title: Intraoperative neurophysiological monitoring during spine surgery with total intravenous anesthesia or balanced anesthesia with 3% desflurane.
abstract: Total intravenous anesthesia (TIVA) with propofol and opioids is frequently utilized for spinal surgery when somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (tcMEPs) are monitored. Many anesthesiologists would prefer to utilize low dose halogenated anesthetics (e.g. 1/2 MAC). We examined our recent experience using 3% desflurane or TIVA during spine surgery to determine the impact on propofol usage and on the evoked potential responses. After institutional review board approval we conducted a retrospective review of a 6 month period for adult spine patients who were monitored with SSEPs and tcMEPs. Cases were included for the study if anesthesia was conducted with propofol-opioid TIVA or 3% desflurane supplemented with propofol or opioid infusions as needed. We evaluated the propofol infusion rate, cortical amplitudes of the SSEPs (median nerve, posterior tibial nerve), amplitudes and stimulation voltage for eliciting the tcMEPs (adductor pollicis brevis, tibialis anterior) and the amplitude variability of the SSEP and tcMEP responses as assessed by the average percentage trial to trial change. Of the 156 spine cases included in the study, 95 had TIVA with propofol-opioid (TIVA) and 61 had 3% expired desflurane (INHAL). Three INHAL cases were excluded because the desflurane was eliminated because of inadequate responses and 26 cases (16 TIVA and 10 INHAL) were excluded due to significant changes during monitoring. Propofol infusion rates in the INHAL group were reduced from the TIVA group (average 115-45 μg/kg/min) (p<0.00001) with 21 cases where propofol was not used. No statistically significant differences in cortical SSEP or tcMEP amplitudes, tcMEP stimulation voltages nor in the average trial to trial amplitude variability were seen. The data from these cases indicates that 1/2 MAC (3%) desflurane can be used in conjunction with SSEP and tcMEP monitoring for some adult patients undergoing spine surgery. Further studies are needed to confirm the relative benefits versus negative effects of the use of desflurane and other halogenated agents for anesthesia during procedures on neurophysiological monitoring involving tcMEPs. Further studies are also needed to characterize which patients may or may not be candidates for supplementation such as those with neural dysfunction or who are opioid tolerant from chronic use.
authors.affiliation: Department of Anesthesiology, Anschutz Office West (AO1), MS 8202, University of Colorado Denver School of Medicine, 12631 E 17th Avenue, Aurora, CO, 80045, USA, Tod.Sloan@ucdenver.edu.
authors.forename: Tod B
authors.initials: TB
authors.lastname: Sloan
authors.forename: J Richard
authors.initials: JR
authors.lastname: Toleikis
authors.forename: Sandra C
authors.initials: SC
authors.lastname: Toleikis
authors.forename: Antoun
authors.initials: A
authors.lastname: Koht
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000737:chemistry; D000771:Anesthesia, Intravenous / Q000379:methods*; D058126:Balanced Anesthesia / Q000379:methods*; D000077335:Desflurane; D004594:Electrophysiology; D019054:Evoked Potentials, Motor / Q000502:physiology; D005073:Evoked Potentials, Somatosensory / Q000502:physiology; D005260:Female; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D007530:Isoflurane / Q000008:administration & dosage / Q000031:analogs & derivatives*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D015742:Propofol / Q000008:administration & dosage; D012189:Retrospective Studies; D013116:Spinal Cord / Q000601:surgery*; D013997:Time Factors; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D000077335:Desflurane; D007530:Isoflurane; D015742:Propofol