Intraoperative monitoring of motor evoked potentials in very young children

Clinical article

Daniel H. Fulkerson M.D.1, Krishna B. Satyan M.D.1, Lillian M. Wilder R.E.E.G./E.P.T., C.N.I.M., R.N.C.S.T.2, James J. Riviello M.D.2,3, Stephen A. Stayer M.D.4, William E. Whitehead M.D., M.P.H.1, Daniel J. Curry M.D.1, Robert C. Dauser M.D.1, Thomas G. Luerssen M.D.1, and Andrew Jea M.D.1
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  • 1 Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine;
  • | 2 Division of Neurophysiology, Texas Children's Hospital;
  • | 3 Department of Neurology, Baylor College of Medicine;
  • | 4 Division of Pediatric Anesthesiology, Texas Children's Hospital, Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
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Object

Neurophysiological monitoring of motor evoked potentials (MEPs) during complex spine procedures may reduce the risk of injury by providing feedback to the operating surgeon. While this tool is a well-established surgical adjunct in adults, clinical data in children are sparse. The purpose of this study was to determine the reliability and safety of MEP monitoring in a group of children younger than 3 years of age undergoing neurosurgical spine procedures.

Methods

A total of 10 consecutive spinal procedures in 10 children younger than 3 years of age (range 5–31 months, mean 16.8 months) were analyzed between January 1, 2008, and May 1, 2010. Motor evoked potentials were elicited by transcranial electric stimulation. A standardized anesthesia protocol for monitoring consisted of a titrated propofol drip combined with bolus dosing of fentanyl or sufentanil.

Results

Motor evoked potentials were documented at the beginning and end of the procedure in all 10 patients. A mean baseline stimulation threshold of 533 ± 124 V (range 321–746 V) was used. Six patients maintained MEP signals ≥ 50% of baseline amplitude throughout the surgery. There was a greater than 50% decrease in intraoperative MEP amplitude in at least 1 extremity in 4 patients. Two of these patients returned to baseline status by the end of the case. Two patients had a persistent decrement or variability in MEP signals at the end of the procedure; this correlated with postoperative weakness. There were no complications related to the technique of monitoring MEPs.

Conclusions

A transcranial electric stimulation protocol monitoring corticospinal motor pathways during neurosurgical procedures in children younger than 3 years of age was reliably and safely implemented. A persistent intraoperative decrease of greater than 50% in this small series of 10 pediatric patients younger than 3 years of age predicted a postoperative neurological deficit. The authors advocate routine monitoring of MEPs in this pediatric age group undergoing neurosurgical spine procedures.

Abbreviations used in this paper:

MEP = motor evoked potential; SSEP = somatosensory evoked potential; TES = transcranial electric stimulation.

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