European Spine Journal

, Volume 28, Issue 3, pp 484–491 | Cite as

Characteristics of multi-channel Br(E)-MsEP waveforms for the lower extremity muscles in thoracic spine surgery: comparison based on preoperative motor status

  • Kazuyoshi Kobayashi
  • Kei Ando
  • Mikito Tsushima
  • Masaaki Machino
  • Kyotaro Ota
  • Masayoshi Morozumi
  • Satoshi Tanaka
  • Shunsuke Kanbara
  • Naoki Ishiguro
  • Shiro ImagamaEmail author
Original Article



To evaluate the characteristics of brain-evoked muscle action potential [Br(E)-MsEP] waveforms of lower limb muscles in thoracic spine surgery.


The subjects were 159 patients who underwent thoracic spine surgery with intraoperative Br(E)-MsEP monitoring from January 2009 to December 2015, using a total of 2226 muscles in the extremities. The waveform derivation rate for each lower extremity muscle was examined at baseline and intraoperatively. Data were interpreted based on the preoperative motor status.


The preoperative ambulatory and non-ambulatory rates were 38% (60/159, McCormick grades I and II) and 62% (99/159, grades III–V), respectively. Eleven cases (all non-ambulatory) had undetectable baseline waveforms in all muscles, and in 19 cases (12%) a baseline waveform could only be derived from the abductor hallucis (AH). The waveform derivation rate in all lower limb muscles was significantly higher in ambulatory cases (p < 0.05), and the rates for the AH were the highest in both groups (p < 0.05). Postoperative paralysis occurred in 31 cases (19%). A decrease in intraoperative amplitude of ≥ 70% from baseline occurred in 54 cases and had sensitivity of 100% and specificity of 82% for prediction of postoperative motor deficit.


This is the first study of Br(E)-MsEP waveforms for each lower limb muscle based on preoperative ambulatory status. Detection of waveforms from distal muscles was still possible in a case with preoperative motor deficit, and the AH had an especially high derivation rate, even in cases with preoperative muscle weakness. Collectively, the results support use of Br(E)-MsEP monitoring using the AH in the lower extremities.

Graphical abstract


Br(E)-MsEP Lower limb muscle Thoracic surgery Waveform change Abductor hallucis 



Funding was from institutional sources only.

Compliance with ethical standards

Conflict of interest

None of the authors has any potential conflict of interest.

Supplementary material

586_2018_5825_MOESM1_ESM.pptx (1.4 mb)
Supplementary material 1 (PPTX 1437 kb)


  1. 1.
    Hamilton DK, Smith JS, Sansur CA et al (2011) Scoliosis Research Society Morbidity and Mortality Committee. Rates of new neurological deficit associated with spine surgery based on 108,419 procedures: a report of the scoliosis research society morbidity and mortality committee. Spine 36:1218–1228CrossRefGoogle Scholar
  2. 2.
    Matsuyama Y, Sakai Y, Katayama Y et al (2009) Surgical results of intramedullary spinal cord tumor with spinal cord monitoring to guide extent of resection. J Neurosurg Spine 10:404–413CrossRefGoogle Scholar
  3. 3.
    Matsumoto M, Toyama Y, Chikuda H et al (2011) Outcomes of fusion surgery for ossification of the posterior longitudinal ligament of the thoracic spine: a multicenter retrospective survey: clinical article. J Neurosurg Spine 15:380–385CrossRefGoogle Scholar
  4. 4.
    Zanirato A, Damilano M, Formica M et al (2018) Complications in adult spine deformity surgery: a systematic review of the recent literature with reporting of aggregated incidences. Eur Spine J 27:2272–2284CrossRefGoogle Scholar
  5. 5.
    Ghobrial GM, Williams KA Jr., Arnold P et al (2015) Iatrogenic neurologic deficit after lumbar spine surgery: a review. Clin Neurol Neurosurg 139:76–80CrossRefGoogle Scholar
  6. 6.
    Rustagi T, Tallarico RA, Lavelle WF (2018) Early lumbar nerve root deficit after three column osteotomy for fixed sagittal plane deformities in adults. Int J Spine Surg 12:131–138CrossRefGoogle Scholar
  7. 7.
    Lo YL, Dan YF, Teo A et al (2008) The value of bilateral ipsilateral and contralateral motor evoked potential monitoring in scoliosis surgery. Eur Spine J 17:S236–S238CrossRefGoogle Scholar
  8. 8.
    Kobayashi K, Ando K, Yagi H et al (2017) Prevention and prediction of postoperative bowel bladder disorder using an anal plug electrode with Tc-MsEP monitoring during spine surgery. Nagoya J Med Sci 79:459–466Google Scholar
  9. 9.
    Kobayashi K, Imagama S, Ito Z et al (2017) Prevention of spinal cord injury using brain-evoked muscle-action potential (Br(E)-MsEP) monitoring in cervical spinal screw fixation. Eur Spine J 26:1154–1161CrossRefGoogle Scholar
  10. 10.
    Kobayashi K, Imagama S, Ito Z et al (2017) Transcranial motor evoked potential waveform changes in corrective fusion for adolescent idiopathic scoliosis. J Neurosurg Pediatr 19:108–115CrossRefGoogle Scholar
  11. 11.
    Fehlings MG, Brodke DS et al (2010) The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference? Spine 35:S37–S46CrossRefGoogle Scholar
  12. 12.
    Gonzalez AA, Jeyanandarajan D, Hansen C et al (2009) Intraoperative neurophysiological monitoring during spine surgery: a review. Neurosurg Focus 27:E6CrossRefGoogle Scholar
  13. 13.
    Kobayashi K, Ando K, Shinjo R et al (2018) Evaluation of a combination of waveform amplitude and latency in intraoperative spinal cord monitoring. Spine 43:1231–1237CrossRefGoogle Scholar
  14. 14.
    Kobayashi K, Ando K, Yagi H et al (2018) Efficacy of an anal needle electrode for intraoperative spinal cord monitoring with Tc-MsEP. Asian Spine J 12:662–668CrossRefGoogle Scholar
  15. 15.
    Kobayashi K, Ando K, Shinjo R et al (2018) A new criterion for the alarm point using a combination of waveform amplitude and onset latency in Br(E)-MsEP monitoring in spine surgery. J Neurosurg Spine 27:1–7Google Scholar
  16. 16.
    Luk KD, Hu Y, Wong YW et al (2001) Evaluation of various evoked potential techniques for spinal cord monitoring during scoliosis surgery. Spine 26:1772–1777CrossRefGoogle Scholar
  17. 17.
    Ito Z, Matsuyama Y, Shinomiya K et al (2011) A multicenter study by the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Sekizuikinou Shindangaku 33:116–123 (in Japanese) Google Scholar
  18. 18.
    McCormick PC, Michelsen WJ, Post KD et al (1988) Cavernous malformations of the spinal cord. Neurosurgery 23:459–463CrossRefGoogle Scholar
  19. 19.
    Kobayashi S, Matsuyama Y, Shinomiya K et al (2014) A new alarm point of transcranial electrical stimulation motor evoked potentials for intraoperative spinal cord monitoring: a prospective multicenter study from the Spinal Cord Monitoring Working Group of the Japanese Society for Spine Surgery and Related Research. J Neurosurg Spine 20:102–107CrossRefGoogle Scholar
  20. 20.
    Muramoto A, Imagama S, Ito Z et al (2013) The cutoff amplitude of transcranial motor-evoked potentials for predicting postoperative motor deficits in thoracic spine surgery. Spine 38:E21–E27CrossRefGoogle Scholar
  21. 21.
    Kothbauer KF, Deletis V, Epstein FJ (1998) Motor-evoked potential monitoring for intramedullary spinal cord tumor surgery: correlation of clinical and neurophysiological data in a series of 100 consecutive procedures. Neurosurg Focus 4:e1CrossRefGoogle Scholar
  22. 22.
    Imagama S, Ando K, Kobayashi K et al (2017) Factors for a good surgical outcome in posterior decompression and dekyphotic corrective fusion with instrumentation for thoracic ossification of the posterior longitudinal ligament: prospective single-center study. Oper Neurosurg 13:661–669CrossRefGoogle Scholar
  23. 23.
    Imagama S, Ando K, Ito Z et al (2017) Risk factors for ineffectiveness of posterior decompression and dekyphotic corrective fusion with instrumentation for beak-type thoracic ossification of the posterior longitudinal ligament: a single institute study. Neurosurgery 80:800–808CrossRefGoogle Scholar
  24. 24.
    Imagama S, Ando K, Ito Z et al (2016) Resection of beak-type thoracic ossification of the posterior longitudinal ligament from a posterior approach under intraoperative neurophysiological monitoring for paralysis after posterior decompression and fusion surgery. Global Spine J 6:812–821CrossRefGoogle Scholar
  25. 25.
    Deletis V, Sala F (2008) Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol 119:248–264CrossRefGoogle Scholar
  26. 26.
    Jankowska E, Padel Y, Tanaka R (1975) Projections of pyramidal tract cells to alpha-motoneurones innervating hind-limb muscles in the monkey. J Physiol 249:637–667CrossRefGoogle Scholar
  27. 27.
    Fujiwara Y, Sumida T, Manabe H et al (2011) The difference between spinal tract injury and segmental injury during intraoperative spinal cord monitoring using muscle evoked potentials. J Funct Diagn Spinal Cord 33:157–162Google Scholar
  28. 28.
    Langeloo DD, Lelivelt A, Louis Journée H et al (2003) Transcranial electrical motor-evoked potential monitoring during surgery for spinal deformity: a study of 145 patients. Spine 28:1043–1050Google Scholar
  29. 29.
    Lee JY, Hilibrand AS, Lim MR et al (2006) Characterization of neurophysiologic alerts during anterior cervical spine surgery. Spine 31:1916–1922CrossRefGoogle Scholar
  30. 30.
    Park P, Wang AC, Sangala JR et al (2011) Impact of multimodal intraoperative monitoring during correction of symptomatic cervical or cervicothoracic kyphosis. J Neurosurg Spine 14:99–105CrossRefGoogle Scholar
  31. 31.
    Pelosi L, Lamb J, Grevitt M et al (2002) Combined monitoring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin Neurophysiol 113:1082–1091CrossRefGoogle Scholar
  32. 32.
    Quiñones-Hinojosa A, Lyon R, Zada G et al (2005) Changes in transcranial motor evoked potentials during intramedullary spinal cord tumor resection correlate with postoperative motor function. Neurosurgery 56:982–993Google Scholar
  33. 33.
    Raynor BL, Bright JD, Lenke LG et al (2013) Significant change or loss of intraoperative monitoring data: a 25-year experience in 12,375 spinal surgeries. Spine 38:E101–E108CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Kazuyoshi Kobayashi
    • 1
  • Kei Ando
    • 1
  • Mikito Tsushima
    • 1
  • Masaaki Machino
    • 1
  • Kyotaro Ota
    • 1
  • Masayoshi Morozumi
    • 1
  • Satoshi Tanaka
    • 1
  • Shunsuke Kanbara
    • 1
  • Naoki Ishiguro
    • 1
  • Shiro Imagama
    • 1
    Email author
  1. 1.Department of Orthopaedic SurgeryNagoya University Graduate School of MedicineNagoyaJapan

Personalised recommendations