2017 Certificated for neurophysiology and neuromuscular disease consultant by

Indonesian Neurology Association

ASPEK ANASTESI PADA NEUROPHYSIOLOGY
INTRAOPERATIVE MONITORING (IOM)

NEUROLOGY DEPARTEMENT
dr. Ahmad Yanuar Safri, SpS (K) FACULTY OF MEDICINE
UNIVERSITAS INDONESIA
CIPTO MANGUNKUSUMO GENERAL HOSPITAL
Optimal outcome in spine surgery is
dependent of the coordination of
efforts by the surgeon,
anesthesiologist, and
neurophysiologist
Pajewski, et al. Eur Spine J. 2007;16(Suppl 2):115-29.
TUJUAN NEUROPHYSIOLOGY INTRA
OPERATIVE MONITORING
• Mencegah kerusakan jaringan saraf yang
tidak diinginkan selama tindakan
pembedahan dengan menggunakan
pemeriksaan neurofisiologi

• Monitoring fungsi jaringan saraf

• Identifikasidan mapping jaringan saraf

 IOM di RSCM
• 2009-2017
Type Numbers Percent
• 194 cases
(n) (%)
Scoliosis 37 19,1

Spine surgery 77 39,7

Spinal cord tumors 10 5,2
Brain tumors 9 4,6
Cochlea implant 49 25,3
Other 12 6,1
 Type of spine surgery
60
Spine Tumor
50
50 7
40
35
6
30 6
5
20
19
10 4
4
0 6 3
3 2
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Ekstramedula Intramedula
MONITORING

• SSEP
• MEP
• Free run EMG
• BAEP
• EEG
Mapping dan identifikasi jaringan saraf

• Direct Nerve Stimulation

• Motor mapping
• direct cortical mapping
MONITORING SSEP

Left Median nerve

Fz
L R AVERAGING

C5S Fz
Epc Epi 5 cm
L Cz Ch1 N19
R 2 cm C4’-Fz
Ground C3’ Cz’ C4’

Ch3 N13
7 cm 7 cm C5S-Fz

EP
Stimulation Ch4
Epi-Epc

Recording site: 10 20 30 ms

--i ipsilateral Erb’s point (Epi - Epc)

--c contra lateral
Cervical spinous process (C5s- Fz)
Cortex C3’ / C4’ (C3’- Fz ; C4’ - Fz)
Ground electrodes: between recoding and stimulating electrodes
MONITORING MotorEvoked Potential (MEP)

Left side Stimulating motor cotex

Right APB Right AH

MEP MEP

Recording sites
Left and Right
Localization of SEP Waveforms
 Warning Criteria1,2

• Usually 50% drop in amplitude or 10% latency prolongation (50/10)

• Others use 5% latency prolongation, 30% amplitude drop
• Empiric criteria
• Reproducibility of change should be verified
• Brief transient loss of SEP compatible with good recovery
• Even with permanent loss of SEP, only 50% with new deficits3
• Subcortical waveforms may be more reliable than cortical
• Subcortical less sensitive to anesthetics
• Cortical larger amplitude, quicker to reproduce

1. ACNS. J Clin Neurophysiol, 1994.

2. Burke et al. Electroencephalogr Clin Neurophysiol, 1999.
3. Nuwer et al. Electroencephalogr Clin Neurophysiol, 1995.
MONITORING BAEP Stimulating left
V AVERAGING

L FPz
R IV
III
II
Ch1 I
A1-Cz VI
A1 Cz A2 VII
Cz Run 1
M1 M2

Left Right

A1 A2 Ch2
A2-Cz

5 10 ms
BAEP Stimulation
Freerun EMG:
monitoring mechanical manipulation and ischemia, etc.

16
 Types of Spontaneous
EMG Activity
Activity Frequency (Hz) Pattern Morphology

Semiregular and Normal motor unit

Motor unit potentials 10-15 continuous potentials

Neurotonic discharge 50-200 Short burst or long trains Single or groups of MUP

Small single muscle fiber

Fibrillation potentials 1-5 Regular and continuous action potential

Movement artifact Intermittent Irregular Triangular

From: Harper CM, Daube JR. J Clin Neurophysiol. 1998;15:206-216.

Neurotonic Discharge
 Trains of Spontaneous Activity

Train type Morphology Onset/offset Frequency (Hz) Amplitude (uV) Duration

Sinusoidal 100-22, never Milliseconds to

A patter, high Sudden 60-210
frequency sound exceeding 500 several seconds

Irregular Gradual, starting Maximum

B sequence of with spikes or interval 500 ms 20-5,000 Minutes to hours
single bursts between bursts
components

Continuous,
irregular activity
C with overlapping Gradual Continuous 20-5,000 Minutes
components

Romstock J et al. J Neurosurg. 2000;93:586-593.

 A, B and C Trains

Romstock J et al. J Neurosurg. 2000;93:586-593.

 Trains – Outcomes

Train Disease state Health of nerve Duration Outcome

< 0.5 sec No worsening

CPA tumor Healthy 0.5-10 sec Mild worsening
> 10 sec Worsening

A CPA tumor Diseased < 0.5 - > 10 sec Worsening

MVD Healthy Short ≈ 0.5 sec No worsening

B and C No worsening

Prell J et al. J Neurosurg. 2007;106:826-832; Prell J et al. J Clin Neurophysiol. 2008;25:225-232

IDENTIFIKASI

• Direct nerve stimulation :

IDENTIFIKASI KORTEKS MOTORIK
PRIMER
Stimulating motor cortex - EMG response
“Perubahan hasil pemeriksaan
neurofisiologi tidak hanya
diakibatkan kerusakan
jaringan saraf “
 Faktor yang mempengaruhi hasil
pemeriksaan neurofisiologi
• FAKTOR TEKNIS

• FAKTOR FISIOLOGIS

• ZAT ANASTESI
FAKTOR TEKNIS

• Artefak listrik dan alat-alat listrik

• Stimulasi
• Setting perekaman
Technical Issues – Stimulation
PFd- CP4- PFd- CP3-
PFp CP3 PFp CP4

Stimulator issues; stimulation intensity

increased

L Tibial R Tibial

Reproduced with permission from: Tatum WO et al. Handbook of EEG interpretation. Demos Medical Publishing, 2007.
Faktor teknis peletakan elektroda – C1/C2 vs.
C3/C4

RDelt RECR RTri RFDI RADM RAH

setting perekaman: Nocth Filter On/ Off
Setting perekaman : perubahan filter
AKTOR FISIOLOGI YANG MEMPENGARUHI EVOKED POTENTIAL

Factors Notes
Temperature Temp  ~ Latency , amplitude 
GA: vasodilator  temp 
Warmer, blanket, and warm saline

Cardiovascular CBF: >15 mL/min/100 g

Reduced regional blood flow
Surgical devices compression
Position in surgery
Tourniquet
Vasospasms
Vascular compression

Acid Base Hypoxia and pH <7.20 reduce neurons

conductibility
Hemoglobin >8 g/dL (optimum >10 g/dL; Ht 30-32%)
Metabolics K+, Na+, Ca2+, glucose
Husain AM, editor. A practical approach to neurophysiologic intraoperative monitoring. 1st ed. New York: Demos Medical Publishing; 2011.
Van Der Walt JJN, Thomas
JM, Figaji AA. Intraoperative
neurophysiological
monitoring for the
anaesthetist. South Afr J
Anaesth Analg
2013;19(4):197-202
Hypoperfusion
Low Blood Pressure Lower Limb Ischemia

Low Blood Pressure Lower Limb

PFd-PFp CP3-CP3 Ischemia
PFd-PFp CP4-CP3

Reproduced with permission from: Tatum WO et al. Handbook of

EEG interpretation. Demos Medical Publishing, 2007.
EFEK HIPOTENSI PADA SSEP
FAKTOR ANASTESIA

Anesthesia

Hemodynamics
stability
ANESTHESIOLOGY Amnesia

Motionlessness
Rossi A, Steiner LA. Inhaled
anesthetics. In: Ruskin KJ,
Rosenbaum SH, Rampil IJ.
Fundamentals of neuroanesthesia:
a physiologic approach to clinical
practice. New York: Oxford
University Press; 2014.
EFFECT OF GAS ANASTHESIA IN EVOKED POTENTIAL

• Increase in halogenated agent doses: Latency , amplitude 

of cortical SSEP
• Is NOT the chosen modality for MEP monitoring because abolish
the electrical waveform at as low as 0.5 MAC

BAEP S S EP MEP

Late nc y Amplitude Late nc y Amplitude Late nc y Amplitude

De s flurane  0    

Enflurane  0    

Halo thane  0    

Is o flurane  0    

S e vo flurane  0    

N2 O 0  0   

Husain AM, editor. A practical approach to neurophysiologic intraoperative monitoring. 1st ed. New York: Demos Medical Publishing; 2011.
Stacie D. Neuromonitoring basics: optimizing the anesthetic. In: Ruskin KJ, Rosenbaum SH, Rampil IJ. Fundamentals of neuroanesthesia: a physiologic approach to
clinical practice. New York: Oxford University Press; 2014.
 EFEK ANASTHESIA INTRAVENA TERHADAP IOM

BAEP S S EP MEP

Late nc y Amplitude Late nc y Amplitude Late nc y Amplitude

Barbiturate s

Low dose 0 0 0 0  

High dose      

Be nzo diazepine s 0 0    

Opio ids 0 0   0 0

Eto midate 0 0   0 0

Pro po fo l  0    

Ke tamine  0   0 0

Husain AM, editor. A practical approach to neurophysiologic intraoperative monitoring. 1st ed. New York: Demos Medical Publishing; 2011.
 Effect of Anesthetics in Motor Evoked
Potential (MEP)

Degree of Muscle MEP Agents

Suppression

Potent Halogenated agents,

nitrous oxide

Moderate Propofol, benzodiazepines

Little Etomidate, ketamine,

narcotics
 Inhalational vs. Intravenous Anesthetics

Patients in Whom Muscle MEP was Recordable

Isoflurane (n=17) Propofol (n=18)

BIS Range 55-65 58.8% 100%

BIS Range 45-55 17.8% 100%

BIS Range 35-45 11.8% 100%

BIS Range 25-35 5.9% 100%

Chen Z. J Clin Monitoring Computing, 2004.
 Inhalational Anesthetics and MEP

From: Husain. Handbook of EEG, 2007.

 Total Intravenous Anesthesia
• Propofol • Drugs that decrease muscle MEP
• Narcotic (fentanyl, remifentanil) amplitude
• Magnesium
• NMBA
• Ketanserin
• Alpha 2-receptor antagonists
• Almost TIVA
• < 0.5 MAC halogenated gas
• Use of inhalational agent during
induction and closing
Efek berbagai obat anastesia
terhadap IOM
 Barbiturates
• Used as induction and neuroprotector agent
• Cortical SSEP: latency , amplitude 
• Abolish MEP response

• Thiopental
 Given bolus causes temporary latency , amplitude 
• Phenorbarbital
 Don’t induce conductibility changes until the cardiovascular system
colapses1
Midazolam

• No effect on NIOM when given as pre-medication

• Induction (0.2 mg/kgBB) or maintenance dose
 SSEP: latency , amplitude 
 Reduced MEP responses
• EEG: slowing to q waves, but b waves can be found
in frontal region at low dose
Propofol

• Commonly IV agent used because of titrable GABA

effect
• Depression of EEG, SSEP, MEP responses at
induction dose (2 – 5 mg/kgBB) and continuous
dose (8 – 10mg/kgBB / hours)
• Such effects don’t apply when SSEP and MEP
monitored at epidural space
Opioids

• Morphine, Fentanil, Alfentanil, Remifentanil

• The combination allows other IV anesthetic agents
used at lower doses
• Propofol/Opioid
• Little effect on NIOM at high dose
 Remifentanil - Propofol

Ruskin KJ, Rosenbaum SH, Rampil IJ. Fundamentals of neuroanesthesia: a physiologic approach to clinical practice. New York: Oxford University Press; 2014.
Ketamine

• Amplitude increment of BAEP, SSEP, and MEP at both

cortical and spinal cord
• Useful for anesthetic-sensitive NIOM
• EEG: increase in amplitude dan slowing to theta waves
• Side effects
• Increase in ICP
• Delirium and dissociative hallucination in emergence period
 Etomidate

• Amplitude increment of SSEP and MEP

• EEG
• Low dose: proconvulsant
• High dose: waveform supresion
• Side effect: adrenal gland supresion at induction
dose

1. Husain AM, editor. A practical approach to neurophysiologic intraoperative monitoring. 1st ed. New York: Demos Medical Publishing; 2011.
 Muscle relaxants

• Acetylcholine inhibitors
• No effect on BAEP, SSEP, and EEG
• MEP: partial inhibition in train of four (TOF) technique
 Muscle responses recorded after four consecutive stimulus
(0.5 second/stimuli ~ 2 Hz) at peripheral nerves 1
• When contraindicated, MEP recorded while minimal
movement possible

1. Husain AM, editor. A practical approach to neurophysiologic intraoperative monitoring. 1st ed. New York: Demos Medical Publishing; 2011.
Sloan TB. Muscle relaxant use during intraoperative neurophysiologic monitoring. J Clin Monit Comput. 2013;27:35-46.
Sloan TB. Muscle relaxant
use during intraoperative
neurophysiologic
monitoring. J Clin Monit
Comput. 2013;27:35-46.
Kawaguchi M, Furuya H. Intraoperative spinal cord monitoring of motor functions with myogenic motor evoked potentials: a consideration in anesthesia. J Anesth
2004;18:18-28.
Stacie D. Neuromonitoring basics: optimizing the anesthetic. In: Ruskin KJ, Rosenbaum SH, Rampil IJ. Fundamentals of neuroanesthesia: a physiologic approach to
clinical practice. New York: Oxford University Press; 2014.
TERIMA KASIH