Somatosensory Evoked Potential Monitoring Research Articles

Diagnostic Accuracy of Somatosensory Evoked Potential and Transcranial Motor Evoked Potential in Detection of Neurological Injury in Intradural Extramedullary Spinal Cord Tumor Surgeries: A Short-Term Follow-Up Prospective Interventional Study Experience from Tertiary Care Center of India.

Objective Intraoperative neuromonitoring (IONM) is an acknowledged tool for real-time neuraxis assessment during surgery. Somatosensory evoked potential (SSEP) and transcranial motor evoked potential (MEP) are commonest deployed modalities of IONM. Role of SSEP and MEP in intradural extramedullary spinal cord tumor (IDEMSCT) surgery is not well established. The aim of this study was to evaluate sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and transcranial MEP, in detection of intraoperative neurological injury in IDEMSCT patients as well as their postoperative limb-specific neurological improvement assessment at fixed intervals till 30 days. Materials and Methods Symptomatic patients with IDEMSCTs were selected according to the inclusion criteria of study protocol. On modified McCormick (mMC) scale, their sensory-motor deficit was assessed both preoperatively and postoperatively. Surgery was done under SSEP and MEP (transcranial) monitoring using appropriate anesthetic agents. Gross total/subtotal resection of tumor was achieved as per IONM warning alarms. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP were calculated considering postoperative neurological changes as "reference standard." Patients were followed up at postoperative day (POD) 0, 1, 7, and 30 for convalescence. Statistical Analysis With appropriate tests of significance, statistical analysis was carried out. Receiver-operating characteristic curve was used to find cutoff point of mMC for SSEP being recordable in patients with higher neurological deficit along with calculation of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP for prediction of intraoperative neurological injury. Results Study included 32 patients. Baseline mean mMC value was 2.59. Under neuromonitoring, gross total resection of IDEMSCT was achieved in 87.5% patients. SSEP was recordable in subset of patients with mMC value less than or equal to 2 with diagnostic accuracy of 100%. MEP was recordable in all patients and it had 96.88% diagnostic accuracy. Statistically significant neurological improvement was noted at POD-7 and POD-30 follow-up. Conclusion SSEP and MEP individually carry high diagnostic accuracy in detection of intraoperative neurological injuries in patients undergoing IDEMSCT surgery. MEP continues to monitor the neuraxis, even in those subsets of patients where SSEP fails to record.

Hypothermia effects on neuronal plasticity post spinal cord injury.

SCI is a time-sensitive debilitating neurological condition without treatment options. Although the central nervous system is not programmed for effective endogenous repairs or regeneration, neuroplasticity partially compensates for the dysfunction consequences of SCI. The purpose of our study is to investigate whether early induction of hypothermia impacts neuronal tissue compensatory mechanisms. Our hypothesis is that although neuroplasticity happens within the neuropathways, both above (forelimbs) and below (hindlimbs) the site of spinal cord injury (SCI), hypothermia further influences the upper limbs' SSEP signals, even when the SCI is mid-thoracic. A total of 30 male and female adult rats are randomly assigned to four groups (n = 7): sham group, control group undergoing only laminectomy, injury group with normothermia (37°C), and injury group with hypothermia (32°C +/-0.5°C). The NYU-Impactor is used to induce mid-thoracic (T8) moderate (12.5 mm) midline contusive injury in rats. Somatosensory evoked potential (SSEP) is an objective and non-invasive procedure to assess the functionality of selective neuropathways. SSEP monitoring of baseline, and on days 4 and 7 post-SCI are performed. Statistical analysis shows that there are significant differences between the SSEP signal amplitudes recorded when stimulating either forelimb in the group of rats with normothermia compared to the rats treated with 2h of hypothermia on day 4 (left forelimb, p = 0.0417 and right forelimb, p = 0.0012) and on day 7 (left forelimb, p = 0.0332 and right forelimb, p = 0.0133) post-SCI. Our results show that the forelimbs SSEP signals from the two groups of injuries with and without hypothermia have statistically significant differences on days 4 and 7. This indicates the neuroprotective effect of early hypothermia and its influences on stimulating further the neuroplasticity within the upper limbs neural network post-SCI. Timely detection of neuroplasticity and identifying the endogenous and exogenous factors have clinical applications in planning a more effective rehabilitation and functional electrical stimulation (FES) interventions in SCI patients.

Anesthesia Considerations in Patients Undergoing Spine Surgery with Evoked Potential Monitoring

Intra-operative neuromonitoring (IONM) facilitates monitoring of the functional integrity of neural structures under general anesthesia. It aids in early detection of injury and minimizes postoperative neurologic deficit. IONM may be used during spine surgery, where either the blood supply to the spinal cord could be compromised or the surgical procedures where there is manipulation of the spinal cord. Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) are used to monitor the sensory and motor tracts in the spinal cord, respectively. Preoperatively, a team of surgeons, anesthetists, and neurophysiologists must discuss about modalities of IONM to be used, expected changes, and alarm criteria. Anesthesia drugs need to be appropriately selected to facilitate IONM, as they affect the SSEP and MEP response obtained. Both total intravenous anesthesia and balanced anesthesia technique may be used, with appropriate titration of drugs. False-positive changes in evoked potentials (EPs) must be prevented by a steady anesthesia state and physiologic parameters. It is preferable to have a checklist to follow whenever changes in EP response are observed to rule out surgical, anesthetic, and monitoring-related causes for change in response. Risk–benefit must be assessed before the selection of a patient for EP monitoring as it may be rarely associated with complications such as burns, seizures, and bite injuries to lips, tongue, and endotracheal tube. Teamwork with meticulous planning, preparation, and multidisciplinary communication is essential for the safe conduct of spine surgeries with SSEP and MEP monitoring. In this review, we discuss various considerations for anesthesia management in patients with intraoperative EP monitoring.

The application value and improved warning criterion of D-wave monitoring in intramedullary spinal cord tumor surgery

BACKGROUND CONTEXTThe primary treatment method for intramedullary spinal cord tumor (IMSCT) is surgical resection, but this procedure carries a significant risk of neurological damage. Intraoperative neurophysiological monitoring (IONM) has become a necessary adjunctive tool for IMSCT resection. PURPOSEThe current study aimed to explore the application value of D-wave monitoring in IMSCT surgery, and tried to investigate a tailored criterion for its early warning. STUDY DESIGNA retrospective clinical study. PATIENT SAMPLEA retrospective analysis was conducted based on the data of patients who underwent IMSCT surgeries performed by the same neurosurgical team at our hospital. IONM was applied in all surgeries. According to inclusion and exclusion criteria, ultimately 90 patients were enrolled in the study. OUTCOME MEASURESThe McCormick Scale (MMS) was applied to assess the functional outcome through outpatient visits or telephone follow-up at one month and six months postoperatively. Patients with an MMS grade over II one month after surgery were considered to have newly developed postoperative motor dysfunction (PMD). If the MMS grade could be restored to I or II six months after surgery, it was defined as a short-term PMD. Otherwise, it was defined as a long-term PMD. METHODSThe predictive value of different IONM modalities, including somatosensory evoked potential (SEP), muscle motor evoked potential (MEP), and D-wave for PMD, was assessed with sensitivity, specificity, positive predictive value, negative predictive value, and subsequent logistic regression analysis. At last, the cut-off value of the D-wave amplitude reduction ratio for predicting PMD was obtained through the receiver operating characteristic (ROC) curve analysis. RESULTSSEP showed the worst performance in predicting short-term and long-term PMD. Significant MEP changes were indicated as an independent predictive factor for short-term PMD (OR 5.062, 95% CI 1.947–13.166, p=.001), while D-wave changes were demonstrated as an independent predictor for long-term PMD (OR 339.433, 95% CI 11.337–10770.311, p=.001). The optimum cut-off value of the D-wave amplitude reduction ratio for predicting long-term PMD was 42.18%, with a sensitivity of 100% and a specificity of 93.8% (AUC=0.981, p<.001). CONCLUSIONSD-wave monitoring showed extremely high specificity in predicting PMD compared to SEP and MEP monitoring. Moreover, the authors suggested that a D-wave amplitude reduction of over 40% during IMSCT surgery generally indicates long-term PMD for patients.

Diagnostic accuracy of intraoperative neuromonitoring in transcarotid artery revascularization

BackgroundIn recent years, transcarotid artery revascularization (TCAR) has emerged as a safe and effective alternative to carotid artery stenting. While intraoperative neuromonitoring (IONM) techniques such as electroencephalogram (EEG) and somatosensory...

Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery.

To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21years). Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated. Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively. Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery. Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Feasibility of Saphenous Nerve Somatosensory-Evoked Potential Intraoperative Monitoring during Lumbar Spine Surgery: Early Results.

Retrospective review. Assess the feasibility of saphenous nerve somatosensory evoked potentials (SN-SSEP) monitoring in lumbar spine surgeries. SN-SSEPs have been proposed for detecting lumbar plexus and femoral nerve injury during lateral lumbar surgery where tibial nerve (TN)SSEPs alone are insufficient. SN-SSEPs may also be useful in other types of lumbar surgery, as stimulation of SN below the knee derives solely from the L4 root and provides a means of L4 monitoring, whereas TN-SSEPs often do not detect single nerve root injury. The feasibility of routine SN-SSEP monitoring has not been established. A total of 563 consecutive cases using both TN and SN-SSEP monitoring were included. Anesthesia was at the discretion of the anesthesiologist, using an inhalant in 97.7% of procedures. SN stimulation was performed using 13mm needle electrodes placed below the knee using 200-400μsec pulses at 15-100mA. Adjustments to stimulation parameters were made by the neurophysiology technician while obtaining baselines. Data were graded retrospectively for monitorability and cortical response amplitudes were measured by two independent reviewers. 98% of TN-SSEPs and 92.5% of SN-SSEPs were monitorable at baseline, with a mean response amplitude of 1.35μV for TN-SSEPs and 0.71μV for SN-SSEPs. A significant difference between the stimulation parameters used to obtain reproducible TN and SN-SSEPs at baseline was observed, with SN-SSEPs requiring greater stimulation intensities. Body mass index (BMI) is not associated with baseline monitorability. Out of 20 signal changes observed, 11 involved SN while TN-SSEPs were unaffected. With adjustments to stimulation parameters, SN-SSEP monitoring is feasible within a large clinical cohort without modifications to the anesthetic plan. Incorporating SN into standard intraoperative neurophysiological monitoring (IONM) protocols for lumbar spine procedures may expand the role of SSEP monitoring to include detecting injury to the lumbar plexus. 3.

Evaluating somatosensory evoked potentials in predicting treatment outcomes for thoracolumbar spinal compression fractures using closed reduction and over-extension techniques.

To evaluate the predictive value of somatosensory evoked potentials (SEPs) for the efficacy of closed reduction combined with over-extension reduction technique (PVP) in managing thoracolumbar spinal compression fractures. Data were collected from 125 patients who underwent closed reduction with PVP and SEP monitoring from February 2021 to July 2023. We evaluated surgery success rates, incidence of bone cement leakage, and patient recovery outcomes including vertebral anterior height, Oswestry Disability Index (ODI), and Cobb angle restoration. SEP results were analyzed to categorize patients into effective and ineffective treatment groups. Differences in SEP waveforms between these groups were examined, and ROC analysis was used to assess the predictive value of these differences. Multivariate logistic regression was employed to identify risk factors affecting treatment efficacy. Post-treatment assessments showed significant improvements in vertebral anterior height, ODI, and Cobb angle. SEP monitoring correlated well with intraoperative findings and physical examinations. During reduction, changes in SEP latency and amplitude were noted in 37 patients, with 7 patients meeting SEP amplitude alarm criteria, which normalized after adjustments. During PVP, 28 patients exhibited SEP amplitude fluctuations and 5 experienced a 30% reduction in amplitude following initial cement injection, with no significant latency changes. Treatment was deemed effective in 93 patients and ineffective in 32. SEP amplitudes during vertebral compression and PVP were significantly lower in the effective group (P<0.05). The AUC for predicting treatment efficacy was 0.819 and 0.859, respectively. Multivariate analysis revealed low preoperative vertebral compression ratio, number of fractures, and abnormal SEP amplitudes as independent risk factors for treatment outcomes. SEP monitoring provides an accurate reflection of spinal cord function during closed reduction with PVP, aiding in predicting treatment safety and efficacy. The use of SEP monitoring is thus recommended for clinical application in this context.

Multimodal Intraoperative Neurophysiological Monitoring in Intramedullary Spinal Cord Tumors: A 10-Year Single Center Experience.

The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery. Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up. Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001). The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection.

Effectiveness of MEP and SSEP Monitoring in the Diagnosis of Neurological Dysfunction Immediately After Craniotomy Aneurysm Clipping.

To explore the diagnostic accuracy of motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring in predicting immediate neurological dysfunction after craniotomy aneurysm clipping. A total of 184 patients with neurosurgery aneurysms in the Affiliated Hospital of Qingdao University from April 2019 to December 2021 were retrospectively included. All patients underwent craniotomy aneurysm clipping, and MEP and SSEP were used to monitor during the operation. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff value for early warning of MEP and SSEP amplitude decline and to evaluate the effectiveness of MEP and SSEP changes in predicting immediate postoperative neurological dysfunction. Among the 184 patients with intracranial aneurysms, the incidences of immediate postoperative neurological dysfunction were 44.4% (12/27) and 3.2% (5/157) in patients with intraoperative MEP changes and without changes, respectively. For SSEP, The incidence rates were 52.6% (10/19) and 4.2% (7/165), respectively, and the differences were statistically significant ( P <0.001). Significant changes in intraoperative MEP and SSEP were significantly associated with the development of immediate postoperative neurological deficits ( P <0.05). The critical values for early warning of MEP and SSEP amplitude decrease were: 61.6% ( P < 0.001, area under the curve 0.803) for MEP amplitude decrease and 54.6% ( P <0.001, area under the curve 0.770) for SSEP amplitude decrease. The sensitivity and specificity of MEP amplitude change in predicting immediate postoperative neurological dysfunction were 70.6% and 91.0%, respectively. For SSEP amplitude changes, the sensitivity and specificity were 58.8% and 95.8%, respectively. Motor-evoked potential and SSEP monitoring have moderate sensitivity and high specificity for immediate postoperative neurological dysfunction after craniotomy aneurysm clipping. Motor-evoked potential is more accurate than SSEP. Patients with changes in MEP and SSEP are at greatly increased risk of immediate postoperative neurologic deficits.

Value of multi-channel somatosensory evoked potentials recording in patients undergoing scoliosis correction surgery.

We aimed to investigate the value of intraoperative multi-channel recording of somatosensory evoked potentials (SSEPs) in patients undergoing posterior instrumentation surgery with fusion. This study included 176 patients with scoliosis who underwent posterior correction surgery from January 2019 to June 2020. Among them, 88 patients underwent routine SSEPs monitoring via single-channel (Cz'-Fpz) cortical recording (control group), while the remaining 88 patients underwent multi-channel (Cz'-Fpz and C3'-C4') SSEPs monitoring in the cortex. Chi-square and Fisher's exact tests were used to analyze the influence of age, spinal deformity classification, and Cobb angle on waveform differentiation and the success rate of SSEPs monitoring. Univariate analysis revealed that age, type of scoliosis, and Cobb angle exerted significant effects on the success rate of intraoperative SSEPs monitoring, and the SSEPs waveform differentiation rate was poorest among patients with congenital scoliosis. Intraoperative monitoring results indicated that the success rate of single-channel SSEPs monitoring was 90.9%, while that of multi-channel monitoring was 98.9% (P < 0.05). Among the intraoperative alarm cases, the incidence of adverse events after single-channel SSEPs monitoring was 66.7%, while the incidence of adverse events after multi-channel SSEPs monitoring was only 28.6%. Multi-channel cortical SSEPs monitoring can effectively and accurately evaluate the function of the posterior column of the spinal cord. Use of multi-channel SSEP monitoring may help to improve the success rate of monitoring and reduce the incidence of postoperative adverse events in patients with congenital scoliosis.

Could extended laminectomy effectively prevent spinal cord injury due to spinal shortening after 3-column osteotomy?

ObjectiveTo explore whether the laminectomy extension can effectively prevent spinal cord injury (SCI) due to spinal shortening after 3-column osteotomy in goat models.MethodsA total of twenty healthy goats were included and done with 3-column osteotomy of T13 and L1 under the somatosensory evoked potential (SSEP) monitoring. The samples were divided into two groups. The first group underwent regular laminectomy while the second group underwent an extended laminectomy with an extra 10 mm-lamina cranial to L2. The SSEP measured after 3-column osteotomy was set as the baseline, and the SSEP decreased by 50% from the baseline amplitude and/or delayed by 10% relative to the baseline peak latency was set as positive results, which indicated spinal cord injury. The vertebral column was gradually shortened until the SSEP monitoring just did not show a positive result. The height of the initial osteotomy gap (the distance from the lower endplate of T12 to the upper endplate of L2), the shortened distance (△H), the number of spinal cord angulated and the changed angle of the spinal cord (△α) were measured and recorded in each group. Neurological function was evaluated by the Tarlov scores on day 2 postoperatively.ResultsAll the goats except one of the first group due to changes in the SSEP during the osteotomy were included and analyzed. In the first group, the height of the initial osteotomy segment and the safe shortening distances were 61.6 ± 2.6 mm and 35.2 ± 2.6 mm, respectively; the spinal cord of 5 goats was angulated (46.4 ± 6.6°), the other four goats were kinked and not angulated. In the second group, the height of the initial osteotomy segment and the safe shortening distances were 59.8 ± 1.5 mm and 43.3 ± 1.2 mm, respectively, and the spinal cord of ten goats were angulated (97.6 ± 7.2°). There was no significant difference in the height of the initial osteotomy segment between the two groups by using Independent-Samples T-Test, P = 0.095 (P > 0.05); there were significant difference in the safe shortening distance and the changed angle of the spinal cord between the two groups by using Independent-Samples T-Test (both DeltaH and Deltaα of P < 0.001), the difference between their mean were 8.1 mm and 51.2°. Significant difference was found in the number of spinal cord angulation between the two groups through Fisher’s exact test (5/9 vs. 10/10, P = 0.033).ConclusionsAn additional resection of 10 mm-lamina cranial to L2 showed the satisfactory effect in alleviating SCI after 3-column osteotomy. Timely and appropriate extend laminectomy could be a promising therapeutic strategy for SCI attributable to facilitating spinal cord angulation rather than spinal cord kinking and increasing the safe shortening distance.

Impact of multimodal intraoperative neurophysiological monitoring of the spinal cord during spine and spinal cord surgeries

BackgroundThere is growing evidence of the valuable role of multimodal intraoperative neurophysiological monitoring (IONM) during spine and spinal cord surgeries, as it provides an opportunity to recognize functional changes of the neural elements, usually in the reversible stage, during complex surgical manipulations. Therefore, it may reduce the risk of postoperative neurological dysfunction and improve functional outcomes. The aim of the current study was to evaluate the efficacy of multimodal IONM for preventing and predicting iatrogenic neurological dysfunction during spinal cord and spine surgeries.ResultsSignificant alerts had occurred in 9 out of 24 patients; however, all the changes were reversible and did not contribute to postoperative clinical deterioration. Only one case got worsened in the early postoperative follow-up period, with stable intraoperative monitoring.ConclusionIntraoperative monitoring is a valuable tool in spine and spinal cord surgeries. Combined transcranial motor-evoked potential (TcMEP), somatosensory-evoked potential (SSEP), and spontaneous electromyography (EMG) monitoring may prevent permanent motor deficit and enhance the postoperative outcomes.

Is There a Role for Intraoperative Neuromonitoring in Intradural Extramedullary Spine Tumors? Results and Indications from an Institutional Series.

While intraoperative neurophysiological monitoring (IONM) is considered a standard for intramedullary spinal cord tumor surgery, the effective role of IONM in intradural extramedullary (IDEM) tumors is still debated. We present the results of 60 patients affected by IDEM tumors undergoing surgery with the aid of IONM. Each patient was evaluated according to the modified McCormick scale (MMS) at admission, discharge and at follow-up. During surgery, motor evoked potentials (MEPs) and somatosensory evoked potentials (SEPs) were studied using the Medtronic NIM-eclipse® 32-channel system (Medtronic Xomed, Inc. 6743 Southpoint Drive North Jacksonville FL USA). Patients' age, gender and tumor location did not affect MMS modifications. Tumors involving more than three levels had an increased likelihood of MMS worsening, while meningioma pathology was associated with worse preoperative and 1-year follow-up MMS. No MEP amplitude ratio was able to predict clinical variations, while intraoperative SEP worsening was associated with 100% risk of poor MMS at discharge and with 50% risk of poor MMS at long-term follow-up. In our opinion, SEP monitoring is a valid tool that may contribute to the preservation of the patient's neurological status. MEP monitoring is not mandatory in IDEM surgery while more studies are required to explore the feasibility and the role of D-wave in this kind of surgery.

Diagnostic Accuracy of Somatosensory Evoked Potential monitoring during Scoliosis correction surgery in the pediatric population: A Systematic Review (P7-4.002)

<h3>Objective:</h3> To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring in predicting the risk of perioperative neurological outcomes during scoliosis fusion surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). <h3>Background:</h3> Scoliosis correction surgery is the most effective treatment for pediatric IS. However, new neurological deficits during the surgery can potentially affect the outcomes of this surgery. Intraoperative neuromonitoring techniques like SSEP provide real-time information about the spinal cord and nerve roots and can be used as a reliable indicator to predict perioperative neurological deficits. <h3>Design/Methods:</h3> A systematic review of various databases to find literature on pediatric IS patients who underwent scoliosis correction with intraoperative neuromonitoring. Data collection included study design, patient demographics, procedure, neuromonitoring modalities, SSEP alarm criteria, SSEP changes (including reversible and irreversible changes), and perioperative neurological deficit. We calculated the sensitivity, specificity, and diagnostic odds ratio (DOR) of SSEP changes (total, transient, and persistent) and SSEP loss for predicting perioperative neurological deficits. <h3>Results:</h3> We included eighteen studies for our final analysis, with a total cohort of 4674 children. The incidence of a significant SSEP change was 3.1% (145/4674), while the incidence of a new neurological deficit was 1.01% (47/4674). The incidence of new neurological deficits in children with an intraoperative SSEP change was 28.28% (41/145), while it was 0.13% (6/4529) in children without an SSEP change. SSEP changes had a sensitivity of 72%, specificity of 97%, and DOR of 98.64, while SSEP loss had a sensitivity of 42%, specificity of 99.3%, and a DOR of 143.76 for predicting new neurologic deficit. Transient and Persistent SSEP changes had sensitivities of 37% and 39%, specificities of 97% and 99.2%, and DORs of 18.09 and 75.43, respectively. <h3>Conclusions:</h3> Intraoperative SSEP monitoring can predict perioperative neurological injury and help improve the surgical outcomes in pediatric scoliosis fusion surgery. <b>Disclosure:</b> Dr. Gorijala has nothing to disclose. Dr. Shaik has nothing to disclose. The institution of Dr. Thirumala has received research support from University of Pittsburgh. Dr. Anetakis has nothing to disclose. Jeffery Balzer has nothing to disclose. Donald Crammond has nothing to disclose. Dr. Shandal has nothing to disclose. Dr. Lee has nothing to disclose. The institution of Dr. Shaw has received research support from LSRS. The institution of Dr. Shaw has received research support from CSRS. The institution of Dr. Shaw has received research support from AO Spine. Dr. Shaw has received intellectual property interests from a discovery or technology relating to health care. Mr. Reddy has nothing to disclose.

Application of Intraoperative Electromyography Intelligent Monitoring in Orthopedic Surgery under General Anesthesia.

To study the application of intraoperative EMG intelligent monitoring in orthopedic surgery under general anesthesia, a total of 53 patients who underwent orthopedic surgery from February 2021 to February 2022 were selected. The combined monitoring of somatosensory evoked potential (SEP), motor evoked potential (MEP), and electromyography (EMG) was used to analyze the monitoring efficiency. In 38 of the 53 patients, the intraoperative signal was normal, and there was no postoperative neurological dysfunction; one case had abnormal signal, and the abnormality still existed after debugging, but no obvious neurological dysfunction was found after operation; the remaining 14 cases had abnormal signal. There were 13 early warnings in SEP monitoring; 12 early warnings in MEP monitoring; 10 early warnings in EMG monitoring. There were 15 cases of early warning in the joint monitoring of the three, and the sensitivity of the combined monitoring of SEP + MEP + EMG was significantly higher than that of the single monitoring of SEP, MEP, and EMG (p < 0.05). There was no significant difference in specificity, positive predictive value, and negative predictive value between combined monitoring and single monitoring (p > 0.05). The combined monitoring of EMG, MEP, and SEP in orthopedic surgery can significantly improve the safety of surgery, its sensitivity and negative predictive value were significantly higher than the monitoring effects of the two alone.

Effects of dexmedetomidine on evoked potentials in spinal surgery under combined intravenous inhalation anesthesia: a randomized controlled trial

ObjectiveWe aimed to investigate the effects of different doses of dexmedetomidine (Dex) on evoked potentials in adult patients undergoing spinal surgery under intravenous anesthesia with low-concentration desflurane.MethodsNinety patients were divided into three groups at random. To maintain anesthesia in the control group (group C), desflurane 0.3 MAC (minimal alveolar concentration), propofol, and remifentanil were administered. Dex (0.5 μg·kg−1) was injected for 10 min as a loading dose in the low-dose Dex group (group DL), then adjusted to 0.2 μg·kg−1·h−1 until the operation was completed. Dex (1 μg·kg−1) was injected for 10 min as a loading dose in the high-dose Dex group (group DH), then adjusted to 0.7 μg·kg−1·h−1 until the operation was completed. The additional medications were similar to those given to group C. The perioperative hemodynamics, body temperature, intraoperative drug dosages, fluid volume, urine volume, blood loss, the latency and amplitude of somatosensory evoked potentials (SEPs) at four different time points, the incidence of positive cases of SEPs and transcranial motor evoked potentials (tcMEPs), and perioperative adverse reactions were all recorded.ResultsData from 79 patients were analyzed. The MAP measured at points T2-T4 in group DH was higher than at corresponding points in group C (P < 0.05). The MAP at point T4 in group DL was higher than at corresponding points in group C (P < 0.05). The remifentanil dosage in group DH was significantly lower than in group C (P = 0.015). The fluid volume in group DL was significantly lower than in group C (P = 0.009). There were no significant differences among the three groups in the amplitude and latency of SEP at different time points, nor in the incidence of warning SEP signals. The incidence of positive tcMEP signals did not differ significantly between groups C and DL (P > 0.05), but was significantly higher in group DH than in groups DL (P < 0.05) or C (P < 0.05). The incidence of intraoperative hypertension was significantly higher in group DH than in group C (P = 0.017).ConclusionsLow-dose Dex has no effect on the SEPs and tcMEPs monitoring during spinal surgery. High-dose Dex has no effect on SEPs monitoring, but it may increase the rate of false positive tcMEPs signals and the incidence of intraoperative hypertension.Trial registrationThis study has completed the registration of the Chinese Clinical Trial Center at 11/09/2020 with the registration number ChiCTR2000038154.

What is the predictive value of intraoperative somatosensory-evoked potential monitoring for postoperative neurological deficit in intramedullary tumor resection?

The objective of this study is to determine the accuracy of somatosensory-evoked potential (SSEP) monitoring versus SSEP combined with motor-evoked potential monitoring (MEP) for predicting postoperative neurological deficits following intramedullary tumor resection. A systematic review was conducted to identify the studies examining postoperative neurological deficits following intramedullary tumor resection. The sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for each of the monitoring modalities (SSEP vs. SSEP/MEP) and presented by forest plots and receiver operating characteristic curves. The total cohort consisted of 303 patients for the SSEP group and 350 patients for the SSEP/MEP combined group. The specificity and sensitivity of SSEP monitoring were 76% and 55%, respectively. The DOR of SSEP monitoring is 5.6 (95% confidence interval [CI], 1.55–20.26, I2 = 0%). The specificity and sensitivity of SSEP/MEP monitoring were 86% and 80%, respectively. The DOR of SSEP/MEP monitoring is 30.32 (95% CI, 6.92–132.85, I2 = 0%). SSEP/MEP intraoperative monitoring offers higher sensitivity, specificity, and DOR for predicting postoperative neurological deficits following intramedullary tumor resection. Patients who had a postoperative neurological deficit were 30 times more likely to exhibit a SSEP or MEP change compared to approximately six times more likely to solely exhibit a SSEP change.

A Prediction Model for Normal Variation of Somatosensory Evoked Potential During Scoliosis Surgery

Somatosensory evoked potential (SEP) has been commonly used as intraoperative monitoring to detect the presence of neurological deficits during scoliosis surgery. However, SEP usually presents an enormous variation in response to patient-specific factors such as physiological parameters leading to the false warning. This study proposes a prediction model to quantify SEP amplitude variation due to noninjury-related physiological changes of the patient undergoing scoliosis surgery. Based on a hybrid network of attention-based long-short-term memory (LSTM) and convolutional neural networks (CNNs), we develop a deep learning-based framework for predicting the SEP value in response to variation of physiological variables. The training and selection of model parameters were based on a 5-fold cross-validation scheme using mean square error (MSE) as evaluation metrics. The proposed model obtained MSE of 0.027[Formula: see text][Formula: see text] on left cortical SEP, MSE of 0.024[Formula: see text][Formula: see text] on left subcortical SEP, MSE of 0.031[Formula: see text][Formula: see text] on right cortical SEP, and MSE of 0.025[Formula: see text][Formula: see text] on right subcortical SEP based on the test set. The proposed model could quantify the affection from physiological parameters to the SEP amplitude in response to normal variation of physiology during scoliosis surgery. The prediction of SEP amplitude provides a potential varying reference for intraoperative SEP monitoring.

Intramedullary spinal cord cavernous malformations—association between intraoperative neurophysiological monitoring changes and neurological outcome

BackgroundMicrosurgical resection of spinal cord cavernous malformations can be assisted by intraoperative neurophysiological monitoring (IONM). While the clinical outcome after surgical resection has been discussed in several case series, the association of intraoperative IONM changes and detailed neurological outcome, however, has not been analyzed so far.MethodsSeventeen patients with spinal cavernomas underwent surgery between 02/2004 and 06/2020. Detailed neurological and clinical outcome as well as IONM data including motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring were retrospectively analyzed. Intraoperative IONM changes were compared to outcome at 3-month and 1-year follow-up in order to identify surrogate parameters for an impending neurological deficit.ResultsCompared to the preoperative state, McCormick score at 1-year follow-up remained unchanged in 12 and improved in five patients, none worsened, while detailed neurological examination revealed a new or worsened sensorimotor deficit in 4 patients. The permanent 80% amplitude reduction of MEP and 50% amplitude reduction of SSEP showed the best diagnostic accuracy with a sensitivity of 100% and 67% respectively and a specificity of 73% and 93% respectively. The relative risk for a new neurological deficit at 1-year follow-up, when reversible IONM-deterioration was registered compared to irreversible IONM deterioration, was 0.56 (0.23–1.37) for MEP deterioration and 0.4 (0.18–0.89) for SSEP deterioration.ConclusionsReversible IONM changes were associated with a better neurological outcome at follow-up compared to irreversible IONM deterioration during SCCM surgery. Our study favors the permanent 80% amplitude reduction criterion for MEP and 50% amplitude reduction criterion for SSEP for further prospective evaluation of IONM significance and the effectiveness of corrective maneuvers during SCCM surgeries.