title: Multimodality intraoperative neuromonitoring in extreme lateral interbody fusion. Transcranial electrical stimulation as indispensable rearview.
abstract: To optimize intraoperative neuromonitoring during extreme lateral interbody fusion (XLIF) by adding transcranial electrical stimulation with motor evoked potential (TESMEP) to previously described monitoring using spontaneous EMG (sEMG) and peripheral stimulation (triggered EMG: tEMG).
  
  
  
  Twenty-three patients with degenerative lumbar scoliosis had XLIF procedures and were monitored using sEMG, tEMG and TESMEP. Spontaneous and triggered muscle activity, and the MEP of 5 ipsilateral leg muscles, 2 contralateral leg muscles and 1 arm muscle were monitored.
  
  
  
  During XLIF surgery decreased MEP amplitudes were measured in 9 patients and in 6 patients sEMG was documented. In 4 patients, both events were described. In 30 % of the cases (n = 7), the MEP amplitude decreased immediately after breaking of the table and even before skin incision. After reduction of the table break, the MEP amplitudes recovered to baseline. In two patients, the MEP amplitude deteriorated during distraction of the psoas with the retractor, while no events were reported using sEMG and tEMG. Repositioning of the retractor led to recovery of the MEP.
  
  
  
  Monitoring the complete nervous system during an XLIF procedure is found to be helpful since nerve roots, lumbar plexus as well as the intradural neural structures may be at risk. TESMEP has additional value to sEMG and tEMG during XLIF procedure: (1) it informed about otherwise unnoticed events, and (2) it confirmed and added information to events measured using sEMG.
authors: Department of Anesthesiology, Sint Maartenskliniek, P.O. Box 9011, 6500 GM, Nijmegen, The Netherlands. h.berends@maartenskliniek.nl.
authors: Hanneke I
authors: HI
authors: Berends
authors: Ortho-Spine Research Department, Sint Maartenskliniek, Nijmegen, The Netherlands.
authors: Henricus L
authors: HL
authors: Journée
authors: Department of Anesthesiology, Sint Maartenskliniek, P.O. Box 9011, 6500 GM, Nijmegen, The Netherlands.
authors: Ilona
authors: I
authors: Rácz
authors: Department of Orthopedics, Sint Maartenskliniek, Nijmegen, The Netherlands.
authors: Jan
authors: J
authors: van Loon
authors: Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, USA.
authors: Roger
authors: R
authors: Härtl
authors: Department of Orthopedics, Sint Maartenskliniek, Nijmegen, The Netherlands.
authors: Maarten
authors: M
authors: Spruit
mesh_terms: D004576:Electromyography; D019054:Evoked Potentials, Motor; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D059348:Peripheral Nerve Injuries / Q000517:prevention & control; D012600:Scoliosis / Q000601:surgery; D013123:Spinal Fusion / Q000379:methods*; D065908:Transcranial Direct Current Stimulation
keywords: Intraoperative neuromonitoring; TESMEP; Transcranial electrical stimulation; XLIF