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Physiologic and anesthetic predictors of false-positive motor-evoked potential alerts during pediatric spine surgery
Alex La Poche1,2, Austin Montgomery3, John Sestito4
1Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. alex.lapoche@downstate.edu.
Insights
False-positive transcranial motor-evoked potential (tcMEP) alerts during pediatric spinal surgery are often linked to bispectral index (BIS) suppression. Monitoring BIS may help prevent unnecessary surgical delays caused by these false alerts.
Area of Science:
- Anesthesiology
- Neurophysiology
- Pediatric Surgery
Background:
- False-positive transcranial motor-evoked potential (tcMEP) alerts can disrupt pediatric spinal deformity surgery.
- Standardized total intravenous anesthesia (TIVA) aims to maintain stable anesthetic conditions.
Purpose of the Study:
- To identify anesthetic and physiologic predictors of false-positive tcMEP alerts.
- To evaluate the role of bispectral index (BIS) monitoring in differentiating false-positive from true-positive alerts during TIVA.
Main Methods:
- A cohort study of pediatric spinal deformity surgeries with intraoperative tcMEP alerts was conducted.
- Alerts were classified as false positive (FP), true positive (TP), or true negative (TN).
- Anesthetic variables, including BIS and electroencephalography (EEG) suppression, were analyzed alongside physiologic data.
Main Results:
- BIS values were significantly lower during FP alerts (28.8) compared to TP (53.6) or TN (40.1) alerts (p < 0.001).
- EEG suppression occurred in 36.4% of FP alerts versus 0% of TP and 0.9% of TN events (p < 0.001).
- BIS demonstrated outstanding discrimination between FP and TP alerts (AUC 0.924).
Conclusions:
- BIS suppression strongly correlates with false-positive tcMEP alerts in pediatric spinal surgery.
- Integrating BIS monitoring into decision-making can help reduce unnecessary surgical interruptions.
- This approach may improve surgical management by distinguishing false alarms from true neurologic events.
Purpose:
False-positive transcranial motor-evoked potential (tcMEP) alerts during pediatric spinal deformity surgery can delay or alter surgical management. This cohort study evaluated anesthetic and physiologic predictors of false-positive alerts under standardized total intravenous anesthesia (TIVA).
Methods:
All pediatric spine deformity surgeries with intraoperative tcMEP alerts (June-November 2024) at a single tertiary center were identified from a quality registry. Alerts were classified as false positive (FP), true positive (TP), or true negative (TN) by intraoperative assessment and postoperative outcomes. Standardized total intravenous anesthesia with bispectral index (BIS) and electroencephalography (EEG) monitoring was used. Physiologic and anesthetic variables were retrospectively extracted and compared using appropriate parametric and nonparametric tests (p < 0.05).
Results:
Of 99 patients during the study period, 15 experienced tcMEP alerts, yielding 631 timepoints: 80 FP, 13 TP, and 538 TN. BIS values were significantly lower during FP alerts (28.8 ± 14.5) than TP (53.6 ± 9.9) or TN (40.1 ± 12.9) (p < 0.001). EEG suppression occurred in 36.4% of FP timepoints but in 0% of TP and 0.9% of TN events (p < 0.001). Receiver operating characteristic (ROC) analysis showed that BIS had outstanding discrimination between false-positive and true-positive alerts (AUC 0.924, 95% CI: 0.823-1.00).
Conclusion:
Periods of BIS suppression, in the setting of stable hemodynamics and anesthetic delivery, strongly correlate with false-positive tcMEP alerts. Incorporating BIS into intraoperative decision-making may help distinguish false positives from true neurologic injury, reducing unnecessary interruptions in pediatric spinal deformity surgery.
