Focal hole versus screw stimulation to prevent false negative results in detecting pedicle breaches during spinal instrumentation.

OBJECTIVE: We describe a stimulus-evoked EMG approach to minimize false negative results in detecting pedicle breaches during lumbosacral spinal instrumentation. METHODS: In 36 patients receiving 176 lumbosacral pedicle screws, EMG threshold to nerve root activation was determined using a focal probe inserted into the pilot hole at a depth, customized to the individual patients, suitable to position the stimulating tip at the point closest to the tested nerve root. Threshold to screw stimulation was also determined. RESULTS: Mean EMG thresholds in 161 correctly fashioned pedicle instrumentations were 7.5 mA ±â€¯2.46 after focal hole stimulation and 21.8 mA ±â€¯6.8 after screw stimulation. Direct comparison between both thresholds in individual pedicles showed that screw stimulation was always biased by an unpredictable leakage of the stimulating current ranging from 10 to 90%. False negative results were never observed with hole stimulation but this was not true with screw stimulation. CONCLUSIONS: Focal hole stimulation, unlike screw stimulation, approaches absolute EMG threshold as shown by the lower normal limit (2.6 mA; p < 0.05) that borders the upper limit of threshold to direct activation of the exposed root. SIGNIFICANCE: The technique provides an early warning of a possible pedicle breakthrough before insertion of the more harmful, larger and threaded screw.

Non-invasive high voltage electrical stimulation as a monitoring tool of nerve root function in lumbosacral surgery.

OBJECTIVE: To verify the safety and clinical use of non-invasive high-voltage electrical stimulation (HVES) in patients with compressive radiculopathy. To test the feasibility of HVES to survey nerve root function during lumbosacral surgery. METHODS: In 20 patients undergoing lumbosacral surgery for degenerative spinal diseases, compound muscle action potentials (CMAPs) evoked by maximal HVES were bilaterally recorded throughout surgery from L3 to S2 radicular territories. A preliminary study was performed in awake patients to rule out detrimental effects caused by HVES. RESULTS: Preoperative study confirmed the safety of HVES. Unexpectedly, a transient but significant remission of pain was observed after root stimulation. Intraoperative monitoring (IOM) was accomplished in all patients. HVES never hindered surgical procedures and never caused mechanical damage within the operatory field. In 4 patients acute, highly focal and reversible conduction failure was promptly detected by HVES in radicular territories congruent with the root manipulated at that moment. CONCLUSIONS: HVES is a safe and sensitive tool to monitor nerve root function in lumbosacral surgery. SIGNIFICANCE: The method is based on the assumption that any acute conduction failure occurring during surgery can be immediately and unambiguously detected by HVES if root stimulation is supramaximal and delivered rostral to the surgical level.

Inter-species competition-facilitation in stochastic riparian vegetation dynamics.

Riparian vegetation is a highly dynamic community that lives on river banks and which depends to a great extent on the fluvial hydrology. The stochasticity of the discharge and erosion/deposition processes in fact play a key role in determining the distribution of vegetation along a riparian transect. These abiotic processes interact with biotic competition/facilitation mechanisms, such as plant competition for light, water, and nutrients. In this work, we focus on the dynamics of plants characterized by three components: (1) stochastic forcing due to river discharges, (2) competition for resources, and (3) inter-species facilitation due to the interplay between vegetation and fluid dynamics processes. A minimalist stochastic bio-hydrological model is proposed for the dynamics of the biomass of two vegetation species: one species is assumed dominant and slow-growing, the other is subdominant, but fast-growing. The stochastic model is solved analytically and the probability density function of the plant biomasses is obtained as a function of both the hydrologic and biologic parameters. The impact of the competition/facilitation processes on the distribution of vegetation species along the riparian transect is investigated and remarkable effects are observed. Finally, a good qualitative agreement is found between the model results and field data.