Article abstract Electrical stimulation of the vagus nerve, a recently available option for patients with refractory epilepsy, has demonstrated safety and efficacy. We report four patients with refractory epilepsy who experienced ventricular asystole intraoperatively during initial testing for implantation of the vagus nerve stimulator. Acute intraoperative vagus nerve stimulation may create ventricular asystole in humans. Extracorporeal cervical vagus nerve stimulation testing with continuous EKG monitoring intraoperatively before generator implantation is warranted.

Background: Intraoperative neurophysiologic monitoring (IONM) is a technique that is helpful for assessing the nervous system during spine surgery. Methods: This is a review of the field describing the basic mechanisms behind the techniques of IONM. These include the most often utilized trancranial motor evoked potentials (Tc-MEPs), somatosensory evoked potentials (SSEPs), and stimulated and spontaneous EMG activity. It also describes some of the issues regarding practices and qualifications of practitioners. Results: Although the anatomic pathways responsible for the Tc-MEP and SSEP are well known and these clinical techniques have a high sensitivity and specificity, there is little published data showing that monitoring actually leads to improved patient outcomes. It is evident that IONM has high utility when the risk of injury is high, but may be only marginally helpful when the risk of injury is very low. The monitoring team must be well trained, be able to provide the surgeon feedback in real time, and coordinate activities with those of the surgical and anesthesia teams. Conclusions: Although IONM is a valuable technique that provides sensitive and specific indications of neurologic injury, it does have limitations that must be understood. Maintaining a high quality of practice with appropriately trained personnel is critical.