Intraoperative motor evoked potential monitoring – A position statement by the American Society of Neurophysiological Monitoring

MacDonald, David B.; Skinner, Stanley A.; Shils, Jay L.; Yingling, Charles D.

doi:10.1016/j.clinph.2013.07.025

Cited by 451 publications

(362 citation statements)

References 129 publications

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“…[1][2][3]8 According to MacDonald and colleagues, the incidence of seizures was 0.03% and the incidence of bite injuries was 0.2%. 6 Therefore, a risk/benefit analysis should be performed prior to utilizing TceMEPs.…”

mentioning

confidence: 99%

Intraoperative neuromonitoring alerts in a pediatric deformity center

Zuccaro¹,

Zuccaro²,

Samdani

et al. 2017

Neurosurgical Focus

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OBJECTIVEIntraoperative neuromonitoring (IONM) involves the use of somatosensory evoked potentials (SSEPs) and transcranial electric motor evoked potentials (TceMEPs). In this retrospective study the authors examined the sensitivity and specificity of both SSEPs and TceMEPs during pediatric spinal deformity surgeries.METHODSThe authors performed a retrospective quantitative analysis of data obtained in 806 patients (197 males and 609 females) treated from December 2011 until October 2015. All patients were diagnosed with scoliosis that was classified as one of the following: adolescent idiopathic scoliosis (AIS) (38%), congenital scoliosis (22%), or syndromic scoliosis (40%). Also, 53 patients underwent vertebral column resection (VCR). All surgeries were monitored by high-level neuromonitoring specialists and were performed with total intravenous anesthesia. Alerts were described as a decrease in amplitude by 50% or greater (bilateral or unilateral) in SSEPs, TceMEPs, or both.RESULTSTrue-positive alerts for TceMEPs were observed in 60 of the 806 patients (7.4%). True-positive alerts for SSEPs were observed in 7 of the 806 patients (0.9%). In contrast, there were no false-positive or false-negative outcomes. Only 1 case (0.1%) was reported with a permanent postoperative deficit. No reported false negatives or false positives were observed, and thus sensitivity was 100% and specificity was 93%–100% for TceMEPs. The rate of sensitivity was 13.2% and the rate of specificity was 100% for SSEPs. The breakdown of total alert was as follows: 6.6% in AIS cases, 24.5% in congenital scoliosis cases, and 10.2% in syndromic scoliosis cases. Neurological injury rates were significantly lower than in previous studies, as there were 0% for AIS cases (p = 0.12), 0.6% for congenital scoliosis cases (p = 0.17), and 0% for syndromic scoliosis cases (p = 0.07). One injury in a patient with congenital scoliosis occurred during a VCR procedure, which brought the injury rate to 1.9% (p < 0.005). IONM alerts occurred during 34% of rod/correction cases, 25% of thoracic screw placements, 20% of the osteotomies, 17% of the resections, 3% of the cage insertions, and 2% of the sublaminar wiring procedures.CONCLUSIONSThe authors hypothesize that the results of this study will support the necessity, as a standard of care, of multimodality neuromonitoring during high-risk pediatric spinal deformity surgery because of the decrease in postoperative deficits. Their data suggest that the TceMEPs are more sensitive than SSEPs, but when used in combination, they offer the patient a level of safety that would otherwise not exist. Last, these findings support the notion that better outcomes are achieved with high-level IONM professionals.

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mentioning

confidence: 99%

Intraoperative neuromonitoring alerts in a pediatric deformity center

Zuccaro¹,

Zuccaro²,

Samdani

et al. 2017

Neurosurgical Focus

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“…For the practical adoption of MT determination during an ECT or MST procedure, the MT titration should ideally be fast (no longer than a minute) and under the same anesthetic used for the seizure induction, as the patients are anesthetized for a relatively short period of time. This could be accomplished by using more efficient thresholding algorithms (Awiszus, 2003;Götz et al, 2011;Qi et al, 2011) and making the motor-evoked potentials under anesthesia more stable by delivering rapid bursts of 3-5 pulses instead of single pulses during the titration (Macdonald et al, 2013;Szelenyi et al, 2007).…”

Section: Interindividual Threshold Variation and Stimulus Individualimentioning

confidence: 99%

“…Addressing these limitations, we individualize the ECT and MST pulse amplitude by titrating the motor threshold (MT) with a sequence of single pulses delivered through the ECT electrodes or MST coil, respectively. This approach is analogous to MT titration to individualize transcranial magnetic stimulation (TMS; Rossini et al, 1994) and the use of transcranial electric stimulation (TES) for intraoperative monitoring under anesthesia (Macdonald et al, 2013). Since MT captures individual variability in anatomy and neurophysiology, as well as the effects of the anesthesia, we hypothesize that it predicts the pulse-amplitude-titrated ST in ECT and MST.…”

Section: Introductionmentioning

confidence: 99%

Individualized Low-Amplitude Seizure Therapy: Minimizing Current for Electroconvulsive Therapy and Magnetic Seizure Therapy

Peterchev

Krystal

Rosa³

et al. 2015

Neuropsychopharmacol

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Electroconvulsive therapy (ECT) at conventional current amplitudes (800-900 mA) is highly effective but carries the risk of cognitive side effects. Lowering and individualizing the current amplitude may reduce side effects by virtue of a less intense and more focal electric field exposure in the brain, but this aspect of ECT dosing is largely unexplored. Magnetic seizure therapy (MST) induces a weaker and more focal electric field than ECT; however, the pulse amplitude is not individualized and the minimum amplitude required to induce a seizure is unknown. We titrated the amplitude of long stimulus trains (500 pulses) as a means of determining the minimum current amplitude required to induce a seizure with ECT (bilateral, right unilateral, bifrontal, and frontomedial electrode placements) and MST (round coil on vertex) in nonhuman primates. Furthermore, we investigated a novel method of predicting this amplitude-titrated seizure threshold (ST) by a non-convulsive measurement of motor threshold (MT) using single pulses delivered through the ECT electrodes or MST coil. Average STs were substantially lower than conventional pulse amplitudes (112-174 mA for ECT and 37.4% of maximum device amplitude for MST). ST was more variable in ECT than in MST. MT explained 63% of the ST variance and is hence the strongest known predictor of ST. These results indicate that seizures can be induced with less intense electric fields than conventional ECT that may be safer; efficacy and side effects should be evaluated in clinical studies. MT measurement could be a faster and safer alternative to empirical ST titration for ECT and MST.

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“…In all cases, there were no alterations in either signal modality, except in one case where the amplitude of MEPs decreased more than 50% leading to a temporary stop in the surgery, with return of the signal after a few minutes following irrigation with warm ringer solution and increase in blood pressure (BP) (7)(8)(9).…”

Section: Methodsmentioning

confidence: 99%