A new criterion for the alarm point using a combination of waveform amplitude and onset latency in Br(E)-MsEP monitoring in spine surgery

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OBJECTIVE

Monitoring of brain evoked muscle-action potentials (Br[E]-MsEPs) is a sensitive method that provides accurate periodic assessment of neurological status. However, occasionally this method gives a relatively high rate of false-positives, and thus hinders surgery. The alarm point is often defined based on a particular decrease in amplitude of a Br(E)-MsEP waveform, but waveform latency has not been widely examined. The purpose of this study was to evaluate onset latency in Br(E)-MsEP monitoring in spinal surgery and to examine the efficacy of an alarm point using a combination of amplitude and latency.

METHODS

A single-center, retrospective study was performed in 83 patients who underwent spine surgery using intraoperative Br(E)-MsEP monitoring. A total of 1726 muscles in extremities were chosen for monitoring, and acceptable baseline Br(E)-MsEP responses were obtained from 1640 (95%). Onset latency was defined as the period from stimulation until the waveform was detected. Relationships of postoperative motor deficit with onset latency alone and in combination with a decrease in amplitude of ≥ 70% from baseline were examined.

RESULTS

Nine of the 83 patients had postoperative motor deficits. The delay of onset latency compared to the control waveform differed significantly between patients with and without these deficits (1.09% ± 0.06% vs 1.31% ± 0.14%, p < 0.01). In ROC analysis, an intraoperative 15% delay in latency from baseline had a sensitivity of 78% and a specificity of 96% for prediction of postoperative motor deficit. In further ROC analysis, a combination of a decrease in amplitude of ≥ 70% and delay of onset latency of ≥ 10% from baseline had sensitivity of 100%, specificity of 93%, a false positive rate of 7%, a false negative rate of 0%, a positive predictive value of 64%, and a negative predictive value of 100% for this prediction.

CONCLUSIONS

In spinal cord monitoring with intraoperative Br(E)-MsEP, an alarm point using a decrease in amplitude of ≥ 70% and delay in onset latency of ≥ 10% from baseline has high specificity that reduces false positive results.

ABBREVIATIONS AIS = adolescent idiopathic scoliosis; Br(E)-MsEP = brain evoked muscle-action potential; EMG = electromyography; FNR = false negative rate; FPR = false positive rate; MIOM = multimodal intraoperative monitoring; MMT = manual muscle test; NPV = negative predictive value; OLF = ossification of the ligament flavum; OPLL = ossification of the posterior longitudinal ligament; PPV = positive predictive value; SBP = systolic blood pressure; SCEP = spinal cord evoked potential; SSEP = somatosensory evoked potential.
Article Information

Contributor Notes

Correspondence Shiro Imagama: Nagoya University Graduate School of Medicine, Aichi, Japan. imagama@med.nagoya-u.ac.jp.INCLUDE WHEN CITING Published online July 27, 2018; DOI: 10.3171/2018.3.SPINE171348.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Accadbled FHenry Pde Gauzy JSCahuzac JP: Spinal cord monitoring in scoliosis surgery using an epidural electrode. Results of a prospective, consecutive series of 191 cases. Spine (Phila Pa 1976) 31:261426232006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bartley KWoodforth IJStephen JPBurke D: Corticospinal volleys and compound muscle action potentials produced by repetitive transcranial stimulation during spinal surgery. Clin Neurophysiol 113:78902002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Ben-David BHaller GTaylor P: Anterior spinal fusion complicated by paraplegia. A case report of a false-negative somatosensory-evoked potential. Spine (Phila Pa 1976) 12:5365391987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Calancie BHarris WBroton JGAlexeeva NGreen BA: “Threshold-level” multipulse transcranial electrical stimulation of motor cortex for intraoperative monitoring of spinal motor tracts: description of method and comparison to somatosensory evoked potential monitoring. J Neurosurg 88:4574701998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Chen YWang BPYang JDeng Y: Neurophysiological monitoring of lumbar spinal nerve roots: A case report of postoperative deficit and literature review. Int J Surg Case Rep 30:2182212017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Duncan JWBailey RABaena R: Intraoperative decrease in amplitude of somatosensory-evoked potentials of the lower extremities with interbody fusion cage placement during lumbar fusion surgery. Spine (Phila Pa 1976) 37:E1290E12952012

    • Search Google Scholar
    • Export Citation
  • 7

    Gunnarsson TKrassioukov AVSarjeant RFehlings MG: Real-time continuous intraoperative electromyographic and somatosensory evoked potential recordings in spinal surgery: correlation of clinical and electrophysiologic findings in a prospective, consecutive series of 213 cases. Spine (Phila Pa 1976) 29:6776842004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Ito ZImagama SSakai YKatayama YWakao NAndo K: A new criterion for the alarm point for compound muscle action potentials. J Neurosurg Spine 17:3483562012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Jimenez JCSani SBraverman BDeutsch HRatliff JK: Palsies of the fifth cervical nerve root after cervical decompression: prevention using continuous intraoperative electromyography monitoring. J Neurosurg Spine 3:92972005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Jones SJHarrison RKoh KFMendoza NCrockard HA: Motor evoked potential monitoring during spinal surgery: responses of distal limb muscles to transcranial cortical stimulation with pulse trains. Electroencephalogr Clin Neurophysiol 100:3753831996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Kobayashi KAndo KYagi HIto KTsushima MMorozumi M: Prevention and prediction of postoperative bowel bladder disorder using an anal plug electrode with Tc-MsEP monitoring during spine surgery. Nagoya J Med Sci 79:4594662017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kobayashi KImagama SIto ZAndo KHida TIshiguro N: Prevention of spinal cord injury using brain-evoked muscle-action potential (Br(E)-MsEP) monitoring in cervical spinal screw fixation. Eur Spine J 26:115411612017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Kobayashi KImagama SIto ZAndo KHida TIto K: Transcranial motor evoked potential waveform changes in corrective fusion for adolescent idiopathic scoliosis. J Neurosurg Pediatr 19:1081152017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kobayashi SMatsuyama YShinomiya KKawabata SAndo MKanchiku T: 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. J Neurosurg Spine 20:1021072014

    • Search Google Scholar
    • Export Citation
  • 15

    Kothbauer KFDeletis VEpstein FJ: Motor-evoked potential monitoring for intramedullary spinal cord tumor surgery: correlation of clinical and neurophysiological data in a series of 100 consecutive procedures. Neurosurg Focus 4(5):e11998

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Langeloo DDJournée HLde Kleuver MGrotenhuis JA: Criteria for transcranial electrical motor evoked potential monitoring during spinal deformity surgery: a review and discussion of the literature. Neurophysiol Clin 37:4314392007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Langeloo DDLelivelt ALouis Journée HSlappendel Rde Kleuver M: Transcranial electrical motor-evoked potential monitoring during surgery for spinal deformity: a study of 145 patients. Spine (Phila Pa 1976) 28:104310502003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Lesser RPRaudzens PLüders HNuwer MRGoldie WDMorris HH III: Postoperative neurological deficits may occur despite unchanged intraoperative somatosensory evoked potentials. Ann Neurol 19:22251986

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Luk KDHu YWong YWCheung KM: Evaluation of various evoked potential techniques for spinal cord monitoring during scoliosis surgery. Spine (Phila Pa 1976) 26:177217772001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Macdonald DB: Intraoperative motor evoked potential monitoring: overview and update. J Clin Monit Comput 20:3473772006

  • 21

    Matsuyama YShinomiya KAndo MKazuhiko SToshikazu TIshiguro N: [Intraoperative spinal cord monitoring—multi center study of Japanese Society for Spine Surgery and Related Research (JSSR).] Rinsho-Nouha 51:2862912009 (Jpn)

    • Search Google Scholar
    • Export Citation
  • 22

    McCormick PCMichelsen WJPost KDCarmel PWStein BM: Cavernous malformations of the spinal cord. Neurosurgery 23:4594631988

  • 23

    Muramoto AImagama SIto ZAndo KTauchi RMatsumoto T: The cutoff amplitude of transcranial motor evoked potentials for transient postoperative motor deficits in intramedullary spinal cord tumor surgery. Spine (Phila Pa 1976) 39:E1086E10942014

    • Search Google Scholar
    • Export Citation
  • 24

    Muramoto AImagama SIto ZWakao NAndo KTauchi R: The cutoff amplitude of transcranial motor-evoked potentials for predicting postoperative motor deficits in thoracic spine surgery. Spine (Phila Pa 1976) 38:E21E272013

    • Search Google Scholar
    • Export Citation
  • 25

    Paradiso GLee GYSarjeant RHoang LMassicotte EMFehlings MG: Multimodality intraoperative neurophysiologic monitoring findings during surgery for adult tethered cord syndrome: analysis of a series of 44 patients with long-term follow-up. Spine (Phila Pa 1976) 31:209521022006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Park PWang ACSangala JRKim SMHervey-Jumper SThan KD: Impact of multimodal intraoperative monitoring during correction of symptomatic cervical or cervicothoracic kyphosis. J Neurosurg Spine 14:991052011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Pelosi LLamb JGrevitt MMehdian SMWebb JKBlumhardt LD: Combined monitoring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin Neurophysiol 113:108210912002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Quiñones-Hinojosa ALyon RZada GLamborn KRGupta NParsa AT: Changes in transcranial motor evoked potentials during intramedullary spinal cord tumor resection correlate with postoperative motor function. Neurosurgery 56:9829932005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Raynor BLLenke LGBridwell KHTaylor BAPadberg AM: Correlation between low triggered electromyographic thresholds and lumbar pedicle screw malposition: analysis of 4857 screws. Spine (Phila Pa 1976) 32:267326782007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Sala FBricolo AFaccioli FLanteri PGerosa M: Surgery for intramedullary spinal cord tumors: the role of intraoperative (neurophysiological) monitoring. Eur Spine J 16 (Suppl 2):S130S1392007

    • Search Google Scholar
    • Export Citation
  • 31

    Sala FPalandri GBasso ELanteri PDeletis VFaccioli F: Motor evoked potential monitoring improves outcome after surgery for intramedullary spinal cord tumors: a historical control study. Neurosurgery 58:112911432006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Sutter MEggspuehler AGrob DJeszenszky DBenini APorchet F: The diagnostic value of multimodal intraoperative monitoring (MIOM) during spine surgery: a prospective study of 1,017 patients. Eur Spine J 16 (Suppl 2):S162S1702007

    • Search Google Scholar
    • Export Citation
  • 33

    Yang CXu JChen JLi SCao YZhu Y: Experimental study of brachial plexus and vessel compression: evaluation of combined central and peripheral electrodiagnostic approach. Oncotarget 8:50618506282017

    • PubMed
    • Search Google Scholar
    • Export Citation
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