Influence of Remimazolam and Propofol on Intraoperative Motor Evoked Potentials During Spinal Surgery: A Randomized Crossover Trial

<b>Background/Objectives:</b> Total intravenous anesthesia (TIVA) typically combines propofol and remifentanil. Remifentanil exerts minimal influence on motor evoked potential (MEP), whereas propofol partially reduces MEP amplitude. Remimazolam, a novel agent, is a component of TIVA. However, evidence of remimazolam on MEP is limited. We aimed to compare the effects of propofol and remimazolam, combined with remifentanil, on relative MEP depression. <b>Methods:</b> Using a crossover design, 18 patients undergoing spine surgery were randomly assigned to receive either propofol or remimazolam as the first agent. In the propofol first sequence, anesthesia was induced and maintained with propofol, which was then switched to remimazolam 60 min after surgery. In the remimazolam first sequence, remimazolam was used first and then switched to propofol. The primary outcomes measured were the MEP amplitude and latency. <b>Results:</b> MEP amplitude and latency during propofol and remimazolam infusions were as follows: amplitude (mean (SD); 635.3 (399.1) vs. 738.4 (480.4) μV, <i>p</i> = 0.047) and latency (median [IQR]; 22.4 [20.3-24.6] vs. 21.4 [19.6-23.5] ms, <i>p</i> = 0.070), indicating propofol caused greater depression in amplitude than remimazolam. However, an incident of severe body movement disrupting surgery occurred under remimazolam anesthesia in a young, healthy male patient, although bispectral index remained below 60. This suggests that remimazolam, at hypnotic levels similar to propofol, may result in reduced akinesia in major surgeries, such as spinal surgery, when neuromuscular blockade is not employed. <b>Conclusions:</b> Remimazolam demonstrated comparable or superior effects to propofol on MEP latency and amplitude when combined with remifentanil during spinal surgery, rendering it a potential alternative to propofol for MEP monitoring.