Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature

Wang, Anthony; Than, Khoi D.; Etame, Arnold B.; Marca, Frank La; Park, Paul

doi:10.3171/2009.8.focus09145

Cited by 96 publications

(66 citation statements)

References 34 publications

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“…Motor evoked potentials are highly affected by anesthesia in general and muscle relaxation in particular, and detailed coordination and communication among the monitoring personnel, the spine surgeon, and the anesthesiologist prior to and during the case is necessary. 2,10,11,18,24,40 The health of the surgical Successful monitoring of both SSEP and MEP data may not be achieved in more than 25% of patients, and muscle-specific MEP monitoring may not be possible in 75% of patients. 6 Using several different types of monitoring not only introduces multiple constraints on the surgery, it also greatly increases the costs associated with IOM that are ultimately passed on to the patient, payer, or society.…”

Section: May and Colleaguesmentioning

confidence: 99%

Cervical decompression and reconstruction without intraoperative neurophysiological monitoring

Traynelis

Abode-Iyamah

Slingluff

et al. 2012

SPI

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Object The primary goal of this study was to review the immediate postoperative neurological function in patients surgically treated for symptomatic cervical spine disease without intraoperative neurophysiological monitoring. The secondary goal was to assess the economic impact of intraoperative monitoring (IOM) in this patient population. Methods This study is a retrospective review of 720 consecutively treated patients who underwent cervical spine procedures. The patients were identified and the data were collected by individuals who were not involved in their care. Results A total of 1534 cervical spine levels were treated in 720 patients using anterior, posterior, and combined (360°) approaches. Myelopathy was present preoperatively in 308 patients. There were 185 patients with increased signal intensity within the spinal cord on preoperative T2-weighted MR images, of whom 43 patients had no clinical evidence of myelopathy. Three patients (0.4%) exhibited a new neurological deficit postoperatively. Of these patients, 1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy. The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment. The Current Procedural Terminology (CPT) codes for IOM during cervical decompression include 95925 and 95926 for somatosensory evoked potential monitoring of the upper and lower extremities, respectively, as well as 95928 and 95929 for motor evoked potential monitoring of the upper and lower extremities. In addition to the charge for the baseline [monitoring] study, patients are charged hourly for ongoing electrophysiology testing and monitoring using the CPT code 95920. Based on these codes and assuming an average of 4 hours of monitoring time per surgical case, the savings realized in this group of patients was estimated to be $1,024,754. Conclusions With the continuing increase in health care costs, it is our responsibility as providers to minimize expenses when possible. This should be accomplished without compromising the quality of care to patients. This study demonstrates that decompression and reconstruction for symptomatic cervical spine disease without IOM may reduce the cost of treatment without adversely impacting patient safety.

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Section: May and Colleaguesmentioning

confidence: 99%

Cervical decompression and reconstruction without intraoperative neurophysiological monitoring

Traynelis

Abode-Iyamah

Slingluff

et al. 2012

SPI

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“…17,18,35 The use of intraoperative neuromonitoring allows the surgical team the potential for real-time identification of neural element dysfunction and the possibility to remedy reversible causes, including hypotension, ongoing cord compression, or overcorrection of deformity. 21,31,40 Due to the strong relationship between anesthetic administration and the effectiveness of monitoring, [12][13][14]36,45,49 which can result in false-positive monitoring alerts, 32 effective teamwork and communication between the anesthesia, neuromonitoring, and surgical teams is necessary to determine the cause and to institute corrective action in response to monitoring alerts. Furthermore, a need for evidencebased protocols for responding to neuromonitoring alerts has been recognized, 17 and to this end some groups have proposed management protocols for high-risk spine patients that include responses to neuromonitoring changes.…”

Section: 2941mentioning

confidence: 99%

The design, development, and implementation of a checklist for intraoperative neuromonitoring changes

Ziewacz¹,

Berven

Mummaneni³

et al. 2012

FOC

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Object The purpose of this study was to provide an evidence-based algorithm for the design, development, and implementation of a new checklist for the response to an intraoperative neuromonitoring alert during spine surgery. Methods The aviation and surgical literature was surveyed for evidence of successful checklist design, development, and implementation. The limitations of checklists and the barriers to their implementation were reviewed. Based on this review, an algorithm for neurosurgical checklist creation and implementation was developed. Using this algorithm, a multidisciplinary team surveyed the literature for the best practices for how to respond to an intraoperative neuromonitoring alert. All stakeholders then reviewed the evidence and came to consensus regarding items for inclusion in the checklist. Results A checklist for responding to an intraoperative neuromonitoring alert was devised. It highlights the specific roles of the anesthesiologist, surgeon, and neuromonitoring personnel and encourages communication between teams. It focuses on the items critical for identifying and correcting reversible causes of neuromonitoring alerts. Following initial design, the checklist draft was reviewed and amended with stakeholder input. The checklist was then evaluated in a small-scale trial and revised based on usability and feasibility. Conclusions The authors have developed an evidence-based algorithm for the design, development, and implementation of checklists in neurosurgery and have used this algorithm to devise a checklist for responding to intraoperative neuromonitoring alerts in spine surgery.

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“…This often results in failure to elicit muscle MEPs. Even so, responses can always be obtained when no halogenated agents are administered and patients do not have severe neurological deficits (8,23). And also, using double train stimulation compensates the relative hyperpolarisation of motor neurons resulting in reliable MEP responses in this situation (5,6).…”

Section: █ Discussionmentioning

confidence: 99%

“…We avoided using volathile anesthetics because they reduce the tcMEP amplitude significantly more than propofol. In particular, this effect was considerably distinct in the patients who had preexisting neurologic deficiencies (10,19,23). A short half-life muscle relaxant was used only during tracheal intubation procedure.…”

Section: Monitoringmentioning

confidence: 99%

Multimodal intraoperative neurophysiologic monitoring in the spinal cord surgery

Taşkıran

Brandmeier²,

Özek³

et al. 2015

Turkish Neurosurgery

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Intraoperative neurophysiological monitoring (IONM) is the use of electrophysiological methods to monitor the functional integrity of critical neural structures during surgery. IONM can predict an increased risk of injury during surgery based on electrophysiological changes. The most commonly used electrophysiological modalities are evoked potentials (Somatosensory Evoked Potentials -SSEP and Motor Evoked Potentials -MEP) and electromyography (EMG) in spinal cord █ INTRODUCTION S pinal surgeries carry a very high risk of injury to the spinal cord, spinal nerves and/or blood vessels. Neurological deficits, such as paralysis, muscle weakness, pain, bladder/bowel disturbances and sexual dysfunction, which emerge after these surgeries can seriously affect basic human functions and increase morbidity (1,3,11,14).AIm: Intraoperative neurophysiological monitoring (IONM) monitors the functional integrity of critical neural structures by electrophysiological methods during surgery. Multimodality combines different neurophysiological methods to maximize diagnostic efficacy and provide a safety margin to improve the outcomes of spinal surgery. Our aim was to share our intraoperative monitoring experiences with patients who underwent surgery because of spinal cord pathologies between September 2013 and January 2015. mATERIAl and mEThODS:We had twenty-six cases. Location of the lesions, surgery, neurological findings, and electrophysiological findings intraoperatively and postoperatively were documented. RESUlTS:The combination of motor evoked potential (MEP), somatosensorial evoked potential (SSEP), free-run and trigger electromyography (EMG) were performed according to lesion localization. MEPs plus SSEPs were run in 23 patients and MEPs with triggered EMG were performed in 4 patients. In only one patient, optimal recording could not be elicited because of technical problems. MEP and SSEP changes were recorded in 12 and 3 patients respectively. Postoperative neurological deficits were observed in 2 patients. Deficits were transient in one case and permanent in the other. While baseline MEP responses were either absent or low amplitude (<50 microvolt) in 7 patients, following resection they were either visible or increased in amplitude. Surgery was ended in one patient with C7-T2 intramedullary tumour after the right distal MEP response disappeared. CONClUSION:Multimodal IONM is an important method to monitor the neural structures under risk in spine surgery and to keep the surgery within safety limits, especially for intramedullary spinal cord lesion surgery.

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Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature

Cited by 96 publications

References 34 publications

Cervical decompression and reconstruction without intraoperative neurophysiological monitoring

Cervical decompression and reconstruction without intraoperative neurophysiological monitoring

The design, development, and implementation of a checklist for intraoperative neuromonitoring changes

Multimodal intraoperative neurophysiologic monitoring in the spinal cord surgery

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