INTRAOPERATIVE

NEUROPHYSIOLOGY AND
NEUROMONITORING
Ramsis F. Ghaly, MD, FACS
and

Todd Sloan MD MBA PhD

University of Colorado Health Science Center
 EEG MONITORING UNDER
ANESTHESIA
VISUAL DIAGRAM (COMPRESSED SPECTRAL
ARRAY)
 ANALYSE (SPECTRA)
 COMPRESS AND SPPRESS
 SMOOTH
(Delta Theta Alpha Beta in a diagram Time against Hz)
NUMERICAL VALUES
 BIS
 Bispectral Index
 Set of features on EEG(bispectrum, etal)
combined and correlated with regression to
clinical exam.
 Bispectrum: A measure of the level of
phase coupling in a signal, as well as the
power in the signal
 BISPECTRAL INDEX (BIS)
 DIGITALIZE RAW SURFACE EEG (15-30SEC) AND PROCESS FREQUENCY
AND AMPLITUDE AND CORRELATE TO DEPTH OF ANESTHESIA
 70-75% RECALL OF WORDS OR PICTURES DEPRESSED
 <70% EXPLICIT RECALL SIGNIFICANTLY DEPRESSED
 60-40% GENERAL ANESTHESIA
 40-60% TARGET IF OPIODS USED AND 35% IF NO OPIODS
 TIVA, HEMODYNAMIC INSTABILITY TO REDUSE ANESTHETIC DOSAGES,
SPEED RECOVERY, CLOSED-LOOP ANESTHESIA
 INTERFERENCE FROM EXTERNAL, MECHANICAL AND MUSCLE ACTIVITY
 SEIZURE SPIKE ERRONEOUS VALUES
 HYPNOTIC AGENTS MAY NOT HAVE LINEAR RELATIONSHIP e.g. N20,
KETAMINE, OPIODS, ETOMIDATE
 ANESTHETIC EFFECTS ON
EEG
DRUG TYPE- DOSE-RELATED (DEPTH OF ANESTHESIA)
AMPILTUDE-FREQUENCY-PATTERN- HEMISPHERIC SYMMETRY

INTRAVENOUS AGENTS
FAST ACTIVITY- SLOW & HIGH VOLTAGE
EPILEPTIFORM ACTIVITY (KETAMINE-METHOHEXITAL)

INHALATIONAL AGENT (FAST-LOW)

 SUB-MAC: FAST ACTIVITY (15-30Hz)
 1 MAC 4-8 Hz - 1.5 MAC 1-4 Hz - 2-2.5MAC BURST SUPPRESSION
 SPIKE WAVE EEG (ENFLURANE)
 ISOLECTRIC EEG
ANESTHETICS PRODUCING
BURST SUPPRESSION
 BARBITURATE
 ETOMIDATE
 ISOFLURANE (2-2.5MAC)
 SEVOFLURANE
 DESFLURANE
 INTRAOPERATIVE EEG
MONITORING
 BISPECTRAL ANALYSIS (BIS) BIS guided
anesthesia demonstrated superiority in monitoring
depth of anesthesia, minimize awareness under
anesthesia, reduction in anesthetic utilization,
guide delivery, fast awakening. Spectral Entropy,
a measure of disorder in EEG activity, is being
evaluated.
FACTORS AFFECTING EEG
 HYPOXIA
 HYPOTENSION, ISCHEMIA (e.g.CEA)
 HYPOTHERMIA
 HYPO-AND HYPER-CARBIA
 BRAIN DEATH
 SURGERY:UNTOWARD EVENTS
CEA- CARDIOPULMONARY BYPASS-
CEREBRAL ANEURYSM CLIPPING
EVOKED POTENTIALS
SSEP/SEP
ABR/BAEP
VEP
MEP
 EVOKED POTENTIAL
 EVOKED STIMULUS (AUDITORY ABR/BAER-VISUAL VEP-SOMATOSENSORY
MN/ULNAR/PTN/CUTANEOUS SSEP) EEG IS SPONTANEOUS
 TRAVELLING PATHWAY
 RESPONSE (CORTICAL- SUBCORTICAL-SPINAL) (NEAR FIELD LATE
LATENCY ABR/SEP- FAR-FIELD BAER/SSEP SHORT LATENCY)
EP CHALLANGES
 MINUTE POTENTIALS IN MICROVOLTS COMPARED TO EEG IN MV
 ELECTRICAL ARTIFACTS
 LENGTHY AND MULTIPLE SYNAPTIC TRACTS AND VULNERABILITY TO
ANESTHETICS AND EXTERNAL FACTORS
TECHNIQUE FOR REPRODUCIBILITY
 AVERAGING
 AMPLIFIER
 Primary
Posterior Tibial N. SSEP Sensory
Cortex

Med.
Lemniscus

Cervico-
Medullary
Junction

Spinal
stimulus Cord
Auditory Brainstem
Response
 VISUAL EVOKED
POTENTIALS (VEPS)
 EYE GOGGLES AND OCCIPITAL
ELECTRODES
 RETINA-OPTIC NERVE-OPTIC- MED.
GENICULATE-OCCIPITAL CORTEX (VP 100)
 PITUITARY, SELLAR AND SUPRASELLAR
SURGERIES
 VARIABLE AND VULNERABLE UNDER
ANESTHESIA
ANESTHETIC EFFECTS ON
EPS
 LATENCY DELAY
 AMPLITUDE REDUCTION (EXCEPT
ETOMIDATE AND KETAMINE)
 VARIABLE AMONG AGENTS
 WORSE IN INHALATIONAL AGENTS AND
DOSE DEPENDANT
 ADDITIVE EFFECTS OF AGENTS
 VEP>SEP>BAER
 FACTORS AFFECTING EPS
RECORDING UNDER ANESTHESIA
 HYPOTHERMIA
 HYPOXIA
 HYPOTENSION/ISCHEMIA
 ANESTHETIC AGENTS
 SURGICAL FACTORS: INJURY-
COMPRESSION- RETRACTION
INTRAOPERATIVE MEP &
EMG INCLUDING CRANIAL
NERVE MONITORING
ElectroMyoGraphy
SSEP cannot
evaluate individual
nerve roots

•Operative Monitoring
–Nerve irritation
–Nerve identification (stimulation)
–Pedicle screw testing
–Reflex testing
–(Motor evoked potentials)
 Methods for Cranial Nerve Monitoring
II Optic sensory: VEP
III Oculomotor motor:inferior rectus m
IV Trochlear motor: superior oblique m
V Trigeminal motor: masseter and/or
temporalis m
VI Abducens motor: lateral rectus m
VII Facial motor: obicularis oculi and/or
obicularis oris m
VIII Auditory sensory: ABR
IX Glossopharyngeal motor: posterior soft palate
(stylopharygeus m)
X Vagus motor: vocal folds, cricothyroid m
XI Spinal Accessory motor: sternocleidomastoid m
and/or trapezious m
XII Hypoglossal motor: tongue, genioglossus m
Facial Nerve Bursts 100 msec

Monitoring
Neurotonic 30 sec
 Muscle relaxation is
usually avoided in
monitoring
spontaneous EMG
(amplitude dec.) cn 9,10,11,12
cn 10
cn 3,4,6 cn 9,12
 Which Nerves?
Cervical
C2, C3, C4 Trapezius, Sternocleidomastoid
Spinal portion of the spinal accessory n.
C5, C6 Biceps, Deltoid
C6, C7 Flexor Carpi Radialis
C8, T1 Abductor Pollicis Brevis, Abductor
Digiti Minimi
Thoracic
T5, T6 Upper Rectus Abdominis
T7, T8 Middle Rectus Abdominis
T9, T10, T11 Lower Rectus Abdominis
T12 Inferior Rectus Abdominis
Lumbosacral
L2, L3, L4 Vastus Medialis
L4, L5, S1 Tibialis Anterior
L5, S1 Peroneus longus
Sacral
S1, S2 Gastrocnemius
S2, S3, S4 External anal sphincter
Stimulator
ANESTHETIC REGIMEN
FOR INTRAOPERATIVE
NEUROPHYSIOLOGICAL
MONITORING
Anesthesia Components: Analgesia
and Sedation/Amnesia
Opioids Ketamine
•Morphine Dexmeditomidine
•Demerol
•Fentanyl
•Alfentanil
•Sufentanil
•Remifentanil
Fentanyl

Excellent drug, blocks pain

in pathways not used by
IONM such that sedative
drugs that do hamper IOM
can be kept at lower level
 Sufentanil Fentanyl

MEP

SSEP
 Ketamine
Perspective:
 Provides amnesia and analgesia
 Inexpensive as infusion in TIVA
 Problem of hallucinations
 Increases ICP with
intracranial pathology
 May inc seizures
 Anesthesia Components:
Analgesia and
Sedation/Amnesia
 Barbiturates (thiopental, methohexitol)
 Benzodiazepines (midazolam)
 Propofol
 Etomidate
• Droperidol
• [Ketamine]
• [Dexmeditomidine
Propofol is the most common
TIVA sedative
 Muscle Relaxation
 Paralysis ok during intubation and some other
times (e.g. back incision)
 Full paralysis may be necessary to reduce EMG
interference near recording electrodes
( e.g. SSEP cervical response, epidural or
neural response)
 Full or partial paralysis may reduce patient
movement with stimulation
 Partial paralysis may be acceptable for
electrically stimulated pathways
 Absence of paralysis may be necessary with
mechanical stimulation or with pathology
 Motor Evoked Responses: Start
with TIVA
 - Induction with appropriate medications
(limit barbiturates and benzodiazepines)
Using short to intermediate acting relaxants
Propofol 1-2 mg/kg
Succinylcholine, vecuronium, rocuronium, etc.
Desflurane 3%
- Basic maintenance with TIVA inhaled (1/2
Propofol 120-140 mg/kg/min
MAC) may be
Sufentanil 0.3-0.5 ug/kg/hr
tolerated in
- Use EEG to guide propofol
healthy
- No nitrous oxide, No potent inhalational
patients
- No muscle relaxation
 Summary: Effective Anesthesia
Work with monitoring to develop an anesthetic
plan based on monitor techniques used
Start the case with the best anesthesia possible
and begin monitoring (use a bite block!)
Review the responses
Liberalize or improve anesthesia
Hold the physiology and anesthesia steady
Develop an anesthesia
“protocol”
THANK YOU FOR
LISTENING

QUESTIONS?