The Percentage of Amplitude Decrease Warning Criteria for Transcranial MEP Monitoring.

Muscle motor evoked potentials (MEPs) from transcranial electrical stimulation (TES) became a standard technique for monitoring the motor functions of the brain and spinal cord at risk during spinal and brain surgery. However, a wide range of criteria based on the percentage of amplitude decrease is used in practice. A survey of the current literature on clinical outcome parameters reveals a variety of percentages in a range of 30% to 100% (50% to 100% spinal procedures) with no consensus. The interpretation of muscle MEPs is hampered by their sensitivity to many interfering factors. Trial-to-trial MEP variations may partly be reduced by controllable parameters of which TES parameters are in the hands of the neuromonitorist. We propose an operational model based on basic neurophysiologic knowledge to interpret the characteristics of MEP-TES voltage curves and predict the influences of the location on the sigmoid voltage curve on spontaneous MEP-variations and influences of factors affecting the voltage curve. The model predicts a correlation between the slope, expressed by a gain, and variations of muscle MEP amplitudes. This complies with two case examples. The limited specificity/sensitivity of warning criteria based on the percentage of amplitude reduction can possibly be improved by developing standards for set-up procedures of TES paradigms. These procedures include strategies for desensitizing MEPs for variations of controllable parameters. The TES voltage or current is a feasible controlling parameter and should be related to the motor threshold and the onset of the supramaximal level being landmarks of MEP-voltage functions. These parameters may offer a valuable addition to multicenter outcome studies.