Intraoperative neurophysiological monitoring of a 3-day-old infant

A successful surgery was performed for the first time on a 3-day-old infant weighing 3 kg with congenital myelomeningocele (MMC) in the cervicothoracic region with complete neuromonitoring (IONM) of the upper and lower extremities using MEP, SEEP and EMG modes with 18 pairs of electrode wires in January 2025 at the Al-Zahra Hospital affiliated with Isfahan University of Medical Sciences. The neural tube defect (NTD) repair process lasted for 5 hours and then the infant was transferred to the ICU with desired reactions and discharged from the hospital after 2 daysFor the case under study, and the surgeon's emphasis on the need for IONM, there was inadequate scientific evidence, but a decision was made to perform IONM using MEP, SEEP, and EMG modes as well as a bipolar stimulator to differentiate neural tissue from non-neural tissue. Since it was impossible to insert screw leads in the patient's fontanel due to his specific conditions as well as the inappropriate size of the leads specifically designed for adults, needle leads, which had their own limitations, were utilized in the patient's head instead of screw leads. A lead for the FZ area was inserted next to the left fontanel area. Three needles were inserted in the CZ and CZ prime areas on the right and left sides to receive SEEP from the upper and lower extremities, and two leads were also used to send current flow to receive MEP with a functional distance of 15%. The trapezius, deltoid, biceps, thenar, rectus femoris and abductor hallucis muscles were also placed in both directions. To send current to receive SEEP, 4 pairs of electrode wires were utilized in the posterior and median area of both directions. Moreover, 2 Grand ones were placed in the frontal and lateral tibial areas . To receive SEEP throughout the surgery, a 7 mA current was used to receive MEP starting with a current of 50 and in some times up to a maximum of 90 mA. During the surgery, MEP and SEEP were prepared as many times as necessary and sometimes at the request of the surgeon and recorded on the hard disk of the computer system along with the instantaneous EMG . At one stage of the surgery, a bipolar stimulator was utilized to differentiate neural tissue from non-neural one.

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