve. UPMC Presbyterian, Suite B-400 200 Lothrop Street Pittsburgh, PA 15213. The nerve monitoring system allows for the exact location and identification of a motor nerve, as well as the prevention of nerve damage. (Color-coded placement guides are included in the NIM™ software.) The journal's editor, E. Steve Roach, in conjunction with the … Transcutaneous electrical nerve stimulation, four or more leads, for multiple nerve stimulation E0731 Form fitting conductive garment for delivery of TENS or NMES E0740 . Journal of AAPOS, Vol.22, No.4, p286-289.e2. A nerve in the body works somewhat like an electrical wire in your house. Facial nerve monitoring has been increasingly routinely used as an intraoperative adjunctive method to help the head and neck surgeon to identify and minimize facial nerve injury during parotid surgery. It is commonly seen used in critical care units. This makes spine surgery safer. Intraoperative neuromonitoring (IONM) is the continuous surveillance of a patient’s nervous system (the brain, spinal cord, and nerves) when it can be at risk of injury during surgery. 8. The test is used to help detect neuromuscular abnormalities. These waves, labeled with Roman numerals in Jewett and Williston convention, occur in the … Ulnar nerve SSEP monitoring can be used when the surgery involves the lower cervical segments (above C8). Many complications involving the nervous system can be avoided with careful monitoring during surgery. Additionally, nerve monitoring can help identify abnormalities in the anatomy of the nerve and aid in dissection. The Peripheral Nerve Center at Johns Hopkins has assembled a group of specialists that provide expertise in most nerve disorders, including diagnosis and both medical and surgical treatments. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. No part of this manuscript has been published or submitted for publication elsewhere. The goals, current applications, recent technical advances, and limitations of the method are reviewed. The EMG assesses the integrity of cranial/spinal nerve roots and indirectly peripheral nerves from the … Retinal nerve fiber layer thickness represents the ganglion cell axons before they enter the optic nerve. Facial nerve monitoring is cost effective and beneficial for neurotologic and mastoid surgery, and its use, at the discretion of the operating surgeon, can reduce the risk of iatrogenic facial nerve injury. Rising prevalence of neurological diseases is anticipated to be the highest impact rendering driver for the industryAccording to the statistics published by the … from a Karen Zupko seminar, we learned that the nerve monitoring is reported by a physician other than the operating surgeon. Nerve conduction studies or electromyography are sometimes used to help determine the type and extent of nerve damage. The use of Dragonfly electrodes deliver EMG signals on most sizes and types of ET tubes and connect to most nerve monitoring systems. Monitoring can also identify new systemic impairment; identify or separate nervous system structures, e.g., around or in a tumor; and demonstrate which tracts or nerves are still functional. Our NIM TM Nerve Monitoring System is an electromyographic (EMG) monitor for intraoperative use during various surgeries, including ENT and general surgical procedures in which a nerve may be at risk due to unintentional manipulation. NIM™ nerve monitoring electrodes are placed in the appropriate muscle locations in the patient for the procedure being performed. A trained Sensory Testing Systems clinician, under the supervision of a qualified professional, constantly … 2005. Intraoperative neurophysiologic monitoring (IONM) is a technique that is directly aimed at reducing the risk of neurological deficits after operations that involve the nervous system. June 11, 2020. Monitoring the condition of the nervous system helps prevent damage to the spinal cord, brain, and/or nerves. Electrical and electromagnetic sensors connected to the patient via adhesive electrodes or needles transmit information from the nervous system that can be monitored on a computer … Also called a myogram, an electromyography (EMG) measures muscle response or electrical activity in response to a nerve’s stimulation of the muscle. Once the procedure has begun, always confirm that current flow is present by using a stimulating probe or Kartush surgical instrument to touch muscle, soft tissue, or wet bone. Journal of AAPOS, Vol.24, No.4, p216-217. Futility of Monitoring Inappropriate Pathways In order to be useful, monitoring should assess the appropriate sensory or motor pathways. Train Of Four Monitoring. Jul 14, 2009 #3 EMG nerve Monitoring ----- We billed a 60240 with dx codes 240.9 and 242.00. This causes the blood vessels to relax, lowering blood pressure. Depending on the battlefield injury, and 5 ID: are we able to for! 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