Johannes J. Struijk

Excitation of dorsal root fibers in spinal cord stimulation: a theoretical study

In epidural spinal cord stimulation it is likely not only that dorsal column fibers are activated, but also that dorsal root fibers will be involved as well. In this investigation a volume conductor model of the spinal cord was used and dorsal root fibers were modeled by an electrical network including fiber excitation. The effects of varying some geometric fiber characteristics, as well as the influence of the dorsal cerebrospinal fluid layer and the electrode configuration on the threshold stimulus for their excitation, were assessed. The threshold values were compared with those of dorsal column fibers. The results of this modeling study predict that, besides the well known influence of fiber diameter, the curvature of the dorsal root fibers and the angle between these fibers and the spinal cord axis are a major influence on their threshold values. Because of these effects, threshold stimuli of dorsal root fibers were relatively low as compared to dorsal column fibers. Excitation of the dorsal root fibers occurred near the entry point of the fibers.<<ETX>>

Recruitment of dorsal column fibers in spinal cord stimulation: influence of collateral branching

An electrical network model of myelinated dorsal column nerve fibers is presented. The effect of electrical simulation was investigated using both a homogeneous volume conductor and a more realistic model of the spinal cord. An important feature of dorsal column nerve fibers is the presence of myelinated collaterals perpendicular to the rostro-caudal fibers. It was found that transmembrane potentials, due to external monopolar stimulation, at the node at which a collateral is attached, is significantly influenced by the presence of the collateral. It is concluded that both excitation threshold and blocking threshold of dorsal column fibers are decreased up to 50% compared to unbranched fibers.<<ETX>>

Autonomic alterations and cardiac changes in epilepsy

Studies with heart rate variability have revealed interictal autonomic alterations in patients with epilepsy. In addition, epilepsy is frequently associated with ictal tachycardia or bradycardia, which sometimes precedes the onset of seizures. Ictal tachycardia is sometimes associated with electrocardiography (ECG) morphologic changes and ictal bradycardia often progresses to asystole. Such cardiac manifestations of seizures have been hypothesized as possible causes for sudden unexplained death in epilepsy (SUPEP). The present review relates to interictal and ictal cardiac manifestations of epilepsy with focus on heart rate, heart rate variability, and ECG changes. Aspects of the supporting mechanisms are discussed and attention is drawn to the interaction between central and peripheral effects, interictal autonomic conditions, ictal autonomic discharges, and administration of antiepileptic drugs in shaping the ictal cardiac changes. Because these interactions are complex and not totally understood, closer surveillance of patients and more experimental work is necessary to elucidate the mechanistic support of autonomic and cardiac changes in epilepsy, and to design better strategies to avoid their undesirable effects. It is also suggested that some of these changes could be used as predictors or markers for the onset of seizures.

Paresthesia thresholds in spinal cord stimulation: a comparison of theoretical results with clinical data

The potential distributions produced in the spinal cord and surrounding tissues by dorsal epidural stimulation at the midcervical, midthoracic, and low thoracic levels were calculated with the use of a volume conductor model. Stimulus thresholds of myelinated dorsal column fibers and dorsal root fibers were calculated at each level in models in which the thickness of the dorsal cerebrospinal fluid (CSF) layer was varied. Calculated stimulus thresholds were compared with paresthesia thresholds obtained from measurements at the corresponding spinal levels in patients. The influences of the CSF layer thickness, the contact separation in bipolar stimulation and the laterality of the electrodes on the calculated thresholds were in general agreement with the clinical data. >

Effects of electrode geometry and combination on nerve fibre selectivity in spinal cord stimulation

The differential effects of the geometry of a rostrocaudal array of electrode contacts on dorsal column fibre and dorsal root fibre activation in spinal cord stimulation are analysed theoretically. 3-D models of the mid-cervical and mid-thoracic vertebral areas are used for the computation of stimulation induced field potentials, whereas a cable model of myelinated nerve fibre is used for the calculation of the excitation thresholds of large dorsal column and dorsal root fibres. The size and spacing of 2-D rectangular electrode contacts are varied while mono-, bi- and tripolar stimulation are applied. The model predicts that the highest preferential stimulation of dorsal root fibres is obtained in monopolar stimulation with a large cathode, whereas dorsal column fibre preference is highest in tripolar stimulation with small contacts and small contact spacings. Fibre type preference is most sensitive to variations of rostrocaudal contact size and least sensitive to variations of lateral contact size. Dorsal root fibre preference is increased and sensitivity to lead geometry is reduced as the distance from contacts to spinal cord is increased.

The extracellular potential of a myelinated nerve fiber in an unbounded medium and in nerve cuff models

A model is presented for the calculation of single myelinated fiber action potentials in an unbounded homogeneous medium and in nerve cuff electrodes. The model consists of a fiber model, used to calculate the action currents at the nodes of Ranvier, and a cylindrically symmetrical volume conductor model in which the fibers nodes are represented as point current sources. The extracellular action potentials were shown to remain unchanged if the fiber diameter and the volume conductor geometry are scaled by the same factor (principle of corresponding states), both in an unbounded homogeneous medium and in an inhomogeneous volume conductor. The influence of several cuff electrode parameters, among others, cuff length and cuff diameter, were studied, and the results were compared, where possible, with theoretical and experimental results as reported in the literature.

The prognostic value of the Tpeak-Tend interval in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

INTRODUCTION The Tpeak-Tend interval (TpTe) has been linked to increased arrhythmic risk. TpTe was investigated before and after primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI). METHOD Patients with first-time STEMI treated with pPCI were included (n = 101; mean age 62 years; range 39-89 years; 74% men). Digital electrocardiograms were taken pre- and post-PCI, respectively. Tpeak-Tend interval was measured in leads with limited ST-segment deviation. The primary end point was all-cause mortality during 22 +/- 7 months (mean +/- SD) of follow-up. RESULTS Pre- and post-PCI TpTe were 104 milliseconds [98-109 milliseconds] and 106 milliseconds [99-112 milliseconds], respectively (mean [95% confidence interval], P = .59). A prolonged pre-PCI TpTe was associated with increased mortality (hazard ratio, 10.5 [1.7-20.4] for a cutoff value of 100 milliseconds). Uncorrected QT and heart rate-corrected QT intervals (Fridericia-corrected QT) were prolonged after PCI (QT: 401 vs 410 milliseconds, P = .022, and Fridericia-corrected QT: 430 vs 448 milliseconds, P < .0001). CONCLUSION In patients with STEMI undergoing pPCI, pre-PCI TpTe predicted subsequent all-cause mortality, and the QT interval was increased after the procedure.

Cuff electrodes for long-term recording of natural sensory information

Cuff electrodes for recording of the electro-neurogram from peripheral nerves were introduced by Hoffer [1974] and Stein, et al. [1975]. The cuffs were used to obtain higher signal amplitudes than previously possible, at least in chronic recordings, and to decrease the pick-up of noise, especially from muscles. Cuff electrodes are relatively stable in long-term recordings, but the stability has never been quantified in terms of input-output relationships; i.e., in terms of responses to repeatable stimuli over time. Moreover. The relationship between nerve damage and electrophysiological parameters has never been assessed. In this article, after reviewing the development of cuff electrodes and their applications, we present a long-term study of tactile peripheral nerve signals, electrically activated nerve signals, and impedance measurements. We show how the recordings vary over a 16-month period after implantation of nerve cuff electrodes in rabbits, and how nerve damage is reflected in the recorded signals.

A modeling study of nerve fascicle stimulation

A nerve-stimulation model incorporating realistic cross-sectional nerve geometries and conductivities is discussed. The potential field in the volume conductor was calculated numerically using the variational method. Nerve fiber excitation was described by the model of McNeal (ibid., vol.BME-23, p.329-37, 1976). Cross-sectional geometries of small monofascicular rat common peroneal nerve and multifascicular human deep peroneal nerve were taken as sample geometries. Selective stimulation of a fascicle was theoretically analyzed for several electrode positions: outside the nerve, in the connective tissue of the nerve, and inside a fascicle. The model results predict that the use of intraneural or even intrafascicular electrodes is necessary for selective stimulation of fascicles not lying at the surface of the nerve. Model predictions correspond to experimental results on intrafascicular and extraneural stimulation of rat common peroneal nerve and to results on muscle selective stimulation in multifascicular dog sciatic nerve using an extraneural multielectrode configuration.<<ETX>>

Transverse tripolar spinal cord stimulation: theoretical performance of a dual channel system.

A new approach to spinal cord stimulation is presented, by which several serious problems of conventional methods can be solved. A transverse tripolar electrode with a dual-channel voltage stimulator is evaluated theoretically by means of a volume conductor model, combined with nerve fibre models. The simulations predict that a high degree of freedom in the control of activation of dorsal spinal pathways may be obtained with the described system. This implies an easier control of paraesthesia coverage of skin areas and the possibility to correct undesired paraesthesia patterns, caused by lead migration, tissue growth, or anatomical asymmetries, for example, without surgical intervention. It will also be possible to preferentially activate either dorsal column or dorsal root fibres, which has some important clinical advantages. Compared to conventional stimulation systems, the new system has a relatively high current drain.