Use of Posterior Root-Muscle Reflexes in Peripheral Nerve Surgery: A Case Report

It is well established that a mixed-agent general anesthetic regimen of volatile gas and intravenous anesthetic or total intravenous anesthetic (TIVA) is required to obtain adequate transcranial motor-evoked potentials (TcMEPs) to detect and hopefully prevent injury during brain, spinal cord, and peripheral nerve surgery. But even under ideal general anesthetic conditions, TcMEPs are not always detectable in every muscle monitored, and are prone to anesthetic fade, especially when neuropathic or injured tissue is monitored. TcMEP sensitivity to general anesthesia can be especially problematic during peripheral nerve surgery where there is often only one or a few essential muscles required to provide adequate monitoring; thus, maximum fidelity is essential. However, there is an anesthetic-resistant high-fidelity modality available to successfully monitor the motor component of distant peripheral nerves originating from the cauda equina. Percutaneus transabdominal electrical stimulation elicits a relatively anesthetic-resistant, robust motor response in muscles innervated by cauda equina nerve roots. We report the successful use of posterior root-muscle (PRM) reflex to monitor the decompression of the sciatic nerve at its bifurcation in a 22-year-old female with a history of severe sciatic nerve neuropathic pain and muscle weakness following benign thigh tumor resection.