Intraoperative Neurophysiological Monitoring During Lead Placement for Dorsal Root Ganglion Stimulation: A Literature Review and Case Series

Introduction: Dorsal root ganglion stimulation (DRG-S) is a viable interventional option for intractable pain management. Although systematic data are lacking regarding the immediate neurologic complications of this procedure, intraoperative neurophysiological monitoring (IONM) can be a valuable tool to detect real -time neurologic changes and prompt intervention(s) during DRG-S performed under general anesthesia and deep sedation. Materials and Methods: In our single-center case series, we performed multimodal IONM, including peripheral nerve somatosensory evoked potentials (pnSSEPs) and dermatomal somatosensory evoked potentials (dSSEPs), spontaneous electromyography (EMG), transcranial motor evoked potentials (MEPs), and electroencephalogram (EEG) for some trials and all permanent DRG-S lead placement per surgeon preference. Alert criteria for each IONM modality were established before data acquisition and collection. An IONM alert was used to implement an immediate repositioning of the lead to reduce any possible postoperative neurologic deficits. We reviewed the literature and summarized the current IONM modalities commonly applied during DRG-S, including somatosensory evoked potentials and EMG. Because DRG-S targets the dorsal roots, we hypothesized that including dSSEP would allow more sensitivity as a proxy for potential sensory changes under generalized anesthesia than would including standard pnSSEPs. Results: From our case series of 22 consecutive procedures with 45 lead placements, one case had an alert immediately after DRG-S lead positioning. In this case, dSSEP attenuation was seen, indicating changes in the S1 dermatome, which occurred despite ipsilateral pnSSEP from the posterior tibial nerve remaining at baselines. The dSSEP alert prompted the surgeon to reposition the S1 lead, resulting in immediate recovery of the dSSEP to baseline status. The rate of IONM alerts reported intraoperatively was 4.55% per procedure and 2.22% per lead (n = 1). No neurologic deficits were reported after the procedure, resulting in no postoperative neurologic complications or deficits. No other IONM changes or alerts were observed from pnSSEP, spontaneous EMG, MEPs, or EEG modalities. Reviewing the literature, we noted challenges and potential deficiencies when using current IONM modalities for DRG-S procedures. Conclusions: Our case series suggests dSSEPs offer greater reliability than do pnSSEPs in quickly detecting neurologic changes, and subsequent neural injury, during DRG-S cases. We encourage future studies to focus on adding dSSEP to standard pnSSEP to provide a comprehensive, real -time neurophysiological assessment during lead placement for DRG-S. More investigation, collaboration, and evidence are required to evaluate, compare, and standardize comprehensive IONM protocols for DRG-S.