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Adkins G, Mirallave Pescador A, Koht A, Gosavi S. Intraoperative neuromonitoring in intracranial surgery. BJA Educ 2024; 24:173-182. [PMID: 38646449 PMCID: PMC11026914 DOI: 10.1016/j.bjae.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 04/23/2024] Open
Affiliation(s)
- G.B. Adkins
- South East School of Anaesthesia, London, UK
| | | | - A.H. Koht
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Liu H, Jian M, Wang C, Nie L, Liang F, Liu K, Zhang K, Qiao H, Han R. Effect of Sugammadex During Transcranial Electrical Motor Evoked Potentials Monitoring in Spinal Surgery: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2023; 35:224-231. [PMID: 34839318 DOI: 10.1097/ana.0000000000000820] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Neuromuscular blockade suppresses transcranial electrical motor evoked potential (TceMEP) amplitude and is usually avoided during TceMEP monitoring. In this randomized controlled trial, we investigated whether rocuronium-induced suppression of TceMEP amplitude could be reversed by sugammadex in patients undergoing spine surgery. METHODS Seventy-six patients undergoing spinal surgery were randomly allocated into sugammadex and control groups. In the sugammadex group, a rocuronium infusion was titrated to maintain moderate neuromuscular blockade (2 twitches on train-of-four) until dural opening when the rocuronium infusion was discontinued and 2 mg/kg sugammadex administered. In the control group, no neuromuscular blockade was administered after induction of anesthesia. The primary outcome was a comparison between sugammadex and control groups of mean TceMEP amplitudes in the abductor pollicis brevis muscles of both upper extremities 5 minutes after dural. Secondary outcomes included TceMEP amplitudes at 10, 20, 30, and 60 minutes after dural opening. RESULTS Sixty-six patients were included in the analysis. TceMEP amplitudes were significantly greater in the sugammadex group (629 μV, interquartile range: 987 μV) than in the control group (502 μV, interquartile range: 577 μV; P =0.033) at 5 minutes after dural opening. TceMEP amplitudes were also greater in the sugammadex group at 10 minutes ( P =0.0010), 20 minutes ( P =0.003), 30 minutes ( P =0.001), and 60 minutes ( P =0.003) after dural opening. CONCLUSIONS Moderate neuromuscular blockade induced by continuous infusion of rocuronium was effectively reversed by sugammadex. This suggests that sugammadex could be used to enhance TceMEP waveform monitoring during spine surgery requiring muscle relaxation.
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Affiliation(s)
- Haiyang Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Minyu Jian
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Chengwei Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Lanyi Nie
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
| | - Kuo Liu
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
| | - Kaiying Zhang
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, TX
| | - Hui Qiao
- Department of Electrophysiology, Beijing Neurosurgical Institute, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University
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Jamaludin MR, Lai KW, Chuah JH, Zaki MA, Hum YC, Tee YK, Mohd Salim MI, Saw LB. Transcranial Electrical Motor Evoked Potential in Predicting Positive Functional Outcome of Patients after Decompressive Spine Surgery: Review on Challenges and Recommendations towards Objective Interpretation. Behav Neurol 2021; 2021:2684855. [PMID: 34777631 PMCID: PMC8580690 DOI: 10.1155/2021/2684855] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/18/2021] [Indexed: 11/18/2022] Open
Abstract
Spine surgeries impose risk to the spine's surrounding anatomical and physiological structures especially the spinal cord and the nerve roots. Intraoperative neuromonitoring (IONM) is a technology developed to monitor the integrity of the spinal cord and the nerve roots via the surgery. Transcranial motor evoked potential (TcMEP) (one of the IONM modalities) is adopted to monitor the integrity of the motor pathway of the spinal cord and the motor nerve roots. Recent research suggested that the IONM is conducive as a prognostic tool towards the patient's functional outcome. This paper summarizes the researches of IONM being adopted as a prognostic tool. In addition, this paper highlights the problems associated with the signal parameters as the improvement criteria in the previous researches. Lastly, we review the challenges of TcMEP to achieve a prognostic tool focusing on the factors that could interfere with the generation of a stable TcMEP response. The final section will discuss recommendations for IONM technology to achieve an objective prognostic tool.
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Affiliation(s)
- Mohd Redzuan Jamaludin
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Khin Wee Lai
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Joon Huang Chuah
- Department of Electrical Engineering, Faculty of Engineering, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Muhammad Afiq Zaki
- Center of Environmental Health and Safety, Faculty of Health Sciences, Universiti Teknologi Mara Selangor, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor Darul Ehsan, Malaysia
| | - Yan Chai Hum
- Centre for Healthcare Science & Technology, Department of Mechatronics and Biomedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, Malaysia
| | - Yee Kai Tee
- Centre for Healthcare Science & Technology, Department of Mechatronics and Biomedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, Malaysia
| | - Maheza Irna Mohd Salim
- Bioinspired Device and Tissue Engineering Research Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81300 Skudai, Johor, Malaysia
| | - Lim Beng Saw
- Department of Orthopaedic Surgery, Sunway Medical Centre, Malaysia
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Khandelwal A, Chaturvedi A, Sokhal N, Singh A, Sharma HB. Comparison of Propofol and Ketofol on Transcranial Motor Evoked Potentials in Patients Undergoing Thoracolumbar Spine Surgery. Asian Spine J 2021; 16:183-194. [PMID: 34000799 PMCID: PMC9066259 DOI: 10.31616/asj.2020.0562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/08/2021] [Indexed: 11/23/2022] Open
Abstract
Study Design This was a double-blind randomized study. Purpose The primary purpose was to compare the effects of propofol and ketofol on amplitudes and latencies of transcranial motor evoked potentials (TcMEPs) during thoracolumbar spine surgery. In addition, intraoperative hemodynamics and muscle power were compared. Overview of Literature Propofol is commonly used during intraoperative TcMEP monitoring. However, propofol inhibits TcMEP amplitudes and causes hypotension in a dose-dependent fashion. Methods Amplitude and latency of TcMEPs were recorded bilaterally from the abductor pollicis brevis (APB) and abductor hallucis (AH) muscles in 38 adult American Society of Anesthesiologists I and II patients undergoing thoracolumbar spine surgery. Baseline recordings of TcMEPs in both groups were recorded under propofol infusion. Group X patients then received propofol and fentanyl (1 mcg/kg/hr), and group Y patients received ketofol and fentanyl (1 mcg/kg/hr). Bispectral index was maintained at 40-60 in both groups. Amplitude and latency were recorded at 30 minutes intervals for 2 hours. Results Propofol caused no significant changes in amplitude and latency in any muscle. In contrast, amplitude increased significantly at all time points in the bilateral APB muscles and 60, 90, and 120 minutes in the left AH muscle without changes in latency in response to ketofol. When the two groups were compared, ketofol induced significantly higher amplitudes at 60, 90, and 120 minutes in the (left) APB, at all time points in the (right) APB, and at 120 minutes in both AH muscles, compared with propofol. Blood pressures were lower and fluid and vasopressor requirements were higher in group X. Muscle power was similar between the two groups. Conclusions Ketofol facilitates TcMEP amplitudes without affecting latency. Use of ketofol resulted in a better and more stable hemodynamic profile than did use of propofol.
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Affiliation(s)
- Ankur Khandelwal
- Department of Anaesthesia and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, India
| | - Arvind Chaturvedi
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Navdeep Sokhal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Akanksha Singh
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Hanjabam Barun Sharma
- Department of Physiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India Study
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Goyal K, Khandelwal A, Sokhal S, Dube S, Singh A, Tandon V, Phalak M, Chaturvedi A, Kale S. Perioperative Management of a Patient with Chin-On-Chest Deformity Presenting for Reconstructive Spine Surgery. Neurol India 2021; 69:1756-1758. [DOI: 10.4103/0028-3886.333489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kondo T, Toyota Y, Narasaki S, Watanabe T, Miyoshi H, Saeki N, Tsutsumi YM. Intraoperative responses of motor evoked potentials to the novel intravenous anesthetic remimazolam during spine surgery: a report of two cases. JA Clin Rep 2020; 6:97. [PMID: 33300097 PMCID: PMC7726079 DOI: 10.1186/s40981-020-00401-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/11/2020] [Accepted: 11/26/2020] [Indexed: 12/03/2022] Open
Abstract
Background Remimazolam is a novel short-acting benzodiazepine characterized by metabolism independent from organ function. We report intraoperative MEP responses of two patients who underwent spine surgery under general anesthesia using remimazolam. Case presentation In case 1, MEP monitoring was successfully performed with the use of a fixed dose of remimazolam at 0.5 mg/kg/h and remifentanil at 0.2 μg/kg/min. In case 2, an increasing dose of remimazolam from 0.5 to 1.5 mg/kg/h during the operation did not affect MEP signals. In both cases, remimazolam was titrated to maintain the values of entropy electroencephalogram (EEG) monitoring at 40–60. Conclusions General anesthesia using remimazolam and remifentanil can be a valuable alternative for spine surgery with MEP monitoring by EEG to assess the optimal dose.
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Affiliation(s)
- Takashi Kondo
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Yukari Toyota
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Soshi Narasaki
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tomoyuki Watanabe
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Noboru Saeki
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Buhl LK, Bastos AB, Pollard RJ, Arle JE, Thomas GP, Song Y, Boone MD. Neurophysiologic Intraoperative Monitoring for Spine Surgery: A Practical Guide From Past to Present. J Intensive Care Med 2020; 36:1237-1249. [PMID: 32985340 DOI: 10.1177/0885066620962453] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intraoperative neuromonitoring was introduced in the second half of the 20th century with the goal of preventing patient morbidity for patients undergoing complex operations of the central and peripheral nervous system. Since its early use for scoliosis surgery, the growth and utilization of IOM techniques expanded dramatically over the past 50 years to include spinal tumor resection and evaluation of cerebral ischemia. The importance of IOM has been broadly acknowledged, and in 1989, the American Academy of Neurology (AAN) released a statement that the use of SSEPs should be standard-of-care during spine surgery. In 2012, both the AAN and the American Clinical Neurophysiology Society (ACNS) recommended that: "Intraoperative monitoring (IOM) using SSEPs and transcranial MEPs be established as an effective means of predicting an increased risk of adverse outcomes, such as paraparesis, paraplegia, and quadriplegia, in spinal surgery." With a multimodal approach that combines SSEPs, MEPs, and sEMG with tEMG and D waves, as appropriate, sensitivity and specificity can be maximized for the diagnosis of reversible insults to the spinal cord, nerve roots, and peripheral nerves. As with most patient safety efforts in the operating room, IOM requires contributions from and communication between a number of different teams. This comprehensive review of neuromonitoring techniques for surgery on the central and peripheral nervous system will highlight the technical, surgical and anesthesia factors required to optimize outcomes. In addition, this review will discuss important trouble shooting measures to be considered when managing ION changes concerning for potential injury.
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Affiliation(s)
- Lauren K Buhl
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andres Brenes Bastos
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Richard J Pollard
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeffrey E Arle
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - George P Thomas
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Yinchen Song
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - M Dustin Boone
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study. Spine (Phila Pa 1976) 2020; 45:911-920. [PMID: 32539292 DOI: 10.1097/brs.0000000000003433] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Expert opinion-modified Delphi study. OBJECTIVE We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals. SUMMARY OF BACKGROUND DATA Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice. METHODS We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus." RESULTS Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals. CONCLUSION Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices. LEVEL OF EVIDENCE 5.
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Effect of Depth of Total Intravenous General Anesthesia on Intraoperative Electrically Evoked Compound Action Potentials in Cochlear Implantation Surgery. Anesthesiol Res Pract 2019; 2019:6838506. [PMID: 31885553 PMCID: PMC6914979 DOI: 10.1155/2019/6838506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/20/2019] [Accepted: 11/14/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose This study aims to compare the effect of the depth of total intravenous anesthesia (TIVA) on intraoperative electrically evoked compound action potential (e-ECAP) thresholds in cochlear implant operations. Methods Prospectively, a total of 39 patients aged between 1 and 48 years who were scheduled to undergo cochlear implantation surgeries were enrolled in this study. Every patient received both light and deep TIVA during the cochlear implant surgery. The e-ECAP thresholds were obtained during the light and deep TIVA. Results After comparing the e-ECAP means for each electrode (lead) between the light and deep anesthesia, no significant differences were detected between the light and deep anesthesia. Conclusion The depth of TIVA may have no significant influence on the e-ECAP thresholds as there was no statistical difference between the light and deep anesthesia.
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Ushirozako H, Yoshida G, Kobayashi S, Hasegawa T, Yamato Y, Yasuda T, Banno T, Arima H, Oe S, Mihara Y, Togawa D, Matsuyama Y. Impact of total propofol dose during spinal surgery: anesthetic fade on transcranial motor evoked potentials. J Neurosurg Spine 2019; 30:705-713. [PMID: 30738399 DOI: 10.3171/2018.10.spine18322] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 10/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative neuromonitoring may be valuable for predicting postoperative neurological complications, and transcranial motor evoked potentials (TcMEPs) are the most reliable monitoring modality with high sensitivity. One of the most frequent problems of TcMEP monitoring is the high rate of false-positive alerts, also called "anesthetic fade." The purpose of this study was to clarify the risk factors for false-positive TcMEP alerts and to find ways to reduce false-positive rates. METHODS The authors analyzed 703 patients who underwent TcMEP monitoring under total intravenous anesthesia during spinal surgery within a 7-year interval. They defined an alert point as final TcMEP amplitudes ≤ 30% of the baseline. Variations in body temperature (maximum - minimum body temperature during surgery) were measured. Patients with false-positive alerts were classified into 2 groups: a global group with alerts observed in 2 or more muscles of the upper and lower extremities, and a focal group with alerts observed in 1 muscle. RESULTS False-positive alerts occurred in 100 cases (14%), comprising 60 cases with global and 40 cases with focal alerts. Compared with the 545 true-negative cases, in the false-positive cases the patients had received a significantly higher total propofol dose (1915 mg vs 1380 mg; p < 0.001). In the false-positive cases with global alerts, the patients had also received a higher mean propofol dose than those with focal alerts (4.5 mg/kg/hr vs 4.2 mg/kg/hr; p = 0.087). The cutoff value of the total propofol dose for predicting false-positive alerts, with the best sensitivity and specificity, was 1550 mg. Multivariate logistic analysis revealed that a total propofol dose > 1550 mg (OR 4.583; 95% CI 2.785-7.539; p < 0.001), variation in body temperature (1°C difference; OR 1.691; 95% CI 1.060-2.465; p < 0.01), and estimated blood loss (500-ml difference; OR 1.309; 95% CI 1.155-1.484; p < 0.001) were independently associated with false-positive alerts. CONCLUSIONS Intraoperative total propofol dose > 1550 mg, larger variation in body temperature, and greater blood loss are independently associated with false-positive alerts during spinal surgery. The authors believe that these factors may contribute to the false-positive global alerts that characterize anesthetic fade. As it is necessary to consider multiple confounding factors to distinguish false-positive alerts from true-positive alerts, including variation in body temperature or ischemic condition, the authors argue the importance of a team approach that includes surgeons, anesthesiologists, and medical engineers.
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Affiliation(s)
- Hiroki Ushirozako
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Go Yoshida
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Sho Kobayashi
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Tomohiko Hasegawa
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Yu Yamato
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Tatsuya Yasuda
- 2Department of Orthopedic Surgery, Hamamatsu Medical Center; and
| | - Tomohiro Banno
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Hideyuki Arima
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Shin Oe
- 3Department of Orthopedic Surgery and Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yuki Mihara
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
| | - Daisuke Togawa
- 3Department of Orthopedic Surgery and Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yukihiro Matsuyama
- 1Department of Orthopedic Surgery, Hamamatsu University School of Medicine
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Püschel A, Ebel R, Fuchs P, Hofmann J, Schubert JK, Roesner JP, Bergt S, Wree A, Vollmar B, Klar E, Bünger CM, Kischkel S. Can Recognition of Spinal Ischemia Be Improved? Application of Motor-Evoked Potentials, Serum Markers, and Breath Gas Analysis in an Acutely Instrumented Pig Model. Ann Vasc Surg 2018. [PMID: 29518504 DOI: 10.1016/j.avsg.2018.01.095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Paraplegia due to spinal cord ischemia (SCI) is a serious complication after repair of thoracoabdominal aortic aneurysms. For prevention and early treatment of spinal ischemia, intraoperative monitoring of spinal cord integrity is essential. This study was intended to improve recognition of SCI through a combination of transcranial motor-evoked potentials (tc-MEPs), serum markers, and innovative breath analysis. METHODS In 9 female German Landrace pigs, tc-MEPs were captured, markers of neuronal damage were determined in blood, and volatile organic compounds (VOCs) were analyzed in exhaled air. After thoraco-phrenico-laparotomy, SCI was initiated through sequential clamping (n = 4) or permanently ligating (n = 5) SAs of the abdominal and thoracic aorta in caudocranial orientation until a drop in the tc-MEPs to at least 25% of the baseline was recorded. VOCs in breath were determined by means of solid-phase microextraction coupled with gas chromatography-mass spectrometry. After waking up, clinical and neurological status was evaluated (Tarlov score). Spinal cord histology was obtained in postmortem. RESULTS Permanent vessel ligature induced a worse neurological outcome and a higher number of necrotic motor neurons compared to clamping. Changes of serum markers remained unspecific. After laparotomy, exhaled acetone and isopropanol showed highest concentrations, and pentane and hexane increased during ischemia-reperfusion injury. CONCLUSIONS To mimic spinal ischemia occurring in humans during aortic aneurysm repair, animal models have to be meticulously evaluated concerning vascular anatomy and function. Volatiles from breath indicated metabolic stress during surgery and oxidative damage through ischemia reperfusion. Breath VOCs may provide complimentary information to conventional monitoring methods.
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Affiliation(s)
- Anja Püschel
- Department of General, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Rasmus Ebel
- Department of General, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Patricia Fuchs
- Clinic for Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Janet Hofmann
- Clinic for Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Jochen K Schubert
- Clinic for Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Jan P Roesner
- Clinic for Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany; Clinic for Anesthesiology and Intensive Care Medicine, Südstadtklinikum Rostock, Germany
| | - Stefan Bergt
- Clinic for Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Andreas Wree
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Brigitte Vollmar
- Institute for Experimental Surgery, Rostock University Medical Center, Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Carsten M Bünger
- Department of General, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany; Department of Vascular Medicine, Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Sabine Kischkel
- Department of General, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany.
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The Correlation Between Recordable MEPs and Motor Function During Spinal Surgery for Resection of Thoracic Spinal Cord Tumor. J Neurosurg Anesthesiol 2018; 30:39-43. [DOI: 10.1097/ana.0000000000000386] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Awad H, Ramadan ME, El Sayed HF, Tolpin DA, Tili E, Collard CD. Spinal cord injury after thoracic endovascular aortic aneurysm repair. Can J Anaesth 2017; 64:1218-1235. [PMID: 29019146 DOI: 10.1007/s12630-017-0974-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 08/04/2017] [Accepted: 09/13/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. SOURCE The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia. PRINCIPAL FINDINGS Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection. CONCLUSION Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.,Department of Anesthesiology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Hosam F El Sayed
- Division of Vascular Diseases & Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel A Tolpin
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Esmerina Tili
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Charles D Collard
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
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Changes in transcranial motor evoked potentials during hemorrhage are associated with increased serum propofol concentrations. J Clin Monit Comput 2017; 32:541-548. [DOI: 10.1007/s10877-017-0057-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/19/2017] [Indexed: 10/19/2022]
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15
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Intraoperative Neuromonitoring and Alarm Criteria for Judging MEP Responses to Transcranial Electric Stimulation. J Clin Neurophysiol 2017; 34:12-21. [DOI: 10.1097/wnp.0000000000000339] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Wilkinson MF, Chowdhury T, Mutch WA, Kaufmann AM. Analysis of facial motor evoked potentials for assessing a central mechanism in hemifacial spasm. J Neurosurg 2016; 126:379-385. [PMID: 27177175 DOI: 10.3171/2016.2.jns151384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hemifacial spasm (HFS) is a cranial nerve hyperactivity disorder characterized by unique neurophysiological features, although the underlying pathophysiology remains disputed. In this study, the authors compared the effects of desflurane on facial motor evoked potentials (MEPs) from the spasm and nonspasm sides of patients who were undergoing microvascular decompression (MVD) surgery to test the hypothesis that HFS is associated with a central elevation of facial motor neuron excitability. METHODS Facial MEPs were elicited in 31 patients who were undergoing MVD for HFS and were administered total intravenous anesthesia (TIVA) with or without additional desflurane, an inhaled anesthetic known to centrally suppress MEPs. All measurements were completed before dural opening while a consistent mean arterial blood pressure was maintained and electroencephalography was performed. The activation threshold voltage and mean amplitudes of the MEPs from both sides of the face were compared. RESULTS There was a significantly lower mean activation threshold of facial MEPs on the spasm side than on the nonspasm side (mean ± SD 162.9 ± 10.1 vs 198.3 ± 10.1 V, respectively; p = 0.01). In addition, MEPs were also elicited more readily when single-pulse transcranial electrical stimulation was used on the spasm side (74% vs 31%, respectively; p = 0.03). Although desflurane (1 minimum alveolar concentration) suppressed facial MEPs on both sides, the suppressive effects of desflurane were less on the spasm side than on the nonspasm side (59% vs 79%, respectively; p = 0.03), and M waves recorded from the mentalis muscle remained unchanged, which indicates that desflurane did not affect the peripheral facial nerve or neuromuscular junction. CONCLUSIONS Centrally acting inhaled anesthetic agents can suppress facial MEPs and therefore might interfere with intraoperative monitoring. The elevated motor neuron excitability and differential effects of desflurane between the spasm and nonspasm sides support a mechanism of central pathophysiology in HFS. Clinical trial registration no.: B2012:099 ( clinicaltrials.gov ).
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Affiliation(s)
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - W Alan Mutch
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
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Rabai F, Sessions R, Seubert CN. Neurophysiological monitoring and spinal cord integrity. Best Pract Res Clin Anaesthesiol 2015; 30:53-68. [PMID: 27036603 DOI: 10.1016/j.bpa.2015.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/10/2015] [Accepted: 11/17/2015] [Indexed: 12/15/2022]
Abstract
An integral part of a major spine surgery is the intraoperative neurophysiological monitoring (IONM). By providing continuous functional assessment of specific anatomic structures, IONM allows the rapid detection of neuronal compromise and the opportunity for corrective action before an insult causes permanent neurological damage. Thus, IONM functions not just as a diagnostic tool but may also improve surgical outcomes. Effective clinical application requires a thorough understanding of the scope and limitations of IONM modalities not only by the monitoring team but also by the surgeon and anesthesiologist. Intraoperatively, collaboration and communication between monitorist, surgeon, and anesthesiologist are critical to the effectiveness of IONM. In this study, we review specific monitoring modalities, focusing on the relevant anatomy, physiology, and mechanisms of neuronal injury during major spine surgery. We discuss how these factors interact with anesthetic and surgical management. This review concludes with the current controversies surrounding the evidence in support of IONM and directions of future research.
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Affiliation(s)
- Ferenc Rabai
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254 JHMHSC, 1600 SW Archer Rd., Room M-509, Gainesville, FL 32610-0254, USA.
| | - Renard Sessions
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254 JHMHSC, 1600 SW Archer Rd., Room M-509, Gainesville, FL 32610-0254, USA.
| | - Christoph N Seubert
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254 JHMHSC, 1600 SW Archer Rd., Room M-509, Gainesville, FL 32610-0254, USA.
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Heid F, Kauff DW, Lang H, Kneist W. Impact of inhalation vs. intravenous anaesthesia on autonomic nerves and internal anal sphincter tone. Acta Anaesthesiol Scand 2015; 59:1119-25. [PMID: 25900126 DOI: 10.1111/aas.12535] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 03/15/2015] [Accepted: 03/17/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pelvic intraoperative neuromonitoring (pIONM) aims to identify and spare the autonomic nerves and maintain patients' quality of life. The effect of anaesthetic agents on the pIONM signal is unknown; therefore, the aim of the present study was to compare the influences of inhalation anaesthesia (IA) and total intravenous anaesthesia (TIVA). METHODS Twenty rectal cancer patients undergoing open nerve-sparing total mesorectal excision (TME) were assigned to pIONM under either IA or TIVA (n = 10 per group). IA was maintained with sevoflurane and TIVA with propofol. During surgery, pelvic autonomic nerves were electrically stimulated under electromyography (EMG) of the internal anal sphincter (IAS). These triggered EMG signals were analysed. RESULTS The absolute EMG amplitude during pIONM increased to 1.20 μV (interquartile range (IQR): 0.94-1.6) for IA and 1.49 μV (IQR: 0.84-2.75) for TIVA (P = 0.002). The relative EMG amplitude increase also was significantly lower for IA (0.59; IQR: 0.30-0.81; TIVA: 0.99; IQR: 0.62-2.5), (P = 0.001). CONCLUSIONS This is the first study to compare the influences of IA and TIVA on the autonomic nervous system. While both anaesthetic regimens proved useful for pIONM, TIVA with propofol may provide better signal quality than IA with sevoflurane.
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Affiliation(s)
- F. Heid
- Department of Anaesthesiology; University Medicine of the Johannes Gutenberg-University Mainz; Mainz Germany
| | - D. W. Kauff
- Department of General, Visceral and Transplant Surgery; University Medicine of the Johannes Gutenberg-University Mainz; Mainz Germany
| | - H. Lang
- Department of General, Visceral and Transplant Surgery; University Medicine of the Johannes Gutenberg-University Mainz; Mainz Germany
| | - W. Kneist
- Department of General, Visceral and Transplant Surgery; University Medicine of the Johannes Gutenberg-University Mainz; Mainz Germany
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Malcharek M, Loeffler S, Schiefer D, Manceur M, Sablotzki A, Gille J, Pilge S, Schneider G. Transcranial motor evoked potentials during anesthesia with desflurane versus propofol – A prospective randomized trial. Clin Neurophysiol 2015; 126:1825-32. [DOI: 10.1016/j.clinph.2014.11.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 11/16/2014] [Accepted: 11/30/2014] [Indexed: 10/24/2022]
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Okamoto E, Ishikawa E, Yamamoto T, Matsuda M, Nakai K, Matsushita A, Masuda Y, Akutsu H, Ayuzawa S, Sakamaki F, Matsumoto Y, Matsumura A. Variability in amplitude and stimulation threshold values in motor evoked potential (MEP) monitoring during the resection of brain lesions. Clin Neurophysiol 2015; 126:1271-1278. [DOI: 10.1016/j.clinph.2014.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 09/05/2014] [Accepted: 10/01/2014] [Indexed: 02/02/2023]
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Hwang W, Lee J, Park J, Joo J. Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study. BMC Anesthesiol 2015; 15:21. [PMID: 25750586 PMCID: PMC4352285 DOI: 10.1186/s12871-015-0004-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 02/18/2015] [Indexed: 11/30/2022] Open
Abstract
Background Total intravenous anesthesia (TIVA) is used widely in spinal surgery because inhalational anesthetics are known to decrease the amplitude of motor evoked potentials. Presently, dexmedetomidine is used as an adjuvant for propofol-based TIVA. We compared the effects of remifentanil and dexmedetomidine on pain intensity as well as the analgesic requirements after post-anesthesia care unit (PACU) discharge in patients undergoing spinal surgery. Methods Forty patients scheduled for posterior lumbar interbody fusion (PLIF) surgery under general anesthesia were enrolled. Anesthesia was maintained using propofol at 3–12 mg/kg/h and remifentanil at 0.01–0.2 μg/kg/min in Remifentanil group or dexmedetomidine at 0.01–0.02 μg/kg/min in Dexmedetomidine group, keeping the bispectral index between 40 and 60. Patient-controlled analgesia (PCA) made of hydromophone was applied once the patients opened their eyes in the PACU. The visual analog scale (VAS) score, PCA dosage administered, and postoperative nausea and vomiting (PONV) were recorded at the time of discharge from the PACU (T1) and at 2 (T2), 8 (T3), 24 (T4), and 48 hours (T5) after surgery. Results The VAS score in Remifentanil group was significantly higher than that in Dexmedetomidine group at immediate and late postoperative period (4.1 ± 2.0 vs. 2.3 ± 2.2 at T1, and 4.0 ± 2.2 vs. 2.6 ± 1.7 at T5; P < 0.05). Dexmedtomidine group had a statistically significantly lower PCA requirement at every time point after surgery except directly before discharge from the PACU (3.0 ± 1.2 ml vs. 2.3 ± 1.4 ml at T1; P > 0.05, but 69.7 ± 21.4 ml vs. 52.8 ± 10.8 ml at T5; P < 0.05). Patients in Remifentanil group displayed more PONV until 24 hours post-surgery. Conclusions Dexmedetomidine displayed superior efficacy in alleviating pain and in postoperative pain management for 48 hours after PLIF. Therefore, dexmedetomidine may be used instead of remifentanil as an adjuvant in propofol-based TIVA. Trial registration Clinical Research Information Service (CRiS) Identifier: KCT0001041.
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Affiliation(s)
- Wonjung Hwang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 137-701 South Korea
| | - Jaemin Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 137-701 South Korea
| | - Jihyun Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 137-701 South Korea
| | - Jin Joo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 137-701 South Korea
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Osburn LL. A Guide to the Performance of Transcranial Electrical Motor Evoked Potentials. Part 1. Basic Concepts, Recording Parameters, Special Considerations, and Application. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2006.11079565] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Leisha L. Osburn
- Neurophysiology Lab Clarian Health Partners Methodist Hospital Indianapolis, Indiana
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Wilkinson MF, Chowdhury T, Mutch WAC, Kaufmann AM. Is hemifacial spasm a phenomenon of the central nervous system? --The role of desflurane on the lateral spread response. Clin Neurophysiol 2014; 126:1354-9. [PMID: 25454282 DOI: 10.1016/j.clinph.2014.09.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/15/2014] [Accepted: 09/27/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A signature EMG feature of hemifacial spasm (HFS) is the lateral spread response (LSR). Desflurane is a common anesthetic with potent effects on synaptic transmission. We tested the hypothesis that the LSR is mediated by corticobulbar components by comparing the LSR during total intravenous anesthesia (TIVA) or TIVA plus desflurane during microvascular decompression (MVD) surgery. METHODS 22 HFS patients undergoing MVD surgery participated in this prospective study. The LSR data was recorded from the o. oculi, o. oris and mentalis muscles prior to opening dura. LSR onset latencies and amplitudes were determined under TIVA and TIVA/desflurane (0.5 and 1MAC). Facial muscle LSRs and EEG were analyzed. RESULTS Desflurane (1MAC) significantly decreased the LSR amplitude in all 3 facial muscles (p<0.01). Pooled LSR data from all facial muscles showed desflurane inhibited the LSR amplitude by 43% compared to TIVA (p<0.001). No effects on the latency of the LSR or on EEG state were observed. CONCLUSIONS LSR inhibition by desflurane suggests a central mechanism involvement in the genesis of this signature HFS response. SIGNIFICANCE This study demonstrates that facial nerve vascular compression and plastic changes within the CNS are part of the pathophysiology of HFS.
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Affiliation(s)
- Marshall F Wilkinson
- Section of Neurosurgery, Faculty of Medicine, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
| | - W Alan C Mutch
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
| | - Anthony M Kaufmann
- Section of Neurosurgery, Faculty of Medicine, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada.
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Differential rates of false-positive findings in transcranial electric motor evoked potential monitoring when using inhalational anesthesia versus total intravenous anesthesia during spine surgeries. Spine J 2014; 14:1440-6. [PMID: 24209393 DOI: 10.1016/j.spinee.2013.08.037] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Revised: 07/30/2013] [Accepted: 08/23/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT False-positive loss of transcranial electrical motor evoked potentials (TCe-MEPs) limits the efficacy of motor tract monitoring during spine surgery. Although total intravenous anesthesia (TIVA) is widely regarded as the optimal regimen for TCe-MEPs, inhalational anesthesia is an alternative regimen. PURPOSE To compare the rates of false-positive TCe-MEPs during spine surgery for patients anesthetized with TIVA and inhalation anesthesia. STUDY DESIGN A retrospective analysis of data collected from consecutive patients undergoing TCe-MEP monitoring during spinal surgery. PATIENT SAMPLE Consecutive adult patients from multiple surgical centers undergoing spine surgery inclusive of cervical or thoracic spinal levels during 2008-2009 who received TIVA or inhalation anesthesia. OUTCOME MEASURES The primary outcome measure was the rate of false-positive alerts using TCe-MEPS, defined as a persistent loss of 90% or greater of the amplitude of TCe-MEP in one or more muscles not attributed to technical or transient systemic factors (hypotension or hypoxia) and not associated with any postoperative neurologic deficit. METHODS Patients were divided into two groups according to anesthetic regimen: those anesthetized with one or more inhalational agents (n=1,303) and patients anesthetized with TIVA (n=511). The Fisher exact test and unpaired t test were used to compare group characteristics and false-positive rates. Each group was further subdivided by spinal region (cervical, thoracic, and thoracolumbar) and by presence of preoperative motor deficit. A Pearson chi-squared test was used to identify differences according to spinal region. This study was not supported by any financial sources nor do the authors have any financial relationships to disclose. RESULTS Patient with inhaled anesthesia showed significantly higher rates of false-positive TCe-MEP changes (15.0% vs. 3.2%) compared with the TIVA group. These differences were significant across all surgical subgroups. The inhaled group had a larger number of patients with preoperative motor deficits compared with TIVA (45.0% vs. 37.4%), a potential confounder for false-positive results. However, a significantly higher rate of false-positive TCe-MEP changes was still observed in the inhaled group (11.4% vs. 0.6% for TIVA) when analyzing only those patients without preoperative motor deficits. CONCLUSIONS Use of inhalation anesthesia during adult spinal surgery is associated with significantly higher rates of false-positive changes compared with TIVA during TCe-MEP monitoring. This relationship appears independent of preoperative motor status. Further study and multivariate analysis of anesthetic agents, diagnosis, and symptoms is necessary to elucidate the impact of these variables. The potential confounding effects of inhalational anesthesia on TCe-MEP monitoring should be considered when determining anesthetic regimen.
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Abstract
The use of intraoperative neuromonitoring (IONM) during pediatric scoliosis repair has become commonplace to reduce the risk of potentially devastating postoperative neurologic deficits. IONM techniques include somatosensory evoked potentials, motor evoked potentials, electromyography, and intraoperative wake-up tests. Special considerations for scoliosis repair in pediatric patients include preexisting neurologic deficits and young patients with immature neural pathways in whom neurophysiologic monitoring may prove difficult or unreliable.
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Affiliation(s)
- Chris D Glover
- Department of Pediatrics and Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, Suite A3300, Houston, TX 77030, USA.
| | - Nicholas P Carling
- Department of Pediatrics and Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, Suite A3300, Houston, TX 77030, USA
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Optimal parameters of transcranial electrical stimulation for intraoperative monitoring of motor evoked potentials of the tibialis anterior muscle during pediatric scoliosis surgery. Neurophysiol Clin 2013; 43:243-50. [PMID: 24094910 DOI: 10.1016/j.neucli.2013.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 06/05/2013] [Accepted: 08/04/2013] [Indexed: 11/21/2022] Open
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Cordella R, Acerbi F, Broggi M, Vailati D, Nazzi V, Schiariti M, Tringali G, Ferroli P, Franzini A, Broggi G. Intraoperative neurophysiological monitoring of the cortico-spinal tract in image-guided mini-invasive neurosurgery. Clin Neurophysiol 2013; 124:1244-54. [DOI: 10.1016/j.clinph.2012.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 11/13/2012] [Accepted: 11/14/2012] [Indexed: 10/27/2022]
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Kim W, Lee J, Lee S, Park M, Park S, Seo D, Chung I. Comparison of motor-evoked potentials monitoring in response to transcranial electrical stimulation in subjects undergoing neurosurgery with partial vs no neuromuscular block †. Br J Anaesth 2013; 110:567-76. [DOI: 10.1093/bja/aes395] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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The usefulness of intraoperative neurophysiological monitoring in cervical spine surgery: a retrospective analysis of 200 consecutive patients. J Neurosurg Anesthesiol 2012; 24:185-90. [PMID: 22525331 DOI: 10.1097/ana.0b013e318255ec8f] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The usefulness of intraoperative neurophysiological monitoring (IONM), including somatosensory-evoked potential (SSEP) and transcranial electrical motor-evoked potentials (TcMEPs) in cervical spine surgery still needs to be evaluated. We retrospectively reviewed 200 cervical spine surgery patients from 2008 to 2009 to determine the role of IONM in cervical spine surgery. Total intravenous anesthesia was used for all patients. IONM alerts were defined as a 50% decrease in amplitude, a 10% increase in latency, or a unilateral change for SSEP and an increase in stimulation threshold of more than 100 V for TcMEP. Three patients had SSEP alerts that were related to arm malposition (2 patients) and hypotension (1 patient). Five patients had TcMEP alerts: 4 alerts were caused by hypotension and 1 by bone graft compression of the spinal cord. All alerts were resolved when causative reasons were corrected. There was no postoperative iatrogenic neurological injury. The sensitivities of SSEP and TcMEP alerts for detecting impending neurological injury were 37.5% and 62.5%, respectively. The sensitivity of both SSEP and TcMEP used in combination was 100%. No false-positive and false-negative alerts were identified in either SSEP or TcMEP (100% specificity). The total intravenous anesthesia technique optimizes the detection of SSEP and TcMEP and therefore improves the sensitivity and specificity of IONM. SSEP is sensitive in detecting alerts in possible malposition-induced ischemia or brachial plexus nerve injury. TcMEP specifically detects hypotension-induced spinal functional compromises. Combination use of TcMEP and SSEP enhances the early detection of impeding neurological damage during cervical spine surgery.
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Abstract
During the last 30 years intraoperative electrophysiological monitoring (IOEM) has gained increasing importance in monitoring the function of neuronal structures and the intraoperative detection of impending new neurological deficits. The use of IOEM could reduce the incidence of postoperative neurological deficits after various surgical procedures. Motor evoked potentials (MEP) seem to be superior to other methods for many indications regarding monitoring of the central nervous system. During the application of IOEM general anesthesia should be provided by total intravenous anesthesia with propofol with an emphasis on a continuous high opioid dosage. When intraoperative MEP or electromyography guidance is planned, muscle relaxation must be either completely omitted or maintained in a titrated dose range in a steady state. The IOEM can be performed by surgeons, neurologists and neurophysiologists or increasingly more by anesthesiologists. However, to guarantee a safe application and interpretation, sufficient knowledge of the effects of the surgical procedure and pharmacological and physiological influences on the neurophysiological findings are indispensable.
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High-frequency Stimulation Restored Motor-evoked Potentials to the Baseline Level in the Upper Extremities but Not in the Lower Extremities Under Sevoflurane Anesthesia in Spine Surgery. J Neurosurg Anesthesiol 2012; 24:113-20. [DOI: 10.1097/ana.0b013e318237fa41] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Novak K, Oberndorfer S. Electrophysiology and intraoperative neurophysiological monitoring. HANDBOOK OF CLINICAL NEUROLOGY 2012; 104:149-161. [PMID: 22230442 DOI: 10.1016/b978-0-444-52138-5.00012-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Klaus Novak
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
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Adhikary SD, Thiruvenkatarajan V, Babu KS, Tharyan P. The effects of anaesthetic agents on cortical mapping during neurosurgical procedures involving eloquent areas of the brain. Cochrane Database Syst Rev 2011:CD006679. [PMID: 22071831 DOI: 10.1002/14651858.cd006679.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In patients presenting for surgical resection of lesions involving, or adjacent to, the functionally important eloquent cortical areas, it is vital to achieve complete or near complete resection of the pathology without damaging the healthy surrounding tissues.The eloquent areas that the surgeons are concerned with are the primary motor, premotor cortex, supplementary motor cortex and speech areas. If the lesions are within these regions surgeons could either take a biopsy or do a intracapsular decompression without damaging the mentioned areas to avoid postoperative dysfunction. If the lesions are adjacent to the above mentioned areas, the normal anatomy would get distorted. However, proper identification of the above mentioned areas would enable the surgeon to radically remove the tumours. Intraoperative mapping of the cortex with stimulating and recording electrodes is termed as electrophysiological (EP) mapping.The EP mapping of motor, sensory and language cortex is widely employed in the resection of lesions involving or adjacent to the eloquent areas. Both intravenous and inhalational agents are known to affect these EP mapping techniques. OBJECTIVES The aim of this review was to evaluate the effect of anaesthetic agents on intra-operative EP mapping in patients undergoing neurosurgical procedures involving, or adjacent to, the functional areas of the cortex under general anaesthesia. SEARCH METHODS We searched the Cochrane Epilepsy Group Specialized Register (7 March 2011), The Cochrane Central Register of Controlled Trials (CENTRAL issue 1 of 4, The Cochrane Library 2011), MEDLINE (Ovid, 1948 to February week 4, 2011), PsycINFO (EBSCOhost, 7 March 2011), and the National Research Register Archive and UK Clinical Research Network (7 March 2011). We also contacted other researchers in the field in an attempt to ascertain unpublished studies. SELECTION CRITERIA We planned to include randomised and quasi randomised controlled trials irrespective of blinding in patients of any age or gender undergoing neurosurgery under general anaesthesia where cortical mapping was attempted to identify eloquent areas using either somatosensory evoked potentials (SSEPs), or direct cortical stimulation (DCS) triggered muscle motor evoked potentials (mMEPs), or both. We excluded patients from trials where the anaesthetic effects were evaluated during spinal cord surgery or where MEPs were recorded from modes other than direct cortical stimulation such as transcranial electrical stimulation (TcMEPs), MEPs derived from epidural electrodes (D waves) and magnetic stimulation and trials involving awake craniotomies or the asleep-awake-asleep technique during cortical mapping. DATA COLLECTION AND ANALYSIS Two review authors planned to independently apply the inclusion criteria and extract data. MAIN RESULTS No RCTs were found for this study population. AUTHORS' CONCLUSIONS This review highlights the need for well-designed randomised controlled trials to assess the effect of anaesthetic agents on cortical mapping during neurosurgical procedures involving eloquent areas of the brain.
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Affiliation(s)
- Sanjib D Adhikary
- Department of Anaesthesia/Discipline of Acute CareMedicine, TheQueen ElizabethHospital/The University of Adelaide,Woodville,Adelaide, Australia
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The use of motor evoked potential monitoring during cerebral aneurysm surgery to predict pure motor deficits due to subcortical ischemia. Clin Neurophysiol 2011; 122:648-55. [PMID: 20869304 DOI: 10.1016/j.clinph.2010.09.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 08/13/2010] [Accepted: 09/02/2010] [Indexed: 11/20/2022]
Abstract
Subcortical infarcts are most commonly the consequence of perforating artery occlusion and pure motor deficit is the most frequent syndrome resulting from an interruption of the corticospinal tract at the level of the corona radiate, the internal capsule or the brainstem. Motor evoked potential (MEP) monitoring is used as an adjunct to surgery as somatosensory evoked potentials (SEP) have been found to be insensitive to these lesions. Two different techniques have been used for monitoring MEPs during aneurysm surgery: transcranial electrical stimulation (TES) and direct cortical stimulation (DCS). TES may result in patient movement, interfering with microdissection. There is also concern that TES MEP may not detect subcortical motor pathway ischemia by stimulating deeper subcortical structures and may thereby bypass the ischemic area. DCS produces focal muscle activation, less movement and more superficial stimulation that should detect cortical and superficial subcortical ischemia, hence avoiding false-negatives. However, this technique also has disadvantages including subdural bleeding and injury to the brain. Using close-to-motor-threshold stimulation and focal stimulating electrode montages, TES and DCS MEPs do not vary significantly in their capacity to detect lesions of the motor cortex or its efferent pathways. Both techniques are prone to interference by anesthetic agents.
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Kempton LB, Nantau WE, Zaltz I. Successful monitoring of transcranial electrical motor evoked potentials with isoflurane and nitrous oxide in scoliosis surgeries. Spine (Phila Pa 1976) 2010; 35:E1627-9. [PMID: 20595924 DOI: 10.1097/brs.0b013e3181cc8dba] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a case series studying the efficacy of concomitant inhalational anesthesia and transcranial electrical motor-evoked potential (tceMEP) monitoring in spinal deformity surgery. OBJECTIVE To determine the affects of inhalational anesthesia on the efficacy of tceMEP monitoring. SUMMARY OF BACKGROUND DATA Inhalational agents inhibit transmission of evoked potentials from the motor cortex. Consequently, many authors have recommended using total intravenous anesthesia during motor-evoked potential monitoring. METHODS A total of 247 consecutive patients, aged 1 to 83 years (156 patients <22 years), undergoing spinal fusion for scoliosis, excluding those with history of seizure or myelopathy, were monitored with tceMEP intraoperatively. Isoflurane with or without nitrous oxide (per anesthesiologist preference) was administered with vecuronium and i.v. agents including propofol and/or narcotic. Vecuronium was titrated for a goal of 2/4 twitches, and isoflurane was decreased (if necessary) to a maximum level at which tceMEP responses were monitorable (patient specific). Patients were grouped according to whether they received nitrous oxide and the anesthetic depth at which responses were monitored (<0.5, 0.5-0.9, 1-1.4, and >1.5 MAC). RESULTS A total of 232 (94%) patients received nitrous oxide. Of these patients, responses were obtained throughout the case in 20 (8.6%) at <0.5 MAC, 118 (50.9%) at 0.5 to 0.9 MAC, 85 (36.6%) at 1 to 1.4 MAC, and 9 (3.9%) at >1.5 MAC. Of the remaining 15 (6%) who received no nitrous oxide, responses were monitored in 3 (20%) at <0.5 MAC, 10 (66.7%) at 0.5 to 0.9 MAC, 2 (13.3%) at 1 to 1.5 MAC, and 0 at >1.5 MAC. No false-positive and 1 true-positive (transient) loss of responses occurred. No operations resulted in postoperative motor deficit. CONCLUSION Although isoflurane and nitrous oxide diminish tceMEP responses, reliable monitoring can still be accomplished while using significant levels of inhalational anesthetic agents.
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Affiliation(s)
- Laurence B Kempton
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA.
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Deiner S. Highlights of anesthetic considerations for intraoperative neuromonitoring. Semin Cardiothorac Vasc Anesth 2010; 14:51-3. [PMID: 20472627 DOI: 10.1177/1089253210362792] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Though relatively new, intraoperative neurophysiological monitoring (IONM) has become standard of care for many neurosurgical procedures. The use of IONM has substantially decreased the rate of paralysis after deformity surgery, and has been validated in cervical spine surgery, and thoracic and lumbar laminectomy (1) (2), (3). The main modalities are: somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), and electromyography (EMGs). Each test examines a functionally separate area of the spinal cord, which test is chosen depends on the location of the surgery and the patient's preexisting injuries and deficits (6). Inhaled anesthetics decrease the waveform amplitude and increase latency, intravenous anesthetics have the same effect but to a lesser degree. Best anesthetic regimen for surgery involving intraoperative monitoring is controversial. Both inhaled and intravenous agents depress signal attainment, however for equal MAC concentrations inhaled agents cause more depression(11). While studies have shown that halogenated agents and nitrous oxide do in fact depress MEP signals more than total intravenous anesthesia, less is known on the relationship between IONM and patient characteristics. Lo's study documenting MEP attainment with 0.5 MAC was done in an otherwise healthy scoliosis population (12), and no study to date has analyzed signal attainment in correlation with patient characteristics and anesthetic technique. While it is clear that anesthetic technique is extremely important, certain patient characteristics appear to be more common in difficult to monitor patients. The identification of these characteristics would suggest to the anesthesiologist the need for a more stringent technique (TIVA) and avert surgical delay or cancellation due to inability to obtain baseline or worse- loss of intraoperative waveform and need for a Stagnara wake-up test. Our group at Mt. Sinai has retrospectively studied patient characteristics, anesthetic technique and attainment of neuromonitoring signals. Hypertension and diabetes are independent predictors of monitoring failure, and these are preferentially sensitive to inhalational agents. Age and weight are also predictors, but less significant. In summary, neurophysiologic monitoring has evolved to be a consistent part of many procedures. The anesthesiologist should strive to understand the rationale behind monitoring and the basis of its utility. IONM has many implications for anesthetic technique and need for control of the physiologic milieu. With this knowledge the anesthesiologist can work together with the neuromonitoring team and surgeon to ensure patient safety during and after surgery.
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Affiliation(s)
- Stacie Deiner
- Department of Anesthesiology, Mount Sinai Medical Center, New York, NY 10029, USA.
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Deiner SG, Kwatra SG, Lin HM, Weisz DJ. Patient Characteristics and Anesthetic Technique Are Additive but Not Synergistic Predictors of Successful Motor Evoked Potential Monitoring. Anesth Analg 2010; 111:421-5. [DOI: 10.1213/ane.0b013e3181e41804] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
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.
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Gonzalez AA, Jeyanandarajan D, Hansen C, Zada G, Hsieh PC. Intraoperative neurophysiological monitoring during spine surgery: a review. Neurosurg Focus 2009; 27:E6. [PMID: 19795955 DOI: 10.3171/2009.8.focus09150] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Spinal surgery involves a wide spectrum of procedures during which the spinal cord, nerve roots, and key blood vessels are frequently placed at risk for injury. Neuromonitoring provides an opportunity to assess the functional integrity of susceptible neural elements during surgery. The methodology of obtaining and interpreting data from various neuromonitoring modalities-such as somatosensory evoked potentials, motor evoked potentials, spontaneous electromyography, and triggered electromyography-is reviewed in this report. Also discussed are the major benefits and limitations of each modality, as well as the strength of each alone and in combination with other modalities, with regard to its sensitivity, specificity, and overall value as a diagnostic tool. Finally, key clinical recommendations for the interpretation and step-wise decision-making process for intervention are discussed. Multimodality neuromonitoring relies on the strengths of different types of neurophysiological modalities to maximize the diagnostic efficacy in regard to sensitivity and specificity in the detection of impending neural injury. Thorough knowledge of the benefits and limitations of each modality helps in optimizing the diagnostic value of intraoperative monitoring during spinal procedures. As many spinal surgeries continue to evolve along a pathway of minimal invasiveness, it is quite likely that the value of neuromonitoring will only continue to become more prominent.
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Affiliation(s)
- Andres A Gonzalez
- Department of Neurology Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Wang AC, Than KD, Etame AB, La Marca F, Park P. Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature. Neurosurg Focus 2009; 27:E7. [DOI: 10.3171/2009.8.focus09145] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Object
Transcranial motor evoked potential (TcMEP) monitoring is frequently used in complex spinal surgeries to prevent neurological injury. Anesthesia, however, can significantly affect the reliability of TcMEP monitoring. Understanding the impact of various anesthetic agents on neurophysiological monitoring is therefore essential.
Methods
A literature search of the National Library of Medicine database was conducted to identify articles pertaining to anesthesia and TcMEP monitoring during spine surgery. Twenty studies were selected and reviewed.
Results
Inhalational anesthetics and neuromuscular blockade have been shown to limit the ability of TcMEP monitoring to detect significant changes. Hypothermia can also negatively affect monitoring. Opioids, however, have little influence on TcMEPs. Total intravenous anesthesia regimens can minimize the need for inhalational anesthetics.
Conclusions
In general, selecting the appropriate anesthetic regimen with maintenance of a stable concentration of inhalational or intravenous anesthetics optimizes TcMEP monitoring.
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Effects of the knee-chest position on cardiac index and propofol requirements during bispectral index (BIS)-guided spine surgery. ACTA ACUST UNITED AC 2008; 27:158.e1-5. [DOI: 10.1016/j.annfar.2007.10.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2007] [Accepted: 10/22/2007] [Indexed: 11/23/2022]
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Sloan TB, Jäntti V. Anesthetic effects on evoked potentials. INTRAOPERATIVE MONITORING OF NEURAL FUNCTION 2008. [DOI: 10.1016/s1567-4231(07)08005-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Macdonald DB, Al Zayed Z, Al Saddigi A. Four-limb muscle motor evoked potential and optimized somatosensory evoked potential monitoring with decussation assessment: results in 206 thoracolumbar spine surgeries. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S171-87. [PMID: 17638028 PMCID: PMC2072898 DOI: 10.1007/s00586-007-0426-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/07/2007] [Indexed: 11/28/2022]
Abstract
The objective of this study was to improve upon leg somatosensory-evoked potential (SEP) monitoring that halves paraplegia risk but can be slow, miss or falsely imply motor injury and omits arm and decussation assessment. We applied four-limb transcranial muscle motor-evoked potential (MEP) and optimized peripheral/cortical SEP monitoring with decussation assessment in 206 thoracolumbar spine surgeries under propofol/opioid anesthesia. SEPs were optimized to minimal averaging time that determined feedback intervals between MEP/SEP sets. Generalized changes defined systemic alterations. Focal decrements (MEP disappearance and/or clear SEP reduction) defined neural compromise and prompted intervention. They were transient (quickly resolved) or protracted (>40 min). Arm and leg MEP/SEP monitorability was 100% and 98/97% (due to neurological pathology). Decussation assessment disclosed sensorimotor non-decussation requiring ipsilateral monitoring in six scoliosis surgeries (2.9%). Feedback intervals were 1-3 min. Systemic changes never produced injury regardless of degree. They were gradual, commonly included MEP/SEP fade and sometimes required large stimulus increments to maintain MEPs or produced >50% SEP reductions. Focal decrements were abrupt; their positive predictive value for injury was 100% when protracted and 13% when transient. Six transient arm decrements predicted one temporary radial nerve injury; five suggested arm neural injury prevention (2.4%). There were 15 leg decrements: six MEP-only, four MEP before SEP, three simultaneous and two SEP-only. Five were protracted, predicting four temporary cord injuries (three motor, one Brown-Sequard) and one temporary radiculopathy. Ten were transient, predicting one temporary sensory cord injury; nine suggested cord injury prevention (4.4%). Two radiculopathies and one temporary delayed paraparesis were unpredicted. The methods are reliable, provide technical/systemic control, adapt to non-decussation and improve spinal cord and arm neural protection. SEP optimization speeds feedback and MEPs should further reduce paraplegia risk. Radiculopathy and delayed paraparesis can evade prediction.
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Affiliation(s)
- David B Macdonald
- Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital and Research Center, MBC 76, PO Box 3354, 11211, Riyadh, Saudi Arabia.
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Pajewski TN, Arlet V, Phillips LH. Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16 Suppl 2:S115-29. [PMID: 17619913 PMCID: PMC2072895 DOI: 10.1007/s00586-007-0419-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Accepted: 06/27/2007] [Indexed: 01/08/2023]
Abstract
Optimal outcome in spine surgery is dependent of the coordination of efforts by the surgeon, anesthesiologist, and neurophysiologist. This is perhaps best illustrated by the rising use of intraoperative spinal cord monitoring for complex spine surgery. The challenges presented by neurophysiologic monitoring, in particular the use of somatosensory and motor evoked potentials, requires an understanding by each member for the team of the proposed operative procedure as well as an ability to help differentiate clinically important signal changes from false positive changes. Surgical, anesthetic, and monitoring issues need to be addressed when relying on this form of monitoring to reduce the potential of negative outcomes in spine surgery. This article provides a practical overview from the perspective of the neurophysiologist, the anesthesiologist, and the surgeon on the requirements which must be understood by these participants in order to successfully contribute to a positive outcome when a patient is undergoing complex spine surgery.
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Affiliation(s)
- Thomas N. Pajewski
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA USA
| | - Vincent Arlet
- Division of Scoliosis and Spine Surgery, Department of Orthopedic Surgery, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908-0710 USA
| | - Lawrence H. Phillips
- Department of Neurology, University of Virginia Health System, Charlottesville, VA USA
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Szelényi A, Kothbauer KF, Deletis V. Transcranial electric stimulation for intraoperative motor evoked potential monitoring: Stimulation parameters and electrode montages. Clin Neurophysiol 2007; 118:1586-95. [PMID: 17507288 DOI: 10.1016/j.clinph.2007.04.008] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 03/08/2007] [Accepted: 04/14/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the efficacy of constant current transcranial electric stimulation (TES) parameters for eliciting muscle motor evoked potentials (MEPs) in the abductor pollicis brevis muscles (APB) and the tibialis anterior muscles (TA). The following parameters were tested intraoperatively: interstimulus interval (ISI), individual stimulation pulse duration within a train of five stimuli. Different montages of stimulating electrodes were assessed for effectiveness and focality. Further, reference values for APB and TA motor thresholds in neurosurgical patients with normal motor status under total intravenous anesthesia were determined. METHODS Motor thresholds of contralateral muscle MEPs were determined at 0.1, 0.2, 0.4, and 0.5 ms pulse duration and ISIs of 2, 3, 4, and 5 ms using a train of five monophasic constant current pulses with C3/C4 (27 patients). The stimulating electrodes were positioned at C1, C2, C3, C4, Cz, and Cz+6 cm. Different montages were used to determine the most effective and the most focal stimulation montages for the APB and TA muscles (30 patients). Eighty-six patients with clinically normal motor function were studied for motor threshold reference values. RESULTS The prolongation of the pulse duration has the strongest effect to decrease the motor threshold, which proportionally increases the delivered charge. The lowest stimulation threshold to elicit muscle MEPs in the APB and TA muscles is achieved with a train of stimuli consisting of an individual stimulus pulse duration of 0.5 ms. An ISI of 4 ms gave the lowest motor thresholds, but did not reach statistical significance compared to 3 ms. The stimulating electrode montage C3/C4 (C4/C3) allows for the lowest stimulation thresholds, but the vigorous muscle contractions it has is a disadvantage. The most focal stimulating electrode montages for the contralateral APB muscles are C3/Cz and C4/Cz, respectively, and for the TA muscles Cz/Cz+6 cm. CONCLUSIONS In adult neurosurgical patients with a normal motor status under total intravenous anesthesia, an individual pulse duration of 0.5 ms and an ISI of 4 ms provide the lowest motor thresholds. Pragmatically, C1/C2, resp., C2/C1 montage provides monitorable responses in both APB and TA muscles at reasonable stimulation thresholds without inducing movements disturbing surgery and especially microdissection. If the most focal hemispheric stimulation for the distal upper extremity muscles is required, the use of C3 or C4 referenced to Cz is recommended. SIGNIFICANCE The stimulation parameters within a train of five pulses with an individual pulse duration of 0.5 ms and an ISI of 4 ms provide the lowest motor threshold. These data confirm not only studies for D wave recovery but also provide optimal stimulation parameters for intraoperative near threshold stimulation.
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Affiliation(s)
- Andrea Szelényi
- Department of Neurosurgery, Klinikum der Johann Wolfgang Goethe Universität, Frankfurt/Main, Germany.
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Macdonald DB. Intraoperative Motor Evoked Potential Monitoring: Overview and Update. J Clin Monit Comput 2006; 20:347-77. [PMID: 16832580 DOI: 10.1007/s10877-006-9033-0] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Accepted: 05/23/2006] [Indexed: 01/20/2023]
Abstract
Amidst controversy about methodology and safety, intraoperative neurophysiology has entered a new era of increasingly routine transcranial and direct electrical brain stimulation for motor evoked potential (MEP) monitoring. Based on literature review and illustrative clinical experience, this tutorial aims to present a balanced overview for experienced practitioners, surgeons and anesthesiologists as well as those new to the field. It details the physiologic basis, indications and methodology of current MEP monitoring techniques, evaluates their safety, explores interpretive controversies and outlines some applications and results, including aortic aneurysm, intramedullary spinal cord tumor, spinal deformity, posterior fossa tumor, intracranial aneurysm and peri-rolandic brain surgeries. The many advances in motor system assessment achieved in the last two decades undoubtedly improve monitoring efficacy without unduly compromising safety. Future studies and experience will likely clarify existing controversies and bring further advances.
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Affiliation(s)
- David B Macdonald
- Department of Neurosciences, King Faisal Specialist Hospital & Research Center, MBC 76, PO Box 3354, Riyadh 11211, Saudi Arabia.
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Lo YL, Dan YF, Tan YE, Nurjannah S, Tan SB, Tan CT, Raman S. Intraoperative Motor-evoked Potential Monitoring in Scoliosis Surgery: Comparison of Desflurane/Nitrous Oxide With Propofol Total Intravenous Anesthetic Regimens. J Neurosurg Anesthesiol 2006; 18:211-4. [PMID: 16799350 DOI: 10.1097/01.ana.0000211007.94269.50] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A prospective, randomized study in a large general hospital setting. BACKGROUND During spinal surgery, monitoring motor-evoked potentials (MEPs) is a means of assessing the intraoperative integrity of corticospinal pathways. However, MEPs are known to be sensitive to the effects of anesthetic agents. OBJECTIVE To compare the use of desflurane or total intravenous anesthetic regimens (TIVA) with multipulse cortical stimulation for intraoperative monitoring (IOM). METHODS Twenty consecutive patients (10 in each arm) undergoing scoliosis correction surgery were randomly assigned to 2 equal groups receiving desflurane or TIVA. Inhalational anesthesia was maintained using 66% nitrous oxide in oxygen and a mean end-tidal desflurane concentration of 3.4%. For TIVA, continuous intravenous infusion of propofol was used. For analgesia, fentanyl and morphine were given when required for both groups. Cortical stimulation was achieved with 2 bipolar direct current stimulators connected in parallel by jumper cables. Five equivalent pulses 0.5 ms in duration at 4 ms intervals were delivered at C1C2 positions. MEP recordings were made in the abductor hallucis (AH) and tibialis anterior (TA) with needle electrodes. RESULTS Reproducible MEPs were obtained throughout the operation in all 20 cases, with up to 80 mA per stimulator. Before insertion of pedicle screws, mean MEP amplitudes (SD) obtained were 85 (19) and 21.7 (10.8) mV for AH and TA, respectively, using desflurane. With TIVA, amplitudes were 56.7 (28.4) and 59.1 (24.5) mV, respectively. Both muscle MEP amplitudes were significantly different using different anesthetic regimens (P < 0.05 for all). AH MEP amplitudes obtained with desflurane were significantly larger than TA amplitudes (P < 0.0001). No complications were reported intraoperatively and postoperatively. CONCLUSIONS This is the first study comparing the use of desflurane and TIVA showing that both anesthetic regimens allowed successful intraoperative monitoring useage throughout the procedures. For MEP recording, the AH was the preferred muscle with a desflurane anesthetic regimen.
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Affiliation(s)
- Yew-Long Lo
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore.
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Holdefer RN, Sadleir R, Russell MJ. Predicted current densities in the brain during transcranial electrical stimulation. Clin Neurophysiol 2006; 117:1388-97. [PMID: 16644273 PMCID: PMC2426751 DOI: 10.1016/j.clinph.2006.02.020] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Revised: 01/22/2006] [Accepted: 02/13/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We sought an electrical modeling approach to evaluate the potential application of finite element method (FEM) modeling to predict current pathways and intensities in the brain after transcranial electrical stimulation. METHODS A single coronal MRI section through the head, including motor cortex, was modeled using FEM. White matter compartments with both anatomically realistic anisotropies in resistivity and with a homogeneous resistivity were modeled. Current densities in the brain were predicted for electrode sites on the scalp and after theoretical application of a conductive head restraint device. RESULTS Localized current densities were predicted for the model with white matter anisotropies. Differences in predicted peak current densities were related to location of stimulation sites relative to deep sulci in the brain and scalp shunting that was predicted to increase with inter-electrode proximity. A conductive head restraint device was predicted to shunt current away from the brain when a constant current source was used. CONCLUSIONS The complex geometry of different tissue compartments in the head and their contrasting resistivities may jointly determine the strength and location of current densities in the brain after transcranial stimulation. This might be predictable with FEM incorporating white matter anisotropies. Conductive head restraint devices during surgery may be contraindicated with constant current stimulation. SIGNIFICANCE Individually optimized tcMEP monitoring and localized transcranial activation in the brain might be possible through FEM modeling.
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Reinacher PC, Priebe HJ, Blumrich W, Zentner J, Scheufler KM. The Effects of Stimulation Pattern and Sevoflurane Concentration on Intraoperative Motor-Evoked Potentials. Anesth Analg 2006; 102:888-95. [PMID: 16492846 DOI: 10.1213/01.ane.0000195235.02162.5d] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The usefulness of intraoperative monitoring of motor-evoked potentials (MEPs) during inhaled anesthesia is limited by the suppressive effects of volatile anesthetics on MEP signals. We investigated the effects of different stimulation patterns and end-tidal concentrations of sevoflurane on intraoperative transcranial electrical MEPs. In 12 patients undergoing craniotomy, stimulation patterns (300-500 V, 100-1000 Hz, 1-5 stimuli) and multiples (0.5, 0.75, and 1.0) of minimum alveolar concentration (MAC) of sevoflurane were varied randomly while remifentanil was administered at a constant rate of 0.2 microg x kg(-1) x min(-1). MEPs were recorded from thenar and hypothenar muscles and analyzed without knowledge of the respective MAC. Three-way analysis of variance revealed significant main effects for increasing stimulation intensity, frequency, and number of stimuli on MEP amplitude (P < 0.05). Maximum MEP amplitudes and recording success rates were observed during 4 stimuli delivered at 1000 Hz and 300 V. A significant main effect of sevoflurane concentration (0.5 versus 0.75 and 1 MAC multiple) on MEP amplitude was observed at the thenar recording site only (P < 0.05). In conclusion, MEP characteristics varied significantly with changes in stimulation pattern and less so with changes in sevoflurane concentration. The results suggest that high frequency repetitive stimulation allows intraoperative use of MEP monitoring during up to 1 MAC multiple of sevoflurane and constant infusion of remifentanil up to 0.2 microg x kg(-1) x min(-1).
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