Intraoperative neuromonitoring of anterior root muscle response during hip surgery under spinal anesthesia

  • Pınar Yalınay DikmenEmail author
  • V. Emre Ozden
  • Goksel Dikmen
  • Elif Ilgaz Aydınlar
  • I. Remzi Tozun
Original Research


The aim of this study was to evaluate the anterior root muscle (ARM) response monitorability during total hip arthroplasty (THA) under spinal anesthesia. A total of 20 adults (64.6 ± 13.87 years old) were monitored using ARM response and free-run electromyography during THA. To elicit the ARM response from muscles, percutaneous stimulation of the lumbosacral roots was performed by self-adhesive electrodes placed over the skin of the projection of the first and third lumbar interspinous space (anode) and over the abdominal skin of the umbilicus (cathode). Latency and amplitude values of the ARM response were recorded from both sides (non-operated and operated) and from five muscles as follows: rectus femoris (RF), vastus lateralis (VL), biceps femoris long-head (BF), Tibialis Anterior (TA) and gastrocnemius. The most recorded ARM response in a muscle was the TA (n = 38); the least recorded AMR response in a muscle was the BF (n = 33). The mean stimulus intensities for the non-operated and the operated sides were 462.5 ± 112.8 V and 520.0 ± 172.3 V (p = 0.834), respectively. The mean latencies and amplitude values of the ARM response from muscles were as follows: 8.8 ± 1.4 ms; 98.8 ± 114.5 µV for RF; 9.8 ± 2.1 ms; 119.1 ± 122.23 µV for VL; 9.5 ± 1.6 ms; 39.6 ± 30.3 µV for BF; 15.1 ± 1.9 ms; 146.6 ± 150.9 µV for TA; 15.6 ± 2.4 ms; 81.0 ± 99.9 µV for Gastrocnemius. The present study demonstrates that the ARM response could easily and safely be obtained during THA under spinal anesthesia. This non-invasive technique may have a potential to detect early neurological deficit in patients who need complex hip surgery under spinal anesthesia.


Anterior root muscle response ARM response Free-run electromyography Total hip arthroplasty THA Intraoperative monitoring 



We thank Vedran Deletis for his valuable comments on earlier drafts of this paper.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

None of the authors has any conflicts of interest to disclose.


  1. 1.
    Minassian K, Persy I, Rattay F, Dimitrijevic MR, Hofer C, Kern H. Posterior-root muscle reflexes elicited by transcutaneous stimulation of the human lumbosacral. Muscle Nerve. 2007;35:327–36.CrossRefGoogle Scholar
  2. 2.
    Troni W, Bianco C, Coletti Moia M, Dotta M. Improved methodology for lumbosacral nerve stimulation. Muscle Nerve. 1996;19:595–604.CrossRefGoogle Scholar
  3. 3.
    Dimitrijevic MR, Dimitrijevic M, Kern H, Minassian K, Rattay F. Electrophysiological characteristics of H-reflexes elicited by percutaneous stimulation of the cauda equina. Society for Neuroscience. Vol Program No. 417.11. Washington, DC; Society for Neuroscience; 2014. Online.Google Scholar
  4. 4.
    Maertens de Noordhout A, Rothwell JC, Thompson PD, Day BL, Marsden CD. Percutaneous electrical stimulation of lumbosacral roots in man. J Neurol Neurosurg Psychiatry. 1998;51:174–81.CrossRefGoogle Scholar
  5. 5.
    Jilge B, Minassian K, Rattay F, Pinter MM, Gerstenbrand F, Binder H, et al. Initiating extension of the lower limbs in subjects with complete spinal cord injury be epidural lumbar cord stimulation. Exp Brain Res. 2004;154:308–26.CrossRefGoogle Scholar
  6. 6.
    Minassian K, Jilge B, Rattay F, Pinter MM, Binder H, Gerstenbrand F, et al. Stepping-like movements in humans with complete spinal cord injury induced by epidural stimulation of the lumbar cord: electromyographic study of compound muscle action potentials. Spinal Cord. 2004;42:401–16.CrossRefGoogle Scholar
  7. 7.
    Murg M, Binder H, Dimitrijevic MR. Epidural electric stimulation of posterior structures of the human lumbar spinal cord: 1. Muscle twitches-a functional method to define the site of stimulation. Spinal Cord. 2000;38:394–402.CrossRefGoogle Scholar
  8. 8.
    Troni W, Di Sapio A, Berra E, Duca S, Merola A, Sperli F, Bertolotto A. A methodological reappraisal of non invasive high voltage electrical stimulation of lumbosacral roots. Clin Neurophysiol. 2011;122:2071–80.CrossRefGoogle Scholar
  9. 9.
    Troni W, Benech CA, Perez R, Tealdi S, Berardino M, Benech F. Non-invasive high voltage electrical stimulation as a monitoring tool of nerve root function in lumbosacral surgery. Clin Neurophysiol. 2013;124:809–18.CrossRefGoogle Scholar
  10. 10.
    Climent A, Conejore IF, Coscujuela A, Ribas M, Unakıtan S, Deletis V. Multimodal intraoperative monitoring (IOM) for hip surgery. Clin Neurophysiol. 2013;125:16.CrossRefGoogle Scholar
  11. 11.
    Mandeville RM, Brown JM, Gertsch JH, Allison DW. Use of posterior root-muscle reflexes in peripheral nerve surgery: a case report. Neurodiagnostic J. 2016;56:178–85.CrossRefGoogle Scholar
  12. 12.
    Ochs BC, Herzka A, Yaylali I. Intraoperative monitoring of somatosensory evoked potentials during hip arthroscopy surgery. Neurodiagnostic J. 2012;4:312–9.Google Scholar
  13. 13.
    Telleria JJM, Safran MR, Gardi JN, Harris AHS, Glick JM. Risk of sciatic nerve traction injury during hip arthroscopy—is it the amount or duration? J Bone Joint Surg Am. 2012;94:2025–32.CrossRefGoogle Scholar
  14. 14.
    Sutter M, Hershe O, Leunig M, Guggi T, Dvorak J, Eggspuehler A. Use of multimodal intra-operative monitoring in averting nerve injury during complex hip surgery. J Bone Joint Surg Br. 2012;94:179–84.CrossRefGoogle Scholar
  15. 15.
    Shemesh SS, Robinson J, Overley S, Bronson MJ, Moucha CS, Chen D. Novel technique for intraoperative sciatic nerve assessment in complex primary total hip arthroplasty: a pilot study. HIP Int. 2017;9:0. (Epub ahead of print).Google Scholar
  16. 16.
    Perlas A, Chan VW, Beattie S. Anesthesia technique and mortality after total hip or knee arthroplasty: a retrospective, propensity score-matched cohort study. Anesthesiology. 2016;125:724–31.CrossRefGoogle Scholar
  17. 17.
    Helwani MA, Avidan MS, Ben Abdullah A, Kaiser DJ, Clohisy JC, Hall BL. et al. Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study. J Bone Joint Surg Am. 2015;97:186–93.CrossRefGoogle Scholar
  18. 18.
    Singh JA. Epidemiology of knee and hip arthroplasty: a systematic review. Open Ortho J. 2011;5:80–5.CrossRefGoogle Scholar
  19. 19.
    Bromage PR. Epidural Anesthesia. Philadelphia: WB Saunders; 1978.Google Scholar
  20. 20.
    Weber ER, Daube JR, Coventry MB. Peripheral neuropathies associated with total hip arthroplasty. J Bone Joint Surg Am. 1976;58:66–9.CrossRefGoogle Scholar
  21. 21.
    Schmalzried TP, Amstutz HC, Dorey FJ. Nerve palsy associated with total hip replacement: risk factors and prognosis. J Bone Joint Surg Am. 1991;73:1074–80.CrossRefGoogle Scholar
  22. 22.
    De Hart MM, Riley LH. Nerve injuries in total hip arthroplasty. J Am Acad Orthop Surg. 1999;7:101–11.CrossRefGoogle Scholar
  23. 23.
    MacDonald DR, Stigsby B, Homoud I, Abalkhail T, Mokeem A. Utility of motor evoked potentials in nerve root monitoring. J Clin Neurophysiol. 2012;29:118–25.CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2018

Authors and Affiliations

  1. 1.Neurology Department, School of MedicineAcıbadem Mehmet Ali Aydınlar UniversityIstanbulTurkey
  2. 2.Orthopedic and Traumatology Department, School of MedicineAcıbadem Mehmet Ali Aydınlar UniversityIstanbulTurkey
  3. 3.Department of NeurologyMaslak Acıbadem HospitalIstanbulTurkey

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