Which patients do we need to consider augmentation of muscle active potentials regarding transcranial electrical stimulation motor-evoked potentials monitoring before spine surgery?

Background context: Transcranial electrical stimulation motor-evoked potentials (Tc-MEPs) are the current trend and are important in preventing intraoperative neurological deficits. Posttetanic Tc-MEPs (p-MEP) can augment the amplitudes of compound muscle active potentials (CMAPs), especially in the case of insufficient conventional Tc-MEPs (c-MEP).

Purpose: To retrospectively investigate pre- and intraoperative factors necessitating p-MEP monitoring and to examine changes in the success rates of baseline Tc-MEP monitoring before and after tetanic stimulation in patients with such factors.

Study design: Retrospective observational study.

Patient sample: Patients (n=184) who underwent spinal surgery with Tc-MEP monitoring in our department between August 2020 and July 2022.

Outcome measures: Manual muscle testing (MMT) scores were calculated to identify patients with preoperative motor deficits. c-MEP and p-MEP amplitudes were recorded from the defined muscles.

Methods: We compared preoperative and intraoperative factors between the c-MEP and p-MEP groups (study 1). In cases where the factors were identified, we investigated the success rate of the baseline MEP measurement of each muscle before and after tetanic stimulation (study 2).

Results: One hundred fifty-seven patients were included. Of those, 87 showed sufficient CMAPs with c-MEP. Meanwhile, 70 needed p-MEP because of insufficient CMAPs. In univariate analysis, cervical/thoracic surgery (p<.001), preoperative MMT 3 or below (p=.009), shorter duration of illness (p=.037), previous cerebrovascular disease (p=.014), and dialysis (p=.031) were significantly associated with p-MEP group. Preoperative MMT 3 or below was the only factor requiring p-MEP (odds ratio, 3.34; 95% confidence interval, 1.28-8.73, p=.014) in multivariate analysis. In the p-MEP group, 24 patients had preoperative motor deficits; 16 patients with complete data were included in the analysis (study 2). The success rates of MEP monitoring before and after tetanic stimulation of the entire lower-extremity muscles were 42.7 and 57.3%, respectively (p<.001). The success rates for each muscle before and after tetanic stimulation were abductor pollicis brevis: 81.3% and 96.9%, tibialis anterior: 34.4% and 50.0%, gastrocnemius: 25% and 40.6%, and abductor hallucis: 68.8% and 81.3%, respectively. No significant differences were observed in success rates for any of the muscles.

Conclusions: Patients with preoperative MMT 3 or below highly needed p-MEP. The success rate of baseline MEP monitoring increased with tetanic stimulation, even in patients with preoperative motor deficits. We believe that p-MEP monitoring can result in reliable CMAP recording, especially in cases of preoperative motor deficits with MMT scores of 3 or below.