A new alarm point of transcranial electrical stimulation motor evoked potentials for intraoperative spinal cord monitoring: a prospective multicenter study from the Spinal Cord Monitoring Working Group of the Japanese Society for Spine Surgery and Related Research

Clinical article

Sho Kobayashi M.D., Ph.D. 1 , Yukihiro Matsuyama M.D., Ph.D. 1 , Kenichi Shinomiya M.D., Ph.D. 2 , Shigenori Kawabata M.D., Ph.D. 3 , Muneharu Ando M.D., Ph.D. 4 , Tsukasa Kanchiku M.D., Ph.D. 5 , Takanori Saito M.D., Ph.D. 6 , Masahito Takahashi M.D., Ph.D. 7 , Zenya Ito M.D., Ph.D. 8 , Akio Muramoto M.D., Ph.D. 8 , Yasushi Fujiwara M.D., Ph.D. 9 , Kazunobu Kida M.D., Ph.D. 10 , Kei Yamada M.D., Ph.D. 11 , Kanichiro Wada M.D., Ph.D. 12 , Naoya Yamamoto M.D., Ph.D. 13 , Kazuhiko Satomi M.D., Ph.D. 14 , and Toshikazu Tani M.D., Ph.D. 10
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  • 1 Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu;
  • 2 Department of Orthopedic Surgery, Yokohama City Minato Red Cross Hospital, Yokohama;
  • 3 Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo;
  • 4 Department of Orthopedic Surgery, Wakayama Rosai Hospital, Wakayama;
  • 5 Department of Orthopedic Surgery, Yamaguchi University, Ube;
  • 6 Department of Orthopedic Surgery, Kansai Medical University Takii Hospital, Moriguchi;
  • 7 Department of Orthopedic Surgery, Kyorin University, Tokyo;
  • 8 Department of Orthopaedic Surgery, Nagoya University, Nagoya;
  • 9 Department of Orthopedic Surgery, Hiroshima City Asa Hospital, Asa;
  • 10 Department of Orthopedic Surgery, Kochi Medical School, Nankoku;
  • 11 Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume;
  • 12 Department of Orthopedic Surgery, Hirosaki University, Hirosaki;
  • 13 Department of Orthopedic Surgery, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo; and
  • 14 Department of Orthopedic Surgery, Kugayama Hospital, Tokyo, Japan
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Object

Although multimodal intraoperative spinal cord monitoring provides greater accuracy, transcranial electrical stimulation motor evoked potential (TcMEP) monitoring became the gold standard for intraoperative spinal cord monitoring. However, there is no definite alarm point for TcMEPs because a multicenter study is lacking. Thus, based on their experience with 48 true-positive cases (that is, a decrease in potentials followed by a new neurological motor deficit postoperatively) encountered between 2007 and 2009, the authors set a 70% decrease in amplitude as the alarm point for TcMEPs.

Methods

A total of 959 cases of spinal deformity, spinal cord tumor, and ossification of the posterior longitudinal ligament (OPLL) treated between 2010 and 2012 are included in this prospective multicenter study (18 institutions). These institutions are part of the Japanese Society for Spine Surgery and Related Research monitoring working group and the study group on spinal ligament ossification. The authors prospectively analyzed TcMEP variability and pre- and postoperative motor deficits. A 70% decrease in amplitude was designated as the alarm point.

Results

There were only 2 false-negative cases, which occurred during surgery for intramedullary spinal cord tumors. This new alarm criterion provided high sensitivity (95%) and specificity (91%) for intraoperative spinal cord monitoring and favorable accuracy, except in cases of intramedullary spinal cord tumor.

Conclusions

This study is the first prospective multicenter study to investigate the alarm point of TcMEPs. The authors recommend the designation of an alarm point of a 70% decrease in amplitude for routine spinal cord monitoring, particularly during surgery for spinal deformity, OPLL, and extramedullary spinal cord tumor.

Abbreviations used in this paper:MEP = motor evoked potential; MMT = manual muscle testing; OPLL = ossification of the posterior longitudinal ligament; TcMEP = transcranial electrical stimulation MEP.

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Contributor Notes

Address correspondence to: Sho Kobayashi, M.D., Ph.D., Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashiku, Hamamatsu City 430-1514, Japan. email: shok@hama-med.ac.jp.

Please include this information when citing this paper: published online November 15, 2013; DOI: 10.3171/2013.10.SPINE12944.

  • 1

    Fehlings MG, , Brodke DS, , Norvell DC, & Dettori JR: The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference?. Spine (Phila Pa 1976) 35:9 Suppl S37S46, 2010

    • Search Google Scholar
    • Export Citation
  • 2

    Gonzalez AA, , Jeyanandarajan D, , Hansen C, , Zada G, & Hsieh PC: Intraoperative neurophysiological monitoring during spine surgery: a review. Neurosurg Focus 27:4 E6, 2009

    • Search Google Scholar
    • Export Citation
  • 3

    Ito Z, , Imagama S, , Sakai Y, , Katayama Y, , Wakao N, & Ando K, : A new criterion for the alarm point for compound muscle action potentials. Clinical article. J Neurosurg Spine 17:348356, 2012

    • Search Google Scholar
    • Export Citation
  • 4

    Kim DH, , Zaremski J, , Kwon B, , Jenis L, , Woodard E, & Bode R, : Risk factors for false positive transcranial motor evoked potential monitoring alerts during surgical treatment of cervical myelopathy. Spine (Phila Pa 1976) 32:30413046, 2007

    • Search Google Scholar
    • Export Citation
  • 5

    Langeloo DD, , Lelivelt A, , Louis Journée H, , Slappendel R, & de Kleuver M: Transcranial electrical motor-evoked potential monitoring during surgery for spinal deformity: a study of 145 patients. Spine (Phila Pa 1976) 28:10431050, 2003

    • Search Google Scholar
    • Export Citation
  • 6

    Lee JY, , Hilibrand AS, , Lim MR, , Zavatsky J, , Zeiller S, & Schwartz DM, : Characterization of neurophysiologic alerts during anterior cervical spine surgery. Spine (Phila Pa 1976) 31:19161922, 2006

    • Search Google Scholar
    • Export Citation
  • 7

    Matsumoto M, , Toyama Y, , Chikuda H, , Takeshita K, , Kato T, & Shindo S, : Outcomes of fusion surgery for ossification of the posterior longitudinal ligament of the thoracic spine: a multicenter retrospective survey. Clinical article. J Neurosurg Spine 15:380385, 2011

    • Search Google Scholar
    • Export Citation
  • 8

    Matsuyama Y, , Sakai Y, , Katayama Y, , Imagama S, , Ito Z, & Wakao N, : Surgical results of intramedullary spinal cord tumor with spinal cord monitoring to guide extent of resection. Clinical article. J Neurosurg Spine 10:404413, 2009

    • Search Google Scholar
    • Export Citation
  • 9

    Nohara Y, , Taneichi H, , Ueyama K, , Kawahara N, , Shiba K, & Tokuhashi Y, : Nationwide survey on complications of spine surgery in Japan. J Orthop Sci 9:424433, 2004

    • Search Google Scholar
    • Export Citation
  • 10

    Park P, , Wang AC, , Sangala JR, , Kim SM, , Hervey-Jumper S, & Than KD, : Impact of multimodal intraoperative monitoring during correction of symptomatic cervical or cervicothoracic kyphosis. Clinical article. J Neurosurg Spine 14:99105, 2011

    • Search Google Scholar
    • Export Citation
  • 11

    Pelosi L, , Lamb J, , Grevitt M, , Mehdian SM, , Webb JK, & Blumhardt LD: Combined monitoring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin Neurophysiol 113:10821091, 2002

    • Search Google Scholar
    • Export Citation
  • 12

    Quiñones-Hinojosa A, , Lyon R, , Zada G, , Lamborn KR, , Gupta N, & Parsa AT, : Changes in transcranial motor evoked potentials during intramedullary spinal cord tumor resection correlate with postoperative motor function. Neurosurgery 56:982993, 2005

    • Search Google Scholar
    • Export Citation
  • 13

    Raynor BL, , Bright JD, , Lenke LG, , Rahman RK, , Bridwell KH, & Riew KD, : Significant change or loss of intraoperative monitoring data: a 25-year experience in 12,375 spinal surgeries. Spine (Phila Pa 1976) 38:E101E108, 2013

    • Search Google Scholar
    • Export Citation
  • 14

    Reames DL, , Smith JS, , Fu KM, , Polly DW Jr, , Ames CP, & Berven SH, : Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine (Phila Pa 1976) 36:14841491, 2011

    • Search Google Scholar
    • Export Citation
  • 15

    Sakaki K, , Kawabata S, , Ukegawa D, , Hirai T, , Ishii S, & Tomori M, : Warning thresholds on the basis of origin of amplitude changes in transcranial electrical motor-evoked potential monitoring for cervical compression myelopathy. Spine (Phila Pa 1976) 37:E913E921, 2012

    • Search Google Scholar
    • Export Citation
  • 16

    Sala F, , Palandri G, , Basso E, , Lanteri P, , Deletis V, & Faccioli F, : Motor evoked potential monitoring improves outcome after surgery for intramedullary spinal cord tumors: a historical control study. Neurosurgery 58:11291143, 2006

    • Search Google Scholar
    • Export Citation
  • 17

    Sutter M, , Eggspuehler A, , Grob D, , Jeszenszky D, , Benini A, & Porchet F, : The validity of multimodal intraoperative monitoring (MIOM) in surgery of 109 spine and spinal cord tumors. Eur Spine J 16:Suppl 2 S197S208, 2007

    • Search Google Scholar
    • Export Citation

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