William Martin

Evoked and spontaneous electromyography to evaluate lumbosacral pedicle screw placement

Study Design A prospective study was performed to evaluate the effectiveness of evoked and spontaneous electromyography in predicting pedicle wall breakthrough and subsequent lumbar radiculopathy occurring after placement of pedicle screw instrumentation of the lumbar spine. Objectives To correlate cortical breakthrough of the pedicle wall with an electrically evoked electromyography threshold of stimulation, to assess the sensitivity of mechanically evoked electromyography for nerve root irritation, and to correlate postoperative nerve root irritation with intraoperative findings. Summary of Background Data Pedicle wall breakthrough has been evaluated by radiographic means and found to be difficult to evaluate. Methods to perform both electrically evoked and mechanically evoked electromyography have been developed more sensitive tests for breakthrough. Methods Twenty‐five patients receiving 112 pedicle screws were evaluated. Results Cortical breakthrough was associated with electrically evoked electromyography threshold of less than 11 milliAmps. Not all screws that had broken through the pedicle wall caused a postoperative radiculopathy. Electromyographic activity was sensitive to nerve root stimulation. Conclusions Measuring the electrically evoked electromyography threshold of stimulation helps to assess pedicle screw placement. Mechanically evoked electromyography indicates intraoperative nerve root displacement. Postoperative radiculopathy correlated with pedicle wall breakthrough, but did not occur in every case.

Electrical stimulation for intraoperative evaluation of thoracic pedicle screw placement.

Study Design. Thoracic pedicle screws were stimulated electrically while recording electromyography (EMG) activity in associated muscle groups intraoperatively. Screw position was then evaluated after surgery using computed tomography (CT). The CT results were compared with evoked EMG threshold values. Objective. To report our experience with pedicle screw stimulation in thoracic vertebrae in 22 patients who underwent thoracic level spinal instrumentation from May 1999 to March 2001. Summary of Background Data. Pedicle screw stimulation for intraoperative assessment of screw placement has been reported in lumbosacral spinal procedures. Evoked EMG thresholds >10 or 11 mA are associated with increased probability of vertebral cortex violation and postoperative complications. Thresholds >15 mA provide a 98% confidence of accurate screw positioning on postoperative CT scans. Methods. Evoked EMG activity was recorded from ulnar carpal flexors, intercostals, or abdominal muscle groups, depending on the level of screw placement. Postoperative CT scans were read by a staff orthopedic spine surgeon, a senior resident in orthopedics, and a musculoskeletal radiologist. Results. Results of 87 screws are reported. Five screws (5.7%) showed penetration on postoperative CT scans. Six screws (6.9%) had stimulation thresholds ≤11 mA, of which three showed cortical breakthrough. Of the 81 screws with thresholds >11 mA, 79 (97.5%) were within the vertebra. No postoperative neurologic complications were noted in any of the 22 patients. Conclusion. These results are consistent with previous studies of lumbosacral pedicle screws. In this series, stimulation thresholds >11 mA have a 97.5% negative predictive value, suggesting that cortical violation is highly unlikely. Although judgment of screw placement should not depend solely on stimulation thresholds, pedicle screw stimulation may provide rapid and useful intraoperative information on screw placement during procedures involving the use of thoracic pedicle screws.

Salicylate-induced changes in cat auditory nerve activity.

The purpose of this study was to measure, in the cat, spontaneous auditory nerve (AN) activity before and after injection with sodium salicylate. Ten cats were anesthetized, and the AN and round window (RW) were surgically exposed. Electrodes were applied to allow recording from three channels, including bipolar electrodes and monopolar electrodes located directly on the auditory nerve, in addition to an RW electrode. Spectral averaging of the spontaneous activity was performed before and during salicylate treatment. An increase in spectral activity near 200 Hz was noted in all cats by 3 hours after salicylate injection. This activity was present in bipolar, monopolar, and RW records, and was temporarily diminished or eliminated by injection of lidocaine. No such spectral changes were found in saline-injected control animals. These results show promise of developing a noninvasive, objective, quantitative measure of tinnitus for studies in animals and in man.

The origin of the human auditory brain-stem response wave II

Auditory brain-stem responses (ABRs) were recorded from human subjects undergoing neurosurgical procedures which exposed the auditory nerve. Scalp recordings indicated that the latency of the negativity between waves I and II (In) and the latency of positive peak II (IIp) were shorter when the nerve was suspended in air than when the nerve was submerged in cerebrospinal fluid or saline, while earlier and later waves remained unaffected. These results could not be attributed to changes in stimulus or recording parameters or conduction velocity. Computational and somatosensory experimental evidence of stationary potentials generated by physical properties of the volume conductor, including changes in conductivity or geometry, are presented to develop a model of wave IIp generation. The results of this study suggest that wave IIp (and probably In) are manifestations of current flux asymmetries across conductivity boundaries created by the temporal bone-cerebrospinal fluid intradural space-brain-stem interfaces. The current flux asymmetries are generated as the propagating auditory nerve action potential crosses the conductivity boundaries. These results also indicate that the physical characteristics of the volume conductor and neural pathways must be considered when interpreting surface recorded evoked potentials.

ABR and DPOAE Detection of Cochlear Damage by Gentamicin

Auditory brainstem responses (ABR) and distortion product otoacoustic emissions (DPOAE) have been applied to the evaluation of peripheral auditory function. To date, no comparison of their relative sensitivities to aminoglycoside toxicity has been reported. The purpose of this study was to compare click evoked ABR testing and 2f1-f2 DPOAEs as detectors of cochlear damage induced by gentamicin treatment in guinea-pigs. ABR thresholds to click stimuli were recorded. DPOAE amplitude input/output functions were recorded using three different primary tone level conditions. In one condition, L1 was changed relative to a fixed L2. In the next condition, L2 was changed relative to a fixed L1. In the third condition, L1 and L2 were both changed while maintaining a consistent L1-L2 difference. Baseline L1-L2 differences were determined by adjusting L2 to produce the maximum DPOAE amplitude in each ear of each subject. Guinea-pigs were treated for a four week period with intramuscular injections of gentamicin. ABRs and DPOAEs were monitored and compared to baseline recordings or untreated control groups. DPOAE testing detected cochlear damage earlier than ABR testing. Changes in DPOAE input/output functions were noted after two weeks of treatment while changes in ABR threshold were not identified until after three weeks of treatment. The sensitivity of the DPOAE testing was related to the stimulus conditions utilized. L1-L2 differences were determined in the control group and for the initial test session by fixing L1 at 75 dB SPL and lowering L2 until the maximum DPOAE amplitude was obtained for each ear. All subsequent testing was begun using the optimal L1-L2 difference for each ear. The stimulus condition in which only L1 was changed and L2 was fixed resulted in the least sensitive DPOAE indicator of cochlear damage. The condition in which both L1 and L2 were changed, but the L1-L2 difference remained constant, resulted in the most sensitive indicator of damage. The onset and degree of cochlear damage secondary to gentamicin treatment was subject dependent. This study demonstrates that 2f1-f2 DPOAE testing is preferable to click evoked ABR testing for early detection of gentamicin toxicity of the cochlea. It also indicates that DPOAE stimulus parameters must be considered when developing test protocols. Specifically, recording the DPOAE amplitude input/output function while maintaining an effective L1-L2 difference is preferable to changing either L1 or L2 individually.

Pneumatic ankle tourniquets: Physiological factors related to minimal arterial occlusion pressure

This study investigates several physiological measurements for their correlation to the minimal arterial occlusion pressure using the pneumatic ankle tourniquet. Blood pressure (brachial), height, weight, body fat percentage, ankle circumference, and leg circumference measurements were collected from 50 normotensive healthy subjects. Ankle brachial index (ABI) was also compared. A pneumatic ankle tourniquet was applied to the right ankle and inflated until Doppler insonation confirmed that arterial occlusion had occurred. Mean arterial occlusion pressure was 161.7 mm Hg (N = 50, Nmales = 33, Nfemales = 17), and statistically less than 170 mm Hg (p < .05). The authors present a data model to predict the lowest necessary ankle tourniquet pressure for this study group. Forward stepwise linear regression (critical significance = .01) yields two variables, ankle brachial index and systolic blood pressure, which are used to predict occlusion pressure in this study group.

Brain-stem auditory evoked responses to hypercarbia in preterm infants

To determine the effect of acute hypercarbia on brain-stem function in preterm neonates, we compared brain-stem auditory evoked responses (BAERs) during 8% CO2 breathing to those elicited during room air breathing in 12 healthy preterm infants during the first week of life. End-tidal CO2 (ETpCO2), respiratory rate and depth were monitored throughout the protocol. Absolute wave latencies and interpeak intervals of the BAERs were analyzed from duplicate trials. During 8% CO2 breathing, ETpCO2, respiratory rate and depth of respiration increased significantly (P < 0.05). The absolute latency of wave V was prolonged (P < 0.025) in the hypercarbic state as compared to baseline. Interpeak interval III-V was also prolonged (P < 0.025). Values of absolute peak latencies I and III were unaffected by the hypercarbic state. These data demonstrate that elevations in pCO2 which elicit ventilatory responses also effect the BAER. The specific effects on ventilatory pattern, peak V latency and interpeak interval III-V indicate brain-stem responsiveness and alterations in the more central components of the auditory pathway. These findings raise important considerations regarding the influence of hypercarbia on brain-stem function in preterm infants and the clinical management of such infants with abnormalities of gas exchange.

Intraoperative stimulation of pedicle screws: A new method for verification of screw placement ☆

Pedicular fixation of the lumbosacral spine has become a popular procedure for improving fusion rates. Even in experienced hands, it can be associated with a significant rate of screw malpositioning and potential nerve root injury. In this report, we describe a technique for improving screw localization utilizing evoked electromyography responses from direct stimulation of pedicle instrumentation.