Motor evoked potentials for femoral nerve protection in transpsoas lateral access surgery of the spine

Detecting potential intraoperative injuries to the femoral nerve should be the main goal of neuromonitoring of lateral lumber interbody fusion (LLIF) procedures. We propose a theory and technique to utilize motor evoked potentials (MEPs) to protect the femoral nerve (a peripheral nerve), which is at risk in LLIF procedures. MEPs have been advocated and widely used for monitoring spinal cord function during surgical correction of spinal deformity and surgery of the cervical and thoracic spine, but have had limited acceptance for use in lumbar procedures. This is due to the theoretical possibility that MEP recordings may not be sensitive in detecting an injury to a single nerve root considering there is overlapping muscle innervation of adjacent root levels. However, in LLIF procedures, the surgeon is more likely to encounter lumbar plexus elements than nerve roots. Within the substance of the psoas muscle, the L2, L3, and L4 nerve roots combine in the lumbar plexus to form the trunk of the femoral nerve. At the point where the nerve roots become the trunk of the femoral nerve, there is no longer any alternative overlapping innervation to the quadriceps muscles. Insult to the fully formed femoral nerve, which completely blocks conduction in motor axons, should theoretically abolish all MEP responses to the quadriceps muscles. On multiple occasions over the past year, our neuro-monitoring groups have observed significantly degraded amplitudes of the femoral motor and/or sensory evoked potentials limited to only the surgical side. Most of these degraded response amplitudes rapidly returned to baseline values with a surgical intervention (i.e., prompt removal of surgical retraction)