Assessing The Nervous System Function

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Introduction
Neurological procedures can lead to significant postoperative deficits. It is important for physicians to assess nervous system function intraoperatively so that any deficits can be corrected before they become permanent. The oldest method of assessing spinal cord function is with the Stagnara wake up test where patients are awoken in the middle of surgery in order to assess motor function(1). Once the neurological status of the patient is evaluated, the patient would be reanesthetized and the surgery would resume. The wake up test is limited in that it only provides a brief assessment of motor function. It fails to detect ischemia and sensory function(2). Now, intraoperative neurophysiological monitoring with motor evoked potentials (MEPs), somatosensory evoked potentials (SEPs), electromyography (EMG), electrocorticography (ECoG), and cortical mapping has become the new standard of care. It allows physicians to examine the nervous system function without waking the patient. It has become an essential intraoperative tool to improve safety in surgical procedures and helping minimize postoperative deficits. It has allowed surgeons to accept high-risk patients who might have been otherwise denied for a surgical procedure. There are many intraoperative monitoring modalities used to assess different part of brain, spinal cord, and the peripheral nervous system. The strength of each modality is able to offset the limitations of other monitoring modalities, and when combined together, they provide a comprehensive picture on the complex spinal cord function.

Motor Evoked Potentials (MEPs)
Motor evoked potentials (MEPs) have widespread use to diagnose and assess the functional integrity of the descending motor path...

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... for assessing postoperative sensory function.
It is important to note some of the strengths and limitations of SEPs. The strengths of SEPs are that it allows for continuous monitoring, has excellent specificity, and can be used with neuromuscular blocking agents(11). A limitation of SEPs is that it requires temporal summation of neural signals that enter the spinal cord. Recorded data are based on calculated averages, so it may take several minutes after an acute insult for it to show up on the data. Studies have shown that that the average delay time of SEPs is 16 minutes after MEPs and that SEPs can be as delayed for as long as 33 minutes(19). Other limitations of SEPs are that it does not directly monitor the corticospinal tract, has low sensitivity for motor deficits, and its recording can remain unchanged in patients with anterior spinal artery injury(11).

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