Successful Motor Evoked Potential Monitoring in Cervical Myelopathy : Related Factors and the Effect of Increased Stimulation Intensity

Abstract

Objective: Intraoperative neurophysiological monitoring (IONM) has been widely used during spine surgery to reduce or prevent neurologic deficits, however, its application to the surgical management for cervical myelopathy remains controversial. This study aimed to assess the success rate of IONM in patients with cervical myelopathy and to investigate the factors associated with successful baseline monitoring and the effect of increasing the stimulation intensity by focusing on motor evoked potentials (MEPs).

Methods: The data of 88 patients who underwent surgery for cervical myelopathy with IONM between January 2016 and June 2018 were retrospectively reviewed. The success rate of baseline MEP monitoring at the initial stimulation of 400 V was investigated. In unmonitorable cases, the stimulation intensity was increased to 999 V, and the success rate final MEP monitoring was reinvestigated. In addition, factors related to the success rate of baseline MEP monitoring were investigated using independent t-test, Wilcoxon rank-sum test, chi-squared test, and Fisher's exact probability test for statistical analysis. The factors included age, sex, body mass index, diabetes mellitus, smoking history, symptom duration, Torg-Pavlov ratio, space available for the cord (SAC), cord compression ratio (CCR), intramedullary increased signal intensity (SI) on magnetic resonance imaging, SI length, SI ratio, the Medical Research Council (MRC) grade, the preoperative modified Nurick grade and Japanese Orthopedic Association (JOA) score.

Results: The overall success rate for reliable MEP response was 52.3% after increasing the stimulation intensity. No complications were observed to be associated with increased intensity. The factors related to the success rate of final MEP monitoring were found to be SAC (p<0.001), CCR (p<0.001), MRC grade (p<0.001), preoperative modified Nurick grade (p<0.001), and JOA score (p<0.001). The cut-off score for successful MEP monitoring was 5.67 mm for SAC, 47.33% for the CCR, 3 points for MRC grade, 2 points for the modified Nurick grade, and 12 points for the JOA score.

Conclusion: Increasing the stimulation intensity could significantly improve the success rate of baseline MEP monitoring for unmonitorable cases at the initial stimulation in cervical myelopathy. In particular, the SAC, CCR, MRC grade, preoperative Nurick grade and JOA score may be considered as the more important related factors associated with the success rate of MEP monitoring. Therefore, the degree of preoperative neurological functional deficits and the presence of spinal cord compression on imaging could be used as new detailed criteria for the application of IONM in patients with cervical myelopathy.

Keywords: Cervical myelopathy; Evoked potentials, Motor; Stimulation intensity; Success rate.

Fig. 1.

Measurements of the preoperative radiological factors in cervical myelopathy. A : Torg-Pavlov ratio (a/b). B : Space available for the cord (b-a). C : Cord compression ratio (a/b). D : SI ratio (a/b). E : SI grade. F : SI length. SI : signal intensity.

Fig. 2.

The graphs show the success rate of motor evoked potentials according to the signal intensity, and total success rate increased by 1.48 folds.

Fig. 3.

The graphs show the success rate associated with each preoperative neurologic factors. A : Medical Research Council grade. B : Modified Nurick grade. C : Modified Japanese Orthopedic Association score.

Fig. 4.

The graphs represent the receiver operating characteristics (ROC) curves of important relevant factors for success of obtaining motor evoked potentials (MEPs). A : Space available for the cord (SAC). B : Cord compression ratio (CCR). C : Medical Research Council (MRC) grade. D : Modified Nurick grade. E : Modified Japanese Orthopedic Association (JOA) score.