Intraoperative Monitoring: Recent Advances in Motor Evoked Potentials.

Advances in electrophysiological monitoring have improved the ability of surgeons to make decisions and minimize the risks of complications during surgery and interventional procedures when the central nervous system (CNS) is at risk. Individual techniques have become important for identifying or mapping the location and pathway of critical neural structures. These techniques are also used to monitor the progress of procedures to augment surgical and physiologic management so as to reduce the risk of CNS injury. Advances in motor evoked potentials have facilitated mapping and monitoring of the motor tracts in newer, more complex procedures.

Intraoperative neurophysiological monitoring during spine surgery with total intravenous anesthesia or balanced anesthesia with 3% desflurane.

Total intravenous anesthesia (TIVA) with propofol and opioids is frequently utilized for spinal surgery when somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (tcMEPs) are monitored. Many anesthesiologists would prefer to utilize low dose halogenated anesthetics (e.g. 1/2 MAC). We examined our recent experience using 3% desflurane or TIVA during spine surgery to determine the impact on propofol usage and on the evoked potential responses. After institutional review board approval we conducted a retrospective review of a 6 month period for adult spine patients who were monitored with SSEPs and tcMEPs. Cases were included for the study if anesthesia was conducted with propofol-opioid TIVA or 3% desflurane supplemented with propofol or opioid infusions as needed. We evaluated the propofol infusion rate, cortical amplitudes of the SSEPs (median nerve, posterior tibial nerve), amplitudes and stimulation voltage for eliciting the tcMEPs (adductor pollicis brevis, tibialis anterior) and the amplitude variability of the SSEP and tcMEP responses as assessed by the average percentage trial to trial change. Of the 156 spine cases included in the study, 95 had TIVA with propofol-opioid (TIVA) and 61 had 3% expired desflurane (INHAL). Three INHAL cases were excluded because the desflurane was eliminated because of inadequate responses and 26 cases (16 TIVA and 10 INHAL) were excluded due to significant changes during monitoring. Propofol infusion rates in the INHAL group were reduced from the TIVA group (average 115-45 µg/kg/min) (p<0.00001) with 21 cases where propofol was not used. No statistically significant differences in cortical SSEP or tcMEP amplitudes, tcMEP stimulation voltages nor in the average trial to trial amplitude variability were seen. The data from these cases indicates that 1/2 MAC (3%) desflurane can be used in conjunction with SSEP and tcMEP monitoring for some adult patients undergoing spine surgery. Further studies are needed to confirm the relative benefits versus negative effects of the use of desflurane and other halogenated agents for anesthesia during procedures on neurophysiological monitoring involving tcMEPs. Further studies are also needed to characterize which patients may or may not be candidates for supplementation such as those with neural dysfunction or who are opioid tolerant from chronic use.

Lidocaine infusion adjunct to total intravenous anesthesia reduces the total dose of propofol during intraoperative neurophysiological monitoring.

Total intravenous anesthesia (TIVA) with propofol and opioids is frequently utilized for spinal surgery where somatosensory evoked potentials (SSEP) and motor evoked potentials (tcMEP) are monitored. Lidocaine infusions can contribute to antinociception and unconsciousness, thus allowing for a reduction in the total dose of propofol. We examined our recent experience with lidocaine infusions to quantify this effect. After institutional review board approval, we conducted a retrospective review of propofol usage in propofol-opioid TIVA (with and without lidocaine) for spine cases monitored with SSEP and tcMEP over a 7 months period. The propofol infusion rate, cortical amplitudes of the SSEP (median nerve, posterior tibial nerve), amplitudes and stimulation voltage of the tcMEP (adductor pollicis brevis, tibialis anterior) were evaluated. The savings of propofol and sufentanil were estimated based on utilization in 50 milliliter (ml) bottles and 5 ml ampules, respectively. 129 cases were evaluated. Propofol infusion rates were reduced with lidocaine infusion from an average of 115-99 µg/kg/min (p = 0.00038) and sufentanil infusions from an average of 0.36-0.29 µg/kg/h (p = 0.0059). This reduction in propofol infusion was also seen when the cases were divided into anterior cervical, posterior cervical, or posterior thoraco-lumbar procedures. No significant differences in the cortical SSEP or tcMEP amplitudes or the tcMEP stimulation voltages used were observed. No complications were associated with the use of the lidocaine infusion. The total estimated drug savings included 104 50 ml bottles of propofol and 5 5 ml ampules of sufentanil. These cases indicate that a lidocaine infusion can be effectively utilized in spine surgery with SSEP and tcMEP monitoring as a means to reduce propofol and sufentanil usage without a negative effect on the monitoring.

Methohexital in total intravenous anesthesia during intraoperative neurophysiological monitoring.

Total intravenous anesthesia (TIVA) is usually recommended during spinal surgery when transcranial motor evoked potentials (tcMEPs) are used to monitor. A shortage of propofol has prompted a search for an alternative sedative-hypnotic agent. We explored the use of methohexital as an alternative. TIVA was provided for two adult patients having spinal surgery using an infusion of methohexital. TcMEPs and somatosensory evoked potentials were acquired to monitor neurological function and electroencephalogram was used to titrate the methohexital dose. Two cases are presented in which the anesthesia and monitoring that was provided were successful. These cases indicate that methohexital can be a suitable alternative to propofol in some patients.

Muscle relaxant use during intraoperative neurophysiologic monitoring.

Neuromuscular blocking agents have generally been avoided during intraoperative neurophysiological monitoring (IOM) where muscle responses to nerve stimulation or transcranial stimulation are monitored. However, a variety of studies and clinical experience indicate partial neuromuscular blockade is compatible with monitoring in some patients. This review presents these experiences after reviewing the currently used agents and the methods used to assess the blockade. A review was conducted of the published literature regarding neuromuscular blockade during IOM. A variety of articles have been published that give insight into the use of partial pharmacological paralysis during monitoring. Responses have been recorded from facial muscles, vocalis muscles, and peripheral nerve muscles from transcranial or neural stimulation with neuromuscular blockade measured in the muscle tested or in the thenar muscles from ulnar nerve stimulation. Preconditioning of the nervous system with tetanic or sensory stimulation has been used. In patients without neuromuscular pathology intraoperative monitoring using peripheral muscle responses from neural stimulation is possible with partial neuromuscular blockade. Monitoring of muscle responses from cranial nerve stimulation may require a higher degree of stimulation and less neuromuscular blockade. The role of tetanic or sensory conditioning of the nervous system is not fully characterized. The impact of neuromuscular pathology or the effect of partial blockade on monitoring muscle responses from spontaneous neural activity or mechanical nerve stimulation has not been described.

Neurophysiologic monitoring in neurosurgery.

This article focuses on the application of neurophysiologic monitoring in uniquely neurosurgical procedures. Neurophysiologic monitoring provides functional testing and mapping to identify neural structures. Once identified, the functionality of the central and peripheral nervous system areas at risk for neurosurgical injury can be monitored. It discusses the use of motor-evoked potentials, sensory evoked potentials, electromyography and electroencephalography to assess neurologic change.

American Society of Neurophysiologic Monitoring and American Society of Neuroimaging joint guidelines for transcranial doppler ultrasonic monitoring.

The American Society of Neurophysiologic Monitoring (ASNM) and American Society of Neuroimaging (ASN) Guidelines Committees formed a joint task force and developed guidelines to assist in the use of transcranial Doppler (TCD) monitoring in the surgical and intensive care settings. Specifically, these guidelines: (1) delineate the objectives of TCD monitoring; (2) characterize the responsibilities and behaviors of the sonographer during monitoring; (3) describe methodological and ethical issues uniquely relevant to monitoring. The ASNM and ASN strongly support the positions that (1) acquisition and interpretation of intraoperative TCD ultrasonograms be performed by qualified individuals, (2) service providers define their diagnostic criteria and develop on-going self-validation programs of these performance criteria in their practices. We agree with the guidelines of other professional societies regarding the technical and professional qualifications of individuals responsible for TCD signal acquisition and interpretation (Class III evidence, Type C recommendation). On the basis of current clinical literature and scientific evidence, TCD monitoring is an established monitoring modality for the: (1) assessment of cerebral vasomotor reactivity and autoregulation; (2) documentation of the circle of Willis functional status; (3) identification of cerebral hypo- and hyperperfusion, recanalization and re-occlusion; and (4) detection of cerebral emboli (Class II and III evidence, Type B recommendation).

Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement.

Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problem-solving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options.

Nitrous oxide and isoflurane are synergistic with respect to amplitude and latency effects on sensory evoked potentials.

OBJECTIVE: Combinations of anesthetic agents are frequently employed to produce the desired clinical effect. No systematic study has been conducted on the effect of the combination of nitrous oxide with a potent inhalational agent such as isoflurane on sensory evoked responses. METHODS: Median nerve somatosensory evoked responses from the cervical and cortical regions (SSEP), auditory brainstem responses (ABR) and flash visual evoked responses (VEP) were tested in baboons. The latency and amplitude of the major response peaks were recorded at five proportionate mixtures of isoflurane (I) and nitrous oxide (N(2)O) (0.8% I only, 0.6% I/20% N(2)O, 0.4% I/40% N(2)O, 0.2% I/60% N(2)O, and 79% N(2)O only). A similar set of experiments were also conducted with 0.8% isoflurane and 0.6% halothane. All data were normalized to 0.8% isoflurane only and Dunnett's method of analysis used to determine which mixtures deviated from the reference values with 0.8% isoflurane. RESULTS: Several combinations of isoflurane with nitrous oxide produced increases in latency (ABR: wave V, VEP, SSEP cervical and cortical) and decreases in amplitude (ABR: amplitude ratio V/I, VEP, cortical SSEP) from that expected if the effects were additive. No deviations were observed with combinations of isoflurane and halothane. CONCLUSIONS: These studies are consistent with drug synergy when isoflurane is mixed with nitrous oxide. This suggests that if these agents are considered for anesthesia when sensory evoked responses are to be monitored that the combination of these agents may produce more amplitude and latency changes than expected from a proportionate mixture of the individual agents.

The incidence, volume, absorption, and timing of supratentorial pneumocephalus during posterior fossa neurosurgery conducted in the sitting position.

BACKGROUND: Supratentorial pneumocephalus (STP) is a known complication of neurosurgical procedures of the posterior fossa when conducted in the sitting position. Few studies have examined STP as differentiated from pneumocephalus in the operative field. METHODS: Ninety-five of 106 consecutive patients had postoperative radiographic studies and median nerve somatosensory evoked potential (SSEP) recording during surgery. STP was identified on postoperative skull films or computerized tomography (CT). STP volume was measured on CT scans. SSEP changes were identified in the monitoring records. RESULTS: STP was identified in 40 patients (42.1%). STP volume on CT scans within 4 hours of surgery ranged from 6 to 280 cm3 (cubic centimeters). An extraventricular drain or ventriculo-peritoneal shunt did not increase the incidence of STP (P=0.85). The absorption of STP in 5 patients with multiple CT scans showed an immediate reduction of 24% followed by exponential decay with an half life of 1.5 days. Four patients with an extraventricular drain or ventriculo-peritoneal shunt had excessive volume of STP when measured at 1 day or later. Six patients with significant SSEP amplitude reductions attributed to STP had volumes exceeding 90 cm3 on a CT scan within 4 hours of surgery. The onset of these changes occurred at various times from dural opening to closing. CONCLUSIONS: STP is common after posterior fossa neurosurgical procedures conducted in the sitting position. Further studies are needed to fully characterize the absorption of air and the timing of the entry.

Anesthesia and intraoperative neurophysiological monitoring in children.

PURPOSE: Anesthesia for pediatric patients undergoing surgery where intraoperative neurophysiological monitoring (IONM) is performed is based on an understanding of the anesthetic influence on the neural pathways involved and the physiology that supplies nutrients to the neural systems. Anesthesia in pediatric patients may be different than in adults due to the specific anesthesia considerations in children, notably the propofol infusion syndrome (PRIS) and the need to monitor immature neural pathways. This review was done to determine if the anesthesia protocols used were different than those used in adults. METHODS: After reviewing the implications of anesthetic action, a survey of pediatric anesthesia practitioners in 40 North American centers was conducted to determine the anesthesia protocols used in pediatric surgery with IONM and if these were specifically modified over concerns about PRIS. RESULTS: Twenty-five centers responded with 35 different protocols used by practitioners. These protocols are similar to protocols used in adult patients. Although no centers specifically avoided propofol in all patients, several strategies were used to reduce the dosage, avoid its use in selected patients, or monitor for the onset of the syndrome. CONCLUSION: Anesthesia for pediatric patients undergoing surgery where IONM is being performed is consistent with the practice and principles of anesthesia for adults. Although PRIS has not caused major alterations in most patients, concern has modified the practice of some anesthesiologists.

Dose and timing effect of etomidate on motor evoked potentials elicited by transcranial electric or magnetic stimulation in the monkey and baboon.

OBJECTIVE: Etomidate has been shown to both enhance and depress the cortical amplitude of somatosensory evoked potentials (SSEP) depending on the dose used. Similar amplitude increases with etomidate and motor evoked potentials resulting from cortical magnetic (tcMMEP) and electric (tcEMEP) stimulation have not been consistent. We used a primate model to elucidate the time and dose characteristics of the effect. METHODS: tcMMEP and tcEMEP were characterized during bolus injections of 0.1-1.8 mg/kg etomidate in 10 adult cynomologous monkeys during a baseline anesthesia with a continuous ketamine infusion. Responses were assessed by measuring the amplitude and onset latency of the hypothenar compound action potential response. In a second experiment the epidural and hypothenar response to tcEMEP was recorded under 0.3% isoflurane anesthesia and following intravenous injection of 0.05-0.35 mg/kg etomidate. Cortical stimulation was accomplished using a Cadwell MES-10 (tcMMEP) and Digitimer D180 (tcEMEP). RESULTS: The amplitude of the hypothenar muscle response was increased for tcEMEP and tcMMEP at 20 min following 0.1 mg/kg etomidate in the monkey. The amplification of the tcMMEP response was significantly greater than the tcEMEP response (1.95 + 0.62 SD vs. 1.43 + 0.68 SD, P = 0.023). Responses at higher doses were all below baseline. The tcMMEP response was significantly smaller than the tcEMEP at doses above 0.9 mg/kg (all P<0.001). The onset latency values were not significantly increased at any dose or time. The epidural recording demonstrated a large increase in the number of I waves compared to the isoflurane baseline. CONCLUSIONS: This study demonstrates that a low dose (0.1 mg/kg) of etomidate increases the com- pound muscle action potential (CMAP) amplitude for tcEMEP and tcMMEP in the monkey whereas higher doses decrease the amplitude. Epidural recordings demonstrate a marked increase in the number of I waves consistent with a cortical effect similar to the postulated effect that results in amplification of the cortical SSEP. This suggests the amplitude loss in the hypothenar muscles may be due to depression of the spinal cord by etomidate. The CMAP response amplification at low doses was greater in tcMMEP than tcEMEP and the depression at higher doses was more with the tcMMEP technique consistent with the greater dependence of the tcMMEP technique on synaptic activation.

Intraoperative autologous transfusion of hemolyzed blood.

During two cases of lumbar spine surgery with instrumentation, we used intraoperative autologous transfusion (IAT), resulting in hemolysis during collection and hemoglobinuria and coagulation abnormalities after transfusion. Hemolysis during IAT collection can lead to hemoglobinuria and binding of nitric oxide, leading to vasoconstriction. The literature suggests that stroma from damaged cells and contact of the blood with the IAT device can lead to coagulation abnormalities and other morbidities, including adult respiratory distress syndrome.

Differential effect of halothane on motor evoked potentials elicited by transcranial electric or magnetic stimulation in the monkey.

OBJECTIVE: Halothane (HAL) is known to depress motor evoked potentials produced by transcranial magnetic (tcMMEP) or transcranial electric (tcEMEP) stimulation. This study was designed to determine if differences existed between tcEMEP and tcMMEP with increasing HAL concentra- tions. METHODS: tcMMEP and tcEMEP were characterized during 0-2% inspired HAL in 10 adult cynomologous monkeys during a baseline anesthesia with a continuous ketamine infusion. tcEMEP and tcMMEP were assessed by measuring the onset latency (time from stimulation to the initial response), amplitude of the thenar compound action potential response and threshold (relative power required to elicit a response). Cortical stimulation was accomplished using a Cadwell MES-10 (tcMMEP) and Digitimer Dl80 (tcEMEP). RESULTS: The baseline (no HAL) onset latency for tcEMEP (10.68 ms) was significantly shorter than that of tcMMEP (12.28 ms) (P < 0.05). The amplitudes (7,916, 4,858 microV, respectively) were not significantly different (P > 0.112). The onset latency increased and amplitude decreased for both techniques (no significant difference between tcEMEP and tcMMEP) with increase in HAL. All animals lost their responses below 2% HAL. In each animal the tcMMEP was lost at a HAL concentration below or equal to that for tcEMEP. T The ED(50) (where 50% of the animals lost the response) was significantly different between tcMMEP (0.66% HAL) and tcEMEP (1.04% HAL) (P < 0.05). The relative threshold gradually increased for tcEMEP and abruptly increased above 0.4% HAL for tcMMEP. CONCLUSIONS: These differences in sensitivity to HAL are consistent with other studies with intravenous anesthesia and are consistent with the known difference in the physiological mechanisms by which magnetic and electrical stimulation activates the motor cortex.

Multimodality monitoring of the central nervous system using motor-evoked potentials.

PURPOSE OF REVIEW: This review was conducted to examine the role of motor-evoked potential monitoring in spine and central nervous system surgery to determine whether other monitoring modalities such as the wake-up test or somatosensory-evoked potentials can be eliminated. RECENT FINDINGS: The current literature suggests that motor-evoked potential, despite some advantages, still requires that other monitoring modalities such as somatosensory-evoked potentials or electromyography be used to provide optimal monitoring. SUMMARY: The literature supports the use of multimodality monitoring using all of the electrophysiological techniques that can provide intraoperative information about the neural structures at risk during the surgery.

Electrophysiologic monitoring during surgery to repair the thoraco-abdominal aorta.

Prevention of paraplegia during the repair of thoraco-abdominal aortic aneurysms and dissections present a substantial challenge to the operative team. The value of intraoperative electrophysiological monitoring (IOM) is to identify spinal cord ischemia that occurs during the procedure and guide the intraoperative management to reduce the risks of paralysis. The usefulness of IOM techniques requires an understanding of spinal cord blood flow and the spinal cord physiology, the surgical technique and their interaction. This paper will integrate these factors to review the laboratory and clinical experience with somatosensory evoked responses (SSEP) and motor evoked potentials (MEP) during thoraco-abdominal aorta surgery.