Basic Principles and Recent Trends of Transcranial Motor Evoked Potentials in Intraoperative Neurophysiologic Monitoring

Abstract

Transcranial motor evoked potentials (TcMEPs), which are muscle action potentials elicited by transcranial brain stimulation, have been the most popular method for the last decade to monitor the functional integrity of the motor system during surgery. It was originally difficult to record reliable and reproducible potentials under general anesthesia, especially when inhalation-based anesthetic agents that suppressed the firing of anterior horn neurons were used. Advances in anesthesia, including the introduction of intravenous anesthetic agents, and progress in stimulation techniques, including the use of pulse trains, improved the reliability and reproducibility of TcMEP responses. However, TcMEPs are much smaller in amplitude compared with compound muscle action potentials evoked by maximal peripheral nerve stimulation, and vary from one trial to another in clinical practice, suggesting that only a limited number of spinal motor neurons innervating the target muscle are excited in anesthetized patients. Therefore, reliable interpretation of the critical changes in TcMEPs remains difficult and controversial. Additionally, false negative cases have been occasionally encountered. Recently, several facilitative techniques using central or peripheral stimuli, preceding transcranial electrical stimulation, have been employed to achieve sufficient depolarization of motor neurons and augment TcMEP responses. These techniques might have potentials to improve the reliability of intraoperative motor pathway monitoring using TcMEPs.

Fig. 1.

A schematic of the multi-train stimulation (MTS) technique, in which a pulse train is delivered repeatedly at constant repetitive rates (e.g., 2 Hz, 5 Hz, and 10 Hz). A pulse train consists of five biphasic stimuli with 0.5-ms in duration (two phases of 0.25 ms in each stimulus) and an inter-pulse interval of 2 ms. Transcranial motor evoked potentials are recorded from a pair of needle electrodes inserted in the muscle belly of the abductor hallucis (AH).

Fig. 2.

The within-patient variability of the amplitude of transcranial motor evoked potentials recorded from the abductor halluces muscle, which is assessed with the coefficient of variation (CV: standard deviation/mean). There is a statistically significant difference in CV between single-train stimulation (STS) and multi-train stimulation (MTS) (*p = 0.026, Mann-Whitney U test).

Fig. 3.

The trial-to-trial variability of transcranial motor evoked potentials recorded from the abductor halluces muscle. Multi-train stimulation (MTS) can reduce the trial-to-trial variability, and enables to obtain more stable responses throughout a surgery when compared to single-train stimulation (STS).