Efficacy of intraoperative monitoring of transcranial electrical stimulation-induced motor evoked potentials and spontaneous electromyography activity to identify acute-versus delayed-onset C-5 nerve root palsy during cervical spine surgery: clinical article.

OBJECT: Deltoid muscle weakness due to C-5 nerve root injury following cervical spine surgery is an uncommon but potentially debilitating complication. Symptoms can manifest upon emergence from anesthesia or days to weeks following surgery. There is conflicting evidence regarding the efficacy of spontaneous electromyography (spEMG) monitoring in detecting evolving C-5 nerve root compromise. By contrast, transcranial electrical stimulation-induced motor evoked potential (tceMEP) monitoring has been shown to be highly sensitive and specific in identifying impending C-5 injury. In this study the authors sought to 1) determine the frequency of immediate versus delayed-onset C-5 nerve root injury following cervical spine surgery, 2) identify risk factors associated with the development of C-5 palsies, and 3) determine whether tceMEP and spEMG neuromonitoring can help to identify acutely evolving C-5 injury as well as predict delayed-onset deltoid muscle paresis. METHODS: The authors retrospectively reviewed the neuromonitoring and surgical records of all patients who had undergone cervical spine surgery involving the C-4 and/or C-5 level in the period from 2006 to 2008. Real-time tceMEP and spEMG monitoring from the deltoid muscle was performed as part of a multimodal neuromonitoring protocol during all surgeries. Charts were reviewed to identify patients who had experienced significant changes in tceMEPs and/or episodes of neurotonic spEMG activity during surgery, as well as those who had shown new-onset deltoid weakness either immediately upon emergence from the anesthesia or in a delayed fashion. RESULTS: Two hundred twenty-nine patients undergoing 235 cervical spine surgeries involving the C4-5 level served as the study cohort. The overall incidence of perioperative C-5 nerve root injury was 5.1%. The incidence was greatest (50%) in cases with dual corpectomies at the C-4 and C-5 spinal levels. All patients who emerged from anesthesia with deltoid weakness had significant and unresolved changes in tceMEPs during surgery, whereas only 1 had remarkable spEMG activity. Sensitivity and specificity of tceMEP monitoring for identifying acute-onset deltoid weakness were 100% and 99%, respectively. By contrast, sensitivity and specificity for spEMG were only 20% and 92%, respectively. Neither modality was effective in identifying patients who demonstrated delayed-onset deltoid weakness. CONCLUSIONS: The risk of new-onset deltoid muscle weakness following cervical spine surgery is greatest for patients undergoing 2-level corpectomies involving C-4 and C-5. Transcranial electrical stimulation-induced MEP monitoring is a highly sensitive and specific technique for detecting C-5 radiculopathy that manifests immediately upon waking from anesthesia. While the absence of sustained spEMG activity does not rule out nerve root irritation, the presence of excessive neurotonic discharges serves both to alert the surgeon of such potentially injurious events and to prompt neuromonitoring personnel about the need for additional tceMEP testing. Delayed-onset C-5 nerve root injury cannot be predicted by intraoperative neuromonitoring via either modality.

Transcranial electric motor evoked potential detection of compressional peroneal nerve injury in the lateral decubitus position.

The peroneal nerve is susceptible to injury due to compression at the fibular head for patients placed in the lithotomy, hemilithotomy or lateral decubitus positions during surgery. Upper extremity somatosensory and transcranial electric motor evoked potential monitoring has proven efficacious for identifying impending positional brachial plexopathy or upper extremity peripheral neuropathy in adult and pediatric patients undergoing spine surgery. We report on two cases to illustrate the usefulness of monitoring transcranial electric motor evoked potentials recorded from tibialis anterior muscle to identify emerging peroneal nerve compression secondary to lateral decubitus positioning.

Mixed blocked/event-related designs separate transient and sustained activity in fMRI.

Recent functional magnetic resonance imaging (fMRI) studies using mixed blocked/event-related designs have shown activity consistent with separable sustained task-related processes and transient trial-related processes. In the mixed design, control blocks are intermixed with task blocks, during which trials are presented at varying intervals. Two studies were conducted to assess the ability of this design to detect and dissociate sustained task-related from transient trial-related activity. Analyses on both simulated and empirical data were performed by using the general linear model with a shape assumed for sustained effects, but not transient effects. In the first study, simulated data were produced with sustained time courses, transient time courses, and the sum of both together. Analyses of these data showed appropriate parsing of sustained and transient activity in all three cases. For the empirical fMRI experiment, counterphase-flickering checkerboard stimuli were constructed to produce sustained, transient, and combined sustained and transient responses in visual cortex. As with the simulation, appropriate parsing of sustained and transient activity was seen in all three cases; i.e., sustained stimuli produced sustained time courses and transient stimuli produced transient time courses. Combined stimuli produced both transient and sustained time courses. Critically, transient stimuli alone did not produce spurious positive sustained responses; sustained stimuli alone produced negligible spurious transient time courses. The results of these two studies along with supplemental simulations provide strong evidence that mixed designs are an effective tool for separating transient, trial-related activity from sustained activity in fMRI experiments. Mixed designs can allow researchers a means to examine brain activity associated with sustained processes, potentially related to task-level control signals.