Anaesthetic considerations for Intra-operative

Neurophysiological Monitoring (IONM) during spinal surgery.

Written by Helen Grover, Clinical Physiologist (Neurophysiology) and Dr Paul Barker, Consultant
Anaesthetist. Norfolk and Norwich University Hospital.
August 2013.

Summary

1) Use TIVA- Total Intravenous Anaesthesia

2) No muscle relaxants after initial intubation
3) Use soft bite block
4) Maintain steady level of anaesthesia
5) Maintain Blood pressure at >MAP 65mmHg

Details

1) Use of TIVA- Propofol + Remifentanil

Suggested Propofol level: gradual increase at induction then maintained-

usually will be at less than 4µg/ml, but can be considerable variation
between individuals.

Suggested Remifentanil level: 0.05-0.2mcg/kg/min.

When recording Transcranial motor evoked potentials (TcMEP for

monitoring cortico-spinal tracts) or cortical sensory evoked potentials (SEP
for monitoring the dorsal columns) both these modalities are very
susceptible to inhalational anaesthetic agents. It may be impossible to
record reliable TcMEP’s if any inhalational agents are used.

2) Avoid use of muscle relaxants during surgery.

When using TcMEP’s for monitoring we need to record the peripheral leg
muscle twitch. Any muscle relaxant agents will prevent TcMEP monitoring.
Short acting muscle relaxants can be used during intubation, but if
possible should be avoided after this. If they are required for clinical
reasons the Neurophysiology staff must be informed.

3) Use bite block

One of the most common adverse effects of performing TcMEP’s is a

tongue bite injury. This is because the electrical stimulation over the vertex
area of the scalp normally results in current spread across the scalp which
causes jaw muscle contraction. Tongue/jaw injury can be avoided by
placing a soft bite block between the patient’s molars. A rolled up piece of
gauze is adequate for this purpose.
4) Maintain a steady level of anaesthesia.

Any adjustments should be gradual. Neurophysiology monitoring may

include 2 channels of EEG which will indicate if the patient is ‘too deep’ by
the presence of a ‘burst suppression’ EEG pattern.
Conversely if the patient is ‘too light’ the monitoring can be adversely
affected by too much spurious muscle artefact as the patient tenses up.

5) Maintenance of Mean Arterial blood pressure at >65mmHg.

Some patient’s monitoring (particularly the TcMEP’s) will be more

susceptible than other to Blood pressure changes. In general maintaining
the MAP at over 65mmHG is adequate for successful IONM in most
cases.

If there is a Neurophysiological event (ie loss or significant reduction of

SEP or MEP signals) then check the BP.

6) The upper limb’s (SEP and MEP) are also monitored with all spinal surgery
and can be used as a control. If the monitoring of the upper limbs is lost
during thoraco-lumbar surgery the change is most likely to be a systemic
one and so anaesthesia and BP levels should be checked and adjusted if
necessary. Hypovolaemia can also cause monitoring changes.

Note the patient’s hands will twitch during SEP and MEP stimulation.

Other:
The use of Ketamine can help enhance the SEP/MEP potentials and may
be beneficial at induction (0.1-0.2mg/kg at induction).

Use of Tranexamic acid 10mg/kg loading dose then 10mg/kg/hr (not

necessary for IOM but used routinely at NNUH).

Anaesthetic considerations when there is deterioration or loss of the

SEP/TcMEP.

1) Get Hb>10.
2) Elevate BP to >120 systolic using fluid, blood, ephedrine, metaraminol
as appropriate.
3) Prepare for wake up test.
4) Reduce Propofol infusion rate/concentration.