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Combined motor and somatosensory evoked potentials for intraoperative monitoring: intra- and postoperative data in a series of 69 operations

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Abstract

The primary objective of neurophysiologic monitoring during surgery is to avoid permanent neurological injury resulting from surgical manipulation. To prevent motor deficits, either somatosensory (SSEP) or transcranial motor evoked potentials (MEP) are applied. This prospective study was conducted to evaluate if the combined use of SSEP and MEP might be beneficial. Combined SSEP/MEP monitoring was attempted in 100 consecutive procedures, including intracranial and spinal operations. Repetitive transcranial electric motor cortex stimulation was used to elicit MEP from muscles of the upper and lower limb. Stimulation of the tibial and median nerves was performed to record SSEP. Critical SSEP/MEP changes were defined as decreases in amplitude of more than 50% or increases in latency of more than 10% of baseline values. The operation was paused or the surgical strategy was modified in every case of SSEP/MEP changes. Combined SSEP/MEP monitoring was possible in 69 out of 100 operations. In 49 of the 69 operations (71%), SSEP/ MEP were stable, and the patients remained neurologically intact. Critical SSEP/ MEP changes were seen in six operations. Critical MEP changes with stable SSEP occurred in 12 operations. Overall, critical MEP changes were recorded in 18 operations (26%). In 12 of the 18 operations, MEP recovered to some extent after modification of the surgical strategy, and the patients either showed no (n = 10) or only a transient motor deficit (n = 2). In the remaining six operations, MEP did not recover and the patients either had a transient (n = 3) or a permanent (n = 3) motor deficit. Critical SSEP changes with stable MEP were observed in two operations; both patients did not show a new motor deficit. Our data again confirm that MEP monitoring is superior to SSEP monitoring in detecting impending impairment of the functional integrity of cerebral and spinal cord motor pathways during surgery. Detection of MEP changes and adjustment of the surgical strategy might allow to prevent irreversible pyramidal tract damage. Stable SSEP/MEP recordings reassure the surgeon that motor function is still intact and surgery can be continued safely. The combined SSEP/ MEP monitoring becomes advantageous, if one modality is not recordable.

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Authors and Affiliations

  1. Department of Neurosurgery, University of Aachen, Aachen, Germany

    M. R. Weinzierl, P. Reinacher, J. M. Gilsbach & V. Rohde

  2. Department of Neurosurgery, Georg-August-University, Goettingen, Germany

    V. Rohde

  3. Neurosurgical Department, RWTH Aachen, Pauwelsstr. 30, 52057, Aachen, Germany

    M. R. Weinzierl

Authors
  1. M. R. Weinzierl
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  2. P. Reinacher
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  3. J. M. Gilsbach
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  4. V. Rohde
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Corresponding author

Correspondence to M. R. Weinzierl.

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Comments

Josef Zentner, Freiburg, Germany

This prospective study was designed to evaluate the value of combined SEP and MEP monitoring in intercranial and spinal surgery. In particular, Weinzierl et al. tried to clarify whether additional recording of SEP provides more information as compared to recording of MEP alone.

The authors conclude that (1) the loss of MEP indicates motor deficit, (2) unchanged MEP indicate uneventful motor outcome, and (3) the preserved but changed MEP may or may not coincide with additional motor deficits. Moreover, additional recording of SEP may only provide complementary information to MEP with respect to the sensory status.

Although the conclusions of this study are well known, it is the merit of the authors to substantiate this information by a prospectively designed study. Further work is necessary to define more clearly patients in whom intraoperative monitoring is definitely useful and in whom surgical treatment may be similarly done without.

Comments

Georg Neuloh, Johannes Schramm, Bonn, Germany

This prospective case series is a valuable contribution to the literature on combined MEP and SEP monitoring, both for intracranial and spinal procedures. Previously described principles of MEP (and SEP) change interpretation to trigger surgical intervention are confirmed. Specifically, a superior sensitivity of MEP monitoring to detect impending motor deficit is demonstrated, as well as the value of a combined SEP and MEP monitoring approach if one modality fails. Note that the transcranial MEP stimulation technique applied here must be handled with great care for pericentral cortical lesions to avoid distal deep stimulation.

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Weinzierl, M.R., Reinacher, P., Gilsbach, J.M. et al. Combined motor and somatosensory evoked potentials for intraoperative monitoring: intra- and postoperative data in a series of 69 operations. Neurosurg Rev 30, 109–116 (2007). https://doi.org/10.1007/s10143-006-0061-5

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  • DOI: https://doi.org/10.1007/s10143-006-0061-5

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