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Four-limb muscle motor evoked potential and optimized somatosensory evoked potential monitoring with decussation assessment: results in 206 thoracolumbar spine surgeries

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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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Acknowledgments

The following technologists participated in the recordings: Mohammad Al Enazi, William Gene, Betty Jarvis, Judy Barclay, Andrew Warrington, Brent Hedgecock, Ameer Jan, Saima Naseer and Marela Bien.

Conflict of interest statement None of the authors has any potential conflict of interest.

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Authors and Affiliations

  1. Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital and Research Center, MBC 76, PO Box 3354, 11211, Riyadh, Saudi Arabia

    David B. MacDonald

  2. Department of Orthopedics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

    Zayed Al Zayed & Abdulmoneam Al Saddigi

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  1. David B. MacDonald
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  2. Zayed Al Zayed
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  3. Abdulmoneam Al Saddigi
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Correspondence to David B. MacDonald.

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MacDonald, D.B., 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. Eur Spine J 16 (Suppl 2), 171–187 (2007). https://doi.org/10.1007/s00586-007-0426-7

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