ORIGINAL RESEARCH
Overview of Intraoperative Neurophysiological Monitoring During
Spine Surgery
Parastou Shilian, Gabriel Zada, Aaron C. Kim, and Andres A. Gonzalez
University of Southern California, Los Angeles, CA, U.S.A.
Summary: Intraoperative neurophysiologic monitoring has
had major advances in the past few decades. During spine
surgery, the use of multimodality monitoring enables us to
assess the integrity of the spinal cord, nerve roots, and
peripheral nerves. The authors present a practical approach
to the current modalities in use during spine surgery,
including somatosensory evoked potentials, motor evoked
potentials, spinal D-waves, and free-run and triggered
electromyography. Understanding the complementary
O ver the past several decades, various modalities of electrophys-
iological tests have been increasingly used in the operating room
to monitor different parts of the nervous system specifically at risk, to
prevent or minimize the probability of neurological injury. In
addition, the information gleaned from intraoperative neurophysio-
logical monitoring provides guidance to the neurosurgical team
throughout the course of the operation. Intraoperative neurophysi-
ological monitoring has become a useful adjunct to a variety of spinal
operations, including spinal tumor resection, spinal decompression
and fusion, deformity surgery, and vascular surgery of the spinal cord.
Intraoperative monitoring has been in use since the 1970s. One
of the first methods used to detect neurological injury during surgery
was the wake-up test, pioneered by Vauzele (1973). As part of this
cursory, yet pioneering monitoring test, general anesthesia was
transiently discontinued after insertion of spinal hardware to perform
a neurological examination. Benefits of the Stagnara wake-up test
were that it was relatively simple to perform, without the need for
special equipment. Although the wake-up test was functional, it had
several inherent limitations, such as a potential delay in identification
of neurological deficits (because it was only performed at one time
point), risk of accidental extubation, or other anesthesia complica-
tions, air embolization, and possible movement of surgical instru-
mentation (Hall et al., 1978; Nuwer and Dawson, 1984; Vauzelle
et al., 1973). In recent decades, the evolution of safer and more
sophisticated real-time modalities for neurophysiological monitoring
have essentially replaced the need to perform such wake-up tests and
have transformed the subspecialty of neurophysiological monitoring
and modern spinal surgery into the discipline it is today.
SOMATOSENSORY EVOKED POTENTIALS
Somatosensory evoked potentials (SSEPs) are an extremely
useful and sensitive modality for the intraoperative assessment of
Address correspondence and reprint requests to Parastou Shilian D.O., Department
of Neurology, University of Southern California, 1520 San Pablo, Suite 3000,
Los Angeles, CA 90033; email: pshilian@med.usc.edu
Copyright Ó 2014 by the American Clinical Neurophysiology Society
ISSN: 0736-0258/14/3304-0333
DOI 10.1097/WNP.0000000000000132
clinicalneurophys.com Journal of Clinical Neurophysiology Volume 33, Number 4, August 2016
nature of these modalities will help tailor monitoring to
a particular procedure to minimize postoperative neurologic
deficit during spine surgery.
Key words: Intraoperative Neurophysiological Monitoring, Spine
surgery, Somatosensory evoked potentials, Motor evoked po-
tentials, Electromyography.
(J Clin Neurophysiol 2016;33: 333–339)
spinal cord function. A typical protocol includes delivery of
a peripheral stimulus and subsequent recording proximally in the
region of the somatosensory cortex, thereby monitoring the
integrity of major afferent pathways of the dorsal spinal cord.
Somatosensory evoked potentials were first recorded by Dr.
Dawson in 1947, by stimulating the peripheral nerve and
recording responses over the somatosensory cortex (Dawson,
1947). Two decades later, this technology was applied for the
first time in the operating room in an institution affiliated with the
University of Southern California. In 1974, Nash et al introduced
the use of SSEP for intraoperative monitoring of the nervous
system during spine surgery.
Early SSEP monitoring used middle and long-latency
cortical potentials but had limited use due to a high degree of
variability, excess noise, and sensitivity to anesthesia. Nuwer and
Dawson established parameters for SSEP monitoring to improve
its reproducibility and efficacy in the operating room. These
modifications involved optimizing the stimulation rate, filter
settings, anesthesia protocol, and scalp montages to achieve
a more favorable signal-to-noise ratio (Nuwer and Dawson,
1984).
Anatomy
Somatosensory evoked potentials assess the integrity of the
dorsal column-medial lemniscus pathway, as initially described
by D’Angelo et al. (1973).
The dorsal column–medial lemniscus pathway conducts the
sensory modalities of vibration, proprioception, and fine touch.
From the peripheral mechanoreceptors and stretch receptors,
signal travels through dorsal horn neurons. First-order neuron
axons ascend through the cuneatus and gracilis fasciculi and
synapse on second-order neurons in the cuneate and gracile
nuclei, respectively. These fibers cross midline as internal arcuate
fibers and ascend as the medial lemniscus en route to the
pathway’s second synapse in the ventral posterolateral nucleus of
the thalamus. Axons of the third-order neurons ascend through
the posterior limb of the internal capsule to the primary
somatosensory cortex.
333
 P. Shilian, et al.
METHODOLOGY
Stimulation sites are selected based on the spinal cord level
of interest. The median nerve is typically monitored for high
cervical procedures, and the ulnar nerve is generally used for
lower cervical procedures. Even if the pathway of the upper
extremity nerve used is outside the area at risk (i.e., thoraco-
lumbar procedures), monitoring can provide general information
about systemic (blood pressure, temperature), anesthetic, or
changes due to positioning. For thoracolumbar and cervical
operations, the posterior tibial nerve at the ankle is the preferred
monitoring site. If the posterior tibial nerve is compromised (i.e.,
below the knee amputation or severe peripheral neuropathy), the
peroneal nerve at the knee can be used as an alternate.
A stimulation rate of approximately 5 Hz (that are not
multiple of 60, i.e., 4.47 Hz) is optimal (Nuwer and Dawson,
1984) for SSEP monitoring. A slower stimulation frequency will
yield higher amplitude responses but will slow the time to obtain
averaged sets of responses. The cortical N20 potential can be
recorded at CPc-CPi or CPc-FPz (International 10-10 system),
and P37 can be recorded at CPi-CPc, CPi-FPz, and Cz-FPz
channels (Fig. 1). Subcortical far field potentials, including N13,
P14, N18, P31, and N34 can be recorded from C5s-FPz channel.
It is advisable to use multiple channels to record cortical
potentials. This allows monitoring to continue without interrup-
tion should one channel become compromised. Because sub-
cortical channels are less susceptible to anesthesia, the reliability
of SSEP and subsequent interpretation of SSEPs may be higher
than other monitoring modalities (Sloan and Heyer, 2002). The
typical filter settings used to record SSEPs can be found in the
Appendix 1.
EFFICACY OF SSEP MONITORING
The use of SSEP monitoring has virtually eliminated the
necessity to wake patients up during surgery and has greatly
improved the safety and ability to provide near continuous
FIG. 1. Multiple channels are recommended for recording cortical
and subcortical potentials in the upper and lower extremities.
Subcortical channels can be recorded from brainstem and thalamic
sources and are less affected by anesthetics.
334 Journal of Clinical Neurophysiology Volume 33, Number 4, August 2016
Overview of IOM During Spine Surgery
assessment of spinal cord function during spinal surgery.
However, SSEP monitoring has its own set of limitations and
is very sensitive to various anesthetics (particularly halogenated
agents and nitrous oxide), as well as temperature and blood
pressure (Eager et al., 2011; Jou, 2000; Porkkala et al., 1997;
Sloan and Heyer, 2002). Optimization of many intraoperative
parameters and a close working relationship with the anesthesia
team is therefore generally required during these operations.
Because of a low signal-to-noise ratio in the operating room,
averaging of many stimuli is usually required to provide
a reproducible signal.
Many monitoring practitioners use an amplitude and latency
criteria to raise alarm during SSEP monitoring. Most accepted
criteria include either a 50% decrease in SSEP waveform
amplitude or a 10% increase in latency from baseline (Nuwer,
2008; Nuwer et al., 1995). However, although not systematically
studied, a 30% drop in amplitude observed during a critical
portion of the surgery with an otherwise stable waveform may be
significant. Changes due to anesthesia need to be taken into
account when evaluating cortical potential amplitudes. Sub-
cortical responses are more resistant and can be helpful in
distinguishing changes caused by anesthetics. Changes in SSEP
monitoring can sometimes be offset by optimization of blood
pressure, patient temperature, and/or anesthesia medications or
dosing.
The clinical efficacy of SSEP monitoring was evaluated in
a multicenter outcome survey of 51,263 spinal cases performed
by 53 US surgeons as part of the Scoliosis Research Society. The
study reported a sensitivity of 92% and specificity of 98.9% in
the ability of SSEP monitoring to detect postoperative deficits
and a 60% ability to reduce major neurologic deficits (Nuwer
et al., 1995). The same study also demonstrated that using SSEP
monitoring as a sole modality is associated with a false-negative
rate of 0.127%. Many studies have since calculated a sensitivity
range of 80% to 100% in detecting postoperative deficits when
using SSEP monitoring alone. In one operative series of spinal
tumor resections, the sensitivity of SSEP was found to be 88%
for detecting any neurological deficits and 100% for detecting
severe deficits (Wiedemayer et al., 2004).
The literature regarding SSEP monitoring demonstrates
a disparity regarding false-negative and false-positive results,
which is an inherent limitation of many of these studies. An
example of a false positive might be a case in which there are
significant changes in the monitoring, with notification of
surgeon, yet no detectable neurological deficits postoperatively.
Although these cases are usually considered to be false positives
according to the majority of the literature, this may underestimate
the test’s sensitivity because the detection and notification in
some cases may have altered the course of the surgery, thereby
preventing a deficit if the surgeon had not been notified. Perhaps,
more concerning is the specter of false-negative monitoring,
where the patient wakes up with motor deficits with no detectable
changes in SSEP monitoring. Given that SSEP are not represen-
tative of corticospinal tract function, the relative inability of
SSEP monitoring to detect isolated motor deficits may be
considered a limitation of SSEP monitoring, rather than a failure
of this test. Motor changes with unchanged SSEP signals should
therefore not be considered to be a false-negative result.
clinicalneurophys.com
 Overview of IOM During Spine Surgery
INTRODUCTION TO MULTIMODALITY
Because of their sensitivity for detecting motor deficits and
the lack of a more specific modality, for two decades, SSEP
monitoring was the only way to monitor global spinal cord
function. We now know that this SSEP monitoring reflects only
the integrity of the dorsal column–medial lemniscus pathway. In
recent decades, however, the advent of multimodality neuro-
monitoring techniques has provided the ability to monitor both
motor and sensory pathways, in addition to nerve root function.
In addition to SSEP monitoring, multimodality testing often
includes some permutation of transcranial motor evoked potential
(TcMEP), continuous free running electromyography, evoked or
triggered electromyography, dermatomal SSEP (DSSEP), and
spinal D-wave monitoring. Selection of the appropriate combi-
nation of monitoring modalities depends on the structure(s) at
risk, as determined by an experienced neurophysiologist in
conjunction with the neurosurgeon. The widespread availability
and experience gained with multimodality neurophysiologic
monitoring have greatly improved the efficacy of this strategy
in the operating room.
DERMATOMAL SOMATOSENSORY
EVOKED POTENTIALS
Dermatomal somatosensory evoked potentials provide the
ability to monitor nerve root function, by way of dermatomal
stimulation in the cervical and lumbosacral regions. Needle or
surface electrodes can be used for surface stimulation of
dermatomes of interest, and recording is typically done at the
scalp. In general, C39 and C49 (2 cm posterior to C3 and C4 of
International 10-20 system) electrodes can be used for the upper
extremities and Cz9 and Fpz9 for the lower extremities.
There are limited studies regarding the effectiveness of
DSSEP in monitoring nerve root function. If DSSEPs are
obtained, they may provide valuable information to the surgeon
regarding nerve root function. However, many authors allude to
the variability of its usefulness depending on the level being
monitored (Owen et al., 1993; Owen et al., 1991).
Dermatomal somatosensory evoked potentials are very
small potentials with amplitudes averaging less than half of
median or tibial SSEPs. Furthermore, dermatomes are inherently
variable regarding anatomical distribution, potentially compro-
mising the specificity of this technique. Dermatomal patterns
across individuals are inconsistent, and adjacent dermatomes
often overlap, making the recording an interpretation of DSSEP
signals frequently challenging (Tsai et al., 1997). In addition,
high sensitivity of DSSEPs to anesthesia further limits their use
in the operating room (Herdmann et al., 1996; Sloan and Heyer,
2002). On account of this variability and poor reproducibility,
DSSEPs have limited use in the operating room.
TRANSCRANIAL MOTOR EVOKED POTENTIALS
Selective activation of the human cortex by direct electrical
stimulation was first demonstrated by Penfield and Boldrey
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P. Shilian, et al.
(1939). Forty years later, in the early in the 1980’s, cortical
stimulation through an intact skull was first developed by Merton
and Morton (1980). This technique was later adapted to provide
intraoperative monitoring of the major components of the motor
pathway, the corticospinal tracts.
During TcMEP monitoring, motor fibers are nonspecifically
stimulated transcranially, and responses are recorded from
appropriate muscles as dictated by the surgical procedure.
Transcranial stimulation may recruit motor fibers from the motor
cortex or deeper structures, such as corona radiata and the
internal capsule. Most centers use a multipulse train, ranging
from 3 to 7 pulses, which can help overcome anesthetic
inhibition of the anterior horn cell synapse (Husain, 2008).
Stimulation is performed through an interpulse interval ranging
from 2 to 4 milliseconds (Legatt, 2002), typically using
corkscrew or needle electrodes. Electrodes are placed over C1
and C2 (International 10-10 system) or more laterally at C3 and
C4 to optimize desired potentials. Recording is performed by
placing intramuscular needles 2 to 3 cm apart in the desired target
muscles. At least two muscles distal to the surgical level(s) are
monitored, and one muscle proximal to the surgical level(s) is
typically used as a control. The monitoring of distal rather than
proximal muscles is typically favored, on account of their richer
corticospinal representation. Increasing the number of muscles
monitored improves the specificity and the predictive value of
motor evoked potentials (Sala et al., 2006).
Alarm criteria for TcMEP monitoring are not as well
established as with SSEP monitoring. When a robust baseline
signal is present, a complete loss or abrupt decrease in amplitude
of $ 80% has been described as a preferred method used to
report critical changes. The “all or none” method for TcMEP
monitoring may lack sensitivity and may delay the time to
notifying the surgeon of a potential injury. Other criteria, like
changes in the morphology of responses, such as a complex
multiphasic response evolving to a biphasic or a monophasic
response, can also be cause for alarm (Quinones-Hinojosa et al).
It is important to consider that a gradual loss of signal may
indicate a potentially reversible anesthetic effect (Husain, 2008).
Overall, routine use of TcMEP neurophysiological assessment
has improved spinal cord monitoring by effectively evaluating
the integrity and functionality of the corticospinal tract during
surgery and improving predictability of postoperative motor
deficits. A study by Sala et al. (2006) showed significant
improvement in motor outcomes in patients undergoing TcMEP
monitoring during intramedullary spinal cord tumor removal, as
compared with nonmonitored historical controls.
Some of the limitations inherent to using TcMEP monitoring
during spinal surgery include susceptibility to anesthetic medi-
cations (particularly inhalational and neuromuscular blockade
agents) and intrinsic variability. The use of total intravenous
anesthesia is sometimes preferred when responses are difficult to
obtain or demonstrate high variability. Chen et al. (2007)
reported a success rate of 94.8% for the upper extremity and
66.6% for the lower extremity in the ability to obtain reliable
MEPs. These rates drop to 81% and 39.1%, respectively, in the
presence of preexisting weakness (Chen et al., 2007). Further-
more, TcMEPs are more sensitive than SSEPs in detecting spinal
cord ischemia and can be helpful in preventing paraplegia if
335
 P. Shilian, et al. Overview of IOM During Spine Surgery

appropriate measures are undertaken by the surgical team during
thoracic and thoracoabdominal aneurysm surgery (Dong et al.,
2002).
Although TcMEPs are conventionally used to monitor
spinal cord function, there is evidence to suggest that they may
also be used to assess nerve root function (Fig. 2). A study by
Fan et al showed that addition of TcMEP monitoring of the
deltoids and biceps, in addition to spontaneous EMG of the same
muscles, provided sufficient warning for the surgeon during
posterior cervical spine surgery. In patients with MEP changes in
addition to EMG firing, a foraminotomy was performed at C4-C5
level to decompress the C5 nerve root. Patients undergoing this
monitoring technique generally recovered within 1 to 7 days,
compared with up to 2 years in patients operated on with the use
of conventional multimodality techniques (Fan et al., 2002). A
follow-up study done by Bose et al. (2007) evaluated similar
techniques during anterior cervical spine surgeries. They also
demonstrated that the addition of TcMEP to spontaneous EMG
offered complementary information and improved prognostica-
tion of postoperative deficits (Bose et al., 2007). Lieberman et al
studied MEP monitoring in 35 patients undergoing complex
lumbar surgery. They showed that a drop in the MEP amplitude
of greater than 80% from baseline was 100% sensitive for
detecting nerve root injury. Conversely, no patients had a new
motor deficit if the final MEP was at least 67% of baseline. In
addition, the severity and duration of injury was reduced in MEP
monitored patients compared with patients from previous studies
(Lieberman et al., 2008). Review of the literature by MacDonald
et al suggests that the use of MEP monitoring for assessing nerve
root function may be limited due to radicular overlap (each nerve
root supplies many different muscles and each muscle is
innervated by many different nerve roots), limited sampling
(only a small portion of motor axons are sampled with MEPs),
and variability (intrinsic quality of MEP, variability in amplitude,
threshold, and morphology) (Macdonald et al., 2012).
SPINAL D-WAVE
Another method used to assess corticospinal tract function is
recording of spinal D-waves. Stimulation is given at the cortical
level, and responses are recorded from the spinal cord through an
epidural electrode. Some of the benefits of this method include
less sensitivity to anesthesia and an ability to monitor after

FIG. 2. This is a 58-year-old man who underwent an anterior cervical discectomy and fusion for a herniated nucleus pulposus.
Intraoperatively, changes developed in the right intrinsic hand muscle motor evoked potential. The patient developed postoperative right
hand weakness suggesting a C8 or T1 root compromise.

336 Journal of Clinical Neurophysiology Volume 33, Number 4, August 2016 clinicalneurophys.com
 Overview of IOM During Spine Surgery P. Shilian, et al.

neuromuscular blockade. D-waves can be used in conjunction with

TcMEPs to provide improved prediction of postoperative out-
comes (Fig. 3). Kothbauer et al. (1998) studied 100 cases of
intramedullary spinal cord tumor resections. The authors found
that although unaffected MEPs prognosticate no motor deficit,
significant changes in the TcMEP, along with a change in the
D-wave, suggest a permanent deficit. A change in TcMEP recording,
however, with no changes in D-wave, was more likely to predict
a transient neurological deficit (Kothbauer et al., 1998).

SPONTANEOUS ELECTROMYOGRAPHY
To record spontaneous EMG activity, active and reference
electrodes are placed in the muscles of interest, depending on the
nerve roots at risk. Nerve roots of cervical, lumbar, and sacral
segments can all be monitored. Spontaneous free-run EMG shows
no activity at baseline in the presence of healthy nerve root function
(Fig. 4). However, discharges can be seen with nerve stretch, blunt
trauma, compression, or ischemia (Nichols and Manafov, 2012).
High-frequency and/or high-amplitude trains are clinically signif-
icant and suggest irritation to the nerve roots (Fig. 5). Myokymic
discharges may suggest more severe damage to the nerve root.
Spontaneous EMG allows monitoring of multiple nerve roots
at the same time, with immediate and continuous feedback as there
is no need for signal averaging. Furthermore, this modality is not
as affected by parameters such as blood pressure and temperature
as are other neurophysiological monitoring methods. Muscle
relaxants, however, should be avoided whenever possible because
they can significantly attenuate EMG activity. One of the pitfalls of
this modality occurs with sharp nerve transection, as the EMG may
not show any abnormal activity (Nelson and Vasconez, 1995).
Gunnarsson et al. (2004) demonstrated that spontaneous electro-
myography has a high sensitivity (100%), yet a low specificity
(23.7%) to detect postoperative neurologic deficits and is therefore
more reliable as a screening tool for nerve root function.
FIG. 4. Baseline spontaneous electromyogram is quiet with no
discharges seen.
Accurate placement of pedicle screws is often challenging, mainly
on account of anatomical and pathological variations, and the
proximity of the spinal cord and nerve roots. Pedicle screw breaches
may cause compression of the spinal cord or nerve roots and have
been reported in as high as 10% of spinal fixation sites (Parker et al.,
2011). Radiologic imaging has a sensitivity of only 63% in detecting
a breach of the medial or inferior aspect of the pedicle wall (Maguire
et al., 1995). Triggered EMG may be a useful adjunct in detecting
compression of the neural elements during spinal surgery and
involves electrical stimulation of the screw while recording time-
locked EMG activity from the corresponding myotome. Because
Calancie et al. (1994) demonstrated the sensitivity and reliability of
this technique, it has been commonly used to detect pedicle wall
breaches. Trigger EMG increases the sensitivity of identifying

TRIGGERED ELECTROMYOGRAPHY
Pedicle screws are commonly used for mechanical stabilization
of the thoracic, lumbosacral, and more recently cervical spinal levels.

FIG. 3. Obtaining D-wave in addition to TcMEP during spinal cord

surgery can help with prognosis. With loss of MEP, stability of D-
waves can be used by surgeons to decide on a more aggressive FIG. 5. Trains of firing are observed in the left tibialis anterior and
resection without causing a permanent deficit. left foot.

clinicalneurophys.com Journal of Clinical Neurophysiology Volume 33, Number 4, August 2016 337
 P. Shilian, et al.
FIG. 6. Anterior lumbar interbody fusion: increased latency and
decreased amplitude in the left lower SSEP, followed by complete
loss of left N20 response. The cortical SSEP response recovered
after replacement of the retractor (descending timeline).
a misplaced pedicle screw in up to 93% of lumbosacral instrumen-
tation cases (Maguire et al., 1995). Calancie et al reported that EMG
thresholds $ 10 mA in the lumbosacral spine suggest absence of
a pedicle wall breach. Another study by Raynor et al. (2007) showed
that using a threshold of 8 mA, triggered electromyography has
a specificity of 94% and a sensitivity of 86% in identifying a pedicle
screw breach. With thoracic pedicle screws, Shi et al show that
stimulation thresholds .11 mA have a 97.5% negative-predictive
value. Practitioners should remain mindful that the use of muscle
relaxants, preexisting radiculopathy, or current shunting may
increase the threshold of stimulation of lumbosacral nerve roots,
potentially resulting in false-negative results.
ANTERIOR LUMBAR INTERBODY FUSION
Special consideration needs to be given to anterior lumbar
surgery due to the risk of vascular compromise. It is reported that up
to 57% of patients undergoing anterior lumbar interbody fusion at
the L4-L5 level are subject to left iliac artery compression (Brau
et al., 2003). Vascular compromise and oxygen desaturation
correlates with changes in the left lower extremity SSEP (Fig. 6).
These changes are usually transient and typically resolve with
adjustment or removal of the retractor. If SSEP recovery is not seen,
thrombosis to the corresponding iliac artery should be considered.
MULTIMODALITY PREDICTIVE VALUE
A prospective study by Kelleher et al. (2008) of 1055 patients
undergoing cervical spine surgery using multimodality monitoring
showed a 52% sensitivity and 100% specificity for SSEP
monitoring, 100% sensitivity and 96% specificity for MEP
monitoring, and 46% sensitivity and 73% specificity for EMG in
predicting postoperative motor deficits. Multimodality monitoring
provides independent and complementary information in monitor-
ing spinal cord function. Sutter et al studied multimodality testing
in 1017 patients undergoing spine surgery. They showed that
multimodality intraoperative monitoring had a sensitivity of 89%
and a specificity of 99%, with a false-negative rate of 0.8%. Using
multimodality monitoring can help prevent and/or minimize the
degree of neurologic deficits in patients undergoing spinal surgery.
338 Journal of Clinical Neurophysiology Volume 33, Number 4, August 2016
Overview of IOM During Spine Surgery
The true efficacy of IOM has not been directly studied in
humans because of inability to perform double-blinded random-
ized controlled trials. Evidence-based guidelines established by
Nuwer et al, however, concluded that intraoperative monitoring
is effective in predicting postoperative paraparesis, paraplegia,
and quadriplegia during spinal surgery (Nuwer et al., 2012). This
was based on four class I and seven class II studies (based on the
AAN four-tiered evidence classification scheme). These com-
bined data resulted in a level A recommendation to alert the
surgical team about increased risk of severe adverse neurologic
outcomes in patients with reported IOM changes.
CONCLUSIONS
The ability to monitor the functional integrity of the nervous
system in real-time fashion is crucial to the very essence of surgery of
the spinal cord and central nervous system as a whole. The discipline
of intraoperative neurophysiological monitoring has evolved rapidly
over the past several decades, from rudimentary wake-up tests to
advanced and sophisticated methods for multimodality monitoring.
Selective use of various intraoperative modalities, including SSEP,
TcMEP, spinal D-wave, and EMG monitoring now provide
a methodology for complimentary and highly sensitive screening
of specific anatomical subsets of the nervous system. Multimodality
neurophysiological monitoring has been shown to augment the
course of many spinal operations and is known to prevent
and minimize the degree of major postoperative neurological deficits.
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APPENDIX 1

TABLE 1. Typical intraoperative Neuromonitoring Settings at Our Institution

Stimulation Parameters Recording Parameters
Stimulation Stimulation Pulse Number of Low-Frequency High-Frequency
Modality Rate Type Width Intensity Averages Filter Filter
SSEP 4–5 (avoiding multiples of 60) Constant current 100–200 ms 20–60 mA* 250–500 30 Hz 500–1500 Hz
TcMEP 250–500 Hz (5–7 pulses) Constant voltage 50–75 ms 100–400 V None 30 Hz 3000 Hz
EMG 2.79 Hz Constant current 100 ms 2–40 mA None 10 Hz 3000 Hz
*Adjusted to produce adequate muscle twitch.

TABLE 2. Typical Channel Setting Used at Our Institution

Modality Recording Channels
Upper SSEP CPc-CPi, Cz-FPz, A1/C5s-FPz
Lower SSEP CpPi-CPc, CPi-FPz, Cz-FPz, A1-FPz
TcMEP Various muscles in all extremities
spEMG Various muscles in all extremities
tEMG Various muscles in all extremities
c, contralateral; i, ipsilateral.

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