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Intraoperative Neurophysiological Monitoring
Second Edition
Intraoperative
Neurophysiological Monitoring
Second Edition
Aage R. Møller, PhD

University of Texas at Dallas
Dallas, TX
© 2006 Humana Press Inc.
999 Riverview Drive, Suite 208
Totowa, New Jersey 07512
www.humanapress.com
All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any
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Publisher.
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views of the publisher.
This publication is printed on acid-free paper. ∞

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eISBN: 1-59745-018-9
Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Møller, Aage R.
Intraoperative neurophysiological monitoring / Aage R. Møller. -- 2nd ed.
p. cm.
Includes bibliographical references and index.
ISBN 1-58829-703-9 (alk. paper)
1. Neurophysiologic monitoring. 2. Evoked potentials (Elecrophysiology) I. Title.
RD52.N48M65 2006
617.4'8--dc22
2005050259
Preface
This book is based on two earlier works: Section IV is devoted to peripheral nerves,
Aage R. Møller: Evoked Potentials in Intraop- and Chapter 12 covers the anatomy and physiol-
erative Monitoring published in 1988 by Will- ogy, whereas Chapter 13 discusses practical as-
iams and Wilkens; and more directly by Aage R pects of monitoring peripheral nerves.
Møller: Intraoperative Neurophysiologic Moni- Section V discusses different ways that intra-
toring published in 1995 by Gordon and Breach operative electrophysiological recordings can
under the imprint of Harwood academic publish- guide the surgeon in an operation. Chapter 14
ers. The present book represents an expansion discusses methods to identify motor and sensory
and extensive rewriting of the 1995 book. In par- nerves and map the spinal cord and the floor of
ticular, new chapters related to monitoring of the the fourth ventricle. Chapter 15 describes meth-
spinal motor system and deep brain stimulation ods that can guide the surgeon in an operation,
(DBS) have been added. The anatomical and such as microvascular decompression operations
physiological basis for these techniques are for hemifacial spasm and placement of elec-
described in detail as are the practical aspects of trodes for DBS and for making lesions in the
such monitoring. Chapters on monitoring of sen- thalamus and basal ganglia.
sory systems and monitoring in skull base sur- Section VI discusses practical aspects of in-
gery have been rewritten as has the chapter on traoperative monitoring. Chapter 16 covers the
monitoring of peripheral nerves. role of anesthesia in monitoring and Chapter 17
The general principles of intraoperative discusses general matters regarding monitoring
monitoring are discussed in Section I where such as how to reduce the risk of mistakes and
Chapter 2 describes the basis for intraoperative how to reduce the effect of electrical interfer-
monitoring and Chapter 3 discusses the various ence of recorded neuroelectrical potentials.
forms of electrical activity that can be recorded Chapter 18 discusses equipment and data
from nerve fibers and nerve cells; near-field ac- analysis related to intraoperative monitoring.
tivity from nerves, nuclei, and muscles recorded This chapter also discusses electrical stimulation
with monopolar and bipolar electrodes. This of nervous tissue. The final chapter, Chapter 19
chapter also discusses far-field potentials and the discusses the importance of evaluation of
responses from injured nerves and nuclei. Chap- the benefits of intraoperative neurophysiologi-
ter 4 discusses practical aspects of recording cal monitoring, to the patient, the surgeon, and
evoked potentials from nerves, nuclei, and muscles the field of surgery in general.
including a discussion of various stimulus tech- Aage R. Møller
niques.
Section II covers sensory systems. Chapter 5
covers the anatomy and physiology of the audi-
tory, somatosensory and visual systems. Moni-
toring of the auditory system is covered in
Chapter 6; Chapter 7 covers monitoring the
somatosensory system and Chapter 8, monitor-
ing the visual system.
Section III discusses motor systems. The
anatomy and physiology that is of interest for
intraoperative monitoring is discussed in Chap-
ter 9 and practical aspects of the spinal motor
and brainstem motor systems are covered in
Chapters 10 and 11, respectively.
v
Acknowledgments
I have had valuable help from many individuals in writing this book. Mark Steckert, MD, PhD,
provided important comments on several aspects of this second edition.
I want to thank Hilda Dorsett for preparing much of the new artwork and for revising some of the
illustrations from the first edition of the book. I thank Renee Workings for help with editing the
manuscript and Karen Riddle for transcribing many of the revisions of the manuscript.
I also want to thank Richard Lansing and Jennifer Hackworth, production editor, of Humana Press
for their excellent work on the book.
I would not have been able to write this book without the support from the School of Behavioral
and Brain Sciences at the University of Texas at Dallas.
Last but not least I want to thank my wife, Margareta B. Møller, MD, PhD, for her support during
writing of this book and for her valuable comments on earlier versions of the book manuscript.
Aage R. Møller
vii
Contents
Preface ..................................................................................................................................... v
Acknowledgments ..................................................................................................................vii
1 Introduction ..................................................................................................................... 1
SECTION I: PRINCIPLES OF INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING

2 Basis of Intraoperative Neurophysiological Monitoring .................................................. 9
3 Generation of Electrical Activity in the Nervous System and Muscles .......................... 21
4 Practical Aspects of Recording Evoked Activity From Nerves,
Fiber Tracts, and Nuclei ............................................................................................ 39
References to Section I .......................................................................................................... 49
SECTION II: SENSORY SYSTEMS

5 Anatomy and Physiology of Sensory Systems ................................................................ 55
6 Monitoring Auditory Evoked Potentials ......................................................................... 85
7 Monitoring of Somatosensory Evoked Potentials ......................................................... 125
8 Monitoring of Visual Evoked Potentials ....................................................................... 145
References to Section II ....................................................................................................... 147
SECTION III: MOTOR SYSTEMS

9 Anatomy and Physiology of Motor Systems ............................................................... 157
10 Practical Aspects of Monitoring Spinal Motor Systems ............................................... 179
11 Practical Aspects of Monitoring Cranial Motor Nerves ............................................... 197
References to Section III ...................................................................................................... 213
SECTION IV: PERIPHERAL NERVES

12 Anatomy and Physiology of Peripheral Nerves ........................................................... 221
13 Practical Aspects of Monitoring Peripheral Nerves ..................................................... 229
References to Section IV ..................................................................................................... 233
SECTION V: INTRAOPERATIVE RECORDINGS THAT CAN GUIDE THE SURGEON IN THE OPERATION
14 Identification of Specific Neural Tissue ....................................................................... 237
15 Intraoperative Diagnosis and Guide in Operations ..................................................... 251
References to Section V ...................................................................................................... 273
ix
x Contents
SECTION VI: PRACTICAL ASPECTS OF ELECTROPHYSIOLOGICAL RECORDING IN THE OPERATING ROOM

16 Anesthesia and Its Constraints in Monitoring Motor and Sensory Systems ................. 279
17 General Considerations About Intraoperative Neurophysiological Monitoring .......... 283
18 Equipment, Recording Techniques, Data Analysis, and Stimulation ........................... 299
19 Evaluating the Benefits of Intraoperative Neurophysiological Monitoring .................. 329
References to Section VI ..................................................................................................... 339
Appendix ............................................................................................................................. 343

Abbreviations ...................................................................................................................... 347
Index ................................................................................................................................... 349
1
I n t ro d u c t i o n
Surgery can generally be regarded as a risk- caused a problem so that the surgeon can reverse
filled method for treating diseases, and it has a the step that caused the injuries before they
potential for causing injury to the nervous sys- become severe enough to result in permanent
tem. Because such injuries might not be detected neurological deficits.
by visual inspection of the operative field by the The benefits to the patient and to the surgeon
surgeon, they could occur and progress without of using appropriate neurophysiological monitor-
the surgeon’s knowledge. Intraoperative neuro- ing methods during operations in which neural
physiological monitoring involves the use of tissue is at risk of being injured are well recog-
neurophysiological recordings for detecting nized, and intraoperative neurophysiological
changes in the function of the nervous system monitoring is now widely practiced in many hos-
that are caused by surgically induced insults. pitals in connection with such operations. Indi-
Intraoperative recording of neuroelectric viduals on the neurophysiological monitoring
potentials makes it possible to assess function team are now accepted as members of the
nearly continuously throughout an operation. operating room team. Although monitoring of
Although evoked potentials are important in patients’ vital signs in the operating room has
making clinical diagnoses, there are often alter- been done for many years, monitoring the func-
native methods available to obtain the required tion of the nervous system is a relatively new
information in the clinical setting, such as imag- addition to the operating room and it has a wider
ing modalities (computed axial tomography range of applications than just the monitoring
[CAT] and magnetic resonance imaging [MRI]), function.
which have made evoked potentials and other During the late 1970s and early 1980s, the
electrophysiological studies less important for application of electrophysiological methods in
clinical diagnosis of neurological disorders. the operating room was primarily focused within
However, although the CAT scan is available in university centers and a few large hospitals. It
a few operating rooms (mainly for stereotaxic soon became evident that standard laboratory
surgery and biopsy), it is not practical for moni- techniques transplanted to the operating room
toring neural injuries, at least not yet. Imaging could reduce the risk of inadvertently injuring
methods mainly detect changes in structures, neural tissue and thereby reduce the risk of per-
whereas neurophysiological methods assess manent neurological deficits. This new use of
changes in function, therefore providing obvious standard laboratory techniques became known as
advantages for intraoperative monitoring. intraoperative neurophysiological monitoring.
Appropriate use of intraoperative recording Routine use of intraoperative neurophysio-
of various types of neuroelectric potential makes logical monitoring developed during the 1980s,
it possible to assess the function of specific parts and during that time, intraoperative neurophys-
of the nervous system continuously during an iological monitoring got its own society in the
operation and detect changes in neural function United States (the American Society for Neuro-
with little delay. Early detection of such func- physiological Monitoring [ASNM]).
tional changes can reduce the risk of postopera- Although it is assumed that the era of intra-
tive deficits caused by iatrogenic injuries to the operative neurophysiological monitoring
nervous system. These methods makes it possi- started in the late 1970s, electrophysiological
ble to identify which specific surgical step has methods were used in the operating room for
the purpose of reducing the risk of permanent
From: Intraoperative Neurophysiological Monitoring: Second Edition
By A. R. Møller neurological deficits even before that time. In
© Humana Press Inc., Totowa, NJ. the early 1960s, monitoring of the facial nerve
1
2 Intraoperative Neurophysiological Monitoring
was mainly done to reduce the risks of facial spread to other surgical specialties, such as
paresis or palsy after operations for vestibular otoneurological surgery and to plastic surgery,
schwannoma (1,2). where it serves mainly to preserve the function
Leonid Malis, a neurosurgeon, used record- of peripheral nerves.
ings of evoked potentials from the sensory cor- The spread of the use of intraoperative neuro-
tex in his neurosurgical operations. Malis, physiological monitoring to other types of hos-
however, fascinated by the development of pital came in the beginning of the 1990s when
microneurosurgery, stated later that microneu- also certification processes were established by
rosurgery had made intraoperative monitoring the American Board for Neurophysiological
unnecessary (3) although others expressed the Monitoring, (ABNM) that certifies Diplomats of
opposite opinion in support of the usefulness of the American Board for Neurophysiological
intraoperative monitoring (4). Monitoring (DABNM). Certification in Neuro-
Orthopedic surgery was one of the first spe- physiological Intraoperative Neurophysiological
cialties to make systematic use of intraoperative Monitoring (CNIM) is available through the
neurophysiological monitoring, particularly in American Board of Registration of Electroen-
operations involving the spine. In the 1970s, cephalographic and Evoked Potential Technolo-
work by Dr. Richard Brown, a neurophysiologists (ABRET).
gist, reduced the risk of damage to the spinal While the techniques that were used in the
cord during scoliosis operations by using record- beginning of the era of intraoperative neuro-
ings of somatosensory evoked potentials (5,6), physiological monitoring were transplanted
and intraoperative neurophysiological monitor- from the animal laboratories, the increased use
ing has been used for several decades for many of intraoperative neurophysiological monitor-
additional types of neurosurgical operations (5). ing promoted the development of specialized
Monitoring of auditory brainstem evoked techniques to become commercially available
responses (ABRs) was also one of the earliest by several companies.
applications of intraoperative neurophysiologi- Methods for monitoring of spinal motor sys-
cal monitoring and was used in microvascular tems advanced during the 1990s with the devel-
decompression (MVD) operations for hemi- opment of techniques using magnetic (17) and
facial spasm (HFS) and trigeminal neuralgia electrical stimulation (18) of the motor cortex
pioneered by Grundy (7) and Raudzens (8) in and stimulation of the spinal cord (19). Methods
the early 1980s and others (9,10) thereafter. that provided satisfactory anesthesia and also
Direct recordings from the exposed intracranial permitted activation of motor system by stimula-
structures such as the eighth cranial nerve and tion of the motor cortex were developed (20,21).
the cochlear nucleus decreased the time to get an Intraoperative neurophysiological monitoring
interpretable record (11,12). Such recordings is an inexpensive and effective method for reduc-
had been used earlier for research purposes (13). ing the risk of permanent postoperative deficits in
In the 1980s, intraoperative neurophysiolog- many different operations where nervous tissue
ical monitoring was introduced in operations is being manipulated. It provides real-time mon-
for large skull base tumors (14,15) and later by itoring of function to an extent that makes it
other investigators (16). Intraoperative neuro- superior to imaging methods that provide infor-
physiological monitoring for such operations mation about structure and that are impractical
could involve monitoring of cranial motor for use in the operating room. Intraoperative neuro-
nerves, including CN III, IV, and VI, especially physiological monitoring relates to the spirit of
for tumors involving the cavernous sinus, and the Hippocratic oath: namely “Do no harm.” We
the motor portion of CN V (portio minor). might not be able to relieve suffering from ill-
Later, intraoperative monitoring of the func- ness, but we should at least not harm the patient
tion of the ear and the auditory nerve came into in our attempts to relieve the patient from illness.
general use by neurosurgeons and its use Intraoperative neurophysiological monitoring
Chapter 1 Introduction 3
provides an example in medicine and surgery least adequately, by teams of experts that
of improvements accomplished specifically by include members with a thorough understand-
reducing failures and, thus, improving performing of neuroscience and the pathophysiology of
ance by reducing failures, a principle that is the disorders that are to be treated.
now regarded with great importance in the design There is little doubt that the use of proce-
of complex applications, such as in military dures such as DBS will expand to include disor-
procedures and space exploration. ders that are currently treated with medication
Although the greatest benefit of intraoperative alone. The implementation of stimulation treat-
neurophysiological monitoring is that it provides ments will be broadened, consequently increas-
the possibility to reduce the risk of postoperative ing the demands on neurosurgeons who perform
neurological deficits, it can also be of great value these procedures, as well as neurophysiologists
to the surgeon by providing other information who are providing the neurophysiological guid-
about the effects of the surgeon’s manipulations ance for proper placement of such stimulating
that is not otherwise available. Intraoperative electrodes.
recordings of neuroelectric potentials can help Neurophysiology in the operating room also
the surgeon identify specific neural structures, provides an opportunity for research and study
making it possible to determine the location of of the normal function of the human nervous
neural blockage on a nerve. Intraoperative neuro- system as well as the function of the diseased
physiological recordings can often help the sur- nervous system. In fact, use of neurophysiol-
geon carry out the operation and, in some cases, ogy in the operating room for research was
to determine when the therapeutic goal of the practiced before it came into general use for
operation has been achieved. Intraoperative neuro- intraoperative monitoring. For the neurophysi-
physiological monitoring can often give the sur- ologist, the operating room offers possibilities
geon a justified increased feeling of security. for research that are otherwise not available.
We are now seeing the beginning of an era Performing studies on patients undergoing neu-
of treatment of certain movement disorders and rosurgical operations often makes it possible to
severe pain that moves away from the use of do intracranial recordings in a unique way to
medications and toward the use of complex examine the normal functions of parts of the
procedures such as deep brain stimulation nervous system that are not affected by the dis-
(DBS) and other forms of functional interven- order for which the patient is undergoing the
tion, some of which involve prompting the operation. Electrophysiological recording dur-
expression of neural plasticity. ing operations also offers unique possibilities
Using neurophysiological methods is criti- to study the pathophysiology of disease
cal for treatments using DBS and selective processes, because it is possible to record elec-
lesioning of brain tissue for treating movement trical activity directly from the parts of the
disorders and severe pain. The obvious advan- nervous system that are affected by the disease.
tage of such procedures as DBS and selective There are two kinds of research that can be
lesions is that the treatment is directed specifi- done in the operating room. The first is basic
cally to structures that are involved in produc- research, the purpose of which is to gain new
ing the symptoms, whereas other general knowledge but no direct benefit to patients is
medical (pharmaceutical) treatment, even when expected. However, experience has taught us
applied in accordance with the best known that even basic research can provide (unex-
experience, is much less specific and often has pected) immediate as well as long-term benefit
severe side effects and limited beneficial effect. to patient treatment. The other kind of research,
Although any licensed physician can prescribe applied research, has as its aim to provide
any drug, even such drugs that have complex immediate improvement of treatment, including
actions and known and unknown side effects, reduction of postoperative deficits. This means
procedures such as DBS can only be done, at that both types of research can be beneficial to
the patients either in providing better therapeu- Ojemann, working with Otto Creutzfeldt from
tic achievements or by reducing the risk of post- Germany, developed methods for microelectrode
operative permanent neurological deficits. recordings from the brain of awake patients.
There are several advantages of doing They studied neuronal activity during face recog-
research in the operating room. Humans are dif- nition, but their studies also contributed to the
ferent from animals and the results are directly development of the use of microelectrodes in
applicable to humans. Second, but not least, it is recordings from the human brain.
easier to study the physiology of diseased sys- A neurologist, Gaston Celesia, has expanded
tems in humans than trying to make animal our knowledge about the organization of the
models of diseases. Humans can respond and human cerebral cortex by recordings of evoked
tell you how they feel, which is an advantage responses directly from the surface of the
when evaluating results of, for instance, efforts human auditory cortex (24,25). Celesia mapped
to reduce postoperative deficits. the auditory cortex in humans and studied
Research in the operating room has a longer somatosensory evoked potentials from the thal-
history that intraoperative neurophysiological amus and primary somatosensory cortex (26).
monitoring. One of the first surgeons-scientists Other investigators have studied other structures
who understood the value of research in the such as the dorsal column nuclei, the cochlear
neurosurgical operating room was Wilder nucleus, and the inferior colliculus in patients
Penfield (1891–1976), who founded the Mon- undergoing neurosurgical operations where
treal Neurological Institute in 1934. Penfield these structures became exposed (27–30). The
was a neurosurgeon who had a solid background methods used to record evoked potentials from
in neurophysiology, inspired by Sherrington the surface of the cochlear nucleus by inserting
during a Rhodes Scholarship to Oxford. He an electrode into the lateral recess of the fourth
stated that, “Brain surgery is a terrible profes- ventricle (28,31) became a useful method for
sion. If I did not feel it will become different in monitoring the integrity of the auditory nerve in
my lifetime, I should hate it,” (1921). Penfield operations for vestibular schwannoma, where
might be regarded as the founder of intraopera- preservation of hearing was attempted (32), as
tive neurophysiological research and he did well as in microvascular decompression opera-
ground-breaking work in many areas of neuro- tions for trigeminal neuralgia, hemifacial
science. His work on the somatosensory system spasm, and disabling positional vertigo.
is especially known (22,23). In the 1950s, he Studies of the neural generators of the ABR
used electrical stimulation to find epileptic foci, have likewise benefited from recordings from
and in connection with these operations, he did structures that became exposed during neurosur-
extensive studies of the temporal lobe, espe- gical operations. Recordings from the auditory
cially with regard to memory. nerve that were first published in 1981 by two
Other neurosurgeons have followed Penfield’s groups, one in Japan (Isao Hashimoto, neurosur-
tradition, such as George A. Ojemann, who has geon) (33) and one in the United States (13)
contributed much to understanding pathologies showed that the auditory nerve is the generator
related to the temporal lobe as well as to provide of two vertex positive deflections in the auditory
basic research regarding memory and, in particu- brainstem responses, whereas the auditory
lar, regarding the large individual variations of nerve in small animals such as the rhesus mon-
the brain. Like Penfield, he operated on many key is the generator of only one (major) peak
patients for epilepsy, and during these operations, (34–36).
he mapped the temporal lobe and studied the The neurosurgeon Fred Lenz has studied the
centers for memory and speech using electrical responses from nerve cells in the thalamus in
current to inactivate specific regions of the brain awake humans using microelectrodes and
in patients who were awake and therefore were mapped the thalamus with regard to involve-
able to respond and perform memory tasks. ment in painful stimulation as well as in
Chapter 1 Introduction 5
response to innocuous somatosensory stimula- that an effective collaboration between sur-

tion (37–39). geons and neurophysiologists promotes.
Electrophysiological studies of patients
undergoing MVD operations for HFS have sup-
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future patients by the progress in treatment cranial nerves in operations in the skull base.
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SECTION I
PRINCIPLES OF INTRAOPERATIVE
NEUROPHYSIOLOGICAL MONITORING
Chapter 2
Basis of Intraoperative Neurophysiological Monitoring
Chapter 3
Generation of Electrical Activity in the Nervous System and Muscles
Chapter 4
Practical Aspects of Recording Evoked Activity From Nerves, Fiber Tracts, and Nuclei
The basic principles of recording and stimulation of the nervous system used in intraoperative
neurophysiological monitoring resemble techniques used in the clinical diagnostic laboratory with
some very important differences. The electrical potentials that are recorded from the nervous sys-
tem in the operating room must be interpreted immediately and are recorded under circumstances
of interference of various kinds. This means that the person who does intraoperative neurophysio-
logical monitoring must be knowledgeable about the function of the neurological systems that are
monitored, how electrical potentials are generated by the nervous system, and how such potentials
change as a result of pathologies that occur because of surgical manipulations. This section pro-
vides basic information about the principles of intraoperative neurophysiological monitoring.
Chapter 3 describes how electrical activity is generated in the nervous system and how such elec-
trical activity can be recorded and can be used as the basis for detecting injuries to specific parts of
the peripheral and central nervous system. Chapter 4 provides some practical information about
recording of neuroelectric potentials from the nervous system and how to stimulate the nervous sys-
tem in anesthetized patients. This chapter also discusses how to record very small electrical poten-
tials in an electrically hostile environment such as the operating room.
2
B a s i s o f I n t ra o p e ra t i ve N e u ro p hy s i o l o g i c a l
Monitoring
Introduction
Reducing the Risk of Neurological Deficits
Aiding the Surgeon in the Operation
Working in the Operating Room
How to Evaluate the Benefits of Intraoperative Neurophysiological Monitoring
Research Opportunities
can increase the likelihood of achieving the

INTRODUCTION
therapeutical goal of an operation. Intraopera-
tive neurophysiological recordings have shown
Intraoperative neurophysiological monitor-
to be of help in identifying the offending blood
ing is often associated with reducing the risk of
vessel in a cranial nerve disorders (hemifacial
postoperative neurological deficits in operations
spasm).
where the nervous system is at risk of being per-
manently injured. Although the main use of
electrophysiological methods in the operating REDUCING THE RISK
room might be for reducing the risk of postoper- OF NEUROLOGICAL DEFICITS
ative neurological deficits, electrophysiological
methods are now in increasing use for other The use of intraoperative neurophysiological
purposes. For example, electrophysiological monitoring to reduce the risk of loss of func-
methods are now regarded as necessary for guid- tion in portions of the nervous system is based
ing the placement of electrodes for deep brain on the observation that the function of neural
stimulation or for making lesions in specific structures usually changes in a measurable way
structures for treating movement disorders and before being permanently damaged. By revers-
pain. Intraoperative electrophysiological recording the surgical manipulation that caused the
ings can also help the surgeon in carrying out change within a certain time will result in a
other surgical procedures. Finding specific neural recovery to normal or near-normal function,
tissue such as cranial nerves or specific regions whereas if no intervention had been taken,
of the cerebral cortex are examples of tasks that there would have been a risk that permanent
are included in the subspecialty of intraoperative postoperative neurological deficit would have
neurophysiological monitoring. Neurophysio- resulted.
logical methods are in increasing use for diag- Surgical manipulations such as stretching,
nostic support in operations such as those compressing, or heating from electrocoagulation
involving peripheral nerves. In certain operations, are insults that can injure neural tissue, as can
intraoperative electrophysiological recordings ischemia caused by impairment of blood sup-
ply resulting from surgical manipulations or
By A. R. Møller intentional clamping of arteries, that could also
© Humana Press Inc., Totowa, NJ. result in permanent (ischemic) injury to neural
9
structures, causing a risk of noticeable postop- methods for stimulation and recordings of elec-
erative neural deficits. trical activity in the nervous system. Most of the
The effect of such insults represents a con- methods that are used in intraoperative neuro-
tinuum; at one end, function decreases for the physiological monitoring are similar to those
time of the insult, and at the other end of this that are used in the physiological laboratory and
continuum, nervous tissue is permanently in the clinical testing laboratory for many years.
damaged and normal function never recovers,
thus causing permanent postoperative deficits. Sensory System. Intraoperative neurophysi-
Between these extremes, there is a large range ological monitoring of the function of sensory
over which recovery can occur either totally or systems has been widely practiced since the
partially. Thus, up to a certain degree of injury, middle of the 1980s. The earliest uses of
there can be total recovery, but thereafter, the intraoperative neurophysiologic monitoring
neural function might be affected for some of sensory systems were modeled after the
time. After more severe injury, the recovery of clinical use of recording sensory evoked poten-
normal function not only takes a longer time tials for diagnostic purposes.
but the final recovery would only be partial, Sensory systems are monitored by applying
with the degree of recovery depending on the an appropriate stimulus and recording the
nature, degree, and duration of the insult. response from the ascending neural pathway,
Injuries acquired during operations that usually by placing recording electrodes on the
result in a permanent neurological deficit will surface of the scalp to pick up far-field potentials
most likely reduce the quality of life for the from nerve tracts and nuclei in the brain (far-field
patient for many years to come and maybe for responses).
a lifetime. Therefore, it is important that the It has been mainly somatosensory evoked
person responsible for interpreting the results potentials (SSEPs) and auditory brainstem
of monitoring is aware that the neurophysiologist responses (ABRs) that have been recorded in
has a great degree of responsibility, together the operating room for monitoring the function
with the surgeon and the anesthesiologist, in of these sensory systems for the purpose of
reducing the risk of injury to the patient during reducing the risk of postoperative neurological
the operation. deficits. Visual evoked potentials (VEPs) are
also monitored in some operations. When intra-
Techniques for Reducing Postoperative operative neurophysiological monitoring was
Neurological Deficits introduced, it was first SSEPs that were moni-
The general principle of intraoperative neuro- tored routinely (1), followed by ABRs (2–4).
physiological monitoring is to apply a stimulus Although the technique used for recording
and then to record the electrical response from sensory evoked potentials in the operating room
specific neural structures along the neural path- is similar to that used in the clinical diagnostic
way that are at risk of being injured. This can laboratory, there are important differences. In
be done by recording the near-field evoked the operating room, it is only changes in the
potentials by placing a recording electrode on a recorded potentials that occur during the opera-
specific neural structure that becomes exposed tion that are of interest, whereas in the clinical
during the operation or, as more commonly testing laboratory, the deviation from normal
done, by recording the far-field evoked poten- values (laboratory standard) are important
tials from, for instance, electrodes placed on measures. Another important difference is that
the surface of the scalp. results obtained in the operating room must be
Intraoperative neurophysiological monitoring interpreted instantly, which places demands on
that is done for the purpose of reducing the risk the personnel who are responsible for intraoper-
of postoperative neurological deficits makes ative neurophysiological monitoring that differ
use of relatively standard and well-developed from those working in the clinical laboratory. In
Chapter 2 Basis of Intraoperative Neurophysiological Monitoring 11
the operating room, it is sometimes possible to of the spinal cord. Spinal motor systems are
record evoked potentials directly from neural often monitored by recording EMG potentials
structures of sensory pathways (near-field from specific muscles in response to electrical
responses) when such structures become or magnetic stimulation of the motor cortex
exposed during an operation. (Chap. 10).
The use of evoked potentials in intra-
operative neurophysiological monitoring for Peripheral Nerves. Monitoring of motor
the purpose of reducing the risk of postopera- nerves is often accomplished by observing the
tive permanent sensory deficits is based on the electrical activity that can be recorded from one
following: or more of the muscles that are innervated by the
motor nerve or motor system that is to be mon-
1. Electrical potentials can be recorded in itored (evoked EMG potentials). The respective
response to a stimulus. motor nerve might be stimulated electrically or
2. These potentials change in a noticeable way by the electrical current that is induced by a
as a result of surgically induced changes in strong magnetic impulse (magnetic stimula-
function. tion). Recordings of muscle activity that is
3. Proper surgical intervention, such as elicited by mechanical stimulation of a motor
reversal of the manipulation that caused the nerve or by injury to a motor nerve are impor-
change, will reduce the risk that the tant parts of many forms of monitoring of the
observed change in function develops into a motor system. Such muscle activity is moni-
permanent neurological deficit or, at least, tored by continuous recording EMG potentials
will reduce the degree of the postoperative (“free-running EMG”). When such activity is
deficits. made audible, it can provide important feedback
to the surgeon and the surgeon, can then modify
Motor Systems. Intraoperative neurophysi- his/her operative technique accordingly.
ological monitoring of the facial nerve was Monitoring peripheral nerves intraopera-
probably the first motor system that was moni- tively can be done by electrically stimulating
tored systematically. The introduction of skull the nerve in question at one point and recording
base surgery in the 1980s (5) caused an the compound action potentials (CAPs) at a
increased demand for monitoring of other cra- different location. Changes in neural conduc-
nial systems, and the use of monitoring for tion that might occur between these two loca-
many cranial motor nerves spread rapidly (6,7). tions will result in changes in the latency of the
Intraoperative neurophysiological monitoring CAP and/or in the waveform and amplitude of
of spinal motor systems was delayed because the CAP. The latency of the CAP is a measure of
of technical difficulties, mainly in eliciting the (inverse) conduction velocity, and decreased
recordable evoked motor responses to stimula- conduction velocity is a typical sign of injury to
tion of the motor cortex in anesthetized a nerve. The latency and waveform of the
patients. After these technical obstacles in acti- recorded CAP typically increases as a result of
vating descending spinal motor pathways were many kinds of insult to a nerve.
resolved in the 1990s, intraoperative neuro-
physiological monitoring of spinal motor sys- Interpretation of Neuroelectric Potentials
tems gained wide use (8). Monitoring of cranial The success of intraoperative neurophysiolog-
nerve motor systems commonly relies on record- ical monitoring depends greatly on the correct
ings of electromyographical (EMG) potentials interpretation of the recorded neuroelectrical
from muscles that are innervated by specific potentials. In most situations, the usefulness of
motor nerves, whereas monitoring of spinal intraoperative neurophysiological monitoring
motor systems also makes use of recordings depends on the person who watches the display,
directly from the descending motor pathways makes the interpretation, and decides what
information should be given to the surgeon. It is, It must be remembered that the recorded
therefore, imperative for success in intraopera- sensory evoked potentials do not measure the
tive neurophysiological monitoring that the per- function (or changes in function) of the sensory
son who is responsible for the monitoring be system that is being tested. For example, there
well trained. It is also important that he/she is is no direct relationship between the change in
familiar with the different steps of the operation the ABR and the change in the patient’s hearing
and well informed in advance about the patient threshold or change in speech discrimination.
who is to be monitored. This is one reason why it has been difficult to
It is important that information about changes establish guidelines for how much evoked
in recorded potentials be presented in a way potentials could be allowed to change during an
that contributes specific interpreted detail that operation without presenting a noticeable risk
the surgeon will find useful and actionable. for postoperative deficits.
Surgeons are not neurophysiologists and the Interpretation of sensory evoked potentials
knowledge of neurophysiology varies among is based on knowledge of the anatomical loca-
surgeons. The neurophysiologist who provides tion of the generators of the individual com-
results of monitoring to the surgeon must, ponents of SSEP, ABR, and VEP in relation to
therefore, present their skilled interpretation the structures that are being manipulated in a
of the recorded potentials. The surgeon might specific operation. Interpretation of sensory
not always appreciate data such as latency val- evoked potentials also depends on the pro-
ues because the surgeon might not understand cessing of the recorded potentials. For exam-
what such data represent. Monitoring is of no ple, filtering of various kinds are used and that
value if the surgeon does not take action affects the waveform of the potentials. The
accordingly. If the surgeon does not understand amplitude of these sensory evoked potentials
what the information provided by the neuro- is smaller than the background noise (ongoing
physiologist means, then there is little chance brain activity [EEG potentials] and electrical
that he/she will take appropriate action. noise) and it is, therefore, necessary to use signal
Correct and prompt interpretation of changes averaging to enhance the signal-to-noise ratio of
in the waveforms of the recorded potentials is electrical potentials such as sensory evoked
essential for such monitoring to be useful. The potentials. Signal averaging (adding the
far-field potentials such as ABR, SSEP, and responses to many stimuli) is based on the
VEP are often complex and consist of a series assumption that the responses to every stimu-
of peaks and troughs that represent the electri- lus are identical and they always occur at the
cal activity that is generated by successively same time following stimulation. Because the
activated nerve tracts and nuclei of the ascend- sensory evoked potentials that are recorded in
ing neural pathways of the sensory system. the operating room are likely to change during
Exact interpretation of the changes in such the time that responses are being averaged, the
potentials that could occur as a result of various averaging process might produce unpre-
kinds of surgical insult therefore require thor- dictable results. These matters are important
ough knowledge of the anatomy and physiology to take into consideration when interpreting
of the systems that are monitored and of how sensory evoked potentials. (Signal averaging
the recorded potentials are generated. and filtering are discussed in more detail in
The most reliable indicators of changes in Chap. 18.)
neural function are changes (increases) in the Different ways to reduce the time necessary
latencies of specific components of sensory to obtain an interpretable recording are dis-
evoked potentials, and surgically induced cussed and described in Chaps. 4, 6, and 18. The
insults to nervous tissue often also cause specific techniques that are suitable for intra-
changes in the amplitude of the sensory evoked operative neurophysiological monitoring of the
potentials. auditory, somatosensory, and visual systems
are dealt with in more detail in Chaps. 4 and 6, for the surgeon to accurately identify the step in
respectively. the operation that caused the change, which is
In some instances, it is possible to record a prerequisite for proper and prompt surgical
potentials from the structures that actually gen- intervention and, thus, the ability to reduce the
erate the evoked potentials in question (near- risk of postoperative neurological deficits.
field potentials). Such potentials often have Correct identification of the step in an oper-
sufficiently large amplitude, allowing observa- ation that entails a risk of complications might
tion of the potentials directly without signal make it possible to modify the way such an
averaging. If it is possible to base the intraoper- operation is carried out in the future and
ative neurophysiological monitoring on record- thereby makes it possible to reduce the risk of
ing of evoked potentials directly from an active complications in subsequent operations. In this
neural structure (nerve, nerve tract, or nucleus), way, intraoperative neurophysiological moni-
little or no signal averaging might be necessary toring can contribute to the development of
because the amplitudes of such potentials are safer operating methods by making it possible
much larger than those of far-field potentials, to identify which steps in an operation might
such as the ABR and SSEP, and such near-field cause neurological deficits, and it thereby natu-
potentials can often be viewed directly on an rally also plays an important role in teaching
computer screen or after only a few responses surgical residents and fellows.
have been averaged. These matters are also dis-
cussed in more detail in the chapters on sensory When to Inform the Surgeon
evoked potentials (Chaps. 4 and 6). It has been debated extensively whether the
The design of the monitoring system and the surgeon should be informed of all changes in
way the recorded potentials are processed are the recorded electrical activity that could be
important factors in facilitating proper interpre- regarded to be caused by surgical manipula-
tation of the recorded neuroelectric potentials, tions or only when such changes reach a level
as is the way the recorded potentials are dis- that indicate a noticeable risk for permanent
played (see Chap. 18). The proper choice of neurological deficits. The question is thus:
stimulus parameters and the selection of the should the information that is gained be used
location along the nervous pathways where the only as a warning that implies that if no inter-
responses are recorded also facilitate prompt vention is made, there is a likelihood that the
interpretation of recorded neuroelectrical patient will get a permanent postoperative neu-
potentials. rological deficit, or should all information
When recording EMG potentials, it is often about changes in function be conveyed to the
advantageous to make the recorded response surgeon?
audible (9,10) so that the neurophysiologist If only information that is presumed to indi-
responsible for the monitoring and the surgeon cate a high risk of neurological deficits is given
can hear the response and make his/her own to the surgeon, then it must be known how large
interpretation. Still, the possibilities to present a change in the recorded neuroelectrical poten-
the recorded potentials directly to the surgeon tials can be permitted without causing any per-
are currently few, and it is questionable manent damage. This question has so far
whether it would be advantageous. Few sur- largely remained unanswered. The degree and
geons are physiologists and most surgeons the nature of the change and the length of time
want the results of monitoring to be presented that the adverse effect has lasted are all factors
in an interpreted form rather than raw data. that are likely to affect the outcome, and the
The importance of being able to detect a effect of these factors on the risk of postopera-
change in function as soon as possible cannot be tive neurological deficits are largely unknown.
emphasized enough. Prompt interpretation of Individual variation in susceptibility to surgical
changes in recorded potentials makes it possible insults to the nervous system and many other
factors affect the risk of neurological deficits in function in a measurable way is valuable to
mostly unknown ways and degrees. An individ- the surgeon, and continuous monitoring of the
ual’s disposition and homeostatic condition and change can keep his/her option to modify the
perhaps the effect of anesthesia are likely to procedure to remain open because monitoring
affect the susceptibility to surgically induced has identified which step in the operation
injuries. caused the change in function.
If the surgeon is given information about If information about a change in the
any noticeable change in the recorded poten- recorded potentials is withheld until the change
tials that may be related to his/her action it is in the recorded electrical potentials has
not necessary to know how large a change in increased greatly, it would be difficult for the
recorded potentials can be permitted without a surgeon to determine which step in the surgical
risk of permanent neurologic deficits. The sur- procedure caused the adverse effect, and thus it
geon can use such information in the planning would not be possible for the surgeon to inter-
and the decision of how to proceed with the vene appropriately because it would not be
operation, and intraoperative neurophysiological known which step in the procedure caused the
monitoring can thereby effectively help decrease change. Also, in such a situation, the surgeon
the risk of neurological deficits. This means would not have had the freedom of delaying
that it is beneficial to the surgeon to be his/her action to reverse the change because it
informed whenever his or her actions have had already reached dangerous levels.
resulted in a noticeable change in the recorded The more knowledge that is gathered about
neuroelectrical potentials. In that way, intraop- the effect of mechanical manipulation on
erative neurophysiological monitoring provides nerves, the more it seems apparent that even
information rather than warnings. Changes in slight changes in measures of electrical activity
the recorded potentials that are larger than the (such as the CAP) might be signs of permanent
(small) normal variations of the potentials in injury. However, studies that relate changes in
question should be reported to the surgeon if evoked potentials to morphological changes
there is reasonable certainty that these changes and changes in postoperative function are still
are related to surgical manipulations. rare. Thus, relatively little is known quantita-
If the surgeon is made aware of any change tively about the degree to which a nerve can be
in the recorded potentials that is larger than stretched, heated, or deprived of oxygen before
those normally occurring, it can help the sur- a permanent injury results, but there is no doubt
geon to carry out the operation in an optimal that different nerves respond in different ways
way with as little risk of adverse affect on neu- to injury because of mechanical manipulations,
ral function as possible. Providing such infor- heat, or lack of oxygen.
mation gives the surgeon the option of altering Presenting information about changes in the
his/her course of action in a wide range of time. recorded neuroelectrical potentials as soon as
If the change in the recorded potentials is they reach a level where they are detectable
small, it is likely that the surgeon would be able also has an educational benefit in that it tells
to reverse the effect by a slight change in the the surgeon precisely which steps in an opera-
surgical approach or by avoiding further tion might result in neurological deficit. It is
manipulation of the neural tissue affected; often possible on the basis of such knowledge
alternatively, the surgeon might choose not to to modify an operation to avoid similar injuries
alter the technique if the surgical manipulations in future operations.
that caused the changes in the recorded neuro- When conveying information about early
physiological potentials are essential to carry- changes in the recorded potentials, it is impor-
ing out the operation in the anticipated way. tant that it be made clear to the surgeon that
However, even in such a case, the knowledge such information represents guidance details,
that the surgical procedure is affecting neural as opposed to a warning that the surgical
manipulations are likely to result in a high risk monitoring is not to detect when a certain
of serious consequences if appropriate action is surgical manipulation will cause a permanent
not taken promptly by the surgeon. Warnings neurological deficit. Instead, the purpose is to
are justified, however, if, for instance, there is a provide information about when there is a
sudden large change in the evoked potentials or (noticeable) risk that a permanent neurological
if the surgeon has disregarded the need to deficit might occur. In fact, in most cases
reverse a manipulation that has caused a slow when intraoperative neurophysiological moni-
change in the recorded electrical potentials. toring shows changes in function that indi-
The surgeon should be informed of the pos- cates a risk of causing neurological deficits, no
sibility of a surgically induced injury even in permanent deficits occur. There is no serious
cases in which the change (or total disappear- consequences associated with this kind of false-
ance of the recorded potentials) could be positive responses in intraoperative neuro-
caused by equipment or electrode malfunction. physiological monitoring. A situation in which
Thus, only after assuming that the problem is the surgeon was mistakenly alerted of a change
biological in nature can equipment failure be in the recorded potentials that was afterward
considered as a possible cause. shown to be a result of a technical fault or a
harmless change in the nervous system rather
False Alarms than being caused by surgical manipulations
The question of false-positive and false- might be regarded as a true false-positive
negative responses in intraoperative neurophysio- response.
logical monitoring has been extensively debated. The occurrences of false-negative results,
In some of these discussions, a false-positive which mean that a serious risk has occurred
response meant that the surgeon was alerted of a without being noticed, indicate a failure in
situation that would not have led to any notice- reaching the goal of intraoperative neurophysi-
able risk of neurological deficits if no action had ological monitoring and it might have serious
been taken. consequences.
Before discussing false-positive and false- Therefore, the conventional definition of
negative responses in intraoperative neurophysio- false-positive and false-negative results cannot
logical monitoring, the meaning of false-positive be applied to intraoperative neurophysiological
and false-negative responses should be clarified. monitoring because the purpose of monitoring
A typical example of a false-positive result of a is not to identify an individual with a
test for a specific disease occurs when the test neurological deficit but to identify signs that
showed the presence of a disease when there have a certain risk of leading to such deficits if
was, in fact, no disease present. Using the same no action is taken.
analogy, a false-negative test would mean that
the test failed to show that a certain individual Nonsurgical Causes of Changes
in fact had the specific disease. In the clinic or in Recorded Potentials
in screening of individuals without symptoms, Alerting the surgeon as soon as a change
false-negative results are more serious than occurs naturally always implies a faint possibility
false-positive results: false-positive results that a change in evoked potentials might be
might lead to an incorrect diagnosis or caused by technical problems that affected
unnecessary treatment, whereas false-negative some part of the equipment that is used or by a
results might have the dire consequence of no loss of contact of one or more of the electrodes.
treatment being given for an existing disease. The characteristics of changes caused by tech-
These definitions cannot be transposed nical problems are usually so different from
directly to the field of intraoperative neuro- those of changes caused by injury from surgical
physiological monitoring. One reason is that manipulations that these two phenomena can
the purpose of intraoperative neurophysiological easily be distinguished by an experienced
neurophysiologist. It is possible that a total loss change in function to progress, thus increasing
of recorded potentials can be caused by a tech- the risk of a permanent neurological deficit. The
nical failure, but it could also be caused by a opportunity to properly reverse the cause of the
major failure in the part of the nervous system observed change in the recorded neuroelectrical
that is being monitored. However, if such an potentials might be lost if action is delayed
event should occur, it is much better to first while searching for technical problems.
assume that the cause is biological and to In accepting this way of performing intraop-
promptly alert the surgeon accordingly and erative neurophysiological monitoring, it must
then do trouble-shooting of the equipment. In also be assumed that everything is done that
general, when something unusual happens, it is can be done to keep technical failures that
advisable to alert the surgeon promptly that could mimic surgically induced changes in the
something serious could have happened instead recorded potentials to an absolute minimum.
of beginning to check the equipment and Actually, high-quality equipment very seldom
electrodes. It is highly unlikely that a technical malfunctions, and if needle electrodes are used
failure will occur and cause a change in the in the way described in the following chapters
recorded potentials that might be confused with and care is taken when placing the electrodes,
a biological cause for the change. The incidents of electrode failure will be rare.
neurophysiologist should explain to the surgeon There are factors other than surgical manipu-
that a potentially serious event has occurred lations or equipment failure that can cause
and then check the equipment and the elec- changes in the waveform of the recorded
trodes for malfunction. The surgeon, not wait- potentials (e.g., changes in the level of anesthe-
ing for the completion of this equipment check, sia, blood pressure, or body temperature of the
should immediately begin his/her own investi- patient). It is therefore important that the person
gation to ascertain whether a surgically induced who is responsible for the intraoperative
injury has occurred. If it is discovered that the neurophysiological monitoring be knowledge-
change in the recorded potentials was caused by able about how these factors could affect the
equipment malfunction, the surgeon can then be neuroelectric potentials that are being recorded.
apprised of this; thus, the only loss that the inci- The physiologist should maintain consistent and
dent would cause is a few minutes of the frequent communication with the anesthesiolo-
surgeon’s time. If such an occurrence is gist to keep informed about any changes in the
regarded as a “false alarm,” then the price for level of anesthesia and changes in the anesthesia
tolerating such “false alarms,” namely that the regimen that could affect the electrophysiologi-
operation might be delayed unnecessarily for a cal parameters that are to be monitored.
brief time, seems small compared to what could
occur if one chose to check the equipment before How to Evaluate Neurological Deficits
alerting the surgeon. To assess the success of avoiding neurologi-
If the cause of the change in the recorded cal deficits, it is important that patients be
neuroelectrical potentials was indeed a result of properly examined and tested both preopera-
an injury that was caused by surgical manipu- tively and postoperatively so that changes can
lation of neural structures and appropriate be verified quantitatively. In some cases, an
action was not taken immediately by the sur- injury is detectable only by specific neurological
geon, precious time would have been lost. This testing, whereas in other cases, injury causes
would occur if the neurophysiologist had impaired sensory function that is noticeable by
assumed that the cause of the change was tech- the patient. Other patients might suffer alter-
nical in nature. Not only would the opportunity ations in neural function that are noticeable to
to identify the cause of the change be missed by the patient as well as others in everyday
taking the time to check the equipment first, but situations. It is therefore important that careful
such a delay could also have allowed the objective testing and examination of the patient
be performed before and after operations to (DBS) and electrophysiological methods are
make accurate quantitative assessments of sen- equally important for guiding the placement of
sory or neurological deficits. electrodes for DBS.
There is no doubt that the degree to which Implantation of electrodes for DBS and for
different types of neurological deficit affect stimulation of specific structures in the spinal
individuals varies, but reducing the risk of any cord no doubt will increase during the coming
measurable or noticeable deficit as much as years. Such treatments are attractive in compar-
possible must be the goal of intraoperative ison with pharmacological (drug) treatment in
neurophysiological monitoring. that it has fewer side effects. Whereas a
physician with a license to practice medicine
can prescribe many complex medications,
AIDING THE SURGEON procedures such as electrode implantation for
IN THE OPERATION DBS require expertise in both surgery and
neurophysiology and it must involve intraoper-
In addition to reducing the risk of neurological ative neurophysiological recordings being per-
deficits, the use of neurophysiological tech- formed adequately. This means that the need of
niques in the operating room can provide infor- people with neurophysiological knowledge and
mation that can help the surgeon carry out the skills of working in the operating room will be in
operation and make better decisions about the increasing demand for the foreseeable future.
next step in the operation. In its simplest form, There is no doubt that in the future we will
this might consist of identifying the exact see the development of many other presently
anatomical location of a nerve that cannot be unexplored areas in which intraoperative neu-
identified visually or it might consist of identi- rophysiological recording will become an aid
fying where in a peripheral nerve a block of to the surgeon in specific operations, and the
transmission has occurred (11). In operations to use of neurophysiological methods in the oper-
repair peripheral nerves, intraoperative diagnosis ating room will expand as a means to study
of the nature of the injury and its exact location normal as well as pathological functions of the
using neurophysiological methods have nervous system.
improved the outcome of such operations.
An example of a more complex role of intra-
operative recording is the recording of the WORKING IN THE OPERATING
abnormal muscle response in patients undergo- ROOM
ing microvascular decompression (MVD) oper-
ations to relieve hemifacial spasm (HFS) Intraoperative neurophysiological monitoring
(12,13). This abnormal muscle response disap- should interfere minimally with other activities
pears when the facial nerve is adequately in the operating room. If it causes more than
decompressed (14), and by observing this minimal interference, there is a risk that it would
response, it is possible to identify the blood not be requested as often as it should. There is so
vessel or blood vessels that caused the symptoms much activity in modern neurosurgical, otologic,
of HFS as well as to ensure that the facial nerve and orthopedic operating rooms that adding
has been adequately decompressed. activity that consumes time will naturally be met
Electrophysiological guidance for place- with a negative attitude from all involved and
ment of lesions in the basal ganglia and the might result in the omission of intraoperative
thalamus for treatment of movement disorders neurophysiological monitoring in certain cases.
and pain is absolutely essential for the success Careful planning is necessary to ensure that
of such treatment. More recently, making intraoperative neurophysiological monitoring
lesions in these structures has been replaced by does not interfere with other forms of monitoring
electrical stimulation deep brain stimulation and the use of life-support equipment.
How to Reduce the Risk of Mistakes personnel operate the stimulus equipment. This
in Intraoperative Neurophysiological will reduce the risk of mistakes but not elimi-
Monitoring nate mistakes.
The importance of selecting the appropriate In a similar way, monitoring the wrong side
modality of neuroelectric potentials for moni- of the spinal cord could cause serious neuro-
toring purposes cannot be overemphasized and logical deficits without any change in the
making sure that the structures of the nervous recorded neuroelectrical potentials being
system that are at risk are included in the mon- noticed during the operation. When an operation
itoring is essential. Thus, monitoring SSEP involves the spinal cord distal to the cervical
elicited by stimulating the median nerve while spine and stimulating electrodes are placed in
operating on the thoracic or lumbar spine natu- the median nerve as well as in a nerve on the
rally could lead to a disaster, because it is the lower limb, the median nerve might mistakenly
thoracic lumbar spinal portion of the be stimulated when the intention was to elicit
somatosensory pathway that is at risk of being evoked potentials from the lower limb. This
injured when only the cervical portion of the could happen if the stimulation is controlled by
somatosensory pathway is being monitored. the user. The considerable difference between
Monitoring the wrong side of the patient’s the waveform of the upper limb SSEP and that
nervous system is also a serious mistake. An of the lower limb SSEP might make this mis-
example of this is presenting the sound stimulus take more easily detectable than when eliciting
to the ear opposite the side on which the opera- ABR when the wrong ear is being stimulated or
tion is being done while monitoring ABR. This when eliciting SSEP from the wrong side.
kind of mistake could occur when earphones are
fitted in both ears and selection of which ear- Reliability of Intraoperative
phone to be used is controlled by the neurophys- Neurophysiological Monitoring
iologist. A user mistake can cause the wrong Like any other new addition to the operating
earphone to be used. Because the ABR is not room armamentarium, intraoperative neuro-
fundamentally different when elicited from the physiological monitoring must be reliable in
opposite side, such a mistake will not be imme- order to be a tool that is used routinely. It is not
diately obvious, but it will naturally prevent the unreasonable to assume that if intraoperative
detection of any change in the ear or auditory neurophysiological monitoring cannot always
nerve as a result of surgical manipulation. The be carried out and, consequently, operations are
possible catastrophic consequence of failing to done without the aid of monitoring, it might be
detect any change in the recorded potentials assumed by the surgeon that it is not necessary
when the auditory nerve is injured by surgical at all to have such monitoring.
manipulation is obvious. Reliability can best be achieved if only rou-
Generally speaking, if a mistake can be made tines that are well thought through and that have
by the action of the user (neurophysiologist), it been thoroughly tested are used in the operating
will be made; it might be rare. Mistakes might room. The same methods that have been found
be tolerated, depending on the consequences to work well over a long time should be used
and the frequency of its expected occurrence. consistently. New routines or modifications of
Mistakes can only be avoided if it is physically old routines should only be introduced in the
impossible to make the mistake. Thus, only by operating room after thorough consideration
placing an earphone solely in the ear on the and testing. Procedures of intraoperative neuro-
operated side can the risk of stimulating the physiologic monitoring should be kept as simple
wrong ear be eliminated. If earphones are as possible. The KISS Principle (Keep it Simple
placed in each ear, the risk of making mistakes [and] Stupid) (or Keep it Simple and Straight-
can be reduced by clearly marking the right and forward) is applicable to intraoperative neuro-
left earphone and only having properly trained physiological monitoring.
Electrical Safety and Intraoperative monitoring. Many of the severe postoperative

Neurophysiological Monitoring neurological deficits that were common before
A final, but not inconsiderable, concern is that the introduction of intraoperative neurophysio-
intraoperative neurophysiological monitoring logical monitoring are now rare occurrences. It
should not add risks to the safety, particularly is not only the use of intraoperative neurophys-
electrical safety, of any operation. Intraoperative iological monitoring that has caused these
neurophysiological monitoring requires the improvements of medical care, but also better
addition of complex electrical equipment to an surgical techniques and various technological
operating room already crowded with a variety advancements have provided significant
of complex electrical equipment. Electrical progress. There is no doubt that the introduc-
safety is naturally of great concern whenever tion of microneurosurgery and, more recently,
electronic equipment is in direct galvanic contact minimally invasive surgery has made opera-
with patients, but this is particularly true in the tions that affect the nervous system less brutal
operating room, where many pieces of electrical than it was 25 yr ago, and even the last decade
equipment are operated together, often in has seen steady improvements regarding reduc-
crowded conditions, and frequently under wet ing complications.
conditions. The equipment and procedures used
for intraoperative neurophysiological monitoring Assessment of Reduction of Neurological
must, therefore, be chosen with consideration for Deficits
the protection of the patient as well as of the per- It has been difficult to accurately assess the
sonnel in the operating room from electrical value of intraoperative neurophysiological
hazard. Accidents can best be avoided when monitoring with regard to reducing the risk of
those who work in the operating room and who postoperative neurological deficits. One of the
use the electronic equipment are knowledgeable reasons for these difficulties is that it has not
about the function of the equipment and how been possible to apply the commonly used
risks of electrical hazards that are associated scheme, such as double-blind methods, to
with specific equipment could arise. For the determine the value of intraoperative neuro-
neurophysiologist, it is important to have a basic physiological monitoring. Surgeons who have
understanding about how electrical hazards experienced the advantages of intraoperative
could occur and to specifically have an under- neurophysiological monitoring are reluctant to
standing of the basic functions of the various deprive their patients of the benefits provided
pieces of equipment used in electrophysiological by an aid in the operation that they believe can
monitoring. The area of greatest concern in improve the outcome. The use of historical data
maintaining electrical safety for the patient is, for comparison of outcomes before and after the
naturally, the placement of stimulating and introduction of monitoring has been described
recording electrodes on the patient. It is particu- in a few reports, but such methods are criticized
larly important to consider the safety of the because advancements in surgical technique
equipment that is connected to electrodes placed other than intraoperative neurophysiological
intracranially for either recording or stimulation. monitoring might have contributed to the
observed improvement of outcome. Even more
difficult to evaluate is the increased feeling of
HOW TO EVALUATE THE BENEFITS security that surgeons note while operating with
OF INTRAOPERATIVE the aid of intraoperative neurophysiological
NEUROPHYSIOLOGICAL monitoring.
MONITORING For the sake of evaluating future benefits
from monitoring, it is important that all patients
Naturally, it is the patient who can gain the who are monitored intraoperatively be evalu-
most from intraoperative neurophysiological ated objectively before and after the operation
and that the results obtained during monitoring mainly by its help in reducing the risk of post-
be well documented. operative neurological deficits as well as by its
ability to provide the surgeon with a feeling of
Which Surgeons Benefit Most security from knowing that he/she will know
From Intraoperative Monitoring? when neural tissue is being adversely manip-
Surgeons at all levels of experience could ulated. Most surgeons will appreciate the aid
benefit in one way or another from the use of that monitoring can provide in confirming the
intraoperative neurophysiological monitor- anatomy when it deviates from normal as a
ing, but the degree of benefit depends on the result of tumors, other pathologies, or extreme
experience of the surgeon in the particular variations.
kind of operation being performed. Whereas
an extremely experienced surgeon might bene-
fit from monitoring only in unusual situations RESEARCH OPPORTUNITIES
or for confirming the anatomy, a surgeon with
moderate-to-extensive experience might feel The operating room offers a wealth of
more secure and might have additional help in research opportunities. In fact, many important
identifying specific neural structures when discoveries about the function of the normal
using monitoring. A surgeon with moderate-to- nervous system as well as about the function of
extensive experience will also benefit from the pathological nervous system have been
knowing when surgical manipulations have derived from research activities within the
injured neural tissue. A less experienced surgeon operating room. Neurophysiological recording
who has done only a few of a specific type of is almost the only way to study the pathophys-
operation is likely to benefit more extensively iology of many disorders. Many important
from using intraoperative neurophysiological discoveries were made by applying neuro-
monitoring, and surgeons at this level of experi- physiological methods to work in the operating
ence will learn from intraoperative monitoring room, but many discoveries were made before
and through that improve his/her surgical skills. the introduction of intraoperative neurophysio-
Even some extremely experienced surgeons logical monitoring (15,16) and many studies
declare the benefit from neurophysiological were made in connection with intraoperative
monitoring and appreciate the increased feeling neurophysiological monitoring (14,17,18).
of security when operating with the assistance Some studies have concerned basic research
of monitoring. Many very experienced sur- (19), whereas other studies have been directly
geons are in fact not willing to operate without related to the development of better treat-
the use of monitoring. ment and better surgical methods (14,17,18);
In fact, most surgeons can benefit from some studies have served both purposes
intraoperative neurophysiological monitoring (15,17,19–24).
3
G e n e ra t i o n o f E l e c t r i c a l A c t i v i t y
i n t h e N e rvo u s S y s t e m a n d M u s c l e s
Introduction
Unit Responses
Near-Field Responses
Far-Field Potentials
Effect of Insults to Nerves, Fiber Tracts, and Nuclei
Unit potentials are potentials recoded from

INTRODUCTION
single nerve fibers, nerve cells, or from small
groups of nerve fibers or nerve cells (multiunit
To understand why and how neuroelectrical
recordings). Such potentials can be either spon-
potentials, such as evoked potentials, might
taneous activity that occurs without any inten-
change as a result of surgical manipulations, it is
tional stimulation or evoked by some form of
necessary to understand the basic principles
stimulation. Unit or multiunit responses are
underlying the generation of the neuroelectrical
recorded by placing small electrodes (micro-
potentials that can be recorded from various parts
electrodes) in indirect contact with nerve fibers
of the nervous system. In this volume, we discuss
or nerve cells. Recording of such potentials
electrical potentials that are generated in
have played important roles in animal studies
response to intentional stimulation and we
of the function of the nervous system. These
describe how the waveform of such recorded
techniques have only recently been introduced
potentials might change as a result of injury to
for use in the operating room.
nerves or nuclei. It is also important to under-
Near-field evoked potentials are recorded by
stand the nature of the responses that might be
placing a much larger recording electrode
elicited by surgical manipulations of neural tis-
directly on a nerve, a nucleus, or a muscle, and
sue and from surgically induced injuries. Fur-
these potentials represent the sum of the activ-
ther, it is important to know where in the nervous
ity in many nerve cells or fibers in one of only
system specific components of the recorded
a few structures. It is not always possible to
evoked potentials are generated, so that the exact
record near-field potentials because it is not
anatomical location of an injury can be identified
possible to place a recording electrode directly
on the basis of changes in specific components of
on the structure in question; instead, one often
the electrical potentials that are being monitored.
has to rely on far-field potentials.
The potentials that can be recorded from
Far-field potentials are recorded from elec-
nerves and structures of the central nervous
trodes that are placed at a (long) distance from
system can be divided into three large cate-
the structures that generate the potentials that
gories: unit (or multiunit), near-field, and far-
are being recorded. Whereas near-field poten-
field potentials.
tials, such as those recorded by placing an elec-
trode directly on a nerve, nucleus, or muscle,
By A. R. Møller reflect electrical activity in that specific struc-
© Humana Press Inc., Totowa, NJ. ture, far-field potentials are usually mixtures of
21
potentials that are generated by several differ- added change (slowly) over the time during
ent structures. which the data are being collected and averaged
Far-field potentials have smaller amplitudes and, therefore, make the added response difficult
than near-field potentials and their waveforms to interpret. This is another reason why changes
are more difficult to interpret because they repre- in far-field evoked potentials are more difficult to
sent more than one generator. The generation of interpret than are changes in near-field potentials.
far-field potentials is complex and it is not com- In this chapter, we discuss in greater detail the
pletely understood. The contribution from such three categories of neuroelectrical potentials that
different structures depends on the distance from are often recorded in the operating room: unit
the recording electrode(s) as well as the proper- (multiunit), near-field, and far-field potentials.
ties of the sources. For example, only under cer-
tain circumstances can propagated neural activity
in a long nerve generate stationary peaks in
UNIT RESPONSES
potentials recorded at a distance from the nerve.
The far-field potentials generated by nuclei
Unit potentials reflect the activity of a single
depends on the orientation of the dendrites of the
neural element or from a small group of ele-
cells in the nuclei. The contributions from differ-
ments (multiunit recordings). Action potentials
ent structures to recorded far-field potentials are
from individual nerve fibers and from nerve
therefore weighted with regard to factors such as
cells are recorded by placing microelectrodes,
the distance from the source and the rate at which
the tips of which could be from a few micro-
the amplitudes of the recorded potentials
meter to a fraction of a micrometer in diameter,
decrease with distance to the source, which
in or near individual nerve fibers. The wave-
depends on the properties of the source.
form of such action potentials is always the
Components of the evoked potentials from
same in a specific nerve fiber or cell body,
different sources might overlap, depending on
regardless of how it has been elicited. Infor-
whether they appear with the same, or different,
mation that is transmitted in a nerve fiber is
latencies from the stimulus that was used to
coded in the rate and the time pattern of the
evoke the response. Therefore, the waveform of
occurrence of such action potentials. That
far-field potentials is usually different from that
means that it is the occurrence of nerve
of near-field potentials and are generally more
impulses and their frequency (rate) that is
difficult to interpret than near-field potentials.
important rather than their waveform.
Because of their small amplitude, far-field
evoked potentials are usually not directly dis- The action potentials of nerve fibers are the
cernable from the background noise that always result of depolarization of a nerve fiber. Usu-
exists when recording neuroelectrical potentials; ally, the electrical potential inside a nerve
therefore, it is necessary to add many responses fiber is about –70 mV. When this intracellular
using the method of signal averaging (described potential becomes less negative (brought
in Chap. 18) so that an interpretable waveform closer to zero, or “depolarized”), a complex
can be obtained. The use of signal averaging to exchange of ions occurs between the interior
enhance a signal (evoked response) that is cor- of the nerve fiber and the surrounding fluid
rupted by noise assumes that the waveforms of through the membrane. When the electrical
all the responses that are added are the same and potential inside an axon becomes sufficiently
occur in an exact time relation (latency) to the less negative than the resting potential, a
stimulus. This might not be the case when the nerve impulse (action potential) will be gener-
neural system that is being monitored is affected ated and the depolarization propagates along
by surgical manipulation, excess heat, or anoxia. the nerve fiber. This depolarization and subse-
The necessity to average many responses might quent repolarization is associated with the
distort the waveform if the responses being generation of an action potential (also known
Chapter 3 Electrical Activity in the Nervous System 23
as a nerve impulse, nerve discharge, or nerve specific part of the cerebral cortex. Such poten-
spike). In myelinated nerve fibers (such as tials reflect neural activity in many nerve fibers
those in mammalian sensory and motor or cells, but typically only in a single structure.
nerves), neural propagation occurs along a The responses are usually elicited by transient
nerve fiber by saltatory conduction between stimuli that activate many fibers of cells at about
the nodes of Ranvier, which can be recognized the same time. Such responses are known as com-
as small interruptions in the myelin sheath pound action potentials (CAPs) because they are
that covers the nerve fiber. Unit potentials the sum of many action potentials. The potentials
have the character of nerve discharges are graded potentials and their waveforms are
(spikes) and are recorded by fine-tipped metal specific for nerves and nuclei; the waveform
electrodes that are insulated except for the tip. changes in a characteristic way when the struc-
ture, from which recordings are made, is injured.
The main use intraoperatively of recording of
unit potentials is for guiding the surgeon in the Responses From Nerves
placement of lesions in brain structure, such as
Near-field potentials from nerves reflect the
the basal ganglia or thalamus, for treatment of
activity in many nerve fibers; hence, it is obtained
movement disorders and pain. More recently,
as a sum of the action potentials of many nerve
lesions have been replaced by implantation of
fibers. The CAPs recorded from a nerve or fiber
electrodes for electrical stimulation (deep brain
tract reflect the propagation of action potentials
stimulation [DBS]), which have a similar benefi-
along individual nerve fibers (axons). When a
cial effect as lesions but with the advantage of
depolarization is initiated at a certain point along
being reversible. The responses that are observed
a nerve fiber, the depolarization propagates along
in such operations are either spontaneous activity
the nerve fiber with a (propagation) velocity that
that occurs without any intentional stimulation,
is approximately proportional to the diameter of
or by natural stimulation of the skin (touch), or
the axons of the nerve. The relation between
from voluntary or passive movement of the
neural conduction velocity (in meters per second
patient’s limbs. For such purposes, usually multi-
[m/s]) and fiber diameter (in micrometers [μm])
unit recordings are made, using electrodes with
is approx 4.5 m/s/μm (25). Older data (26) indi-
slightly larger tips than those used for recording
cate a slightly higher velocity: 6 m/s/μm. The
of the responses from single fibers or cell bodies.
conduction velocity of peripheral sensory and
These responses represent the activity of small
motor nerves typically ranges from 40 to 60 m/s.
groups of cells or fibers.
The auditory nerve has an unusually low propa-
gation velocity of about 20 m/s (27). Normally,
depolarization of nerve fibers is initiated at one
NEAR-FIELD RESPONSES end of a nerve fiber (peripheral end of sensory
fibers and central end of motor fibers), but neural
Near-field evoked potentials are defined as propagation can occur in both directions of a
potentials recorded with the recording elec- nerve fiber, and it does so with about the same
trode(s) placed directly on the surface of a spe- conduction velocity.
cific neurological structure. Responses recorded
from fiber tracts and nuclei are the most impor- Initiation of Nerve Impulses. Initiation of
tant for intraoperative monitoring, but record- nerve impulses in sensory nerves normally
ings from specific regions of the cerebral cortex occurs through activation of sensory receptors
are also regarded as near-field evoked potentials. (28), and motor nerves are activated through
Near-field evoked potentials are recorded by motoneurons either in the spinal cord for
placing recording electrodes that are much larger somatic nerves or in the brainstem for cranial
than microelectrodes (gross electrodes) on the motor nerves (29). In the operating room, sen-
surface of a nerve, fiber tracts, a nucleus or a sory nerves are almost always activated by
sensory stimuli and motor nerves might be acti- high, as compared to when it is low (31). Another
vated by (electrical or magnetic) stimulation of reason for stimulus-dependent latency is the non-
the motor cortex or the brainstem. Peripheral linear properties of the sensory organs such as
nerves and cranial motor nerves are also acti- the cochlea (see Chap. 5) (32).
vated by electrical stimulation. Such stimula-
tion depolarizes axons at the location of Electrical Stimulation. Although sound stim-
stimulation of a nerve. uli (click sounds) is the most common stimula-
tion for monitoring the auditory system,
Natural Stimulation. Nerve impulses in sen- electrical stimulation of peripheral nerves is
sory nerves are normally initiated by an activa- the most common way of stimulating the
tion of specialized sensory receptor cells that somatosensory system and for monitoring and
respond to a specific physical stimulation (28). intraoperative diagnosis of peripheral nerves.
The frequency of the elicited action potentials in Electrical stimulation is also in increasing use
individual nerve fibers (discharge rate) is a func- for stimulation of the motor cortex for monitor-
tion of the strength of the sensory stimulation. ing motor systems (transcranial electrical stim-
The time pattern of the occurrence of action ulation [TES]).
potentials in a fiber of a sensory nerve also car- The electrical stimulation that is used to depo-
ries information about the sensory stimulus in the larize the fibers of a peripheral nerve use brief
somatosensory and the auditory nerves, because (0.1–0.2 ms long) electrical current impulses that
the discharge pattern is statistically related to the are passed through the nerve that is to be stimu-
time pattern of the stimuli, which means that the lated. A negative current is excitatory because it
probability of the occurrence of a discharge causes the interior of the axons to become less
varies along the waveform of the stimulus (28). negative, thus causing depolarization. This might
This neural coding of the stimulus time pattern is sound paradoxical, but, in fact, a negative electri-
of particular importance in the auditory system, cal current flowing through the cross-section of a
in which much information about sound is coded nerve fiber will cause the outside area of that
in the time pattern of the discharges in auditory nerve fiber to become more negative than the
nerve fibers. The ability of the auditory nervous inside area and, thereby, the interior of the axon
system to use the temporal coding of sounds for will become more positive (less negative) than its
interpretation of complex sounds, such as in outer surface—thus, depolarization occurs.
speech, is important for the success of cochlear When a nerve is stimulated by placing two
and cochlear nucleus prostheses (30). In the electrodes on the same nerve a small distance
visual system, the temporal pattern of nerve apart, the negative electrode (cathode) is the
impulses seems to have little importance, as is active stimulating electrode and the positive
also the case in the olfactory and gustatory sen- (anode) electrode might block propagation of
sory systems. nerve impulses (known as an anodal block) so
When sensory nerves are stimulated with nat- that depolarization will only propagate in one
ural stimuli, the latency of the response from a direction, namely away from the negative
sensory nerve decreases with increasing stimulus electrode.
intensity, and this dependence exists over a large The amount of electrical current that is neces-
range of stimulus intensities. One reason for this sary to depolarize the axons of a peripheral
stimulus-dependent latency is the neural trans- nerve and initiate nerve impulses depends on the
duction in sensory cells (such as the hair cells in properties of the individual nerve fibers. Large-
the auditory system), where the excitatory post- diameter axons have lower thresholds than nerve
synaptic potential (EPSP) increases from below fibers with small diameters. The threshold also
threshold at a rate that increases with increasing depends on the duration of the electrical
stimulus intensity and the EPSP thereby reaches impulses that are used to stimulate a nerve. The
the threshold faster when the stimulus intensity is necessary current to activate nerve fibers
Figure 3.1: Monopolar recording from a long nerve of propagated neural activity elicited by
electrical stimulation with a brief impulse of current passed through the nerve far from the location
of recording. Note the stimulus artifact at the beginning of the trace. Negativity is shown as an
upward deflection (as it is in all illustrations in this book).
decreases when the duration of the current 100 V (10–20 mA) when the stimulus duration is
impulses is increased, reaching (asymptotically) 0.1 ms and the stimulating electrodes are located
a duration where further increase in duration has close to a peripheral nerve. Nerves, the function
little effect on the current needed to reach of which is impaired, might require as much as
threshold. That occurs at shorter durations for 300 V (30–60 mA) in order to depolarize all
large fibers than for axons of smaller diameter. fibers. In clinical settings, in which the patient is
The diameters of axons of a peripheral nerve can awake, it is not possible to reach supramaximal
vary considerably and stimulation with impulses stimulus levels because of unacceptable pain that
of certain duration and a certain intensity might such stimulation incurs, but that is not a limita-
therefore depolarize different populations of tion in the anesthetized patient.
nerve fibers in a peripheral nerve. Activation of individual nerve fibers of a
Increasing the stimulus intensity does not peripheral nerve by electrical stimulation with
change the way an electrical stimulus activates an short impulses is an “all-or-none” process and,
individual axon, but it affects the number of therefore, the latency of the response is less
axons that become depolarized. More axons will dependent, if at all, on the stimulus intensity.
be depolarized when the stimulus strength is Only the number of nerve fibers that are acti-
increased from below the threshold of the most vated depends on the stimulus intensity.
sensitive nerve fibers. The anatomical location of
a nerve fiber in relation to the stimulating elec- Monopolar Recording Compound Action
trodes is a factor, because the effectiveness of Potentials From a Long Nerve. An electrode that
stimulation decreases with increasing distance. is much larger than the size of individual nerve
When a normal peripheral nerve is electrically fibers record the sum of the nerve impulses of
stimulated, supramaximal stimulation is usually many nerve fibers (CAP). When a single elec-
desired, which means that the applied electrical trode (monopolar) is placed on a nerve in which
stimulation should depolarize all axons of the a depolarization has been initiated by a transient
nerve. It is a general rule to turn the stimulus stimulation, the waveform of CAPs shows an ini-
current up approximately one-third above that tial (small) positive deflection that is followed by
which produces the maximal response ampli- a large negative peak, and then followed by a
tude. This might require a stimulus strength of small positive peak (Fig. 3.1).
moving region of depolarization yields a CAP

with a wide negative peak.
In the example illustrated in Fig. 3.1, the
potentials were recorded differentially between
one electrode placed on a nerve and the other
electrode—the reference electrode—placed at
a distance from the recording electrode in the
electrically conducting fluid that surrounded
the nerve. This is an example of a monopolar
recording of the CAP from a long nerve. The
CAP occurs with a certain delay after the stim-
ulus. The latency of the negative peak depicts
the time it takes for the depolarization of the
nerve fibers to travel from the site of stimula-
tion to the site of recording.
Because recording of CAPs is done using dif-
ferential recording techniques, it is the differ-
ence in the potentials recorded between two
recording electrodes that is measured. To
make a true monopolar recording, it must be
assured that the reference electrode will not
Figure 3.2: Illustration of how the CAP record any potential that is related to activity
recorded from a long nerve by a monopolar in the nerve. In real recording situations, this
electrode develops. The nerve is being stimu- is often difficult to achieve because the refer-
lated electrically at a location to the far left (not ence electrode will also record evoked poten-
shown), and the resulting area of membrane tials, although of a lower amplitude than the
depolarization (marked by the crosshatched active electrode will record.
area) travels from left to right. The recorded
electrical potentials that develop as the area of The depolarization could have been initiated
depolarization propagates along the nerve are by electrical stimulation at a distance from the
shown to the right. recording site. Similar depolarization could be
initiated by natural transient stimulus such as
Monopolar recording from a long nerve in that of a receptor that is innervated by the
which a region of depolarization travels yields nerve. When a click stimulus is applied to the
a CAP with a characteristic triphasic shape ear, a transient excitation of auditory nerve
(Fig. 3.1). The initial positive deflection of the fibers occurs.
CAP occurs when the depolarization in the
nerve approaches the location of the recording Effects of Temporal Dispersion of Action
electrode (Fig. 3.2A). The large negative peak Potentials. When a nerve is stimulated by an
is generated when the depolarized portion of electrical impulse and all the nerve fibers that
the nerve is directly under the recording elec- discharge (depolarize) have identical properties
trode (Fig. 3.2B). The small positive deflec- so that the action potentials in all of the nerve
tion that follows is generated when the zone of fibers occur simultaneously, then the waveform
depolarization moves away from the recording of the CAP recorded by a monopolar recording
electrode (Fig. 3.2C). The width of the nega- electrode placed on a long nerve is mathemati-
tive peak is related to the length of the depolar- cally described as the second derivative of the
ization and the propagation velocity of the waveform of an action potential of an individ-
nerve. A long area of depolarization or a slowly ual nerve fiber (33). The action potentials of
different nerve fibers elicited by electrical stim-

ulation are assumed to arrive at the site of
recording simultaneously, so that the action
potentials of different nerve fibers coincide. In
such a situation, the amplitude of the negative
peak in the CAP is a measure of the number of
nerve fibers that have been activated (34).
The situation that exists when recording from
mammalian peripheral nerves is different
because such nerves are composed of nerve
fibers with different conduction velocities.
Therefore, the action potentials in individual
nerve fibers do not occur exactly at the same time
at a certain point along a nerve. The shape of the
CAP, therefore, depends on the distribution of the
arrival time of the discharges in the different
nerve fibers at the site of recording. This, in turn,
is a function of the conduction velocity and the
length of travel of nerve impulses in the fibers
that make up the nerve from which the recording
is made. This means that the waveform of the
CAP will reflect the distribution of the differing
diameters of nerve fibers (conduction velocities)
and the distance between the site of stimulation,
and that of the recording.
Such time dispersion will broaden the Figure 3.3: Recording of the CAP from a
recorded CAP compared to what it would have nerve in which there are groups of fibers with
been if the action potentials in all the nerve different conduction velocities. Recordings at
fibers arrived at the recording site accurately different distances from the site of electrical
aligned in time and the amplitude of the CAP stimulation (S) are shown. (Reprinted from:
will be lower than it would if all nerve impulses Erlanger J, Gasser HS. Electrical Signs of Ner-
traveled at the same velocity. The mathematical vous Activity. Philadelphia: University of Penn-
sylvania Press; 1937.)
description of the recorded CAP in such a situa-
tion is the convolution between the waveform of
an individual action potential of a nerve fiber activity in such subgroups might give rise to mul-
and the distribution of action potentials in the tiple peaks in the CAP. The late peaks moves
nerve fibers that make up the respective nerve further away from the initial peak when recorded
(34). This assumes that the waveforms of the at a longer distance from the location of stimula-
action potentials of all nerve fibers are identical. tion (Fig. 3.3). The effect on the waveform of
In such a situation, it is the area under the nega- the recorded CAP from a nerve with subgroups
tive peak of the CAP that is a measure of the of nerve fibers with different conduction velocity
number of nerve fibers that have been activated is dependent on the size of the variations in neu-
rather than the amplitude of the negative peak. ral conduction velocity in the individual nerve
Depending on how great the dispersion is, the fibers and the distance between the site of stimu-
waveform of the CAP could differ from a tripha- lation and the site of recording (Fig. 3.3).
sic waveform to a waveform with several peaks. Not all nerve fibers of a peripheral nerve
If there are specific subgroups of nerve fibers in contribute equally to the CAP; depending on the
a nerve with similar conduction velocities, the recording situation, some nerve fibers might
contribute more than others. The mathematical

solution of the generation of the CAP from a
peripheral nerve might therefore require that dif-
ferent weighting factors be applied to the contri-
bution to the CAP from different populations of
the nerve fibers that makes up a peripheral nerve.
Determining the Number of Active Nerve
Fibers. In the operating room, the task is not to
determine the absolute number of active nerve
fibers but, rather, to obtain an estimate of how
many nerve fibers of a specific nerve have been
rendered inactive as a result of surgical insults.
The area of the negative peak in the CAP offers
an accurate measure of the number of nerve
fibers that have been activated. Because it is
the change in the number of active nerve fibers
that is of interest in connection with intraoper-
ative monitoring, measuring changes in the
amplitude of the negative peak provides a suf-
ficiently accurate measurement for most tasks
in the operating room although this measure
also include the effect of increased dispersion
because of the increased difference in the con-
duction velocity of individual nerve fibers.
An increase in the latency of the response
and/or change in waveform of the recorded
CAP are perhaps the two most important indi-
cators of injury to a nerve, and these measures
are therefore used extensively in intraoperative
monitoring as indicators of injury to a nerve or Figure 3.4: Bipolar recording from a long
fiber tracts. Monitoring the amplitude of the nerve, illustrated in the same way as the
CAP is also important in intraoperative moni- monopolar recording in Fig. 3.2. The two elec-
toring because of its relation to how many trodes are connected to the two inputs of the
fibers are activated and how close together in differential amplifier in such a way that a neg-
time the action potentials of individual nerve ative potential at the electrode closest to the
fibers appear. recording site (left-hand electrode) will result
in an upward deflection (inverting input).
Bipolar Recording From a Nerve. Bipolar
recording from a long nerve can be realized by Two such electrodes act as two monopolar
placing a pair of recording electrodes that are electrodes that are placed on a nerve and the out-
connected to the two inputs of a differential put of the amplifier is the difference between
amplifier close together on the nerve in question these two “monopolar” recordings. When a wave
(Fig. 3.4). The output of the differential ampli- of depolarization approaches the electrodes, the
fier will be the difference between the potentials one closest to the depolarization will record a
that are recorded by each individual electrode. larger positive potential than the electrode that
A bipolar recording from a nerve in which neu- is further away (Fig. 3.4). A large negative
ral activity is propagated produces a waveform potential will be recorded by the electrode that is
that differs from that of monopolar recordings. close to the site of stimulation when the region
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SECTION I: PRINCIPLES OF INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING

SECTION II: SENSORY SYSTEMS

SECTION III: MOTOR SYSTEMS

SECTION IV: PERIPHERAL NERVES

SECTION VI: PRACTICAL ASPECTS OF ELECTROPHYSIOLOGICAL RECORDING IN THE OPERATING ROOM

Appendix ............................................................................................................................. 343

response to innocuous somatosensory stimula- that an effective collaboration between sur-

can increase the likelihood of achieving the

Electrical Safety and Intraoperative monitoring. Many of the severe postoperative

Unit potentials are potentials recoded from

moving region of depolarization yields a CAP

different nerve fibers elicited by electrical stim-

contribute more than others. The mathematical

Creating the works from print editions not protected by U.S.

START: FULL LICENSE

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