Hand or foot train-of-four tests and surgical site muscle relaxation assessed with multiple motor evoked potentials: A prospective observational study

Eur J Anaesthesiol. 2021 Aug 1;38(8):872-879. doi: 10.1097/EJA.0000000000001398.


Background: Intra-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.

Objective: The aim of the study was to assess if hand or foot TOF adequately represents intra-operative muscle relaxation compared with multiple motor evoked potentials.

Design: Prospective observational study.

Setting: A single-centre study performed between February 2016 and December 2018 at the Balgrist University Hospital, Zurich, Switzerland.

Patients: Twenty patients scheduled for elective lumbar spinal fusion were prospectively enrolled in this study after giving written informed consent.

Interventions: To 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 measures: The 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.

Results: Hand 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.

Conclusion: Hand 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 registration: ClinicalTrials.gov (NCT03318718).

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Evoked Potentials, Motor
  • Humans
  • Muscle Relaxation
  • Neuromuscular Blockade*
  • Neuromuscular Nondepolarizing Agents*
  • Switzerland


  • Neuromuscular Nondepolarizing Agents

Associated data

  • ClinicalTrials.gov/NCT03318718