Download PDF
J Neurol Surg A Cent Eur Neurosurg 2019; 80(02): 102-108
DOI: 10.1055/s-0038-1676623
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Cutoff Points, Sensitivities, and Specificities of Intraoperative Motor-Evoked Potential Monitoring Determined Using Receiver Operating Characteristic Analysis

Satoshi Tanaka
1   Department of Neurosurgery, IMS Miyoshi General Hospital, Saitama, Japan
,
Jiro Akimoto
2   Center of Brain and Health Science, Aomori University, Aomori, Japan
,
Ryo Hashimoto
3   Department of Neurosurgery, Tokyo Medical University, Shinjyuku-ku, Tokyo, Japan
,
Junko Takanashi
4   Department of Neurosurgery, Tokyo Medical University Hachiooji Medical Center, Hachiooji-city, Tokyo, Japan
,
Hidehiro Oka
5   Department of Clinical Laboratory, Kitasato University Medical Center, Kitamoto-city, Saitama, Japan
› Author Affiliations
Further Information

Publication History

02 September 2017

16 April 2018

Publication Date:
24 December 2018 (online)

Also available at
    Permissions and Reprints

Abstract

Background Although intraoperative motor-evoked potential (MEP) monitoring is widely performed during neurosurgical operations, evaluating its results is controversial.

Study Aims The cutoff point of MEP monitoring should be determined not only to predict but also to prevent postoperative neurologic deficits.

Material and Methods MEP monitoring was performed during 484 neurosurgical operations for patients without definitive preoperative motor palsy including 325 spinal operations, 102 cerebral aneurysmal operations, and 57 brain tumor operations, all monitored by transcranial stimulation, and 34 brain tumor operations monitored under direct cortical stimulation. To exclude the effects of muscle relaxants on MEP, the compound muscle action potential (CMAP), measured immediately after transcranial stimulation or direct cortical stimulation at supramaximal stimulation of the peripheral nerve, was used for normalization. The cutoff points, sensitivity, and specificity of MEP recorded during neurosurgery were examined by receiver operating characteristic (ROC) analyses and categorized according to the type of operation and stimulation.

Results In spinal operations under transcranial stimulation, amplitude reduction of 77.9% and 80.6% as cutoff points for motor palsy with and without CMAP normalization, respectively, provided a sensitivity of 100% and specificity of 96.8% and 96.5%. In aneurysmal operations under transcranial stimulation, cutoff points of 70.7% and 69.6% offered specificities of 95.2% and 95.7% with and without CMAP normalization, respectively. The sensitivities for both were 100%. In brain tumor operations under direct stimulation, cutoff points were 83.5% and 86.3% with or without CMAP normalization, respectively, and the sensitivity and specificity for both were 100%.

Conclusion An amplitude decrease of 80% in brain tumor operations, 75% in spinal operations, and 70% in aneurysmal operations should be used as the cutoff points.

Keywords

motor-evoked potential - transcranial stimulation - compound muscle action potential - receiver operating characteristic
 

  • References

  • 1 Morota N, Deletis V, Constantini S, Kofler M, Cohen H, Epstein FJ. The role of motor evoked potentials during surgery for intramedullary spinal cord tumors. Neurosurgery 1997; 41 (06) 1327-1336
    CrossrefPubMedSearch in Google Scholar
  • 2 Szelényi A, Bueno de Camargo A, Flamm E, Deletis V. Neurophysiological criteria for intraoperative prediction of pure motor hemiplegia during aneurysm surgery. Case report. J Neurosurg 2003; 99 (03) 575-578
    CrossrefPubMedSearch in Google Scholar
  • 3 Burke D, Hicks RG. Surgical monitoring of motor pathways. J Clin Neurophysiol 1998; 15 (03) 194-205
    CrossrefPubMedSearch in Google Scholar
  • 4 Kombos T, Kopetsch O, Suess O, Brock M. Does preoperative paresis influence intraoperative monitoring of the motor cortex?. J Clin Neurophysiol 2003; 20 (02) 129-134
    CrossrefPubMedSearch in Google Scholar
  • 5 Kaneko M, Fukamachi A, Sasaki H, Miyazawa N, Yagishita T, Nukui H. Intraoperative monitoring of the motor function: experimental and clinical study. Acta Neurochir Suppl (Wien) 1988; 42: 18-21
    PubMedSearch in Google Scholar
  • 6 Levy Jr WJ. Clinical experience with motor and cerebellar evoked potential monitoring. Neurosurgery 1987; 20 (01) 169-182
    PubMedSearch in Google Scholar
  • 7 Iwasaki M, Kuroda S, Niiya Y, Ishikawa T, Iwasaki Y. Sensitivity of motor evoked potential (MEP) to intraoperative cerebral ischemia: Case report [in Japanese]. Japan J Neurosurg (Toyko) 2008; 17: 622-626
    PubMedSearch in Google Scholar
  • 8 MacDonald DB. Safety of intraoperative transcranial electrical stimulation motor evoked potential monitoring. J Clin Neurophysiol 2002; 19 (05) 416-429
    CrossrefPubMedSearch in Google Scholar
  • 9 Rothwell J, Burke D, Hicks R, Stephen J, Woodforth I, Crawford M. Transcranial electrical stimulation of the motor cortex in man: further evidence for the site of activation. J Physiol 1994; 481 (Pt 1): 243-250
    CrossrefPubMedSearch in Google Scholar
  • 10 Zhou HH, Kelly PJ. Transcranial electrical motor evoked potential monitoring for brain tumor resection. Neurosurgery 2001; 48 (05) 1075-1080 ; discussion 1080–1081
    PubMedSearch in Google Scholar
  • 11 Macdonald DB, Skinner S, Shils J, Yingling C. ; American Society of Neurophysiological Monitoring. Intraoperative motor evoked potential monitoring—a position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol 2013; 124 (12) 2291-2316
    CrossrefPubMedSearch in Google Scholar
  • 12 Metz CE, Goodenough DJ, Rossmann K. Evaluation of receiver operating characteristic curve data in terms of information theory, with applications in radiography. Radiology 1973; 109 (02) 297-303
    CrossrefPubMedSearch in Google Scholar
  • 13 Smith I, White PF, Nathanson M, Gouldson R. Propofol. An update on its clinical use. Anesthesiology 1994; 81 (04) 1005-1043
    CrossrefPubMedSearch in Google Scholar
  • 14 Spielholz NI, Benjamin MV, Engler GL, Ransohoff J. Somatosensory evoked potentials during decompression and stabilization of the spine. Methods and findings. Spine 1979; 4 (06) 500-505
    CrossrefPubMedSearch in Google Scholar
  • 15 Tanaka S, Kobayashi I, Sagiuchi T. , et al. Compensation of intraoperative transcranial motor-evoked potential monitoring by compound muscle action potential after peripheral nerve stimulation. J Clin Neurophysiol 2005; 22 (04) 271-274
    CrossrefPubMedSearch in Google Scholar
  • 16 Tanaka S, Tashiro T, Gomi A, Takanashi J, Ujiie H. Sensitivity and specificity in transcranial motor-evoked potential monitoring during neurosurgical operations. Surg Neurol Int 2011; 2: 111-118
    CrossrefPubMedSearch in Google Scholar
  • 17 Yamamoto T, Katayama Y, Nagaoka T, Kobayashi K, Fukaya C. Intraoperative monitoring of the corticospinal motor evoked potential (D-wave): clinical index for postoperative motor function and functional recovery. Neurol Med Chir (Tokyo) 2004; 44 (04) 170-180 ; discussion 181–182
    CrossrefPubMedSearch in Google Scholar
  • 18 Langeloo DD, Lelivelt A, Louis Journée H, Slappendel R, de Kleuver M. Transcranial electrical motor-evoked potential monitoring during surgery for spinal deformity: a study of 145 patients. Spine 2003; 28 (10) 1043-1050
    PubMedSearch in Google Scholar
  • 19 Suzuki K, Kodama N, Sasaki T. , et al. Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 2003; 98 (03) 507-514
    CrossrefPubMedSearch in Google Scholar
  • 20 Tanaka SK, Iwamoto KT, Sagiuchi TJ, Takanashi J, Sato S, Fujii K. Efficacy of intraoperative transcranial motor evoked potential monitoring in cerebrovascular disease [in Japanese]. Surg Cereb Stroke 2004; 32: 431-436
    CrossrefPubMedSearch in Google Scholar
  • 21 Quiñones-Hinojosa A, Lyon R, Zada G. , et al. Changes in transcranial motor evoked potentials during intramedullary spinal cord tumor resection correlate with postoperative motor function. Neurosurgery 2005; 56 (05) 982-993 ; discussion 982–993
    PubMedSearch in Google Scholar
  • 22 Legatt AD, Emerson RG, Epstein CM. , et al. ACNS guideline: Transcranial electrical stimulation motor evoked potential monitoring. J Clin Neurophysiol 2016; 33 (01) 42-50
    CrossrefPubMedSearch in Google Scholar
  • 23 Yamamoto T, Katayama Y, Fukaya C, Kurihara J, Kasai M, Maeda M. Comparison of the descending spinal cord evoked potentials with direct motor cortex stimulation and with transcranial brain stimulation [in Japanese]. Clin Electroencephalogr 1998; 40: 162-166
    PubMedSearch in Google Scholar
  • 24 Takanashi J, Tanaka S. Efficacy of transcranial high-voltage motor evoked potential as neurosurgical intraoperative monitoring [in Japanese]. Jpn J Clin Neurophysiol 2004; 32: 4-11
    PubMedSearch in Google Scholar
  • 25 McLellan DL. The electromyographic silent period produced by supramaximal electrical stimulation in normal man. J Neurol Neurosurg Psychiatry 1973; 36 (03) 334-341
    CrossrefPubMedSearch in Google Scholar
  • 26 Neuloh G, Pechstein U, Schramm J. Motor tract monitoring during insular glioma surgery. J Neurosurg 2007; 106 (04) 582-592
    CrossrefPubMedSearch in Google Scholar
  • 27 Szelényi A, Hattingen E, Weidauer S, Seifert V, Ziemann U. Intraoperative motor evoked potential alteration in intracranial tumor surgery and its relation to signal alteration in postoperative magnetic resonance imaging. Neurosurgery 2010; 67 (02) 302-313
    CrossrefPubMedSearch in Google Scholar
  • 28 Lyon R, Feiner J, Lieberman JA. Progressive suppression of motor evoked potentials during general anesthesia: the phenomenon of “anesthetic fade.”. J Neurosurg Anesthesiol 2005; 17 (01) 13-19
    PubMedSearch in Google Scholar
  • 29 Tanaka S, Hirao J, Oka H, Akimoto J, Takanashi J, Yamada J. Intraoperative monitoring during decompression of the spinal cord and spinal nerves using transcranial motor-evoked potentials: the law of twenty percent. J Clin Neurosci 2015; 22 (09) 1403-1407
    CrossrefPubMedSearch in Google Scholar