Neuromonitoring and Anesthesia for Spinal Fusion in Cerebral Palsy

  • Sabina DiCindioEmail author
  • Anthony DiNardo
  • Mary Theroux
Living reference work entry


Intraoperative neuromonitoring (IONM) is used to help prevent spinal cord injury, a potential complication of spinal surgery. Neuromonitoring is challenging in patients with cerebral palsy and requires close communication among the anesthesiologist, neurophysiologist, and the surgical team. Factors such as the pathophysiology of cerebral palsy, preexisting neurologic deficits, types of monitoring modalities available, the expertise of the monitoring personnel, anesthetic effects, and surgical maneuvers all have an impact on intraoperative neuromonitoring (IONM) and must be considered in order to safely care for these patients.


Cerebral palsy Spine fusion Neuromonitoring Anesthesia Evoked potentials 


  1. Bala E, Sessler DI, Nair DR, Mclain R, Dalton JE, Farag E (2008) Motor and somatosensory evoked potentials are well maintained in patients given dexmedetomidine during spine surgery. Anesthesiology 109:417–425CrossRefGoogle Scholar
  2. Balmer GA, Macewen GD (1970) The incidence and treatment of scoliosis in cerebral palsy. J Bone Joint Surg Br 52:134–137CrossRefGoogle Scholar
  3. Barsdorf AI, Sproule DM, Kaufmann P (2010) Scoliosis surgery in children with neuromuscular disease: findings from the US National Inpatient Sample, 1997 to 2003. Arch Neurol 67:231–235CrossRefGoogle Scholar
  4. Benson ER, Thomson JD, Smith BG, Banta JV (1998a) Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular 2003. Arch Neurol 67:231–235Google Scholar
  5. Benson ER, Thomson JD, Smith BG, Banta JV (1998b) Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis. Spine (Phila Pa 1976) 23:2308–2317. discussion 2318CrossRefGoogle Scholar
  6. Browning JL, Heizer ML, Baskin DS (1992) Variations in corticomotor and somatosensory evoked potentials: effects of temperature, halothane anesthesia, and arterial partial pressure of CO2. Anesth Analg 74:643–648CrossRefGoogle Scholar
  7. Deletis V, Kiprovski K, Morota N (1993) The influence of halothane, enflurane, and isoflurane on motor evoked potentials. Neurosurgery 33:173–174PubMedGoogle Scholar
  8. Deletis V, Sala F (2008) Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol 119:248–264CrossRefGoogle Scholar
  9. Dicindio S, Theroux M, Shah S, Miller F, Dabney K, Brislin RP, Schwartz D (2003) Multimodality monitoring of transcranial electric motor and somatosensory-evoked potentials during surgical correction of spinal deformity in patients with cerebral palsy and other neuromuscular disorders. Spine (Phila Pa 1976) 28:1851–1855. discussion 1855–6CrossRefGoogle Scholar
  10. Ecker ML, Dormans JP, Schwartz DM, Drummond DS, Bulman WA (1996) Efficacy of spinal cord monitoring in scoliosis surgery in patients with cerebral palsy. J Spinal Disord 9:159–164CrossRefGoogle Scholar
  11. Emerson RG (1988) Anatomic and physiologic bases of posterior tibial nerve somatosensory evoked potentials. Neurol Clin 6:735–749PubMedGoogle Scholar
  12. Fehlings MG, Brodke DS, Norvell DC, Dettori JR (2010) The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference? Spine (Phila Pa 1976) 35:S37–S46CrossRefGoogle Scholar
  13. Gibson PR (2004) Anaesthesia for correction of scoliosis in children. Anaesth Intensive Care 32:548–559PubMedGoogle Scholar
  14. Glover CD, Carling NP (2014) Neuromonitoring for scoliosis surgery. Anesthesiol Clin 32:101–114CrossRefGoogle Scholar
  15. Gonzalez AA, Jeyanandarajan D, Hansen C, Zada G, Hsieh PC (2009) Intraoperative neurophysiological monitoring during spine surgery: a review. Neurosurg Focus 27:E6CrossRefGoogle Scholar
  16. Hammett TC, Boreham B, Quraishi NA, Mehdian SM (2013) Intraoperative spinal cord monitoring during the surgical correction of scoliosis due to cerebral palsy and other neuromuscular disorders. Eur Spine J 22(Suppl 1):S38–S41CrossRefGoogle Scholar
  17. Jameson LC, Sloan TB (2012) Neurophysiologic monitoring in neurosurgery. Anesthesiol Clin 30:311–331CrossRefGoogle Scholar
  18. Kakinohana M, Fuchigami T, Nakamura S, Kawabata T, Sugahara K (2002) Propofol reduces spinal motor neuron excitability in humans. Anesth Analg 94:1586–1588. table of contentsPubMedGoogle Scholar
  19. Kalkman CJ, Drummond JC, Ribberink AA (1991) Low concentrations of isoflurane abolish motor evoked responses to transcranial electrical stimulation during nitrous oxide/opioid anesthesia in humans. Anesth Analg 73:410–415CrossRefGoogle Scholar
  20. Kawaguchi M, Sakamoto T, Inoue S, Kakimoto M, Furuya H, Morimoto T, Sakaki T (2000) Low dose propofol as a supplement to ketaminebased anesthesia during intraoperative monitoring of motor-evoked potentials. Spine (Phila Pa 1976) 25:974–979CrossRefGoogle Scholar
  21. Legatt AD (2002) Current practice of motor evoked potential monitoring: results of a survey. J Clin Neurophysiol 19:454–460CrossRefGoogle Scholar
  22. Lipton GE, Miller F, Dabney KW, Altiok H, Bachrach SJ (1999) Factors predicting postoperative complications following spinal fusions in children with cerebral palsy. J Spinal Disord 12:197–205PubMedGoogle Scholar
  23. Lotto ML, Banoub M, Schubert A (2004) Effects of anesthetic agents and physiologic changes on intraoperative motor evoked potentials. J Neurosurg Anesthesiol 16:32–42CrossRefGoogle Scholar
  24. Macdonald DB (2002) Safety of intraoperative transcranial electrical stimulation motor evoked potential monitoring. J Clin Neurophysiol 19:416–429CrossRefGoogle Scholar
  25. Macdonald DB (2006a) Intraoperative motor evoked potential monitoring: overview and update. J Clin Monit Comput 20:347–377CrossRefGoogle Scholar
  26. Macdonald DB (2006b) Intraoperative motor evoked potential monitoring: overview and update. J Clin Monit Comput 20:347–377CrossRefGoogle Scholar
  27. Macdonald DB, Skinner S, Shils J, Yingling C, American Society of Neurophysiological Monitoring (2013) Intraoperative motor evoked potential monitoring - a position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol 124:2291–2316CrossRefGoogle Scholar
  28. Mahmoud M, Sadhasivam S, Salisbury S, Nick TG, Schnell B, Sestokas AK, Wiggins C, Samuels P, Kabalin T, Mcauliffe J (2010) Susceptibility of transcranial electric motor-evoked potentials to varying targeted blood levels of dexmedetomidine during spine surgery. Anesthesiology 112:1364–1373CrossRefGoogle Scholar
  29. Master DL, Son-Hing JP, Poe-Kochert C, Armstrong DG, Thompson GH (2011) Risk factors for major complications after surgery for neuromuscular scoliosis. Spine (Phila Pa 1976) 36:564–571CrossRefGoogle Scholar
  30. Merton PA, Morton HB (1980) Stimulation of the cerebral cortex in the intact human subject. Nature 285:227CrossRefGoogle Scholar
  31. Nagao S, Roccaforte P, Moody RA (1978) The effects of isovolemic hemodilution and reinfusion of packed erythrocytes on somatosensory and visual evoked potentials. J Surg Res 25:530–7CrossRefGoogle Scholar
  32. Nathan N, Tabaraud F, Lacroix F, Moulies D, Viviand X, Lansade A, Terrier G, Feiss P (2003) Influence of propofol concentrations on multipulse transcranial motor evoked potentials. Br J Anaesth 91:493–497CrossRefGoogle Scholar
  33. Nolan J, Chalkiadis GA, Low J, Olesch CA, Brown TC (2000) Anaesthesia and pain management in cerebral palsy. Anaesthesia 55:32–41CrossRefGoogle Scholar
  34. Nuwer MR, Dawson EG, Carlson LG, Kanim LE, Sherman JE (1995) Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 96:6–11CrossRefGoogle Scholar
  35. Oro J, Haghighi SS (1992) Effects of altering core body temperature on somatosensory and motor evoked potentials in rats. Spine (Phila Pa 1976) 17:498–503CrossRefGoogle Scholar
  36. Padberg AM, Wilson-Holden TJ, Lenke LG, Bridwell KH (1998) Somatosensory- and motor-evoked potential monitoring without a wake-up test during idiopathic scoliosis surgery. An accepted standard of care. Spine (Phila Pa 1976) 23:1392–1400CrossRefGoogle Scholar
  37. Pajewski TN, Arlet V, Phillips LH (2007) Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. Eur Spine J 16(Suppl 2):S115–S129CrossRefGoogle Scholar
  38. Pechstein U, Nadstawek J, Zentner J, Schramm J (1998) Isoflurane plus nitrous oxide versus propofol for recording of motor evoked potentials after high frequency repetitive electrical stimulation. Electroencephalogr Clin Neurophysiol 108:175–181CrossRefGoogle Scholar
  39. Reames DL, Smith JS, Fu KM, Polly DW Jr, Ames CP, Berven SH, Perra JH, Glassman SD, Mccarthy RE, Knapp RD Jr, Heary R, Shaffrey CI, Scoliosis Research Society Morbidity and Mortality Committee (2011) Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society morbidity and mortality database. Spine (Phila Pa 1976) 36:1484–1491CrossRefGoogle Scholar
  40. Sakamoto T, Kawaguchi M, Kakimoto M, Inoue S, Takahashi M, Furuya H (2003) The effect of hypothermia on myogenic motor-evoked potentials to electrical stimulation with a single pulse and a train of pulses under propofol/ketamine/fentanyl anesthesia in rabbits. Anesth Analg 96:1692–1697. table of contentsCrossRefGoogle Scholar
  41. Salem KM, Goodger L, Bowyer K, Shafafy M, Grevitt MP (2016) Does transcranial stimulation for motor evoked potentials (TcMEP) worsen seizures in epileptic patients following spinal deformity surgery? Eur Spine J 25:3044–3048CrossRefGoogle Scholar
  42. Sarwark J, Sarwahi V (2007) New strategies and decision making in the management of neuromuscular scoliosis. Orthop Clin North Am 38:485–496CrossRefGoogle Scholar
  43. Scheufler KM, Zentner J (2002) Motor-evoked potential facilitation during progressive cortical suppression by propofol. Anesth Analg 94:907–912. table of contentsCrossRefGoogle Scholar
  44. Schwartz DM, Auerbach JD, Dormans JP, Flynn J, Drummond DS, Bowe JA, Laufer S, Shah SA, Bowen JR, Pizzutillo PD, Jones KJ, Drummond DS (2007) Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am 89:2440–2449PubMedGoogle Scholar
  45. Sloan T, Sloan H, Rogers J (2010) Nitrous oxide and isoflurane are synergistic with respect to amplitude and latency effects on sensory evoked potentials. J Clin Monit Comput 24:113–123CrossRefGoogle Scholar
  46. Sloan TB, Heyer EJ (2002) Anesthesia for intraoperative neurophysiologic monitoring of the spinal cord. J Clin Neurophysiol 19:430–443CrossRefGoogle Scholar
  47. Sloan TB, Janik D, Jameson L (2008) Multimodality monitoring of the central nervous system using motor-evoked potentials. Curr Opin Anaesthesiol 21:560–564CrossRefGoogle Scholar
  48. Stecker MM (2012) A review of intraoperative monitoring for spinal surgery. Surg Neurol Int 3:S174–S187CrossRefGoogle Scholar
  49. Szelenyi A, Kothbauer KF, Deletis V (2007) Transcranial electric stimulation for intraoperative motor evoked potential monitoring: Stimulation parameters and electrode montages. Clin Neurophysiol 118:1586–95CrossRefGoogle Scholar
  50. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG (2008) Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Paediatr Anaesth 18:1082–1088CrossRefGoogle Scholar
  51. Toleikis JR, American Society of Neurophysiological Monitoring (2005) Intraoperative monitoring using somatosensory evoked potentials. A position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 19:241–258CrossRefGoogle Scholar
  52. Ulkatan S, Jaramillo AM, Tellez MJ, Kim J, Deletis V, Seidel K (2017) Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures. J Neurosurg 126:12961302CrossRefGoogle Scholar
  53. Wass CT, Warner ME, Worrell GA, Castagno JA, Howe M, Kerber KA, Palzkill JM, Schroeder DR, Cascino GD (2012) Effect of general anesthesia in patients with cerebral palsy at the turn of the new millennium: a population-based study evaluating perioperative outcome and brief overview of anesthetic implications of this coexisting disease. J Child Neurol 27:859–866CrossRefGoogle Scholar
  54. Yamane T, Tateishi A, Cho S, Manabe S, Yamanashi M, Dezawa A, Yasukouchi H, Ishioka K (1992) The effects of hyperthermia on the spinal cord. Spine (Phila Pa 1976) 17:1386–1391CrossRefGoogle Scholar
  55. Zentner J, Albrecht T, Heuser D (1992) Influence of halothane, enflurane, and isoflurane on motor evoked potentials. Neurosurgery 31:298–305CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Sabina DiCindio
    • 1
    Email author
  • Anthony DiNardo
    • 2
  • Mary Theroux
    • 1
  1. 1.Department of Anesthesia and Perioperative MedicineNemours/Alfred I. duPont Hospital for ChildrenWilmingtonUSA
  2. 2.SpecialtyCareNashvilleUSA

Section editors and affiliations

  • Freeman Miller
    • 1
  1. 1.AI DuPont Hospital for ChildrenWilmingtonUSA

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