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Toleikis JR, Pace C, Jahangiri FR, Hemmer LB, Toleikis SC. Intraoperative somatosensory evoked potential (SEP) monitoring: an updated position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2024; 38:1003-1042. [PMID: 39068294 PMCID: PMC11427520 DOI: 10.1007/s10877-024-01201-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Somatosensory evoked potentials (SEPs) are used to assess the functional status of somatosensory pathways during surgical procedures and can help protect patients' neurological integrity intraoperatively. This is a position statement on intraoperative SEP monitoring from the American Society of Neurophysiological Monitoring (ASNM) and updates prior ASNM position statements on SEPs from the years 2005 and 2010. This position statement is endorsed by ASNM and serves as an educational service to the neurophysiological community on the recommended use of SEPs as a neurophysiological monitoring tool. It presents the rationale for SEP utilization and its clinical applications. It also covers the relevant anatomy, technical methodology for setup and signal acquisition, signal interpretation, anesthesia and physiological considerations, and documentation and credentialing requirements to optimize SEP monitoring to aid in protecting the nervous system during surgery.
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Affiliation(s)
| | | | - Faisal R Jahangiri
- Global Innervation LLC, Dallas, TX, USA
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
| | - Laura B Hemmer
- Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Silverstein JW, D'Amico RS, Mehta SH, Gluski J, Ber R, Sciubba DM, Lo SFL. The diagnostic accuracy of neuromonitoring for detecting postoperative bowel and bladder dysfunction in spinal oncology surgery: a case series. J Neurooncol 2024; 169:409-422. [PMID: 38884662 DOI: 10.1007/s11060-024-04742-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE Postoperative bowel and bladder dysfunction (BBD) poses a significant risk following surgery of the sacral spinal segments and sacral nerve roots, particularly in neuro-oncology cases. The need for more reliable neuromonitoring techniques to enhance the safety of spine surgery is evident. METHODS We conducted a case series comprising 60 procedures involving 56 patients, spanning from September 2022 to January 2024. We assessed the diagnostic accuracy of sacral reflexes (bulbocavernosus and external urethral sphincter reflexes) and compared them with transcranial motor evoked potentials (TCMEP) incorporating anal sphincter (AS) and external urethral sphincter (EUS) recordings, as well as spontaneous electromyography (s-EMG) with AS and EUS recordings. RESULTS Sacral reflexes demonstrated a specificity of 100% in predicting postoperative BBD, with a sensitivity of 73.33%. While sensitivity slightly decreased to 64.71% at the 1-month follow-up, it remained consistently high overall. TCMEP with AS/EUS recordings did not identify any instances of postoperative BBD, whereas s-EMG with AS/EUS recordings showed a sensitivity of 14.29% and a specificity of 97.14%. CONCLUSION Sacral reflex monitoring emerges as a robust adjunct to routine neuromonitoring, offering surgeons valuable predictive insights to potentially mitigate the occurrence of postoperative BBD.
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Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, NY, USA.
| | - Randy S D'Amico
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Shyle H Mehta
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Jacob Gluski
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Roee Ber
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Daniel M Sciubba
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Sheng-Fu Larry Lo
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Allison DW, Verma A, Holman PJ, Huang M, Trask TW, Barber SM, Cockrell AR, Weber MR, Brooks DW, Delgado L, Steele WJ, Sellin JN, Gressot LV, Lambert B, Ma BB, Faraji AH, Saifi C. Transabdominal motor evoked potential neuromonitoring of lumbosacral spine surgery. Spine J 2024; 24:1660-1670. [PMID: 38685276 DOI: 10.1016/j.spinee.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/15/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND CONTEXT Transcranial Motor Evoked Potentials (TcMEPs) can improve intraoperative detection of femoral plexus and nerve root injury during lumbosacral spine surgery. However, even under ideal conditions, TcMEPs are not completely free of false-positive alerts due to the immobilizing effect of general anesthetics, especially in the proximal musculature. The application of transcutaneous stimulation to activate ventral nerve roots directly at the level of the conus medularis (bypassing the brain and spinal cord) has emerged as a method to potentially monitor the motor component of the femoral plexus and lumbosacral nerves free from the blunting effects of general anesthesia. PURPOSE To evaluate the reliability and efficacy of transabdominal motor evoked potentials (TaMEPs) compared to TcMEPs during lumbosacral spine procedures. DESIGN We present the findings of a single-center 12-month retrospective experience of all lumbosacral spine surgeries utilizing multimodality intraoperative neuromonitoring (IONM) consisting of TcMEPs, TaMEPs, somatosensory evoked potentials (SSEPs), electromyography (EMG), and electroencephalography. PATIENT SAMPLE Two hundred and twenty patients having one, or a combination of lumbosacral spine procedures, including anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), posterior spinal fusion (PSF), and/or transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES Intraoperative neuromonitoring data was correlated to immediate postoperative neurologic examinations and chart review. METHODS Baseline reliability, false positive rate, true positive rate, false negative rate, area under the curve at baseline and at alerts, and detection of preoperative deficits of TcMEPs and TaMEPs were compared and analyzed for statistical significance. The relationship between transcutaneous stimulation voltage level and patient BMI was also examined. RESULTS TaMEPs were significantly more reliable than TcMEPs in all muscles except abductor hallucis. Of the 27 false positive alerts, 24 were TcMEPs alone, and 3 were TaMEPs alone. Of the 19 true positives, none were detected by TcMEPs alone, 3 were detected by TaMEPs alone (TcMEPs were not present), and the remaining 16 true positives involved TaMEPs and TcMEPs. TaMEPs had a significantly larger area under the curve (AUC) at baseline than TcMEPs in all muscles except abductor hallucis. The percent decrease in TcMEP and TaMEP AUC during LLIF alerts was not significantly different. Both TcMEPs and TaMEPs reflected three preexisting motor deficits. Patient BMI and TaMEP stimulation intensity were found to be moderately positively correlated. CONCLUSIONS These findings demonstrate the high reliability and predictability of TaMEPs and the potential added value when TaMEPs are incorporated into multimodality IONM during lumbosacral spine surgery.
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Affiliation(s)
- David W Allison
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA.
| | - Amit Verma
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Paul J Holman
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Meng Huang
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Todd W Trask
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Anthony R Cockrell
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Matthew R Weber
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Dalton W Brooks
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Leo Delgado
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - William J Steele
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Jonathan N Sellin
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Loyola V Gressot
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Bradley Lambert
- Department of Orthopedics, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Brandy B Ma
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Amir H Faraji
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Comron Saifi
- Department of Orthopedics, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
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Wilkinson MF, Galdino Chaves JP, Arroyo MV, Zarrabian M. Repeated L5 Nerve Root Compromise Detected with Motor Evoked Potentials (MEP), but Not Electromyography (EMG): A Case Report. Neurodiagn J 2024; 64:24-32. [PMID: 38437023 DOI: 10.1080/21646821.2024.2312098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/24/2024] [Indexed: 03/06/2024]
Abstract
We report a case where neuromonitoring, using motor evoked potentials (MEP), detected an intraoperative L5 nerve root deficit during a lumbosacral decompression and instrumented fusion procedure. Critically, the MEP changes were not preceded nor accompanied by any significant spontaneous electromyography (sEMG) activity. Presumptive L5 innervated muscles, including tibialis anterior (TA), extensor hallucis longus (EHL) and gluteus maximus, were targets for nerve root surveillance using combined MEP and sEMG techniques. During a high-grade spondylolisthesis correction procedure, attempts to align a left-sided rod resulted in repeated loss and recovery cycles of MEP from the TA and EHL. No accompanying EMG alerts were associated with any of the MEP changes nor were MEP variations seen from muscles innervated above and below L5. After several attempts, the rod alignment was achieved, but significant MEP signal decrement (72% decrease) remained from the EHL. Postoperatively, the patient experienced significant foot drop on the left side that recovered over a period of 3 months. This case contributes to a growing body of evidence that exclusive reliance on sEMG for spinal nerve root scrutiny can be unreliable and MEP may provide more dependable data on nerve root patency.
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Affiliation(s)
- Marshall F Wilkinson
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Canada
| | - Jennyfer P Galdino Chaves
- Department of Orthopedic Surgery and Winnipeg Spine Program University of Manitoba and Health Sciences Centre, Winnipeg, Canada
| | - Miguel Vega Arroyo
- Department of Orthopedic Surgery and Winnipeg Spine Program University of Manitoba and Health Sciences Centre, Winnipeg, Canada
| | - Mohammed Zarrabian
- Department of Orthopedic Surgery and Winnipeg Spine Program University of Manitoba and Health Sciences Centre, Winnipeg, Canada
- Division of Orthopedic Surgery, McMaster University, Hamilton, Canada
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Wilkinson M, Ajoku U, Pederson K, McIntrye I, Zarrabian M. Identifying Suspected Volume Conduction Contamination of External Anal Sphincter Motor Evoked Potentials in Lumbosacral Spine Surgery. J Clin Neurophysiol 2024; 41:169-174. [PMID: 38306224 DOI: 10.1097/wnp.0000000000000952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Iatrogenic injury to sacral nerve roots poses significant quality of life issues for patients. Motor evoked potential (MEP) monitoring can be used for intraoperative surveillance of these important structures. We hypothesized that volume conducted depolarizations from gluteus maximus (GM) may contaminate external anal sphincter (EAS) MEP results during lumbosacral spine surgery. METHODS Motor evoked potential from the EAS and medial GM in 40 patients were prospectively assessed for inter-muscle volume conduction during lumbosacral spine surgeries. Peak latency matching between the EAS and GM MEP recordings conditionally identified volume conduction (VC+) or no volume conduction (VC-). Linear regression and power spectral density analysis of EAS and medial GM MEP amplitudes were performed from VC+ and VC- data pairs to confirm intermuscle electrical cross-talk. RESULTS Motor evoked potential peak latency matching identified putative VC+ in 9 of 40 patients (22.5%). Mean regression coefficients (r2) from peak-to-peak EAS and medial GM MEP amplitude plots were 0.83 ± 0.04 for VC+ and 0.34 ± 0.06 for VC- MEP (P < 0.001). Power spectral density analysis identified the major frequency component in the MEP responses. The mean frequency difference between VC+ EAS and medial GM MEP responses were 0.4 ± 0.2 Hz compared with 3.5 ± 0.6 Hz for VC- MEP (P < 0.001). CONCLUSIONS Our data support using peak latency matching between EAS and GM MEP to identify spurious MEP results because of intermuscle volume conduction. Neuromonitorists should be aware of this possible cross-muscle conflict to avoid interpretation errors during lumbosacral procedures using EAS MEP.
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Affiliation(s)
- Marshall Wilkinson
- Section of Neurosurgery, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Uchenna Ajoku
- Department of Orthopedic Surgery and Winnipeg Spine Program, University of Manitoba, Winnipeg, MB, Canada; and
| | - Kristine Pederson
- Section of Neurosurgery, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Ian McIntrye
- Department of Anesthesiology, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Mohammad Zarrabian
- Department of Orthopedic Surgery and Winnipeg Spine Program, University of Manitoba, Winnipeg, MB, Canada; and
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Allison DW, Hayworth MK, Nader R, Ballman M, Sun D, Ninan R, Southern E. Intraoperative transabdominal MEPs: four case reports. J Clin Monit Comput 2023; 37:689-698. [PMID: 35999343 DOI: 10.1007/s10877-022-00903-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022]
Abstract
Four recent cases utilizing transabdominal motor-evoked potentials (TaMEPs) are presented as illustrative of the monitoring technique during lumbosacral fusion, sciatic nerve tumor resection, cauda equina tumor resection, and lumbar decompression. Case 1: In a high-grade lumbosacral spondylolisthesis revision fusion, both transcranial motor-evoked potentials (TcMEPs) and TaMEPs detected a transient focal loss of left tibialis anterior response in conjunction with L5 nerve root decompression. Case 2: In a sciatic nerve tumor resection, TcMEPs responses were lost but TaMEPs remained unchanged, the patient was neurologically intact postoperatively. Case 3: TaMEPs were acquired during an L1-L3 intradural extramedullary cauda equina tumor resection utilizing a unique TaMEP stimulation electrode. Case 4: TaMEPs were successfully acquired with little anesthetic fade utilizing an anesthetic regimen of 1.1 MAC Sevoflurane during a lumbar decompression. While the first two cases present TaMEPs and TcMEPs side-by-side, demonstrating TaMEPs correlating to TcMEPs (Case 1) or a more accurate reflection of patient outcome (Case 2), no inference regarding the accuracy of TaMEPs to monitor nerve elements during cauda equina surgery (Cases 3) or the lumbar decompression presented in Case 4 should be made as these are demonstrations of technique, not utility.
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Affiliation(s)
- David W Allison
- Department of Neurophysiology, Houston Methodist Hospital, 6565 Fannin St., Houston, TX, 77030, USA.
| | - Miranda K Hayworth
- Department of Neurosurgery, University of Texas Medical Branch, 1005 Harborside Drive, Galveston, TX, 77555, USA
| | - Remi Nader
- Department of Neurosurgery, University of Texas Medical Branch, 1005 Harborside Drive, Galveston, TX, 77555, USA
| | - Melodie Ballman
- Medsurant Health, 100 Front Street, Suite 280, West Conshohoken, PA, 19428, USA
| | - Derrick Sun
- Department of Neurosurgery, Houston Methodist Healthcare System, 6560 Fannin St., Houston, TX, 77030, USA
| | - Rony Ninan
- Department of Neurology, Houston Methodist Healthcare System, 6560 Fannin St., Houston, TX, 77030, USA
| | - Edward Southern
- Department of Orthopedic Surgery, University of Texas Medical Branch, 1005 Harborside Drive, Galveston, TX, 77555, USA
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