Intraoperative monitoring of corticospinal tracts in anterior cervical decompression and fusion surgery: Excitability differentials of lower extremity muscles

Highlights • Lower extremity (LE) muscles demonstrate intraoperative excitability differences. • Abductor hallucis is a suitable LE muscle for monitoring the corticospinal tract (CST). • CST monitoring with two LE muscles includes advantages but also practical limitations.
Objective This study examines and compares excitability characteristics of tibialis anterior (TA) and abductor hallucis (AH) transcranial motor evoked potentials (tcMEP) during anterior cervical decompression and fusion (ACDF) surgery. Methods Electrophysiological and clinical data of 89 patients who underwent ACDF procedure were retrospectively reviewed. TcMEP data of TA and AH muscles from 178 limbs were analyzed for availability, robustness and stability during the procedure. Results TA tcMEP was available at 83% whereas AH tcMEP was available at 99% of the monitored lower limbs at preposition baseline. Availability of both TA and AH tcMEP was demonstrated in 147/178 limbs. The baseline amplitude of AH tcMEP was significantly greater than that of TA tcMEP recorded from the same limb (744.6 ± 54.0 and 326.9 ± 33.3 µV, respectively). Simultaneous deterioration of TA and AH tcMEP data was demonstrated in 10/147 limbs. Deterioration of either TA or AH tcMEP data accompanied by unchanged tcMEP data from the other lower limb muscle was noted in 32/147 compared to 1/147 limbs, respectively. The deteriorated TA and AH tcMEP data returned to baseline before closing at incidence of 17% compared to 46%, respectively. No new lower extremity (LE) neurological deficit was presented postoperatively in any patient. Conclusions AH tcMEP is a more reliable candidate than TA tcMEP for intraoperative LE monitoring in ACDF procedure. Significance The excitability differentials in LE tcMEP in ACDF is a variable that need to be considered while interpreting intraoperative neurophysiological data.