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Comparison of Transcranial Electric Motor and Somatosensory Evoked Potential Monitoring During Cervical Spine Surgery
Alan S. Hilibrand, MD1; Daniel M. Schwartz, PhD, DABNM2; Venkat Sethuraman, MD1; Alexander R. Vaccaro, MD1; Todd J. Albert, MD1
1 The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107
2 Surgical Monitoring Associates, 25 Bala Avenue, Suite 105, Bala Cynwyd, PA 19004. E-mail address: danielmschwartz@mac.com
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Surgical Monitoring Associates, Bala Cynwyd, and The Rothman Institute, Philadelphia, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Jun 01;86(6):1248-1253
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Abstract

Background: There has been little enthusiasm for somatosensory evoked potential monitoring in cervical spine surgery as a result, in part, of the increased risk of motor tract injury at this level, to which somatosensory monitoring may be insensitive. Transcranial electric motor evoked potential monitoring allows assessment of the motor tracts; therefore, we compared transcranial electric motor evoked potential and somatosensory evoked potential monitoring during cervical spine surgery to determine the temporal relationship between the changes in the potentials demonstrated by each type of monitoring and neurological sequelae and to identify patient-related and surgical factors associated with intraoperative neurophysiological changes.

Methods: Somatosensory evoked potential and transcranial electric motor evoked potential data recorded for 427 patients undergoing anterior or posterior cervical spine surgery between January 1999 and March 2001 were analyzed. All patients who showed substantial (at least 60%) or complete unilateral or bilateral amplitude loss, for at least ten minutes, during the transcranial electric motor evoked potential and/or somatosensory evoked potential monitoring were identified.

Results: Twelve of the 427 patients demonstrated substantial or complete loss of amplitude of the transcranial electric motor evoked potentials. Ten of those patients had complete reversal of the loss following prompt intraoperative intervention, whereas two awoke with a new motor deficit. Somatosensory evoked potential monitoring failed to identify any change in one of the two patients, and the change in the somatosensory evoked potentials lagged behind the change in the transcranial electric motor evoked potentials by thirty-three minutes in the other. No patient showed loss of amplitude of the somatosensory evoked potentials in the absence of changes in the transcranial electric motor evoked potentials. Transcranial electric motor evoked potential monitoring was 100% sensitive and 100% specific, whereas somatosensory evoked potential monitoring was only 25% sensitive; it was, however, 100% specific.

Conclusions: Transcranial electric motor evoked potential monitoring appears to be superior to conventional somatosensory evoked potential monitoring for identifying evolving motor tract injury during cervical spine surgery. Surgeons should strongly consider using this modality when operating on patients with cervical spondylotic myelopathy in general and on those with ossification of the posterior longitudinal ligament in particular.

Level of Evidence: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients [with universally applied reference "gold" standard]). See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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