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Case Report and Literature Review

Mayank Tyagi, Megha Bir1, Akanksha Sharma1, Pankaj K Singh2, Ashish Bindra,
P Sarat Chandra2
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 03/04/2024

Website:
www.neurologyindia.com

DOI:
10.4103/0028-3886.360931 Abstract:
We report the strategy of anesthesia and intraoperative neurophysiological monitoring (IONM) in a 29‑year‑old,
22 weeks pregnant patient posted for surgery for aggressive vertebral body hemangioma. We used propofol
and fentanyl‑based anesthesia for IONM. Motor‑evoked potentials (MEP) and somatosensory‑evoked
potentials (SSEP) were used to monitor the neural tracts during surgery. Fetal heart rate monitoring was done
preoperatively and postoperatively. Train of 8, 75 µs duration pulse, 250–500 Hz stimulus was used for MEP
and 30 mA, 200–400 µs, 3–5 Hz was used for SSEP. No new motor or somatosensory deficits appeared.
Our findings suggest that IONM can be safely done in pregnant women.
Key Words:
Anesthesia, fetal monitoring, intraoperative neuromonitoring, pregnancy, spine surgery

Key Message:
IONM in pregnancy mandates a multidisciplinary approach to accommodate the safety requirements of mother
and fetus. The current evidence favors the use of total intravenous anesthesia for IONM. Appropriate low
current strength should be chosen to avoid uterine stimulation and premature labor.

I ntraoperative neurophysiological
monitoring (IONM) is considered standard
of care during spinal surgeries which are at risk
laminectomy and posterior fixation under general
anesthesia. Considering a high risk of injury to
the motor tracts, transcranial motor‑evoked
of neuronal insult to the motor tracts. There potential (TcMEP) and somatosensory‑evoked
is limited literature on the use and safety of potential (SSEP) were planned.
IONM and its anesthetic concerns in pregnant
women undergoing spinal surgery. [1,10] This The patient was assessed by a multidisciplinary
case report describes anesthesia strategy and team of neurosurgeons, neuro‑anesthesiologists,
IONM in a pregnant patient posted for surgery neurophysiologists, and obstetricians. Informed
for aggressive vertebral body hemangioma.[2,11] risk consent was obtained for preterm labor and
fetal loss. Preoperative fetal heart rate (FHR)
Departments of Case Report monitoring was done. Maternal optimization and
Neuroanesthesia resuscitation were considered the primary goals.
and Critical Care, A 29‑year‑old female, 22 weeks pregnant
1
Physiology, presented with backache, tingling numbness in The patient was placed in a 15‑degree left lateral
2
Neurosurgery, All India legs, and progressive difficulty in walking. The tilt; standard monitors were applied. Anesthesia
Institute of Medical magnetic resonance imaging was suggestive of was induced with propofol 70 mg, fentanyl
Sciences, New Delhi, hemangioma of the 7th dorsal vertebra. [Figure 1]. 100 ug, and tracheal intubation was facilitated
India Neurological examination revealed 3/5 with rocuronium 50 mg using a C‑MAC video
power in the lower limbs and decreased pain laryngoscope using rapid sequence intubation.
Address for sensation below the lesion. Transabdominal The total intravenous anesthesia with a titrated
correspondence: dose of propofol and fentanyl infusions with
ultrasound (TA‑USG) revealed diamniotic
Dr. Ashish Bindra,
Department of
monochorionic twin pregnancy with one
Neuroanaesthesia and alive fetus. The patient was scheduled for How to cite this article: Tyagi M, Bir M,
Critical Care, All India Sharma A, Singh PK, Bindra A, Chandra PS.
Institute of Medical This is an open access journal, and articles are distributed under the terms Intraoperative Neuromonitoring for Spinal Surgery in a
Sciences (A.I.I.M.S), of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 Pregnant Patient: Case Report and Literature Review.
New Delhi ‑ 110 029, License, which allows others to remix, tweak, and build upon the work Neurol India 2022;70:S314-7.
India. non‑commercially, as long as appropriate credit is given and the new
creations are licensed under the identical terms. Submitted: 23-May-2020   Revised: 13-Aug-2020
E‑mail: dr_ashi2208@ Accepted: 27-Sep-2021   Published: 11-Nov-2022
yahoo.com For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

S314 © 2022 Neurology India, Neurological Society of India | Published by Wolters Kluwer - Medknow
 Tyagi, et al.: Intraoperative neuromonitoring in pregnancy

50% O2 in air targeted to bispectral values between 40 and
60 was used for maintenance. Thereafter, a muscle relaxant
was avoided. The left radial arterial was cannulated for
hemodynamic monitoring and arterial blood gas analysis. The
patient was placed in a left lateral decubitus position with a
lead shield wrapped around the abdomen to avoid radiation
exposure.
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Therefore, the stimulation strength was gradually increased
from 50 V with continuous monitoring of the fetal heart rate and
was limited to 500 V to reduce risk. Consistent TcMEPs could
be obtained only in control muscles at 150 V and left abductor
halluces at 500 V owing to the pre‑existing motor deficit.
SSEP

The posterior tibial nerve was stimulated with patch

TcMEP
Corkscrew electrodes were placed at C3′ and C4′ for
stimulation (train of 8 pulses, 75 µs duration each, 250–500 Hz,
and in each instance, a single of double stimulation was given
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 03/04/2024
electrodes (30 mA, 200–400 µs, 3–5 Hz), and the evoked
potential was recorded and observed best SSEP traces with
corkscrew electrodes at C3, C4, Cz, and FPz (100 ms window,
30–500 Hz bandpass, 200–300 traces averaged). Direct nerve

to elicit MEP response), and a dual twisted needle electrode
was placed bilaterally in the abductor pollicis brevis (control),
rectus abdominus, rectus femoris, tibialis anterior, extensor
halluces longus, and abductor halluces to record the evoked
potentials (100 ms window, 30–3,000 Hz bandpass). A lesser
train count was not used because of patient preoperative
neurological deficits and to avoid the use of higher stimulation
strength which may precipitate fetal distress or labor.
monitoring was not used during pedicle screw implantation.
The NIM‑Eclipse system, Medtronic was used for all IONM
procedures.
D7 laminectomy and posterior spine fixation (pedicle screw
rod fixation done one level above and below D7) with
intralesional 3 mL absolute alcohol (<1% hydrated ethyl
alcohol) injection at D7 pedicle (bilateral) was performed. The
surgical procedure lasted for 6 h. The estimated blood loss
was 800 mL. Intraoperative hemodynamics remained stable.
There were no intraoperative changes in TcMEP and SSEP
responses as compared to the baseline after decompression
and this correlated with the postoperative motor and sensory
status. Tracheal extubation was facilitated at the end of the
surgery. Normal fetal heart rate and viability were confirmed
by postoperative cardiotocography. She was discharged on
the 5th postoperative day. A healthy baby was delivered at
37 weeks gestation.

Discussion

Pregnancy is a well‑recognized state during which asymptomatic

Figure 1: Computed tomography image of dorsal vertebral hemangioma
vertebral hemangiomas can become symptomatic.[3,12,13] Surgery
is suggested in case of severe pain or progressive neurological
deficit.[14] There is little literature regarding intraoperative
anesthetic management and IONM in pregnant women
undergoing spine surgery.

Table 1: Case reviews of pregnant patients who underwent IONM under general anesthesia
Gestation Diagnosis Type of neuromonitoring and Neurological Pregnancy outcome Anesthetic
period stimulation used outcome technique
Pastor[1] (2009) 26 weeks Glioblastoma MEP (43 trains, 650 mA*, 340 No motor or new No significant differences TIVA (propofol
multiforme V†, 200 pulses, with pulse width somatosensory related to electrical stimulation and remifentanil
of 50 µs) deficits after the in either uterus muscle tone infusions)
surgery or FHR observed during the
surgery.
SSEP (35 trains, 25 mA, 13.4 Preterm delivery (LSCS)§
V, 4‑5 pulses, and pulse width
of 200 µs‡ with no significant
change in latency or amplitude)
Guerrero‑ 29 weeks Cervical (MEPs‑t) 100 ms, 100 mV/ Improvement Normal fetal dynamics (during TIVA (propofol
Domínguez R, Intracranial division (SSEPs‑t) 100 ms, 2 in neurological and after the procedure) and remifentanil)
et al.[6] (2015) Tumor micro V/division deficit
Term delivery (LSCS) BIS monitoring
Nitin Manohar[7] 26 weeks Intraventricular MEP (18 trains, pulse width 75 No new‑onset Normal FHR and viability TIVA (propofol
(2019) Tumor µs, 7 pulses, 175 V, and train motor or (during and after the and fentanyl)
rate of 333 per second) with sensory deficits procedure)
no significant intraoperatively
changes in MEP amplitude
BIS monitoring
*Current (mA), †Voltage (V), ‡Pulse width (µs), §lower segment cesarean section

Neurology India | Volume 70 | Supplement 2 | September-October 2022 S315

 Tyagi, et al.: Intraoperative neuromonitoring in pregnancy
Besides maintaining normal hemodynamic, neurophysiological,
and uteroplacental variables, a special anesthetic requirement
is choosing an appropriate anesthetic agent which does not
interfere with the IONM recordings and is safe for the mother
and fetus. Maintenance of an adequate and constant depth of
anesthesia, and body temperature is vital. Total intravenous
anesthesia (a combination of propofol and opioids) is the most
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commonly used anesthetic regimen for IONM in pregnant
women [Table 1].[4,5] Bolus injections of intravenous agents
should be avoided as they can temporarily disrupt MEPs and
cause maternal hypotension impairing the uteroplacental
perfusion.[4,15] Halogenated anesthetics elevate muscle TcMEP
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 03/04/2024
stimulus thresholds, abolish MEPs, and have a greater sedative
effect on the neonates.[4] Muscle relaxants are not recommended
as they can decrease or abolish TcMEPs and affect signal
transmission across the neuromuscular junction.
TcMEP provides invaluable intraoperative information to
monitor motor tracts.[8,16-18] However, it requires electrical
stimulation of the motor cortex to elicit evoked potential in all
muscles. This is accompanied by a muscular contraction in the
whole body, and the amplitude of this contraction increases with
the strength of stimulation, and thus, can precipitate fetal distress
or preterm labor. Hence, the risk can be minimized by titrating
the IONM protocols to elicit the best response with minimal
stimulation and adequate monitoring and readiness in the face
of precipitation of adverse events. SSEP, on the other hand,
can be safely used in pregnant patients as it involves localized
stimulation of the peripheral nerves with no risk of generalized
body movement or great electrical spread.[1] However, SSEP can
only indicate the status of the sensory tract, whereas it is the
motor deficit that can reduce the duration for the persistence of
injury and has a greater impact on the quality of life.[19]
Table 1 describes the IONM protocols and anesthesia techniques
used during IONM in pregnant patients. It includes using the
lowest possible currents and limiting the TcMEP stimulations to
get evoked potentials.[6] Local stimulation at a distance from the
abdominal cavity with 2 cm inter‑electrode distance for SSEP
recordings was used by one author to minimize the effect of
electrical field on myometrium.[1] No substantial changes were
observed either in the uterus muscle tone or FHR with a voltage
of 340 V. Reducing the number of TcMEP stimulation trains,
limiting the voltage strength to 500 V, using a multimodality
approach to IOMN, along with continuous monitoring of the
fetal heart activity have been described in the literature.[7] In
our case, the stimulation strength was gradually increased
from 50 V with continuous monitoring of fetal heart rate and
was limited to 500 V to reduce risk.
There are no guidelines for fetal monitoring in cases with
IONM. If the fetus is considered pre‑viable (<24‑28 weeks),
it is sufficient to ascertain fetal heart monitoring using the
Doppler pre‑ and post‑procedure.[9] Intraoperative electronic
fetal monitoring is recommended in a viable fetus and when
there are provisions and consent for emergency cesarean
section for fetal indications.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient (s) has/have
given his/her/their consent for his/her/their images and
S316
other clinical information to be reported in the journal. The
patients understand that their names and initials will not be
published and due efforts will be made to conceal their identity,
but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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