As we all  know, infants and toddlers are neurologically immature, making the obtaining of  MEPs  intraoperative data very challenging. We aim to determine the safest and more reliable stimulation parameters for eliciting robust MEPs at the minimum stimulating threshold voltage in this age group. In doing so, we have appended two facilitation techniques, double train (DTS), and Linked Quadri-Polar (LQP) stimulation technique.
We prospectively collected and analysed data of 20 pediatric patients undergoing a surgical procedure to the spine and spinal cord for which neurophysiological monitoring was needed (9 males and 12  females), ages from 9 months to 17 years. Surgical treatment of tethered cord syndrome was present in 9 of the patients, 10 had posterior instrumentation for correction of spinal deformity, and one underwent posterior spinal decompression. Preop neurological deficit was present in 13 patients. TIVA was used in all cases.
For our MEP  monitoring protocol, we begin with, a single train stimulation with conventional bipolar stimulation with the electrodes positioned at C1/C2 and M3/M4, followed by a double train stimulation with the same bipolar stimulation montage. Finally, LQS was attempted with linked C1/M3 plus C2/M4 derivations. We deliver first a single train and then a double train stimulation.
Results: Out of the six stimulation modalities, LQP stimulation together with DTS produced the best MEP responses in all cases.
Motor thresholds by transcranial electrical stimulation negatively correlates with age, with a higher threshold in younger children.
There was a similar but much weaker relationship between the number of train count and increasing age.
The intensity threshold to achieve very robust MEP responses was incredibly low, being 70V the lowest and 180V the highest. Patient movement in all cases was almost imperceptible allowing  for continuous monitoring. No side effects were observed post-surgery in any of the 20 cases.
Conclusion: The key point in his preliminary study was our ability to achieve reliable MEP responses while improving the highest MEP amplitude but yet at a very low intensity threshold, making it very safe with minimal patient movement, allowing for almost continuous MEP monitoring.