• Michael Betz, José Aguirre, Martin Schubert, Tobias Götschi, Barbara Huber, Regula Schüpbach, Muriel Brada, José M Spirig, and Mazda Farshad.
• From the Department of Orthopaedics (MB, TG, RS, JMS, MF), Department of Anaesthesiology, Intensive Care and Pain Medicine (JA, MB) and Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland (MS, BH).
• Eur J Anaesthesiol. 2021 Aug 1; 38 (8): 872-879.

BackgroundIntra-operative muscle relaxation is often required in orthopaedic surgery and the hand train-of-four (TOF) test is usually used for its quantification. However, even though full muscle relaxation is claimed by anaesthesiologists based on a TOF count of zero, surgeons observe residual muscle activity.ObjectiveThe aim of the study was to assess if hand or foot TOF adequately represents intra-operative muscle relaxation compared with multiple motor evoked potentials.DesignProspective observational study.SettingA single-centre study performed between February 2016 and December 2018 at the Balgrist University Hospital, Zurich, Switzerland.PatientsTwenty patients scheduled for elective lumbar spinal fusion were prospectively enrolled in this study after giving written informed consent.InterventionsTo assess neuromuscular blockade (NMB) with the intermediate duration nondepolarising neuromuscular blocking agent rocuronium, hand TOF (adductor pollicis) and foot TOF (flexor hallucis brevis) monitoring, and muscle motor evoked potentials (MMEPs) from the upper and lower extremities were assessed prior to surgery under general anaesthesia. Following baseline measurements, muscle relaxation was performed with rocuronium until the spinal surgeon observed sufficient relaxation for surgical intervention. At this timepoint, NMB was assessed by TOF and MMEP.Main Outcome MeasuresThe primary outcome was to determine the different effect of rocuronium on muscle relaxation comparing hand and foot TOF with the paraspinal musculature assessed by MMEP.ResultsHand TOF was more resistant to NMB and had a shorter recovery time than foot TOF. When comparing MMEPs, muscle relaxation occurred first in the hip abductors, and the paraspinal and deltoid muscles. The most resistant muscle to NMB was the abductor digiti minimi. Direct comparison showed that repetitive MMEPs simultaneously recorded from various muscles at the upper and lower extremities and from paraspinal muscles reflect muscle relaxation similar to TOF testing.ConclusionHand TOF is superior to foot TOF in assessing muscle relaxation during spinal surgery. Hand TOF adequately represents the degree of muscle relaxation not only for the paraspinal muscles but also for all orthopaedic surgical sites where NMB is crucial for good surgical conditions.Trial RegistrationClinicalTrials.gov (NCT03318718).Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology.

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