Evaluation of electromyographic monitoring during insertion of thoracic pedicle screws.

We prospectively studied the use of intercostal EMG monitoring as an indicator of the accuracy of the placement of pedicle screws in the thoracic spine. We investigated 95 thoracic pedicles in 17 patients. Before insertion of the screw, the surgeon recorded his assessment of the integrity of the pedicle track. We then stimulated the track using a K-wire pedicle probe connected to a constant current stimulator. A compound muscle action potential (CMAP) was recorded from the appropriate intercostal or abdominal muscles. Postoperative CT was performed to establish the position of the screw. The stimulus intensity required to evoke a muscle response was correlated with the position of the screw on the CT scan. There were eight unrecognised breaches of the pedicle. Using 7.0 mA as a threshold, the sensitivity of EMG was 0.50 in detecting a breached pedicle and the specificity was 0.83. Thoracic pedicle screws were accurately placed in more than 90% of patients. EMG monitoring did not significantly improve the reliability of placement of the screw.

Click evoked EMG responses in sternocleidomastoid muscles: characteristics in normal subjects.

Recordings were obtained from a total of 25 normal subjects of the electromyographic (EMG) responses in the sternocleidomastoid muscle (SCM) to intense sound stimuli. While previous authors have demonstrated these responses exist, it has remained unclear whether the EMG response is unilateral or bilateral in nature. Accordingly, we chose a remote site, linked-wrists, for our reference electrodes so that we could be certain that no significant volume conduction of potentials could occur from the source in the SCM to the reference site. When this was done we found that if the sternum was used as a reference site, as was the case in previous studies, some subjects exhibited bilateral responses while in others, the response was ipsilateral. However, with linked-wrists as the reference site, responses were always purely ipsilateral. Furthermore, recordings that used the sternum or the ipsilateral mastoid process as active sites and linked-wrists as a reference, exhibited responses which were inverted. Thus, both the sternum and the ipsilateral mastoid process are electrically active due to volume conduction from the nearby source in the SCM. The ambiguity in previous recordings can be attributed to the use of these active sites as a reference. When SCM responses are recorded versus a remote, electrically inactive site, the responses are purely ipsilateral.

Spinal cord-evoked potentials and muscle responses evoked by transcranial magnetic stimulation in 10 awake human subjects.

Transcranial magnetic stimulation (TCMS) causes leg muscle contractions, but the neural structures in the brain that are activated by TCMS and their relationship to these leg muscle responses are not clearly understood. To elucidate this, we concomitantly recorded leg muscle responses and thoracic spinal cord-evoked potentials (SCEPs) after TCMS for the first time in 10 awake, neurologically intact human subjects. In this report we provide evidence of direct and indirect activation of corticospinal neurons after TCMS. In three subjects, SCEP threshold (T) stimulus intensities recruited both the D wave (direct activation of corticospinal neurons) and the first I wave (I1, indirect activation of corticospinal neurons). In one subject, the D, I1, and I2 waves were recruited simultaneously, and in another subject, the I1 and I2 waves were recruited simultaneously. In the remaining five subjects, only the I1 wave was recruited first. More waves were recruited as the stimulus intensity increased. The presence of D and I waves in all subjects at low stimulus intensities verified that TCMS directly and indirectly activated corticospinal neurons supplying the lower extremities. Leg muscle responses were usually contingent on the SCEP containing at least four waves (D, I1, I2, and I3).

Somatosensory evoked potential identification of sensorimotor cortex in removal of intracranial neoplasms.

OBJECTIVE: To assess the ease and reliability of routine use of somatosensory evoked potentials (SSEPs) for identification of sensorimotor cortex in brain tumour removal and to document its influence on the performance and outcome of surgery. METHODS: SSEPs in response to contralateral median nerve stimulation were recorded from the cortical surface by means of a four lead electrode strip. Polarity reversal of short latency SSEP waves was used to identify the position of the central sulcus in 46 consecutive craniotomies for removal of metastases, gliomas, or meningiomas located in, near, or overlying sensorimotor cortex. RESULTS: SSEPs were successfully recorded in 43/46 cases (94%) with demonstration of polarity reversal in 42/43 (98%). SSEP localization led to modification of 14/42 (33%) procedures, most frequently because of either displacement or involvement of sensorimotor cortex by tumour. Six patients (14%) developed new neurological deficits but none of these was attributable to incorrect identification of sensorimotor cortex. CONCLUSIONS: SSEP polarity reversal is a simple, reliable, accurate, and inexpensive method of localizing sensorimotor cortex under general anaesthesia. Correct identification is possible when sensorimotor cortex is displaced or when surface anatomy is obscured by tumour. Routine use of this technique should be considered in all procedures for lesions located near the central sulcus.

Spinal cord mapping with evoked responses for accurate localization of the dorsal root entry zone.

Direct spinal cord stimulation and recording techniques were used intraoperatively to localize the dorsal root entry zone (DREZ) in four patients with brachial plexus avulsion and severe intractable pain. The spinal cord was stimulated by a cordotomy needle placed on the pia-arachnoid at the DREZ or the dorsal or dorsolateral aspect of the spinal cord. Recordings were obtained from a subdural silver ball electrode placed rostral or caudal to the stimulation site. Spinal cord conduction velocity was significantly faster following dorsolateral stimulation than dorsal stimulation (mean = 66 and 45 m/sec respectively). The spinal cord evoked potential was significantly larger in amplitude following dorsolateral stimulation than dorsal stimulation at a specific stimulus intensity. Stimulation at the DREZ failed to evoke a response. These neurophysiological phenomena helped to accurately localize the DREZ before DREZ lesioning was undertaken. There were no untoward neurological deficits related to the DREZ lesions and all patients had satisfactory pain relief following the procedure. Intraoperative spinal cord mapping facilitates accurate DREZ localization when the DREZ cannot be visually identified.

Dorsal root entry zone localization using direct spinal cord stimulation: an experimental study.

Direct spinal cord stimulation and recording was performed in five dogs to identify the dorsal root entry zone (DREZ) and long tracts within the dorsal and dorsolateral spinal cord using electrophysiological mapping techniques. Intrathecal recordings were obtained from sites distal to the site of stimulation. Conduction velocity in the fastest conducting fibers was higher following low-intensity stimulation of the dorsolateral spinal cord than after dorsal spinal cord stimulation. The evoked response was larger following dorsolateral than dorsal spinal cord stimulation at a specific stimulus intensity. This technique is useful in identifying the DREZ using electrophysiological criteria alone.

Tongue reinnervation by hypoglossal-lingual nerve transfer.

The morbidity associated with total glossectomy for treatment of base of tongue carcinomas provides the impetus to investigate techniques to salvage the uninvolved normal anterior tongue. This report describes a method of reinnervation of the anterior tongue using a hypoglossal-lingual transfer. In Cynomolgus monkeys, unilateral transfers with and without a subsequent muscle fillet resulted in reinnervation from the base to the tip of the tongue. It is proposed that hypoglossal-lingual nerve transfers be considered to allow sparing and return of function to the anterior tongue in conjunction with a resection of the tongue base. Additional experiments confirmed that the base of the tongue, like other midline muscles, has bilateral and separate innervation. The presence of a physiological lingual-hypoglossal reflex in the normal animal was documented.

Neurophysiologic diagnosis in uncooperative trauma patients: confounding factors.

Median, ulnar, and posterior tibial nerve somatosensory evoked potential (SSEP) studies were performed on a total of 239 comatose or uncooperative trauma patients with head injuries. Twenty-six of those patients were suspected of having an additional spinal cord injury. One patient had more than one suspected spinal cord injury and two patients had a suspected spinal cord injury and a suspected peripheral nerve injury. Eleven of the suspected spinal cord injuries were confirmed and 13 were not confirmed by the SSEP studies. In three patients the SSEP study proved inadequate to add further information on the suspected spinal cord injury. Sixteen patients with suspected spinal cord injuries were able to cooperate with a neurologic examination approximately 6 months after injury and the SSEP findings were clinically verified in all 16 patients. Eleven patients were suspected of having an additional peripheral nerve injury. Four injuries were confirmed and seven not confirmed by the SSEP studies. Eight of those patients were able to cooperate with the follow-up neurologic examination, and the SSEP findings were clinically verified in all eight. Two patients suspected of having an additional spinal cord injury had unsuspected peripheral nerve injuries discovered by the SSEP studies. One patient was cooperative at follow-up and the SSEP findings were clinically verified. In our experience, SSEP studies have been an important diagnostic tool in the study of uncooperative trauma patients.

Correlation between cerebral blood flow, somatosensory evoked potentials, CT scan grade and neurological grade in patients with subarachnoid hemorrhage.

Cerebral blood flow (CBF) and central conduction time (CCT) were recorded from 58 subarachnoid hemorrhage patients and from 49 age-matched controls. CBF was calculated following Xenon inhalation and CCT was determined from somatosensory evoked potentials (SSEP's) following median nerve stimulation. Each patient had a CT scan on the day of admission which was graded from I-IV. CBF, CCT and neurological grade (Hunt and Hess classification) were concomitantly recorded 1, 4, 7 and 14 days after subarachnoid hemorrhage. Mean CBF was highest in patients with neurological grades I and II (48.6 +/- 12.3 and 48.1 +/- 10.3 ml/100gm/min respectively) and lowest in patients with neurological grade IV (37.3 +/- 9.6 ml/100gm/min). Patients in neurological grade I or II had mean CBF and CCT measurements that were significantly different from those obtained from patients in neurological grade IV (P less than 0.05). Neurological grade and CT scan grade correlated with CBF (P less than 0.0001) better than CCT (P = 0.015). Unexpectedly low CBF's from patients in neurological grades II and III (less than 37 and less than 31 ml/100gm/min respectively) failed to significantly prolong CCT suggesting CCT is unable to detect marginal ischemia. A significant correlation between CBF and CCT occurred only when CBF was less than 30 ml/100gm/min (R = 0.75, P = 0.05). It appears that prolonged CCT is associated with a drop in CBF only when CBF drops below a certain threshold.

Median nerve somatosensory evoked potentials and the Glasgow Coma Scale as predictors of outcome in comatose patients with head injuries.

Median nerve somatosensory evoked potential (SSEP) grades and Glasgow Coma Scale (GSC) scores were obtained from 51 patients with head injuries within 1 week after the injury to determine the relationship of these scores, both individually and combined, to outcome scores obtained more than 6 months after the injury. SSEP grading was based on the presence or absence of the cortical evoked potential, the amplitude of the early cortically generated P22 wave form, and the conduction time through the brain (P/N13-N20 interpeak latency). SSEP responses from both sides of the brain were combined and graded from 1 to 6. The GCS was graded without the verbal component (maximum score, 10), because all patients were intubated. All patients were unresponsive to commands. Median SSEP grades correlated better with Glasgow Outcome Scale and Barthel Index scores (R = 0.57 and 0.64, respectively; P less than 0.00001) than GCS scores did (R = 0.35 and 0.37, respectively, P less than 0.00001), and combining SSEP grades and GCS scores did not improve the predictive power of the model (R = 0.57 and 0.64, respectively; P less than 0.00001). All SSEP Grade 1 patients (n = 13) either died or remained in a vegetative state. In contrast, all SSEP Grade 6 patients (n = 7) had a moderate disability or good recovery. This study demonstrates the prognostic value of early quantitative median nerve SSEP grading for patients with head injuries who are unresponsive to commands within 1 week after the injury.

Somatosensory evoked potentials and neurological grades as predictors of outcome in acute spinal cord injury.

An analysis of Motor Index score, pinprick sensory score, joint position sense score, somatosensory evoked potential (SSEP) grade in the ulnar (SSEPu) and posterior tibial (SSEPt) regions, and overall SSEP grade (mean SSEPu + t) was conducted in 36 patients with cervical spinal cord injuries to determine the relationship of these scores, both individually and in combination, to functional outcome (as determined using the Barthel Index) at 6 months after injury. The clinical and electrophysiological data were obtained on the same day within 2 weeks after injury. Nineteen patients underwent two SSEP tests 1 week apart within the first 3 weeks following injury in an attempt to identify mean SSEPu + t improvement. Somatosensory evoked potential grading was based on the presence or absence of the cortical evoked potential, the amplitude of the early cortically generated waveform (P22 or P37), and the interpeak latency across the lesion site. Mean SSEPu + t had the strongest individual relationship with outcome (R-square 0.75, p less than 0.0001) and mean SSEPu + t improvement over a 1-week interval during the first 3 weeks after injury was associated with Motor Index score improvement over a 6 month period. Joint position sense score was the best clinical predictor of outcome (R-square 0.64, p less than 0.0001). Mean SSEPu + t correlated with outcome more closely than the combination of Motor Index score and pinprick sensory score. Mean SSEPu + t in combination with all three clinical indicators produced the strongest correlation with outcome (R-square 0.87, p less than 0.0001). This study confirms the prognostic value of quantitative SSEP analysis for patients with acute spinal cord injuries.