INVITED REVIEW ABSTRACT: The purpose of intraoperative monitoring is to preserve func-

tion and prevent injury to the nervous system at a time when clinical
examination is not possible. Cranial nerves are delicate structures and are
susceptible to damage by mechanical trauma or ischemia during intracranial
and extracranial surgery. A number of reliable electrodiagnostic techniques,
including nerve conduction studies, electromyography, and the recording of
evoked potentials have been adapted to the study of cranial nerve function
during surgery. A growing body of evidence supports the utility of intraop-
erative monitoring of cranial nerve nerves during selected surgical proce-
dures.
Muscle Nerve 29: 339 –351, 2004

INTRAOPERATIVE CRANIAL NERVE MONITORING

C. MICHEL HARPER, MD

Department of Neurology, Mayo College of Medicine, Mayo Clinic, 200 First Street SW,
Rochester, Minnesota 55902, USA

Accepted 1 August 2003

Electrophysiological techniques have been used to
monitor nervous system function during surgery for
over three decades. Initially, the presence of a visible
muscle twitch following electrical stimulation was
used as a gross measure of peripheral nerve integrity.
In the 1960s and 1970s, nerve conduction studies
(NCS) were adapted to the intraoperative study of
peripheral nerves,43 and the recording of evoked
potentials to the study of visual, auditory, and spinal
sensory pathways during surgery.2,11,21,69,76 In 1986,
Harner et al.24 first described the use of continuous
electromyographic (EMG) recordings as an intraop-
erative monitoring tool for peripheral nerve func-
tion. The past two decades have seen refinement and
application of these surgical monitoring techniques.
Cranial nerve dysfunction may occur as the result
of either the underlying pathological condition ne-
cessitating surgery or the operation designed to treat
that condition. Damage occurs by mechanical
trauma or ischemia, and frequently produces pain,
functional disability, and cosmetic deformity. The
cranial nerves are particularly susceptible to injury
because of their small size, circuitous course, and
Abbreviations: AEP, auditory evoked potential; BAEP, brainstem auditory
evoked potential; CMAP, compound muscle action potential; CPA, cerebel-
lopontine angle; ECochG, electrocochleography; EMG, electromyography;
LSR, lateral spread response; MUP, motor unit potential; MVD, microvascular
decompression; NAP, nerve action potential; NCS, nerve conduction studies
Key words: brainstem auditory evoked potentials; cranial nerve; electromyo-
graphic monitoring; intraoperative monitoring; surgical monitoring
Correspondence to: C.M. Harper; e-mail: mharper@mayo.edu
© 2003 Wiley Periodicals, Inc.
delicate epineurium. Tumors and other pathology
distort normal anatomical relationships, which fur-
ther increases the risk of cranial nerve injury during
surgery.
Advances in neuroanesthesia, microsurgical tech-
niques, and intraoperative electrophysiological mon-
itoring have improved the preservation of cranial
nerves during surgery in the middle and posterior
cranial fossa and in extracranial regions of the head
and neck. Cranial nerve function is monitored with
NCS, EMG, and evoked potentials. Compound mus-
cle action potentials (CMAPs), nerve action poten-
tials (NAPs), and motor unit potential (MUP) activ-
ity can be evoked during surgery by electrical,
mechanical, or metabolic stimuli. Auditory evoked
potentials are easily recorded in the surgical setting.
These motor and sensory monitoring modalities pro-
vide immediate feedback concerning the location
and functional status of specific cranial nerves. In
many situations, the surgical procedure is altered in
some manner to prevent further compromise of cra-
nial nerve function. In other cases, the information
provided helps to predict the nature and severity of
postoperative deficits, which is useful in counseling
patients in the immediate postoperative period. Cor-
relation of physiological data with surgical events
helps to understand mechanisms of cranial nerve
injury and thereby leads to improved techniques and
future surgical outcomes.
EMG activity, NCS, and auditory evoked poten-
tials are relatively stable signals that are affected
minimally by anesthetics and other physiological
variables that are of particular importance during

Cranial Nerve Monitoring MUSCLE & NERVE March 2004 339

surgery. In contrast, the inherent susceptibility of
mid-latency responses such as visual evoked poten-
tials to anesthetics prevents their effective use as a
monitoring tool during surgery.11,39,97 Likewise, al-
though potentially useful, technical difficulties with
stimulus artifact, reliability of recordings, origin and
consistency of waveforms, and lack of clear distinc-
tion between normal and pathological conduction
have limited the utility of trigeminal evoked poten-
tials in the surgical setting.22,46,67,86
This review focuses on the current status of cra-
nial nerve monitoring during surgery utilizing a va-
riety of techniques including EMG, NCS, and audi-
tory evoked potentials. Both the technical aspects of
recording these signals during surgery and the appli-
cation of the techniques to specific surgical procedures
that risk injury to cranial nerves are considered.
MONITORING TECHNIQUES
Electromyography. Intraoperative EMG monitoring
involves continuous recording of MUP activity in a
similar manner to standard needle electromyogra-
phy. Although a number of different types of poten-
tials are encountered, neurotonic discharges are the
activity of major interest. These were first described
and characterized in the 1980s14,24 and are defined
as high-frequency intermittent or continuous bursts
of MUPs recorded from a muscle in response to
mechanical or metabolic stimulation (Fig. 1). Neu-
rotonic discharges need to be distinguished from
movement artifact as well as random motor unit
activity secondary to light levels of anesthesia. Elec-
trode movement produces either low-frequency un-
dulation of the baseline or sharp triangular
monophasic spikes with a rise time ⬍500 ␮s followed
by a more gradual return of the potential to baseline.
MUP activity that is associated with a lightened level
of anesthesia is similar to voluntary MUP activity
observed during standard needle electromyogra-
phy.14,28 The activity is random and unrelated to any
mechanical stimulation of the nerve or instillation of
saline into the surgical field. The MUPs discharge at
rates of 10 –30 Hz and usually fire singly or in small
groups, rather than leading to a full interference
pattern.
Neurotonic discharges consist of bursts or trains
of MUPs that fire in a rapid and irregular manner.
Bursts are less than 200 ms in duration and consist of
single or multiple MUPs firing at 30 –100 Hz (Fig. 1).
They appear as single or multiple repetitive bursts
and are typically elicited by touching, rubbing, trac-
tion, or other mechanical manipulations of the
nerve.6,23,24,26,45 A train of neurotonic discharges
consists of MUPs firing at similar frequencies as
short bursts but more continuously for durations of
⬎200 ms (typically 1–30 s) (Fig. 1). Trains are trig-
gered by mechanical stimuli, saline irrigation, and
possibly nerve ischemia.6,12,24,26,80,82 At times, multi-

FIGURE 1. Neurotonic discharges recorded from facial muscles during acoustic neuroma resection. Three traces of continuous EMG from
intramuscular wire electrodes in orbicularis oculi (top), masseter (middle), and orbicularis oris (bottom). Inadvertent mechanical manip-
ulation of the facial nerve in the surgical field resulted in a train of neurotonic discharges (360-ms duration) in the orbicularis oculi (top
trace) and a burst of neurotonic discharges (100-ms duration) in the orbicularis oris muscle (bottom trace).

340 Cranial Nerve Monitoring MUSCLE & NERVE March 2004

ple types of neurotonic discharges firing asynchro- infusion of a short-acting neuromuscular blocking
nously and independently are recorded from a sin- drug adjusted to produce a peripheral CMAP that is
gle muscle. 25% of the baseline response.8,49 This technique
Since neurotonic discharges are precipitated by helps prevent head or body movements that may
mechanical stimulation of the motor axon, they are interfere with microsurgical procedures in or
a sensitive indicator of nerve irritation and give im- around the cranial nerves. Increasing the concentra-
mediate information regarding nerve location. De- tion of inhalation anesthetics and intermittent doses
spite their utility, neurotonic discharges do not nec- of a narcotic or benzodiazepine can also be used to
essarily indicate nerve damage and their absence reduce background muscle activity that interferes
does not exclude nerve injury.14,17,24,26,44 Mechanical with the recording of neurotonic discharges.
stimulation may be strong enough to induce neuro-
tonic discharges but not injure the nerve. Likewise, Nerve Conduction Studies (Compound Muscle and
saline irrigation induces trains of neurotonic dis- Nerve Action Potentials). The integrity of peripheral
charges without producing damage to motor or sen- motor axons can be tested by electrically stimulating
sory axons. Sharp transection of a nerve is less likely the nerve in the surgical field while recording a
to produce neurotonic discharges than mechanical CMAP from one or more distal muscles. CMAP re-
manipulation, and damaged nerves are less likely to cordings are made with intramuscular wire or needle
produce discharges than healthy nerves.14,24,26,70 electrodes (as in EMG) or with surface electrodes
A variety of electrodes are used to record EMG (Fig. 2). Intramuscular electrodes provide selective
activity during surgery.14,28,31 Surface and subcutane- recordings from deep muscles or from those located
ous electrodes will capture some neurotonic dis- adjacent to muscles innervated by different nerves.
charges, but cannot reliably record those from deep Surface electrodes are more suitable for quantitative
areas of the muscle. Standard concentric and mo-
nopolar needle electrodes produce recordings of
excellent quality. The size of the electrode to be used
depends on the depth and location of the muscle
being examined. Small (10-mm length, 0.3-mm di-
ameter) stainless-steel needle electrodes are the
most appropriate for cranial muscle recordings.
Larger needle electrodes are bulky, easily dislodged,
and may injure tissue. Malleable wire electrodes in-
serted into the muscle with a small needle, which is
then removed, also work well for cranial muscle
recordings. They require special adapters for the
amplifier connection, but generally produce stable
selective recordings from superficial or deep mus-
cles, with less movement artifact and tissue trauma
than needle electrodes.14,28
Standard needle EMG settings for sensitivities
(50 –200 ␮V), filters (30 –20,000 Hz), and sweep
speeds (10 –100 ms/cm) are used to record EMG
signals during surgery. Recordings can be made
from almost any cranial-innervated muscle including
extraocular, facial, masticatory, laryngeal, upper cer-
vical, and tongue muscles. With an appropriate elec- FIGURE 2. Facial CMAP recorded with intramuscular electrodes
trodiagnostic instrument designed or modified for in the orbicularis oculi (1), orbicularis oris (2), and masseter (3),
and with surface electrodes over the mentalis muscle (4). The
surgical monitoring, EMG recordings are monitored sweep is triggered by electrical stimulation with a small bipolar
from multiple muscles simultaneously. stimulator applied to the facial nerve in the posterior fossa (du-
Cautery, ultrasound, and other electrical equip- ration, 0.05 ms; intensity, 2.7 mA). The CMAP recorded with
ment, and electrode movement account for the ma- surface electrodes is more quantitative than the response re-
jor sources of interference with intraoperative EMG corded from intramuscular electrodes. The intramuscular elec-
trodes are more selective. Note the sharp rise-time of activity
recordings. With experience, these can be elimi- generated from facial muscles in traces 1 and 2, and the slow rise
nated or discounted in the majority of cases. Neuro- time of the response in the masseter, a muscle not activated by
tonic discharges can be recorded with a constant facial stimulation. O, onset; P, peak.

Cranial Nerve Monitoring MUSCLE & NERVE March 2004 341

measurements because they record activity from a
larger number of muscle fibers.
NAPs recorded directly from peripheral nerves
during surgery represent activity in sensory and mo-
tor axons when triggered by electrical stimulation, or
in sensory axons when triggered by auditory stimu-
lation (Fig. 3).93 Averaging is often needed to record
NAPs during surgery because of their small size. In
addition, NAP recordings are often limited by stim-
ulus artifact caused primarily by the close proximity
of stimulation and recording electrodes. Small hook
or wire electrodes that can be applied directly to the
nerve exposed at surgery are used for recording
NAPs.
Hand-held sterile stimulators of various sizes and
configurations are used intraoperatively.14,93 Factors
to consider in choosing the most appropriate stimu-
lator include the size and location of the nerve and
the ability to isolate the nerve from surrounding
fluid or tissue. Cranial nerves generally require small
stimulating electrodes. Stimulators that expose only
1–3 mm of the electrode tip minimize current shunt-
ing and are therefore more selective than larger
stimulators. Bipolar stimulators (cathode and anode
applied along the nerve and separated by 1–20 mm)
produce a localized flow of current that is less likely
to spread to adjacent nerves.43,93 With selectivity,
some degree of sensitivity is sacrificed as the local-
ized flow of current may be subthreshold when the
nerve is distant or fluid causes shunting. Monopolar
stimulators (cathode on the nerve and anode placed
away from the nerve by at least several centimeters)
reduce the chance of subthreshold stimulation, but
increase the risk of current spread to other nerves
resulting in nonspecific and less selective activa-
tion.28,31
Very low stimulation intensity (1–5 mA) and du-
ration (0.05– 0.1 ms) are typically required for cra-
nial nerve activation during surgery. Higher intensi-
ties may be required if the nerve is damaged, distant,
or insulated by tissue or fluid, but stimulus intensi-
ties greater than 5 mA increase the risk of current
spread and unintended activation of adjacent or
FIGURE 3. Nerve action potential recorded from an electrode
placed on the auditory nerve in the posterior fossa during acous-
tic neuroma resection. The sweep is triggered by an auditory
stimulus of 85dB at a frequency of 10.1 HZ.
342 Cranial Nerve Monitoring
distant nerves. An absent CMAP or NAP may indi-
cate lack of nerve function or a variety of technical
problems such as stimulator failure (faulty connec-
tions, poor contact with nerve, current shunting,
inadequate stimulation intensity, or incorrect re-
cording parameters) or excessive use of neuromus-
cular blocking agents.
With supramaximal stimulation, the size of the
CMAP (recorded from surface electrodes) or NAP is
proportional to the number of functioning axons
between the point of stimulation and recording.43,93
Stimulation of cranial nerves proximal to the poten-
tial site of intraoperative injury (usually close to the
brainstem) at regular intervals during the course of
surgery gives an accurate picture of the amount of
functional loss occurring as a result of the operative
procedure.20,24,26 Although the pathophysiology
(conduction block or axon loss) of this immediate
change cannot be determined, useful information
regarding the presence or absence of nerve injury is
obtained. Preservation of the response with proxi-
mal stimulation reassures the surgical team that no
significant injury has occurred. A partial loss of am-
plitude may lead to alteration of the surgical ap-
proach in an attempt to preserve function, whereas
the absence or severe reduction in size of the re-
sponse correlates directly with the severity of imme-
diate and long-term postoperative cranial nerve def-
icit.20,23,24,26,84
Auditory Evoked Potentials. Auditory evoked poten-
tials (AEPs) are generated in the cochlea, auditory
nerve, cochlear nuclei in the medulla, and dorsolat-
eral regions of the pons and midbrain.13,47 Brain-
stem auditory evoked potentials (BAEPs), electroco-
chleography (ECochG), and NAPs recorded directly
from the eighth cranial nerve have been used to
monitor auditory nerve function during sur-
gery.18,21,29,54 –56,59,62,73,75,95 Stimulation parameters
are similar for all three techniques. The stimulus is
delivered through an external ear canal electrode
designed to provide a watertight seal and reduce the
introduction of ambient noise into the canal. For
BAEP recordings, the ear insert incorporates a re-
cording electrode, which enhances the resolution of
wave I.28,66 The external canal electrode is refer-
enced to a scalp electrode for BAEP recordings. For
ECochG, a needle recording electrode is placed
through the tympanic membrane into the soft tissue
covering the bony promontory of the middle ear and
referenced to the ipsilateral mastoid.73,98 The audi-
tory NAP is recorded with an electrode placed di-
rectly on the auditory nerve at or near the brainstem
when the nerve is exposed during posterior fossa
MUSCLE & NERVE March 2004
surgery.54,63 Wave I of the BAEP, N1 of the ECochG,
and the auditory NAP recorded when the electrode
is placed near the internal auditory canal all repre-
sent activity generated in the lateral portion of the
auditory nerve.47,48,54,73 Waves II and III of the BAEP
and the auditory NAP recorded when the electrode
is placed medially near the brainstem represent ac-
tivity generated in the medial auditory nerve and the
cochlear nuclei.48,62,63 Waves IV and V of the BAEP
are generated bilaterally in the medial lemniscus
and inferior colliculus.47,63
The BAEP is the most widely used of the three
auditory techniques. BAEP recordings are noninva-
sive and relatively easy to perform, monitor the en-
tire auditory pathway, and can be used throughout
the surgical procedure. The BAEP is a sensitive in-
dicator of damage to the auditory pathway, as ab-
sence of wave V of the BAEP at the end of surgery is
associated with hearing loss in the majority of
cases.18,21,29,56,62,63,75,89 However, limitations of the
BAEP technique include poorly defined responses in
some cases of posterior fossa tumors (e.g., acoustic
neuromas) and reduced specificity compared to the
other techniques. This is illustrated by reported
cases of retained useful hearing despite the irrevers-
ible loss of wave V during surgery.18,29,68,73
ECochG has been used as an alternative to BAEP
monitoring particularly in the setting of acoustic
neuromas, when the BAEP is often poorly de-
fined.50,68,73,98 Retention of at least minimal hearing
is predicted by preservation of the N1 potential at
the end of surgery.50,73 However, since the N1 po-
tential originates from the lateral portion of the
auditory nerve, damage that is limited to the medial
portion of the nerve or the brainstem will not be
detected by ECochG monitoring. Thus, significant
loss of hearing can occur despite the preservation of
the N1 at the end of surgery. Technical problems
related to dislodgment of the recording electrode
during surgery are common as well. The auditory
NAP recording is a sensitive real-time monitor of
eighth nerve function, but is only available when the
nerve is exposed and is difficult to use when patho-
logical tissue (e.g., tumors) occupies significant
space within the cerebellopontine angle.
Changes in the auditory NAP and the BAEP
have been correlated with specific operative
events.35,48,54,56,63,96 Some changes are reversible by
altering the surgical approach, whereas others are
permanent and correlate with hearing loss postop-
eratively. Traction, compression, ischemia, avulsion,
or transection are mechanisms of auditory nerve
injury. When the nerve is exposed to air after the
dura is opened, the latency of waves II–V may in-
Cranial Nerve Monitoring
crease by 1.0 –1.5 ms due to nerve cooling (Fig. 4).
This change occurs over several minutes, stabilizes,
and is not associated with postoperative hearing loss.
Cerebellar retraction may stretch the eighth nerve,
typically increasing the latency of wave V with no
significant change in the ECochG. Moderate trac-
tion or contusion of the nerve typically causes in-
creased latency and reduced amplitude of waves I–V
of the BAEP, N1 of the ECochG, and the auditory
NAP.48,50,62,63 An increased latency of greater than
1.0 ms or a 50% reduction in amplitude are usually
considered significant enough to alert the surgeon.
The surgeon must interpret the changes in the con-
text of the surgical situation. Repositioning the cer-
ebellar retractor or a change in the approach to the
dissection frequently reverses or stabilizes the abnor-
mality (Fig. 5). At other times, the BAEP is gradually
lost despite efforts to modify the dissection. Wave I
of the BAEP or the N1 potential ECochG may be
spared if the cochlear blood supply is preserved and
the lateral portion of the auditory nerve is not in-
jured. Either avulsion of the nerve from the cochlea
or interruption of the internal auditory artery results
in rapid irreversible loss of all potentials and hearing
(Fig. 6).
APPLICATIONS
Middle Cranial Fossa. EMG and NCS are used to mon-
itor the oculomotor, trochlear, and abducens nerves
FIGURE 4. Minor change in the latency of waves I–V of the BAEP
caused by cooling of the auditory nerve after spinal fluid drainage
and exposure of the nerve to air in the posterior fossa. Fifteen
traces displayed with 3 min elapsed time between each trace
(stimulus intensity, 65dB; rate, 10.1 HZ; 400 sweeps averaged).
Waves I–V are labeled. Waves IV and V frequently have a bifid
configuration. Waves II and III are often variable during surgery.
MUSCLE & NERVE March 2004 343

FIGURE 5. BAEP monitoring during resection of a small acoustic
neuroma. Series of 24 consecutive recordings with 3 min be-
tween each trace. Waves I, III, and the IV–V complex of the
BAEP are well defined at the beginning of surgery. After the
cerebellar retractor was placed into the surgical field, waves III–V
gradually disappeared, but then reappeared and returned close
to baseline levels for amplitude and latency shortly after the
cerebellar retractor was repositioned (stimulus intensity, 85dB;
rate, 10.1 HZ; 400 sweeps averaged).
during surgery in the middle cranial fossa.1,28,80,81
These nerves may be affected by meningiomas, carci-
nomas, lymphomas, pituitary tumors, or other malig-
nancies in the region of the orbit, supraorbital ridge,
sella, cavernous sinus, or petrous portion of the tem-
poral bone. Neoplasms in these areas often distort
FIGURE 6. BAEP monitoring during acoustic neuroma resection.
There was a sudden loss of all waves when a blood vessel on the
surface of the tumor was cauterized. This presumably interrupted
blood flow through the internal auditory artery, producing isch-
emia of the auditory nerve and cochlea. Hearing was absent
postoperatively (stimulus intensity, 85dB; rate, 10.1 HZ; 400
sweeps averaged).
344 Cranial Nerve Monitoring
normal anatomical relationships, making it difficult to
identify cranial nerves III, IV, and VI. These nerves are
also at risk during repair of vascular lesions in the
middle fossa, such as carotid or ophthalmic artery an-
eurysms. EMG and CMAP signals are recorded from
intramuscular electrodes inserted into extraocular
muscles through the conjunctiva or eyelid under anes-
thesia prior to surgery.1,28,80 Continuous EMG activity is
monitored for the occurrence of neurotonic dis-
charges triggered by mechanical or metabolic stimula-
tion of the nerves (Fig. 7). Selective direct electrical
stimulation is used to identify the nerves. No controlled
studies are available to determine whether cranial
nerve monitoring during middle cranial fossa reduces
the risk of postoperative ophthalmoplegia.
Posterior Cranial Fossa. The posterior fossa is a rel-
atively large area extending from the petrous ridge
of the temporal bone to the foramen magnum. The
trigeminal, facial, auditory, glossopharyngeal, vagus,
spinal accessory, and hypoglossal nerves are in or
near the posterior fossa and are either involved in
pathology or at risk of injury during a variety of
surgical procedures involving the skull base. The
trigeminal and facial nerves are at risk for injury
during resection of cerebellopontine angle (CPA)
tumors,24,25,28 microvascular decompression (MVD)
or open rhizotomy procedures for trigeminal neu-
ralgia,5,10,57 and MVD for hemifacial spasm.4,57,59
Cranial nerve monitoring techniques have been
employed during resection of a variety of CPA tu-
mors including acoustic, facial, and trigeminal neu-
romas, meningiomas, epidermoids, glomus tumors,
chordomas, and metastases.17,53,78,82 Various combi-
nations of monitoring techniques have been re-
ported but the majority involve continuous EMG
FIGURE 7. EMG monitoring of extraocular muscles during resec-
tion of a cavernous sinus meningioma. Intramuscular wire elec-
trodes were placed in the superior oblique (1), lateral rectus (2),
and medial rectus (3) muscles under anesthesia immediately
prior to surgery. Trace 3 displays neurotonic discharges recorded
from the medial rectus muscle in response to inadvertent me-
chanical stimulation of cranial nerve III.
MUSCLE & NERVE March 2004
monitoring of muscles innervated by the trigeminal
and facial nerves, CMAP recordings from facial (and
in some cases trigeminal) muscles, and auditory
evoked potentials. Using modern multimodality re-
cording equipment allows simultaneous monitoring
of continuous EMG activity from multiple muscles,
intermittent electrical stimulation for threshold or
CMAP recordings, and repeated acquisition of audi-
tory evoked potentials (Fig. 8). Neurotonic dis-
charges occur in response to mechanical or meta-
bolic (saline) stimulation of cranial nerves V and
VII.14,24,26,28,31,44 This helps to locate the nerve and in
the absence of irrigation indicates that the nerve is
being mechanically stimulated, which in some cases
leads to nerve injury.
Direct electrical stimulation helps to identify and
distinguish the trigeminal and facial nerves. A mo-
nopolar stimulator is generally used when scanning
the surface of the tumor to see whether the facial
nerve is in close proximity before proceeding with
further dissection.41,51,61,100 A small bipolar stimula-
tor is used when the nerve is clearly visible.41,80,82,87
Measurement of stimulus threshold has been corre-
lated with postoperative function.17,32,52,101 With this
technique, the stimulator is applied to the facial
nerve in the cerebellopontine angle near the brain-

FIGURE 8. Multimodality monitoring including BAEP (1), EMG from facial muscles [intramuscular electrodes in orbicularis oculi (2),
orbicularis oris (3), and masseter (4) muscles], and set up for CMAP recordings (5– 8) during acoustic neuroma resection. Only waves
I and II are present on the BAEP recording in channel 1. Channels 2– 4 are recording trains of neurotonic discharges in facial and
trigeminal innervated muscles in response to saline irrigation of the posterior fossa. Channels 5– 8 are set up for CMAP recordings
triggered by electrical stimulation of the facial or trigeminal nerves in the operative field. The electrical stimulator is currently turned off.
When electrical stimulation is performed, traces 5–7 will display triggered CMAPs from intramuscular electrodes (same input as channels
2– 4), while trace 8 will display the facial CMAP recorded from the mentalis muscle. Amp, amplifier; Free, free-running sweep; Trig,
triggered sweep.

Cranial Nerve Monitoring MUSCLE & NERVE March 2004 345

stem. Short-duration (0.5-ms) stimuli are applied
and the stimulus intensity threshold required for
minimal facial contraction (as measured by surface
or intramuscular electrodes) is determined. Utiliz-
ing this technique, Fenton et al.17 prospectively stud-
ied 67 patients undergoing resection of acoustic neu-
roma with normal preoperative facial function and
an anatomically intact facial nerve at the end of
surgery. Multivariate regression analysis revealed
that the facial nerve stimulus intensity threshold and
tumor size were the greatest independent predictors
of postoperative facial nerve function. In a similar
study of 27 patients, Hone et al.32 showed that a
facial nerve stimulus threshold ⬎0.1 mA was signifi-
cantly associated with facial weakness at 6 days, 1
month, and 6 months after surgery. Similar results
were reported by other investigators.52,101
In addition to stimulus threshold, the size of the
facial CMAP recorded from surface electrodes with
supramaximal stimulation proximal to the injured
area (next to the brainstem) is an excellent measure
of the amount of nerve injury occurring during the
course of surgery.14,20,24,26,28 Using this technique,
Harner et al.26 showed that the size of the facial
CMAP at the end of surgery correlated with imme-
diate and long-term facial nerve function. Specifi-
cally, if the nerve was anatomically intact and a facial
CMAP was recorded, then recovery at 3 and 6
months was excellent. Goldbrunner et al.20 reported
similar findings comparing the facial CMAP ampli-
tude ratio between stimulation sites proximal and
distal to the area of tumor resection in a series of 137
cases undergoing acoustic neuroma surgery. The
risk of exhibiting severe facial weakness 6 months
after surgery increased from 1.6% for an amplitude
(proximal/distal) ratio of ⬎0.8 to 75% for a ratio
⬍0.1.
Changes in the BAEP, ECochG, or auditory NAP
occur with cooling, traction, and mechanical trauma
to cranial nerve VIII.35,48,54,56,62,63,96 These changes
are often reversed when cerebellar retraction is less-
ened or the surgical dissection is altered. Immediate
loss of auditory potentials indicates nerve avulsion or
ischemia and is usually irreversible.
Prior to the advent of modern imaging and mi-
crosurgical techniques, the incidence of permanent
facial paralysis following removal of acoustic neuro-
mas or other CPA tumors was as high as 30%, and
hearing preservation was rare.27 Over the past 20
years, advances in imaging and microsurgery, and
the application of EMG, NCS, and AEP monitoring
have dramatically improved the rates for preserva-
tion of facial motor function and hear-
ing.23,26,35,40,53,56,71,94,95 There are data from retro-
346 Cranial Nerve Monitoring
spective, matched, controlled studies that suggest
EMG, NCS, and AEP monitoring have contributed
significantly to improved facial and auditory func-
tion during surgical treatment of CPA tumors.26,29
Harner et al.26 compared a group of 48 patients who
underwent acoustic neuroma resection with facial
nerve monitoring (continuous facial EMG and inter-
mittent electrical stimulation of the facial nerve) to
48 historical controls matched for age, tumor size,
type of surgical procedure, and surgical team. The
rate of anatomical preservation of the facial nerve
was 67% in monitored patients compared to 33% for
those without monitoring. Although no difference
was noted in quantitative assessment of facial weak-
ness in the immediate postoperative period, by 3
months the degree of improvement was significantly
greater in the monitored group, particularly for me-
dium and large tumors. Utilizing a similar matched
study design with 90 monitored cases of acoustic
neuroma resection, Harper et al.29 demonstrated
that BAEP monitoring was associated with a higher
rate of hearing preservation and a greater chance
that the hearing preserved was clinically useful, es-
pecially in patients with tumors ⬍2.5 cm in diameter.
Surgical procedures for the treatment of trigem-
inal neuralgia, hemifacial spasm, and chronic vertigo
(MVD or rhizotomy) are associated with a 10 –15%
risk of hearing loss and a slight risk of facial nerve
injury.3,4,5,19,77 Because of this risk, AEP and contin-
uous EMG from facial muscles are frequently moni-
tored during these procedures.5,19,77 Retrospective
case-controlled studies have suggested that BAEP
monitoring reduces the risk of hearing loss during
MVD for trigeminal neuralgia.75 Hemifacial spasm is
associated with hyperexcitability of facial neu-
rons.64,72 Electrophysiologically, this is manifested by
variable synkinesis of the blink reflex3 and by the
ability to induce an action potential in one branch of
the facial nerve by an antidromic stimulus of a sep-
arate terminal branch. This phenomenon has been
termed the “lateral spread reflex” (LSR) and is
thought to be caused by ephaptic transmission be-
tween facial axons at the site of vascular compression
near the brainstem or hyperexcitability of the facial
nucleus in the pons.60,64,72 The LSR persists during
anesthesia and in many cases can be recorded intra-
operatively.
Elimination or reduction in size of the LSR dur-
ing surgery generally predicts a good clinical re-
sponse to MVD for hemifacial spasm.30,33,42,60,65,83
Moller and Jannetta60 reported the outcome of 67
consecutive patients who underwent MVD for hemi-
facial spasm with intraoperative monitoring of the
LSR. Of the 44 patients in whom the LSR disap-
MUSCLE & NERVE March 2004
peared during surgery, 42 were free from hemifacial
spasm postoperatively. The prognosis was also excel-
lent for 16 patients who had reduction in the size but
not total disappearance of the LSR, with 14 being
cured of their motor disturbance. In contrast, four of
seven patients with no change in the LSR during
surgery had persistent hemifacial spasm. A similar
experience was reported by other investigators,42,83
but some have questioned the predictive value of the
LSR, citing a high rate of elimination of clinical
symptoms even in cases with a persistent LSR.30,65
For example, in a series of 33 consecutive patients
studied, Hatem et al.30 reported that the LSR was
eliminated during the course of surgery in 23 pa-
tients, and in 20 this correlated with immediate dis-
appearance of hemifacial spasm postoperatively.
However, 7 of the remaining 10 patients that had a
persistent LSR at the end of surgery also were cured.
These, and other similar studies,65 do not report
patients with a decrease in size of the LSR separately
from those that had no change in the LSR during
surgery, which might account for differences be-
tween their observations and those of Moller and
Jannetta.60 Thus, elimination of the LSR during sur-
gery predicts disappearance of the hemifacial spasm,
but persistence of the LSR does not exclude an
excellent surgical outcome. Particularly in severe
cases of hemifacial spasm, the LSR may persist im-
mediately following adequate MVD, only to disap-
pear along with clinical spasms hours, days, or sev-
eral weeks after surgery.79
NCS and EMG have been used to identify and
preserve the motor nuclei of cranial nerves V and VII
during resection of brainstem cavernous malforma-
tions.12 The technique involves placement of elec-
trodes in muscle groups innervated by these nerves
and recording mechanically induced neurotonic dis-
charges as well as CMAPs triggered by electrical stim-
ulation of the corresponding brainstem nuclei. Neu-
rotonic discharges were observed in 7 of 11 patients
during resection of the malformation.12 Surgical de-
cisions were guided by the EMG activity and, in some
cases, only partial resection was accomplished be-
cause of proximity to the cranial nuclei. One patient
had transient postoperative facial paresis.
The lower cranial nerves (IX–XII) are at risk
during a variety of posterior fossa procedures. There
are numerous reports of monitoring, either alone or
in combination, of the glossopharyngeal, laryngeal
branches of the vagus, spinal accessory, and hypo-
glossal nerves during surgical resection of tumors in
the region of the foramen magnum, jugular fora-
men, and clivus.31,53,82 The motor axons of the glos-
sopharyngeal nerve are monitored with wire elec-
Cranial Nerve Monitoring
trodes in the soft palate, laryngeal nerves with
electrodes in the cricothyroid (external laryngeal) or
vocalis (recurrent laryngeal) muscles, spinal acces-
sory nerve with sternocleidomastoid or trapezius
electrodes, and the hypoglossal nerve with elec-
trodes in the tongue. Continuous EMG activity is
monitored for neurotonic discharges, and direct
electrical stimulation is used to identify nerves.14,28,82
Although reported to be useful,36,53,82 there are no
controlled data to indicate that the risk of cranial
nerve injury is lessened by monitoring.
NCS have been used as a monitoring tool during
selective rhizotomy of the glossopharyngeal and sen-
sory portions of the vagus nerve in cases of intracta-
ble glossopharyngeal neuralgia.14,88 With electrodes
in the laryngeal muscles (cricothyroid and/or voca-
lis), direct electrical stimulation of rootlets exiting
the lateral medulla is used to determine the margin
of transition between glossopharyngeal and laryn-
geal innervation, helping to prevent dysphonia as a
complication of the procedure. Further experience
is needed to determine the utility of this technique
since it has only been reported in a few cases.14,88
Head and Neck Surgery. The trigeminal, facial, la-
ryngeal, and spinal accessory nerves are at risk dur-
ing a variety of extracranial surgical procedures of
the head and neck. The mandibular division of the
trigeminal nerve is sometimes injured during man-
dibular sagittal-split osteotomy for treatment of jaw
deformities.90 Far-field trigeminal evoked potentials
recorded from the scalp following mental nerve stim-
ulation have been used to monitor these cases, but a
more reliable technique involves recording of the
inferior alveolar NAP.34 The technique involves stim-
ulation with small stainless steel needle electrodes
inserted near the mental foramen while the inferior
alveolar NAP is recorded from a silver wire electrode
placed on the nerve at the level of the foramen ovale.
Preliminary studies showed that reliable NAP record-
ings were obtained at various intervals during sur-
gery, and that changes in the amplitude and latency
of the inferior alveolar NAP appeared to correlate
with the degree of mandibular retraction.34 Whether
this or other monitors of trigeminal function will
reduce the risk of inferior alveolar nerve injury dur-
ing sagittal-split osteotomy is yet to be proven.
The facial nerve is often entrapped by dense
fibrous tissue in recurrent parotid tumors. Continu-
ous EMG monitoring for neurotonic discharges and
selective electrical stimulation help identify
branches of the facial nerve involved with scar tissue
or tumor.9,15,91,99 With this technique, intramuscular
wire or needle electrodes are inserted into muscles
MUSCLE & NERVE March 2004 347
innervated by the temporal, zygomatic, buccal, and
mandibular branches of the facial nerve. Mechanical
manipulation of facial branches induces neurotonic
discharges, and electrical stimulation elicits small
CMAPs in facial muscles. Two large published series
suggest that monitored patients undergoing paroti-
dectomy for recurrent tumors have a 0 – 4% risk of
permanent facial paralysis.9,15 These studies were un-
controlled, however, and it therefore remains un-
clear whether monitoring significantly reduces the
risk of facial nerve injury. One retrospective case-
controlled study concluded that facial nerve moni-
toring reduced the incidence of short-term paralysis
but did not change the incidence of permanent
paralysis.91 A similar study showed no difference in
the incidence of transient or permanent facial paral-
ysis in monitored cases compared to unmonitored
historical controls.99 Thus, the utility of facial nerve
monitoring during parotidectomy remains in ques-
tion and awaits prospective controlled trials particu-
larly targeted at high-risk subgroups.
The superior and recurrent laryngeal nerves have
been monitored during complicated neck dissec-
tions such as those for recurrent thyroid cancer16,38
or benign goiter,92 or during anterior cervical spine
fusion.37 Intramuscular wire electrodes are placed
into the cricothyroid muscle through the skin, and
in the vocalis muscle via direct laryngoscopy. EMG
activity is recorded during surgery when the laryn-
geal nerves are stimulated mechanically (neurotonic
discharges) or electrically. Contraction of the vocalis
muscle in response to electrical stimulation can also
be confirmed visually with fiberoptic laryngoscopy.
The published data on laryngeal muscle monitoring
clearly demonstrate that the techniques are reliable
and help to identify the external and recurrent
branches of the laryngeal nerves,16,37,38,74 but only
one study has attempted to determine whether mon-
itoring reduces the risk of laryngeal nerve injury.92
Thomusch et al.92 prospectively surveyed 4,382 pa-
tients undergoing surgery for benign goiter at 45
hospitals in Germany. Monitored patients had statis-
tically significant lower rates (P ⬍ 0.05) of transient
and permanent laryngeal nerve palsy (transient,
1.4%; permanent, 0.4%) than unmonitored patients
(transient, 2.1%; permanent, 0.8% ). The results
should be interpreted with caution since the deci-
sion to monitor individual patients was not random-
ized.
The same techniques that are described for EMG
monitoring of the facial and laryngeal nerves during
extra-cranial surgery have been used to monitor the
spinal accessory nerve during supraomohyoid or
modified neck dissections and lymph node biop-
348 Cranial Nerve Monitoring
sies.7,58,85 Again, no controlled data are available to
confirm that these monitoring procedures reduce
the risk of lower cranial nerve injury during head
and neck surgery.
CONCLUSIONS
Several conclusions can be drawn from two decades
of experience with intraoperative monitoring of cra-
nial nerves during a variety of intracranial and ex-
tracranial surgical procedures. First, the basic tech-
niques of EMG, NCS, and recording of auditory
evoked potentials represent accurate and real-time
measures of cranial nerve physiology at a time when
clinical detection of nerve injury is impossible. Sec-
ond, observational studies have identified particular
changes in NCS (e.g., reduced size of facial
CMAP,20,26 change in LSR60) and auditory evoked
potential recordings (e.g., permanent loss of waves I
or V of the BAEP) that can be used to predict
postoperative function. Third, intraoperative moni-
toring has improved understanding of the mecha-
nisms of cranial nerve injury, and thereby contrib-
uted to technical improvements by surgical teams
that utilize monitoring. Fourth, there are controlled
data to suggest that monitoring reduces the risk of
cranial nerve injury in selected situations (e.g., facial
nerve during acoustic neuroma resection,26 and au-
ditory nerve during acoustic neuroma29 and MVD75
surgery).
Thus, although it may be difficult to prove that
cranial nerve monitoring reduces the risk of injury in
all instances, the techniques reviewed in this article
should be viewed as neurophysiological tools that,
when used in the proper setting and with an under-
standing of the nature and limitations of informa-
tion provided, can be logically applied in an attempt
to reduce the risk of nerve damage during surgery
involving the skull base, head, and neck.
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