Intraoperative myogenic motor evoked potentials induced by direct electrical stimulation of the exposed motor cortex under isoflurane and sevoflurane

We monitored myogenic motor evoked potentials (MEPs) during intracranial surgery in 21 patients anesthetized with nitrous oxide in oxygen, fentanyl, and 0.75-1.5 minimum alveolar anesthetic concentration (MAC) isoflurane (n = 11) or sevoflurane (n = 10). The exposed motor cortex was stimulated with a single or train-of-five rectangular pulses at a high frequency (500 Hz), while the compound muscle action potentials (CMAPs) were recorded from the abductor pollicis brevis muscle. Neuromuscular block was monitored by recording the CMAPs from the abductor pollicis brevis muscle in response to electrical stimulation of the median nerve at the wrist (M-response). Stimulation of the motor cortex with a single pulse elicited MEPs in none of the patients, while stimulation with a train-of-five rectangular pulses at high frequency elicited MEPs in all patients. The relationship between MEP amplitude and the level of neuromuscular block induced by vecuronium infusion was evaluated in seven patients. For comparison of the individual measurements, the MEP amplitude at a M-response amplitude of 100% was calculated by means of the individual regression curve as 100% of MEP amplitude. There was a linear correlation between percent MEP amplitude and percent M-response amplitude (r = 0.81; P < 0.01). Intraoperative monitoring of MEP could be performed at a M-response amplitude above 90% of the baseline value in 10 patients and at a M-response amplitude of 20%-50% of the baseline value in 11 patients. During monitoring of the 21 patients, MEPs did not change in 18 patients and disappeared in two patients. In the remaining patient, MEP amplitudes were attenuated to approximately 10% of the baseline value and recovered after cessation of surgical manipulation. In the two patients in whom MEPs disappeared, motor paresis developed postoperatively. We conclude that 1) intraoperative myogenic MEP monitoring is feasible during isoflurane or sevoflurane anesthesia if stimulation is performed with a short train of rectangular pulses, and 2) that electromyographic monitoring of neuromuscular block is useful to assess intraoperative MEP changes under partial neuromuscular block.