Intraoperative Electromyography in Awake Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Case Study on Nerve Activation Under the Effects of Local Anesthesia.

With the versatility of lumbar spine surgery continually expanding, intraoperative electromyography (EMG) has become a common adjunct used to reduce risk of nerve injury and postoperative neurologic deficit. EMG monitoring has been deemed particularly useful in the minimally invasive transforaminal lumbar interbody fusion. A more recent evolution of the minimally invasive transforaminal lumbar interbody fusion entails complete percutaneous access to the disc through Kambin's triangle, followed by a percutaneous lumbar interbody fusion. Given the lack of direct visualization of nervous structures with percutaneous entrance into the disc, there is risk of injury to surrounding nervous structures with this approach. In effort to reduce risk of nerve injury, application of triggered EMG to gauge proximity of nervous tissue has been evaluated. Recently, patients presenting with contraindications or concerns for general anesthesia have been offered the alternative to undergo their procedure with spinal anesthesia, allowing them to remain awake. Spinal anesthesia entails intrathecal administration of local anesthetic, which mechanistically acts to reduce overall excitability of surrounding neural structures. However, nerve activation under conditions of local anesthetic is relatively unknown, and the ability of triggered EMG monitoring to reliably detect nerve proximity becomes questionable. This case report demonstrates nerve activation at thresholds comparable with those seen under general anesthesia. Although this has sparked interest in the possibility that local anesthetic may not remarkably affect nerve excitability as measured by triggered EMG activation, further investigation is recommended to reliably apply triggered EMG monitoring in awake spine surgery.