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Background <p>Intraoperative neurophysiological monitoring (IONM), particularly transcranial electrical stimulation motor evoked potentials (TceMEP), plays a crucial role in preserving motor function during intraspinal tumor resection. However, neuromuscular blocking agents (NMBAs) may attenuate TceMEP signals and complicate reliable monitoring. Partial neuromuscular blockade (pNMB) through continuous NMBA infusion may help balance interpretable TceMEP monitoring with acceptable surgical conditions.</p> Objective <p>This study aimed to evaluate the interpretability of TceMEP signals during continuous cisatracurium infusion and thereby estimate the median effective infusion rate (ED50) associated with preservation of interpretable TceMEP signals during intraspinal tumor resection.</p> Methods <p>Twenty-seven patients undergoing elective intraspinal tumor resection with TceMEP monitoring were enrolled in this prospective, single-center, open-label, sequential dose-finding study using Dixon’s up-and-down method. After a standard intubation dose of cisatracurium, continuous infusion was started at 1.0 µg/(kg·min). TceMEP signal interpretability was used as the binary response variable for sequential allocation. A neurophysiologist blinded to the infusion rate classified the signals as interpretable or uninterpretable; the anesthesiology team was not blinded because dose adjustment was required by the sequential design. The infusion rate for each subsequent patient was increased or decreased by a factor of 1.2 according to the response in the preceding patient. ED50 and its 95% confidence interval (CI) were estimated using Dixon’s method.</p> Results <p>The estimated ED50 of continuous cisatracurium infusion associated with preservation of interpretable TceMEP signals was 1.65 µg/(kg·min) (95% CI, 1.52–1.79 µg/(kg·min)). No clinically significant patient movement or serious infusion-related adverse events were observed during the study.</p> Conclusion <p>In patients undergoing intraspinal tumor resection with TceMEP monitoring, the median effective infusion rate of continuous cisatracurium associated with preservation of interpretable TceMEP signals was 1.65 µg/(kg·min). This value should be interpreted as an ED50 estimate rather than a recommended maximum acceptable infusion rate.</p> Trial registration <p>Chinese Clinical Trial Registry, ChiCTR2200057610. Registered on March 15, 2022, before enrollment of the first participant.</p>

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Median effective infusion rate (ED50) of continuous cisatracurium for preserving interpretable TceMEP signals during intraspinal tumor resection: a prospective up-and-down sequential allocation study

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  • 发表日期：

    2026年8月5日

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  • Siyi Yan,
  • Mengzhuo Guo,
  • Xin Wen,
  • Zhibin He

摘要

Background

Intraoperative neurophysiological monitoring (IONM), particularly transcranial electrical stimulation motor evoked potentials (TceMEP), plays a crucial role in preserving motor function during intraspinal tumor resection. However, neuromuscular blocking agents (NMBAs) may attenuate TceMEP signals and complicate reliable monitoring. Partial neuromuscular blockade (pNMB) through continuous NMBA infusion may help balance interpretable TceMEP monitoring with acceptable surgical conditions.

Objective

This study aimed to evaluate the interpretability of TceMEP signals during continuous cisatracurium infusion and thereby estimate the median effective infusion rate (ED50) associated with preservation of interpretable TceMEP signals during intraspinal tumor resection.

Methods

Twenty-seven patients undergoing elective intraspinal tumor resection with TceMEP monitoring were enrolled in this prospective, single-center, open-label, sequential dose-finding study using Dixon’s up-and-down method. After a standard intubation dose of cisatracurium, continuous infusion was started at 1.0 µg/(kg·min). TceMEP signal interpretability was used as the binary response variable for sequential allocation. A neurophysiologist blinded to the infusion rate classified the signals as interpretable or uninterpretable; the anesthesiology team was not blinded because dose adjustment was required by the sequential design. The infusion rate for each subsequent patient was increased or decreased by a factor of 1.2 according to the response in the preceding patient. ED50 and its 95% confidence interval (CI) were estimated using Dixon’s method.

Results

The estimated ED50 of continuous cisatracurium infusion associated with preservation of interpretable TceMEP signals was 1.65 µg/(kg·min) (95% CI, 1.52–1.79 µg/(kg·min)). No clinically significant patient movement or serious infusion-related adverse events were observed during the study.

Conclusion

In patients undergoing intraspinal tumor resection with TceMEP monitoring, the median effective infusion rate of continuous cisatracurium associated with preservation of interpretable TceMEP signals was 1.65 µg/(kg·min). This value should be interpreted as an ED50 estimate rather than a recommended maximum acceptable infusion rate.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2200057610. Registered on March 15, 2022, before enrollment of the first participant.