NEUOPHYSIOLOGIC MO

SPINE SU NlTORING IN
RGERY
Orit Nahtomi Shick'
317

Intraoperative
. neurophysiologl' c monrtorrnq
'. (IONM) .
ugh varrous neurophysiologic tests th functi IS assessment thro-
. e unctionat : t .
and peripheral nervous system dur' . In egnty of the central
Ing surqical pro d h
structures at risk for iatrogenic injury IONM . ce ures t at place these
y
variety of surgical procedures incJuding . Islcurrentl used during a wide
. . ' splna surgery, intracranial neuro-
surgery,
\' . interventional . neuroradiology ' otolaryngology , o r th ope diICsurgery
sc~10SlSsurgery, carotid endarterectomies and thoracic aortic aneurism re~
parr. Th~ use of IOt~M may improve patient outcome by (a) allowinq early
diaqnosis of Ischemla/hypoxla before irreversible damage occurs (b) identi-
fytng neural irritation ar injurv at a time when the surgeon can take steps to
reduce or reverse it, and (c) enabling surgeons to provide optimal operative
treatment as indicated by the monitoring parameter.
Broadly speaking, the brain can be monitored in terms of (a) function, (b)
blood flow, and (c) metabolism. This lecture will focus an the assessment of
the nervous system function and its anesthetic implieations.
Since the target of IONM is the central and peripheral nervous system,
whieh are the target organs for the anesthetic drugs we use. the success of
Intraoperative monitoring is dependent on approprtate anesthetic manage-
ment. Essentially aii anesthetic agents depress synaptic function, both in the
brain and spinal cord grav matter. .
IONM approaches include wake-up test, somato-sensory evoked potentl-
als(SSEP) transcranial motor-evoked potentials (teMEP), spinal cord MEPs
Ineuroge~ic MEP (nMEP)) spontaneous electromyography (sEMG). and tr+
~ electromyographY' (tEMG). Primary attention nas been dlrected at
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Wake-up test I to assesscorticospinal tract integrity and resul

, In the past th~on ~;~:g surgery was the Stagnara wake-up test, Whic~
tlng motor func,lofn erai anesthesia to permit an intra-operative neuro_
, ed reversa o gen , ,
requtr , '
logic examlnatiOn,
Although the patient does not feei any patn dunng this
hn: int d ' -
!
, t it afterward this tee nrque In ro uces slgnificant
t t and is amnestlc o l' , ,
es " ry and potential anesthetie cornplications sueh as ac-
delay trmes In surge "
,
cidental extu batlron, patient recall of intra-operative
, events, and dlfficUlty
318 , th test in young children or In the presence of language bar-
performmg e 'fi f '
,
ners, Furt hermore, this test lacks the obvious
, ", bene It o ' continuou,, asses-
sment o f neura I runction , and its use ,,' IS lirnited In certam patients, " ,such as
ith cognitive or hearing deficlts, Finallv, if the test IS posltlve and
t hase WI , '" lb
th e pa lent has sustained a deficit in extremlty function,
ti
h "
It ISPOSSIle that a
its d ' FI
substantial period of time has elapsed between t e rnjurv, tts etection, and ir
the ultimate .ntervention.

Somato-sensory evoked potentials (SSEPs)

Somato-sensory evoked potentials provide monitoring of the dorsal co-
d
lumn-medial lemniscus pathway, which mediates tactile drscrimination, vi-
bration sensation, form recognition, and joint/muscle sensation (conscious
proprioception), Receptors in the skin, tendons, and rnuscles generate infor-
mation that corresponds ta these primary sensory modalities and relay these
signals ta neurons whose soma are located in dorsal root ganglia at aii spinal
levels. It should be noted that SSEPsdo not involve the spinothalamic (pain
and temperatureJ pathway, Axons from these first-order neurons project ta
the spinal cord via the medial root entry zone, glviilg rise to the fasciculi
gracilis and cuneatus, which subsequently carry sensory mformation from
the lower and upper extrernitres, respectively, The first synapse in this pa-
thway occurs In the lower medulla after these tracts ascend via the dorsal
columns in the spinal cord. Following a decussation that occurs at the me-
dullary level, the mediallemniscus is formed; it ascends to the thalamus and
ultimately relays sensory mformation to the primary sornatosensory cortex,
Since SSEPsmonitor the dorsal column-medlallemnlscus pathway, standard
patient sensory examination for tactile discrimination, vibration sensation.
and joint/muscle sensation (conscious proprioception) is recommended priar
ta surgery, to document any deficits that may limit intra-operative ma ni-
toring.

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flGo 1. Normal reprcsentotions of SSEPs from median nerves ond posterior tibial nerves,

J/!(Iuding cortical ond subcortical wovetorms.

Transcranial Electric Motor-EvokedPotentials (tcMEPs)

Motor-evoked potentials (MEPs) are neuroelectric impulses elicited from
descendingmotor pathways, including the corticospinal tract, spinal cord
interneurons,anterior horn cells, peripheral nerves, and skeletal muscles in-
nervatedby excited a-motor neurons, following the transcranial applicati-
onof a highvoltage electrical stimulus. A low-output impedance electrical
stimulatoris used to generate a high-volurne, short-duration stimulus (pulse
train)via a series of electrodes that are placed over various scalp regions and
thatexcite a selected area of the motor cortex. This stimulates corticospinal
tractaxons, which course from the cortex through the internal capsule to
thecaudal medulla. Here, the fibers cross over In the lower lateral brainstem
anddescend into the lateral and antenor funiculi of the spinal cord. In con-
trastwith white matter-mediated SSEPs,corticosprnal tract axons that ori-
ginatein the premotor and motor cortex enter the spinal cord grav matter,
wherethey interact with spinal interneurons. The axons go an ta synapse
witha-motor neurons, which innervate peripheral muscle.
BecauseMEPs effectively monitor function of the corticospinal tract (a
pathwaythat ISnot covered by SSEPmonitorinq], changes in MEPs are more
!ensitivein the detection of postoperative motor deficits.

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FIG. 2. Normal representctions of MEPs from intrinsk: hand musctes, vastus lateralis MI,
hamstrings, tiblOlis anterior (TA), gastrocnemius (Gostroc), and plantar foot muscies.

Spinal cord MEP or Neurogenic MEP (nMEP)

Neurogenic MEP is an additional modality developed to address the limi-
tations of SSEP monitoring. nMEP waveforms are ascertained from an elec-
trode placed over the spinal cord in either direct epidural or percutaneous
manner. Electrodes are placed rostral to the surqical site. Recording sitesare
commonly the spinal cord itself (D-wave) or penpheral muscle (CMAP).The
D-wave is the initial wave associated with direct conduction of corticospinal
neurons. nMEP stirnulation appears to cause whole spinal cord stimulation
wrthout selectivity. nMEPs are largely mediated by dorsal column antidro-
mic activity rather than motor tracts. Direct cord stimulation as in nMEPs
simplifies anesthetic considerations unless CMAP recordings are to be made.
As opposed to CMAP recordings, complete muscle relaxation should be ap-
plied for D-wave recordings so as to reduce muscle reactivity.

Spontaneous EMG
Spontaneous EMG activity can be used to intraoperatively monitor the
corresponding nerve roots responsible for muscle innervation. This spon-
taneous motor activity can be measured with recording electrodes placed
in the muscles of interest and based on the structures al risk. Although nO
stimulation is performed for Ihis technique, surgical manipulation suchas
pulling, stretchinq, or compression of nerves produces neurotonic dischar-
ges resulting in activity In the corresponding innervated muscle(s).
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fiG. 3. 5pontoneous EMG recording d .

. emonstratmg a rram of acrivity in the tibia fis anterior
muscle d unnq nerve root rerraction.

Triggered EMG/Pedicle Screw Stimulation (tEMG) 321

A potentiallv preventable risk of pedicle screw placement is a medial
screwbreach of the pedicle wall into the spinal canal. Triggered EMG is a
method that can be used ta determine whether screws have breached the
medialor inferior pedicle wall and thus pose a risk to the exiting nerve root
al that level, Typically, a monopolar electrode is used ta directly stimulate
the tap of the pedicle screw at increasing current intensities. Needle elec-
tradesin the appropriate rnuscle groups will measure CMAP time locked to
thestimulation. Direct stimulation of a misplaced pedicle hole, with breech,
canactiva te the adjacent nerve root and evoke a CMAP in the appropriate
myotomes at lower stimulus intensities than would be expected with and
mperforate pedicle cortex.

Effects of Anesthetics on Neurophysiologic Signals

As mentioned earlier, the success of intra-operative monitoring is de-
pendent on appropriate anesthetic management. Essentially aii anesthetic
agentsdepress synaptic function, both in the brain and spinal cord grav
matter.In spinal cord morutorlnq, the margin for interpretation error is nar-
rowbecause the signal amplitudes are inherently quite srnall. When signal
amplitude is artiflciallv depressed and fluctuant because of anesthesia, it
createsa situation in which signal change must be interpreted in the pre-
senceof extreme clinical uncertainty.
Ingeneral, aii inhalational agents produce a dose-related increase in latency
andreduction in amplitude of the cortical SSEP.When generation of a cortical
Signal,erther ascending (SSEP)or descending (tceMEP), is necessary, it is best
10avoid inhalational agents soon after induction and intubation. On the ba-
lis of the unpredictable amplitude variability and depression a~ociated both
wlth volatile agents and nitrous oxide, it has become routlne m manv hlgh
vOlumespinal surgery centers to use a total mtravenous anesthetic reqimen.

))lIIiiaara 20J }
 Although neuromuscular relaxants have no adverse effect on SSEPs,neu-
romuscular blockade will compromise tceMEP and EMG recordings. AII de-
polarizing and nondepolarizing paralvtic agents should be avoide,d, excrpt
as required at the beginning of the operation during spinal exposun, bt-
cause these agents block the neuromuscular junction and preclude muscle
contractlon,
In the lecture I will emphasis on the effects of different anesthetic agents
on the neurophysiologic signals, and the effects of the anesthesiologist be-
havior on the reliability of the neuromonitoring during surgery.

In summary, the anesthetic recornmendations during IONM are:

322 1. Use TIVA regimens which include propofol and opioids,
2. Try to avoid muscle relaxants, and if used monitor TOF.
3. Use BIS monitor 10 ensure anesthetic not to shallow and noi 10 deep.
4. Be in full cooperation with neurophysiologist
5. Don't make rapid anesthetic changes, and inform about changes made
in anesthetic regimen.

References

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ring In spme surgery: does II rnake a difterence? Spine 2010 Apr; 35(9 Suppl):s37-46.
3. Gonzalez M. Jevanandarajan O. Hansen C, et al. Intra operative neurophvsroloqicat monltoring du,,"!
sprne surgery: a revrew. Neurosurg Focus 2009 Oct: 27(4):E6.
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5. Malhotra NR, Shaffrev CI. Intra operative electrophysiologieal monitoring rn spine surgery. Sp",e20tO
Dec: 35(25):2167-79. .... I h~
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2007.