Intraoperative wake-up test in neonatal neurosurgery.

Intraoperative wake-up test (WPT) still remains the gold standard to monitor anterior spinal cord function during spinal surgery. However, the test requires patient cooperation and hence difficult to perform in very young children or mentally challenged. In this report, we describe a WPT in a newborn during surgical repair of a large myelomeningocele. We relied on mivacurium for intubation and the relaxant effect was allowed to wear-off to permit the use of intraoperative nerve stimulator. We used desflurane and propofol infusion for rapid titration of the anesthetic depth and BIS monitor to 'gauge' the 'wakefulness' of the child during the WPT. We employed lidocaine infusion to improve tolerance to the tracheal tube and to bestow beneficial effect on intracranial pressure during surgery and the WPT. The results of the WPT were judged to be satisfactory after confirming flexion and extension of the lower extremities at the hip and knee level, correlating it with the BIS values, and comparing it with the preoperative status. Frequently associated prematurity, higher possibility of remaining intubated in the immediate postoperative period and any new onset neurologic deficit not becoming apparent until after extubation makes intraoperative neuromonitoring relevant in this age group. Our methodology of management has permitted us to perform a delicate test safely and will allow us to repeat the WPT if needed during neonatal neurosurgery.