{"id":"7869f3cb-ca00-4c3a-923e-9a97fda1cedf","slug":"the-need-to-add-motor-evoked-potential-monitoring-to-somatosensory-and-electromyographic-monitoring-in-cervical-spine-surgery","title":"The need to add motor evoked potential monitoring to somatosensory and electromyographic monitoring in cervical spine surgery","authors":["Nancy E. Epstein"],"abstract":"Intraoperative neural monitoring (IONM), utilizing somatosensory evoked potentials (SEP) and electromyography (EMG), was introduced to cervical spine surgery in the late 1980's. However, as SEP only provided physiological data regarding the posterior cord, new motor deficits were observed utilizing SEP alone. This prompted the development of motor evoked potential monitoring (MEP) which facilitated real-time assessment of the anterior/anterolateral spinal cord. Although all three modalities, SEP, EMG, and MEP, are routinely available for IONM of cervical spine procedures, MEP are not yet routinely employed. The purpose of this review is to emphasize that MEP should now routinely accompany SEP and EMG when performing IONM of cervical spine surgery. Interestingly, one of the most common reasons for malpractice suits involving the cervical spine, is quadriparesis/quadriplegia following a single level anterior cervical diskectomy and fusion (ACDF). Previously, typical allegations in these suits included; negligent surgery, lack of informed consent, failure to diagnose/treat, and failure to brace. Added to this list, perhaps, as the 5th most reason for a suit will be failure to monitor with MEP. This review documents the value of MEP monitoring in addition to SEP and EMG monitoring in cervical spine surgery. The addition of MEP0 should minimize major motor injuries, and more accurately and reliably detect impending anterior cord deterioration that may be missed with SEP monitoring alone. At times, editorials provide guidance as to how to perform a procedure, or select patients for a specific operation. However, in this case, this editorial is focused on why it is essential that more and more spine surgeons utilize intraoperative motor evoked potential monitoring (MEP) to supplement the more commonly employed somatosensory evoked potentials (SEP) and electromyography (EMG). Even if one cannot recall an instance in which MEP helped avoid a neurological deficit, one can read the medicolegal literature to find a plethora of cases in which MEP were not performed and patients incurred major deficits (e.g. quadriplegia, paraplegia). With the availability of TIVA (total intravenous anesthesia), real-time MEP monitoring is feasible, and there is no “waiting”. While some spine surgeons may think they have to perform cervical operations with the patient paralyzed in order to avoid motion during critical phases, those of us who perform these procedures with TIVA and MEP without paralysis think otherwise. Whether operating on the anterior or posterior cervical spinal cord, MEP provide critical and essential information regarding the status of the anterior or anterolateral cervical cord that may be missed by SEP. Those presuming that MEP are only important when dealing with anterior cervical disease are sadly mistaken; MEP can pick up changes and frequently do when both anterior or posterior cervical surgical procedures go awry. Certainly, the evidence points to the value of SEP and MEP monitoring when operating on the spinal cord or spine. This is the principle I follow in my practice from the evidence in the literature and my own experience. Under optimal circumstances, patients should be transferred to a place where this technology is available or the patient and or family should be informed that the circumstances do not permit this technological addition to the surgery, and therefore, the risks will be higher of spinal cord damage. However, I am fully aware that in different places one or both of these options may not be available. Then what do they do? Are they guilty of malpractice? Say in a small community far from a neurological monitoring source? Or in another country? There is no set answer for all circumstances. Nevertheless, when given the option to include MEP, the answer should typically be in the affirmative.","thumbnailUrl":"https://sni-digital-videos.s3.amazonaws.com/articles/7869f3cb-ca00-4c3a-923e-9a97fda1cedf/featured/hero-1782421017427.png","publishDate":"2013-10-29T00:00:00.000Z","doi":"10.4103/2152-7806.120782","categories":["Original Article"],"fullTextUrl":"https://surgicalneurologyint.com/api/articles/7869f3cb-ca00-4c3a-923e-9a97fda1cedf/pdf"}