Main Article Content
Background: Anesthetic management for intraoperative bulbocavernosus reflex (BCR) monitoring is challenging, particularly in pediatric patients. Objective: The aim of this study was to demonstrate anesthetic regimens for successful intraoperative BCR monitoring in pediatric patients. Methods: This retrospective descriptive study was done in pediatric patients who underwent untethered cord surgery with intraoperative BCR monitoring. The data collections were preoperative urinary and anal sphincter function, anesthetic technique, monitorable of BCR, significant change of BCR signal, duration of surgery and anesthesia. The outcomes collected were from postoperative urinary and anal sphincter dysfunction, length of ICU and hospital stay. Results: Seventeen patients obtained intraoperative BCR monitoring during untethered cord surgery for a 3-years period. Intraoperative BCR signal could be recorded in all patients during anesthetic maintenance with total intravenous anesthesia (TIVA) consisting of propofol and fentanyl infusion without muscle relaxant. Mean doses of propofol and fentanyl during BCR monitoring were 170.77±29.84 mcg/kg/min and 1.87±0.91 mcg/kg/hr, respectively. After finishing BCR monitoring, anesthesia was switched to inhalation anesthetics in 16 patients (94.12%). All patients were extubated in the operating room without postoperative ICU admission. Significant BCR signal changes were recorded in three patients. One of these patients had postoperative urinary dysfunction. All of them were discharged without complications. Conclusions: Intraoperative BCR was monitorable during anesthetic maintenance with TIVA using propofol and fentanyl without muscle relaxant in conjunction with maintenance of hemodynamic stability. This anesthetic regimen may contribute to a good neurological outcome as BCR signal was preserved and facilitate extubation.
prevalence estimates for selected birth defects in the United
States, 2004-2006. Birth Defects Res A Clin Mol Teratol
2. Hertzler DA II, DePowell JJ, Stevenson CB, Mangano FT.
Tethered cord syndrome: a review of the literature from
embryology to adult presentation. Neurosurg Focus 2010;29;E1.
3. Pierre-Kahn A, Zerah M, Renier D, et al. Congenital
lumbosacral lipomas. Childs Nerv Syst 1997:13:298-334.
4. Van Leeuwen R, Notermans NC, Vandertop WP. Surgery in
adults with tethered cord syndrome: outcome study with
independent clinical review. J Neurosurg 2001;94:205-9.
5. Deletis V, Vodešek DB. Intraoperative recording of the
bulbocavernosus reflex. Neurosurgery 1997;40:88-93.
6. Skinner SA, Vodešek DB. Intraoperative recording of the
bulbocavernosus reflex. J Clin Neurophysiol 2014;31:313-22.
7. Shinjo T, Hayashi H, Takatani T, Boku E, Nakase H,
Kawaguchi M. Intraoperative feasibility of bulbocavernosus
reflex monitoring during untethering surgery in infants and
children. J Clin Monit Comput 2019;33:155-63.
8. Sala F, Squintani G, Tramontano V, Arcaro C, Faccioli F,
Mazza C. Intraoperative neurophysiology in tethered cord
surgery: techniques and results. Childs Nerv Syst 2013;29:
9. Cha S, Wang K, Park K, et al. Predictive value of intraoperative
bulbocavernosus reflex during untethering surgery for
post-operative voiding function. Clin Neurophysiol 2018;
10. Rodi Z, Vodešek DB. Intraoperative monitoring of the
bulbocavernosus reflex: the method and its problems. Clin
11. Hoving EW, Haitsma E, Ophuis C.M.C.O, Jourńee HL. The
value of intraoperative neurophysiological monitoring in
tethered cord surgery. Childs Nerv Syst2011;27:1445-52.
12. Clemens JQ. Basic bladder neurophysiology. Urol Clin North
13. Hwang H, Wang K, Bang M, et al. Optimal stimulation
parameters for intraoperative bulbocavernosus reflex in
infants. J Neurosurg Pediatr 2017;20:467-70.
14. Taskiran E, Ulu MO, Akcil EF, Hanci M. Intraoperative
neuromonitoring in surgery of cauda equina and conus
medullaris tumor. Turk Neurosug 2019;29:909-14.
15. Morota N. Intraoperative neurophysiological monitoring of
the bulbocavernosus reflex during surgery for conus spinal
lipoma: what are the warning criteria? J Neurosurg Pediatr
16. Lieberman JA, Lyon R, Feiner J, Diab M, Gregory GA. The
effect of age on motor evoked potentials in children under
propofol/isoflurane anesthesia. Anesth Analg 2006;103:
17. Overzet K, Jahangiri FR, Funk R. Bulbocavernosus reflex
monitoring during intramedullary conus tumor surgery.
18. Kothbauer KF, Novak K. Intraoperative monitoring for tethered
cord surgery: an update. Neurosurg Focus 2004;16:1-5.
19. Danial HF, Krishna BS, Lillian MW, James JR, Stephen AS,
William EW. Intraoperative monitoring of motor evoked
potentials in very young children. J Neurosurg Pediatr
20. Chong CT, Manninen P, Sivanaser V, Subramanyam R, Lu
N, Venkatraghavan L. Direct comparison of the effect of
desflurane and sevoflurane on intraoperative motor-evoked
potentials monitoring. J Neurosurg Anestheiol 2014;26:
21. Lo Y, Dan Y, Tan YE, et al. Intraoperative motor-evoked
potential monitoring in scoliosis surgery: comparison of
desflurane/nitrous oxide with propofol total intravenous
anesthetic regimens. J Neurosurg Anesthesiol 2006;18:
22. Balvin MJ, Song KM, Slimp JC. Effects of anesthetic regimens
and other confounding factors affecting the interpretation of
motor evoked potentials during pediatric spine surgery.
Am J Electroneurodiagnostic Technol 2010;50:219-44.
23. Velayutham P, Cherian VT, Rajshekhar V, Babu KS. The
effects of propofol and isoflurane on intraoperative motor
evoked potentials during spinal cord tumour removal
surgery-A prospective randomized trial. Indian J Anaesth
24. Tod S. Anesthesia and intraoperative neurophysiologic
monitoring in children. Childs Nerv Syst 2010;26:227-35.
25. Thornton C, Creagh-Barry P, Jordan C, et al. Somatosensory
and auditory evoked responses recorded simultaneously:
differential effects of nitrous oxide and isoflurane. Br J
26. Isley MR, Balzer JR, Pearlman RC, Zhang XF. Intraoperative
motor evoked potentials. Am J Electroneurodiagnostic
27. Anschel DJ, Aherne A, Soto RG, et al. Successful intraoperative
spinal cord monitoring during scoliosis surgery using a total
intravenous anesthetic regimen including dexmedetomidine.
J Clin Neurophysiol 2008;25:56-61.
28. Sloan TB, Toleikis R, Toleikis SC, Koht A. Intraoperative
neurophysiological monitoring during spine surgery with
total intravenous anesthesia or balanced anesthesia with 3%
desflurane. J Clin Monit Comput 2015;29:77-85.
29. Sala F, Manganotti P, Grossauer S, Tramontanto V, Mazza
C, Gerosa M. Intraoperative neurophysiology of the motor
system in children: a tailored approach. Childs Nerv Syst
30. Govindarajan R, Babalola O, Gad-El-Kareem M, Kodali NS,
Aronson J, Abadir A. Intraoperative wake-up test in neonatal
neurosurgery. Paediatr Anaesth. 2006;16:451-3.
31. Kim WH, Lee JJ, Lee SM, et al. Comparison of motor-evoked
potentials monitoring in response to transcranial electrical
stimulation in subjects undergoing neurosurgery with partial
vs no neuromuscular block. Br J Anaesth 2013;110:567-76.
32. Lyon R, Feiner J, Lieberman JA. Progressive suppression
of motor evoked potentials during general anesthesia.
J Neurosurg Anesthesiol 2005;17:13-9.
33. Williams A, Singh G. Tongue bite injury after use of
transcranial electric stimulation motor-evoked potential
monitoring. J Anaesthesiol Clin Pharmacol 2014;30:439-4