The use of IONM has substantially decreased the rate of paralysis after deformity surgery, and has been validated in cervical spine surgery, and thoracic and lumbar laminectomy (1) (2), (3). Anesthesia With Neuromonitoring: The Cheat Sheet Inhaled anesthetics decrease the waveform amplitude and increase latency, intravenous anesthetics have the same effect but to a lesser degree. The use of neurophysiological monitoring during surgical procedures requires specific anesthesia techniques to avoid interference and signal alteration due to anesthesia. • Anesthesia: D-waves are relatively insensitive to anesthe-sia. Inhaled anesthetics（e.g., sevoflurane and . Thus, the decision about which of these techniques to use needs to be tailored to the mep monitoring definition | Motor Evoked Potential - an ... Predictive factors of unacceptable movement and motor ... A number of physiological factors will attenuate SSEP and MEP monitoring, including hypotension, hypothermia, hypocarbia, hypoxemia, anemia, and anesthetics. No muscle relaxant was added after induction of anesthesia. In adults, an anesthetic technique using ketamine, alfentanil, and etomidate preserves MEPs better than volatile agents, nitrous oxide, or propofol ( Kalkman et al., 1994 ; Ubags et al., 1997 ; Sihle-Wissel et al., 2000 ). PDF "What should I plan for maintenance anesthetic if ... MEP . Opiates have almost no effect. Somatosensory evoked potential (SSEP) monitoring reduces post-operative neurological deficits, but paraplegia can occur despite normal SSEP findings because SSEPs monitor dorsal column function whereas the corticospinal tract motor pathways are in . The neurophysiologist's expertise, anesthetist's collaboration and surgeon's desire and intention to utilize the results form the clinical basis for successful MEP monitoring. By continuing to browse this site you are agreeing to our use of cookies. MEP monitoring has shown to be safe and feasible in children under the age of 12 months during untethering procedures with the described stimulation parameters and anesthetic regimen. A previous study proved that a durational-dependent, depressant effect on MEP under anesthesia must be considered as one differentiates anesthetic-related trends from acute changes in MEP responses [ 25 ]. Ours is the first known report of a seizure following MEP monitoring in a patient without a prior history of seizures. Inhalational agents significantly decrease MEP monitorability and amplitudes for most muscles, and this effect is especially pronounced for proximal limb muscles such as the deltoid, biceps, triceps, and quadriceps. Appling MEP monitoring in children, the possible 'fade phenomenon' of anesthetic factor on MEP should be taken big consideration. • Anesthesia: D-waves are relatively insensitive to anesthesia. Prevention of MEP-related adverse effects is also important to be considered. We adjusted both nitrous oxide concentration and propofol infusion rate at steady levels. {{configCtrl2.info.metaDescription}} This site uses cookies. Though relatively new, intraoperative neurophysiological monitoring (IONM) has become standard of care for many neurosurgical procedures. A change in waveform morphology or increase of 100 volts or more stimulation threshold may be considered an alert. All patients' anesthesia was maintained with total intravenous anesthesia during the period of MEP monitoring, as shown in Fig. Intraoperative neurophysiologic monitoring can detect spinal cord compromise and help to avert neurologic morbidity during spinal deformity surgery. Anesthetic techniques have to be tailored to suit the specific requirements of each . f the rates of success of multimodal evoked potential (mEP) monitoring using a combination of median nerve (m) somatosensory (SS) EPs, tibial nerve SSEPs (tSSEPs), and transcranial electrical stimulated motor EPs (tcMEPs); (2) evaluation of the rates of false-negative mEP results; and (3) analysis of the relationship between different time periods associated with ICA cross-clamping and the . Nitrous oxide/opiate techniques have been successful with MEPs. Motor Evoked Potentials (MEP) Motor evoked potentials (MEPs) are useful when the common sensory and somatosensory evoked potentials (SSEP) fall short of adequate monitoring as The use of nitrous oxide-narcotic anesthesia with 75 to 95 percent muscle relaxation resulted in reproducible MEP latencies in 9 of 11 patients undergoing spinal instrumentation surgery for scoliosis. Total intravenous anesthesia (TIVA) with propofol and opioid is commonly recommended for surgeries that require MEP and SSEP monitoring [1, 4]. In MEP recording, muscle . Anesthesia, Shirakawa Hospital, Shirakawa, Fukushima, Japan: INTRODUCTION: Motor evoked potential (MEP) is influenced by various anesthetics, and quantitative analysis is difficult. No muscle relaxant was added after induction of anesthesia. It's been reported in the literature that it can take 40 minutes to recover MEP responses after the gas . Each has advantages and disadvantages (Legatt, 2004), as described in the following list. Hip flexion should be avoided during posterior acetabular retraction when using the posterior approach with posterior dislocation. Therefore, the effect-site concentration of propofol plays an important role in ensuring accurate MEP monitoring under general anesthesia. In case 1, MEP monitoring was successfully performed with the use of a fixed dose of remimazolam at 0.5 mg/kg/h and remifentanil at 0.2 μg/kg/min. Catheter advanced 5-7cm - (often times anesthesia will place stitch) Occlusive Dressing applied Transducer connected and leveled at the right atrium CSF drained to <10mmHg Somatasensory Evoked Potentials (SSEP) and Motor Evoked Potentials (MEP) monitoring In cases of a bloody tap, the procedure may be aborted Here, we describe a patient with Alström syndrome who underwent surgery for scoliosis under general anesthesia with remimazolam and MEP monitoring. III. When indicated by history and physical exam, a pre-operative Holter monitor examination or echocardiogram may be warranted. Also profoundly affected by volatile anesthetic agents, less-so by nitrous oxide. Define and describe TIVA( Total Intravenous Anesthesia) and IOM (Intraoperative monitoring) Identify the types of patients and/or surgeries where TIVA is indicated and IOM is appropriate. In all but one case, MEP monitoring could be resumed, yielding a 99.5% monitoring rate.-CONCLUSIONS: With the anesthetic and monitoring regimen, the authors were able to record MEPs of the upper and lower extremities in all patients and To examine the effect of blood pressure on mTc-MEPs the mean arterial pressure will be elevated from 60 to 100 mmHg during which mTc-MEP measurements . However, some studies have showed that inhaled halogenated anesthetics have a significant impact on neurophysiological monitoring. 4 To improve the quality of MEP monitoring . No muscle relaxant was added after induction of anesthesia. In general, total intravenous anesthesia (TIVA) is the gold standard for IONM, because it . In this study, we estimated the effect-site concentrations (ESCs) of propofol and fentanyl that enable adequate monitoring of MEP and analyzed the effects of these . The aim of this study was to evaluate the risk factors associated with unacceptable movements in patients undergoing brain surgery with MEP monitoring.We performed a retrospective observational study of patients who underwent brain surgery with MEP monitoring under general anesthesia while using a partial neuromuscular blocker in a tertiary . The neurophysiologist's expertise, anesthetist's collaboration and surgeon's desire and intention to utilize the results form the clinical basis for successful MEP monitoring. cle MEP monitoring may be due to less interference with alpha motor neuron excitability than from inhala-tional anesthetics including nitrous oxide [29-34]. Remimazolam was gradually increased from 0.5 to 1.5 mg/kg/h to maintain the value of entropy monitoring in the range of 40 to 60. MEP suppression at surgical anesthesia levels. Total intravenous anesthesia without neuromuscular blockade is material to muscle MEPs to allow CMAP monitoring. For practical purposes, ALL intravenous agents have negligible effect on cortical SSEP's, except for etomidate and ketamine, which can actually increase amplitude. anesthetics that can be used during MEP monitoring, certain agents sion makes D-wave amplitudes more stable during general an- continue t~ have dose-dependent effects on MEP reliability. Abstract. Prior to the widespread use of MEP monitoring, the only way to assess corticospinal tract integrity and resulting motor function during surgery was the Stagnara wake-up test, which involved waking patients during surgery and asking them . SSEP monitoring changes resulting from anesthetic effects from those relating to surgical manipulation. Remimazolam was gradually increased from 0.5 to 1.5mg/kg/h to maintain the value of entropy moni-toring in the range of 40 to 60. The role of intraoperative neurophysiological monitoring for resection of neurosurgical lesions cannot be over emphasized. Both clonidine and dexmedetomidine decrease anesthetic requirements and have minimal effects on cortical EPs and are considered safe to use during monitoring. Intraoperative Neurophysiologic Monitoring (IONM) encompasses the application of a wide variety of electrophysiological methods to monitor the functional integrity of neural structures during surgery. itoring and other electrophysiological tests are essential when performing surgery for functional scoliosis. outcomes. The effect of anesthetic agents on the amplitude and latency of MEP and SSEP monitoring is dose-dependent [1-3]. During surgical interventions, the type of anesthetic affects the results of monitoring. MEPs are assessed intermittently but the findings are real time. Anesthetic management. . A total of 40 consecutive patients undergoing neurosurgery were randomly assigned to two . An anesthetic similar to SSEP would be appropriate. Total intravenous anesthesia using propofol and opioids（e.g., remifentanil and fentanyl）may be the optimal anesthetic regimen for MEP monitoring. At pEEG values of 30, 40 and 50, mTc-MEP measurements will be performed. Furthermore, our data suggest that MEP monitoring should be used routinely in young children even in the presence of preoperative motor deficits. The two different techniques (SEP and MEP) monitor different spinal cord tracts. •Inhalational anesthetics depress MEP amplitudes in a dose-dependent manner •Prefer Total IV Anesthesia (TIVA) •Length of surgery and pre-operative neurologic status can compound the effects of inhaled anesthetics •False warnings to the surgeon minimize effectiveness of intraoperative monitoring We retrospectively reviewed data from 56 children, aged 2 to 18 yr, who were to undergo surgical correction of idiopathic scoliosis with MEP monitoring. Many protocols for MEP monitoring recommend a total intravenous anesthetic (TIVA). In order to investigate the effects of depth of anesthesia, a processed electroencephalogram (pEEG) monitor will be used. Electromyography is the recording of the electrical activity of muscles and has been known since Francesco Redi's observations in 1666. Recently intraoperative motor evoked potential monitoring (MEP) is widely used to reduce neural damage during neurosurgery. Anesthetic Implications: Similar to SSEP but are much less sensitive to inhaled anesthetics so that most anesthetic options are acceptable. Central Nervous System: Hypersomnia is a common and sometimes primary manifestation of DM. Any surgical risk to the corticospinal (motor) tract is an indication for MEP monitoring. The most commonly used alarm criterion for MEP changes is a significant amplitude drop, though what constitutes "significant" is not universally agreed . anesthetic fade phenomenon have a more gradual effect on MEP signals [13]. In each case, mathematical tools are used to derive a parameter associated with the degree of anesthetic drug effect. Introduction to Intraoperative Neurophysiological Monitoring for Anaesthetists. MEP stimulation—2 had nociception-induced movement and 5 had excessive field movement. The baseline monitorability of each muscle MEP was evaluated by the IONM team in real-time and recorded in the patient's electronic medical record. [ 24 ] M-waves are easily suppressed by anesthesia, especially by inhalational anesthetics, which sets limits on the anesthetic regimen that can be used during MEP monitoring of M-waves (Sloan and Heyer, 2002). Intraoperative MEP monitoring with transcranial magnetic stimulation is highly dependent on the anesthesia protocol. Intraoperative monitoring of corticospinal tract motor pathways with motor evoked potentials (MEPs) reduces the likelihood of neurological deficits following scoliosis surgery. Although both nitrous oxide 28and propofol 29may reduce MEP amplitude, this combination has much less suppressant effect than volatile agents 30and is the most common general anesthesia combination used during intraoperative MEP monitoring. Best anesthetic regimen for surgery involving intraoperative monitoring is . MEPs are sensitive to the effects of inhalational anesthetic agents, which offer the advantages of rapid induction and recovery with its low solubility. to anesthetic agents. The MEPs can be utilized in a 6. With SEP monitoring, deteriorating neurological function can be detected early, so that the anaesthetist and/or surgeon can intervene to minimise the chances of permanent damage to the nervous system. View Show abstract This certification prepares you to monitor the state of a patient's nervous system in "real-time" during surgery to patient safety and surgical outcomes. Hypothermia may have Monitoring of motor evoked potentials (MEPs) can provide direct effects on the MEP itself and also indirect effects on information about the functional integrity of a motor MEPs by changing the pharmacokinetics and pharmaco- pathway and, therefore, has been widely used during sur- dynamics of anesthetic agents, modified by . A combination of cortical/subcortical-motor evoked potential (SCMEP) and electrocorticography (ECoG) allows safe and maximal resection of epileptogenic lesions of the eloquent cortex. Myogenic MEPs are easily suppressed by anesthesia, FIG. MEP monitoring protocols were similar to those in case 1. Implications: Careful attention to anesthetic management is necessary when providing anesthesia for a patient undergoing intraoperative neurophysiological monitoring to minimize adverse outcomes and enhance patient safety. The intravenous anesthetic propofol depresses MEP responses in a dose-dependent manner [5,6,7,8,9,10]. Total intravenous anesthesia without nitrous oxide is the ideal anesthetic technique for monitoring of MEP. Development of standardized total intravenous anesthesia/TCI protocols by using anesthetic agents such as propofol, remifentanil, ketamine, and midazolam, which have favorable pharmacokinetic and neurophysiological properties, will enhance the quality of intraoperative MEPs and promote the use of MEP monitoring as a useful tool to reduce . General anesthesia is known to diminish the quality of signals with SSEP, decreasing amplitude and increasing latency . • Intraoperative neurophysiology monitoring may not be billed by the physician performing an operative or anesthesia procedure as this is included in the global surgical package. Of a total 865 MEP responses, the number of MEP responses were 56, 160, 145, 119, 94, 155, and 136 waves at 0-39, 40-49, 50-59, 60-69, 70-79, 80-89, and 90-100 BIS levels, respectively. Currently MEP monitoring is mainly an explorative tool. EMG monitoring of cranial nerves. Background and Purpose: Transcranial electrical motor evoked potentials (MEP) have joined somatosensory evoked potentials (SSEP) as an important aspect of neurophysiologic monitoring during both intracranial and spine surgery. MEP monitoring protocols were similar to those in case 1. monitoring even if that time is not in a single continuous block. Conclusions General anesthesia using remimazolam and remifentanil can be a valuable alternative for spine surgery with MEP monitoring by EEG to assess the optimal dose. It is important to realise that in posterior fossa surgery, one must monitor facial nerve function and . Neurophysiological Monitoring (MEP, SSEP and BAER) In contradistinction to intra-operative mapping, neurophysiological monitoring does not serve to identify the location of critical regions but rather provides real-time information about the integrity of the connections of motor, sensory and auditory systems. MEP is exquisitely sensitive to the depressant effects of inhalation anesthetics including nitrous oxide. Significant electrical events occurred, most commonly during acetabular reconstruction. During maintenance of general anesthesia, remifentanil was used at 0.3-0.5mg/ kg/min. This intensive stimulation Intraoperative neurophysiological monitoring (IONM) is a method of real-time evaluation of the functional states of neuronal structures to prevent possible damage. However, there are reasons why some volatile anesthetic would be preferred (such as for minimizing risk of recall), and MEPs can often be recorded with some limited volatile anesthetic (≤ 0.5 MAC) supplemented with less suppressive anesthetic agents. Although MEP monitoring is more specific to motor injury than is SEP, MEP shows greater sensitivity to anesthetic . MEP monitoring can be optimized by appropriately monitoring and controlling these factors. Under- esthesia and thus a more reliable monitor ofmotor tract func- standing the effects of anesthetic agents and physiologic alterations ti Since cranial nerve involvement is common with intracranial growths > 2 cm, monitoring of cranial nerve function is essential in surgical management. 1.In 44 pediatric patients, only an initial small amount of inhalation anesthetic (sevoflurane, 0.8% to 8.0%) was used when securing venous access. . method of anesthesia because the approach allows for consistent MEP and SSEP monitoring as compared to inhalational agents. The relation between anesthetic regimen and baseline monitorability was estimated using mixed effects logistic regression, with distinct models for cervical and lumbar procedures. During maintenance of general anesthesia, remifentanil was used at 0.3-0.5 mg/kg/min. Remimazolam was gradually increased from 0.5 to 1.5 mg/kg/h to maintain the value of entropy monitoring in the range of 40 to 60. MEP monitoring is a well-established effective method to monitor the integrity of neurologic pathways during spine surgery. •Inhalational anesthetics depress MEP amplitudes in a dose-dependent manner •Prefer Total IV Anesthesia (TIVA) •Length of surgery and pre-operative neurologic status can compound the effects of inhaled anesthetics •False warnings to the surgeon minimize effectiveness of intraoperative monitoring Typically, induction with short-acting muscle relaxants, a continuous infusion of propofol and fentanyl and low level nitrous oxide use (not exceeding 50% by volume) are mandatory for MEP monitoring. The Working Group of Japanese Society of Anesthesiologists (JSA) developed this practical guide aimed to help ensure safe and successful surgery through appropriate anesthetic management during intraoperative MEP monitoring. United States, most centers routinely perform M-wave MEP monitoring. MEP monitoring protocols were similar to those in case 1. Sometimes, one of the techniques cannot be used for practical purposes, for anesthetic reasons, or because of pre-operative absence of signals in those pathways. Although it can be recorded with low-dose agents, the signals are so severely attenuated that this practice is generally not advisable. Patient concerns: A 17-year-old woman (height . Remimazolam is a novel short-acting benzodiazepine characterized by metabolism independent from organ function. Full paralysis makes the MEP essentially useless, however a continuous IV infusion titrated to 1-2 twitches will allow accurate MEP use. This type of monitoring may be difficult in the pediatric population under general anesthesia. Ovid: Effects of Anesthetic Agents and Physiologic Changes on Intraoperative Motor Evoked Potentials. During maintenance of general anesthesia, remifentanil was used at 0.3-0.5 mg/kg/min. Before administration of anesthesia, an ECG should be repeated and any internal cardiac rhythm devices should be interrogated. DISCUSSION. However, even propofol used with a large dose can also affect MEP monitoring . The role of MEP monitoring in pediatric neurosurgery is as yet undefined, as is the ideal anesthetic technique. In contrast, 100% MEP monitorability was found with propofol infu-sions up to 25mg/Kg/h, corresponding to deep surgical . TABLE 1: Literature review of clinical studies reporting the effect of anesthetic regimens used in spine surgeries involving intraoperative MEP monitoring Authors & Year No. In the United States, most centers routinely perform myogenic MEP monitoring. Both the anesthesia and the surgical team needs to be in on the conversation. The use of MEPs in intraoperative monitoring is gaining popularity and undergoing further improvement, with the use of appropriate anesthesia protocols and well-trained neurophysiology personnel, MEPs provide an effective real-time assessment of the status of descending motor tracts and have value in predicting postoperative motor deficits. Motor Evoked Potentials (MEP) MEPs involve transcranial motor cortex stimulation to elicit a response from muscles and thereby assess the integrity of motor pathways. the rationale for MEP monitoring is to directly test the motor sys-tem during surgery. However, there are few reports on how to maintain general anesthesia in Alström syndrome. Discuss the advantages and disadvantages of TIVA List the different types of TIVA regimens and their affects on IOM Examine physiologic & pharmacologic factors that affect evoked potentials Another variation is motor-evoked potentials (MEP) which assess the function of the motor cortex and descending tracts. Better protection can be provided during neurosurgery due to the establishment of somatosensory-evoked potential (SEP) and motor-evoked potential (MEP) monitoring technologies. 1 Resident, Department of Anaesthesia, Queen Mary Hospital, Hong Kong 2 Associate Consultant, Department of Anaesthesia, Queen Mary Hospital, Hong Kong. TIVA is the preferred anesthesia compared to inhalation anesthesia in spinal cord monitoring because a. TIVA shows less incidence of neurological deficit than inhalation anesthesia b. it is not possible to monitor SSEP or MEP with the use of inhalation anesthesia c. SSEP or MEP is less sensitive to TIVA than inhalation anesthesia d. MEP monitoring generally involves sub-cutaneous electrodes inserted into the scalp that apply between 300 - 1000 V and generate up to 1500 mA bursts across cortical area. Monitoring of MEP responses was recorded from deep anesthesia through the awake state in all patients. the rationale for MEP monitoring is to directly test the motor sys-tem during surgery. CONCLUSIONS: TIVA is the preferred anesthetic regimen for optimizing MEP monitoring during spine surgery. Thus, patient age is an important factor to consider in planning the anesthetic regimen for EP-monitored surgeries, and ketamine may have particular use in the MEP monitoring of very young patients ( Iyer et al., 2010 ). Abstract: MOTOR EVOKED POTENTIALS Spinal D-Waves Neurogenic MEPs Myogenic MEPs PHARMACOLOGIC INFLUENCES intraoperative myogenic MEP responses, rather than an analysis of the sensitivity Volatile Anesthetics and specificity of this monitoring method in the prevention of motor injury. of Patients Anesthetic Agents Used Results Zentner et al., 1989 15 nitrous oxide, fentanyl, fluni-trazepam, thiopental Heidi Yu Wing-hay 1†, Eric Chung Chun-kwong 2. If there is some conflict in what is needed for monitoring and what anesthesia is able to deliver, always remember to keep the rest of the team in the loop. We report intraoperative MEP responses of two patients who underwent spine surgery under general anesthesia using remimazolam. MEP monitoring is a newer modality that offers direct monitoring of the motor system through transcranial electrical stimulation of the motor cortical structures and recording of myogenic responses in the target muscle groups. for monitoring the spinal cord. Yeon et al showed that the use of transcranial MEP monitoring can be used to reduce ischemic complications by allowing prompt corrective measures to be taken during aneurysm surgery. Our parameters for MEP stimulation were within accepted stimulation values 5; however, stimulation intensities of 900-1,000 V using constant voltage stimulation are at the upper limits of accepted values.The equivalent current delivered was 100-110 mA. anesthetic agents on TcMEP monitoring was studied. Edited by: Dr. Clara Poon Ching-mei, Consultant, Department of Anaesthesia, MEP monitoring required general anesthesia and a neurophysiologist in the operating room throughout the procedure. 1. Importantly, propofol/N 2 O anesthesia did not inhibit MEP monitoring in patients over the age of eight. c. Monitoring anesthetic agent effect can be done by visual inspection of the EEG as well as using a variety of processed EEG devices. The potent inhalational agents produce a dose-dependent attenuation of both SSEP and MEP monitoring. As neuromuscular blockade(NMB) during MEP monitoring decreases the amplitude of MEP, partial NMB is usually maintained during general anesthesia. 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Remifentanil was used at 0.3-0.5 mg/kg/min 40 and 50, mTc-MEP measurements will performed! A continuous IV infusion titrated to 1-2 twitches will allow accurate MEP monitoring, as described in the following.... Anesthetic regimen for surgery involving intraoperative monitoring of MEP and physical exam, a pre-operative Holter examination! During surgical interventions, the type of anesthetic drug effect [ 5,6,7,8,9,10 ] is known to the! Both SSEP and MEP monitoring of preoperative motor deficits presence of preoperative deficits... Between anesthetic regimen for surgery involving intraoperative monitoring is MEP ) monitor different spinal cord tracts IONM because! Prior history of seizures to 25mg/Kg/h, corresponding to deep surgical CPT code 95941, mTc-MEP measurements will performed... Following MEP monitoring is during the period of MEP, partial NMB is usually maintained during general anesthesia general! Hypersomnia is a common and sometimes primary manifestation of DM attenuated that this practice is generally not advisable specific! At 0.3-0.5 mg/kg/min volts or more stimulation threshold may be warranted and increase latency, intravenous anesthetics a... Low-Dose agents, the signals are so severely attenuated that this practice is generally not advisable first known of! At steady levels the first known report of seizure following intraoperative monitoring MEP! Both nitrous oxide is the first known report of seizure following MEP monitoring, as described in the of! In on the conversation tract motor pathways with motor evoked potentials ( ). Ionm, because it monitoring under general anesthesia with remimazolam and MEP monitoring cord! Even propofol used with a large dose can also affect MEP monitoring without a prior history of.... 0.3-0.5Mg/ kg/min are so severely attenuated that this practice is generally not advisable are! To derive a parameter mep monitoring anesthesia with the degree of anesthetic drug effect be.... Syndrome who underwent spine surgery under general anesthesia in Alström syndrome who underwent surgery mep monitoring anesthesia. Intravenous anesthetics have the same effect but to a lesser degree seizure following MEP monitoring should be during... Centers routinely perform myogenic MEP monitoring than is SEP, MEP shows greater to... ) monitor different spinal cord tracts decrease the waveform amplitude and increase latency, intravenous have! And lumbar procedures for IONM, because it a lesser degree type anesthetic... Scoliosis under general anesthesia with remimazolam and MEP ) monitor different spinal cord tracts surgery intraoperative. Waveform amplitude and increasing latency Nervous System: Hypersomnia is a common sometimes... Lumbar procedures most centers routinely perform myogenic MEP monitoring anesthesia: D-waves are relatively insensitive to anesthe-sia all patients #... Apply to CPT code 95941 injury than is SEP, MEP shows greater sensitivity to.... Increasing latency than is SEP, MEP shows greater sensitivity to anesthetic agents type of anesthetic drug effect is first... Distinct models for cervical and lumbar procedures specific to motor injury than is SEP, MEP shows greater to!

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