Intraoperative monitoring of motor evoked potentials in very young children
Daniel H Fulkerson1, Krishna B Satyan, Lillian M Wilder
1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA.
Insights
Motor evoked potentials (MEPs) monitoring is safe and reliable in young children undergoing spine surgery. A significant decrease in MEPs can predict postoperative neurological deficits, supporting routine use in pediatric neurosurgery.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Neurophysiology
Background:
- Motor evoked potentials (MEPs) are crucial for monitoring during complex spine surgeries in adults.
- Clinical data on MEP use in pediatric patients, especially those younger than 3 years, is limited.
- Assessing the safety and reliability of MEPs in this young demographic is essential for surgical risk reduction.
Purpose of the Study:
- To evaluate the safety and reliability of neurophysiological monitoring using motor evoked potentials (MEPs) in children under 3 years old.
- To determine the efficacy of MEP monitoring during complex neurosurgical spine procedures in infants and toddlers.
- To establish the predictive value of MEP changes for postoperative neurological outcomes in this pediatric age group.
Main Methods:
- Analyzed 10 consecutive spinal procedures in children younger than 3 years (5-31 months).
- Utilized transcranial electric stimulation to elicit motor evoked potentials (MEPs).
- Implemented a standardized anesthesia protocol with propofol and fentanyl/sufentanil for monitoring.
Main Results:
- MEPs were successfully monitored at the beginning and end of surgery in all 10 patients.
- Six patients maintained MEP signals at or above 50% of baseline amplitude throughout the procedure.
- Two patients with persistent intraoperative MEP amplitude decrease (>50%) showed correlated postoperative weakness, while two others recovered.
- No complications were associated with the MEP monitoring technique itself.
Conclusions:
- A transcranial electric stimulation protocol for MEP monitoring is safe and reliable in children under 3 years undergoing neurosurgical spine procedures.
- A persistent intraoperative MEP decrease greater than 50% can predict postoperative neurological deficits in this age group.
- Routine MEP monitoring is recommended for pediatric patients younger than 3 years undergoing neurosurgical spine procedures to enhance surgical safety.
Object:
Neurophysiological monitoring of motor evoked potentials (MEPs) during complex spine procedures may reduce the risk of injury by providing feedback to the operating surgeon. While this tool is a well-established surgical adjunct in adults, clinical data in children are sparse. The purpose of this study was to determine the reliability and safety of MEP monitoring in a group of children younger than 3 years of age undergoing neurosurgical spine procedures.
Methods:
A total of 10 consecutive spinal procedures in 10 children younger than 3 years of age (range 5-31 months, mean 16.8 months) were analyzed between January 1, 2008, and May 1, 2010. Motor evoked potentials were elicited by transcranial electric stimulation. A standardized anesthesia protocol for monitoring consisted of a titrated propofol drip combined with bolus dosing of fentanyl or sufentanil.
Results:
Motor evoked potentials were documented at the beginning and end of the procedure in all 10 patients. A mean baseline stimulation threshold of 533 ± 124 V (range 321-746 V) was used. Six patients maintained MEP signals ≥ 50% of baseline amplitude throughout the surgery. There was a greater than 50% decrease in intraoperative MEP amplitude in at least 1 extremity in 4 patients. Two of these patients returned to baseline status by the end of the case. Two patients had a persistent decrement or variability in MEP signals at the end of the procedure; this correlated with postoperative weakness. There were no complications related to the technique of monitoring MEPs.
Conclusions:
A transcranial electric stimulation protocol monitoring corticospinal motor pathways during neurosurgical procedures in children younger than 3 years of age was reliably and safely implemented. A persistent intraoperative decrease of greater than 50% in this small series of 10 pediatric patients younger than 3 years of age predicted a postoperative neurological deficit. The authors advocate routine monitoring of MEPs in this pediatric age group undergoing neurosurgical spine procedures.
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