Neurophotonic Scanning System – Towards Automatic Infrared Neurostimulation

Spinal cord function is now routinely monitored with somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) during surgery for intraspinal cervical dumbbell and foraminal tumors. However, upper extremity nerve roots are also at risk during these procedures. Anatomic relations are frequently difficult to interpret because the nerve roots may be displaced by the tumor. We used electrical stimulation with compound muscle action potential (CMAP) recordings at multiple sites to identify the location and course of the involved nerve root and to provide real-time information regarding the functional status of the roots to predict postoperative outcome. Ten patients were monitored during surgery for cervical dumbbell or foraminal tumors. SEPs and MEPs were monitored as a routine procedure. CMAPs were recorded from needle electrodes placed in the deltoid, biceps, triceps, and flexor carpi ulnaris muscles. Spontaneous electromyography (EMG) muscle activity was also continuously monitored. A handheld monopolar stimulation electrode was used to elicit evoked EMG responses to identify and trace the course of nerves in relation to the tumor. In four patients, the stimulation threshold was tested before and after tumor resection to predict postoperative nerve root function. Electrical stimulation with CMAP recording was successful in localizing nerve roots during tumor resection in all 10 patients. Monitoring predicted postoperative nerve root preservation after tumor removal in each case. It was possible to identify either by using low-level stimulation (<2.0 V) or by observing changes in spontaneous EMG amplitude if activation was present during surgical dissection. The monitoring of spontaneous muscle activity in response to direct or indirect surgical manipulation during tumor resection also provided continuous assessment of nerve root function and identified any physiologic disturbance induced by surgical manipulation. Electrical stimulation in the operating field and recording of CMAPs facilitated nerve root identification and predicted postoperative function during dissection and separation from ligamentous or neoplastic tissue in 10 patients. Electrical stimulation might also be useful to predict postoperative preservation of function when nerve root sacrifice is necessary and no motor response is detected intraoperatively.

Objective To study the distribution rule of sense and motor fibers in the normal trigeminal nerve roots by electrophysiologic monitoring. Methods Twenty patients accepted microvascular decompression because of primary mimetic convulsion, collected in our hospital from January 2011 and December 2013, was studied their normal trigeminal nerve roots through electroneurophysiology; during the operation, the trigeminal nerve roots were divided into 8 areas: I area is the external lateral area, II area is the external upper area, III area is the middle upper area, IV area is the internal upper area, V area is the internal lateral area, VI area is the internal bottom area, VII area is the middle bottom area, and VIII area is the external bottom area; and then, one mm diameter bipolar stimulator was adopted to give 0.2 mA electrical stimulation on these areas, respectively; and the compound nerve action potential (CNAP) at the foramina supraorbitale (V1), foramina infraorbitale (V2) and foramina mentale (V3) was recorded as the CNAPV1, CNAPV2 and CNAPV3 respectively; the compound muscle action potential (CMAP) at the masseter muscle (MM) and temporal muscle (TM) was recorded as CMAPMM and CMAPTM respectively; and finally, the distribution rules of the sense and motor fibers inside the trigeminal nerve roots were judged according to the laws of CNAP and CMAP emergence. Results During the operation, all patients could get stable CNAP and CMAP wave patterns at periphery according to the electrical stimulation on trigeminal nerve roots; the CNAPV1, CNAPV2 and CNAPV3, CMAPMM and CMAPTM seldom appeared in the I, II and VIII areas of trigeminal nerve roots, but more often appeared in the IV, V and VI areas, enjoying significant differences (P< 0.05); motor fiber located in the internal lateral area of the nerve, and the sense fiber located in the middle and external lateral area. By stimulating the sense taproot fiber, CNAP could be recorded, and by stimulation the motor taproot fiber, CMAP and several CNAP from V1, V2 and V3 could be recorded. Conclusion Electrical stimulation on motor taproot implies that there are anastomosing fibers existting in both motor and sense fibers; according the 8 areas being divided, motor fiber locating in the internal lateral area of the nerve, and sense fibers locating in the middle and external lateral areas can be concluded. Key words: Trigeminal nerve; Eight area; Electrical stimulation

Compound muscle action potential (CMAP) recordings provide a sensitive electromyographic approach to measure nerve conduction and assess neuromuscular junction functionality in humans and rodents. In humans, it represents a diagnostic tool for neuromuscular disorders. In rodents, this approach is widely employed to dissect the molecular mechanisms driving peripheral nerve degeneration/regeneration, as well as to evaluate the effect of candidate pro-regenerative compounds. The method described here allows recording CMAP from the gastrocnemius muscle of mice after sciatic nerve stimulation. We report some representative traces of CMAP recorded from adult, healthy mice, after sciatic nerve compression and during neurotransmission recovery stimulated by melatonin administration.

BackgroundThis study was designed to investigate whether intraoperative electrical nerve stimulation has effects on the short-term recovery of cubital tunnel syndrome patients after ulnar nerve release.MethodsPatients diagnosed as cubital tunnel syndrome were selected. At the same time, they received conventional surgery treatment. The patients were divided by a randomized digits table into two groups. The control group underwent conventional surgery, and the electrical stimulation (ES) group underwent intraoperative electrical stimulation. All the patients were tested for sensory and motor functions, grip strength, key pinch strength, motor conductivity velocity (MCV), and maximum compound muscle action potential (CMAP) before operation and 1 month and 6 months after operation.ResultsIn patients treated with intraoperative ES, the sensory and motor functions and the strength of muscle were significantly improved after 1-month and 6-month follow-up than the control group. After the follow-up, the patients in the ES group had significantly higher grip strength and key pinch strength than the control group. After the follow-up, the patients in the ES group had significantly higher MCV and CMAP than the control group.ConclusionIntraoperative electrical stimulation of nerve muscle can significantly promote the short-term recovery of nerve and muscle functions after the surgery in cubital tunnel syndrome patients.

BackgroundPeripheral changes to muscle and motor nerves occur following stroke, which may further impair functional capacity. We investigated whether a year-long use of an implanted peroneal FES system reverses stroke-related changes in muscles and motor nerves in people with foot drop in the chronic phase after supratentorial stroke.MethodsThirteen persons with a chronic stroke (mean age 56.1 years, median Fugl-Meyer Assessment leg score 71%) were included and received an implanted peroneal FES system (ActiGait®). Quantitative muscle ultrasound (QMUS) images were obtained bilaterally from three leg muscles (i.e. tibialis anterior, rectus femoris, gastrocnemius). Echogenicity (muscle ultrasound gray value) and muscle thickness were assessed over a one-year follow-up and compared to age-, sex-, height- and weight-corrected reference values. Compound motor action potentials (CMAPs) and motor evoked potentials (MEPs) were obtained from the tibialis anterior muscle. Generalized estimated equation modeling was used to assess changes in QMUS, CMAPs and MEPs outcomes over the follow-up period.ResultsEchogenicity of the tibialis anterior decreased significantly during the follow-up on the paretic side. Z-scores changed from 0.88 at baseline to − 0.15 after 52 weeks. This was accompanied by a significant increase in muscle thickness on the paretic side, where z-scores changed from − 0.32 at baseline to 0.48 after 52 weeks. Echogenicity of the rectus femoris normalized on both the paretic and non-paretic side (z-scores changed from − 1.09 and − 1.51 to 0.14 and − 0.49, respectively). Amplitudes of CMAP and MEP (normalized to CMAP) were reduced during follow-up, particularly on the paretic side (ΔCMAP = 20% and ΔMEP = 14%).ConclusionsWe show that the structural changes to muscles following stroke are reversible with FES and that these changes might not be limited to electrically stimulated muscles. No evidence for improvement of the motor nerves was found.

In nine paraplegic patients we recorded the torque output and compound motor action potentials (CMAPs) produced by the quadriceps muscle during an isometric contraction elicited by electrical stimulation. The torque, the peak to peak amplitude, the latency, the peak to peak duration and the total surface of the rectified CMAPs were computed over a period of 126 s. After a brief increase the mechanical output rapidly decreased and reached a stable minimum level by the end of 126 s. The final torque output values ranged from 7.1 to 54% of initial values. This torque decrease was related neither to length of time between injury and testing, nor to the thoracic level of the spinal cord injury. The peak to peak amplitude of the CMAPs changed over the course of stimulation. It was noted to increase over a period of time after which it decreased to a minimum level. The latency from the onset of stimulation to the onset of the CMAP varied to a relatively small extent compared to the peak to peak duration. Therefore, the conduction velocity along the muscle fibres appeared to be more affected by the test than by the conduction velocity along the nerve fibres and the transmission across the neuromuscular junction. The mechanisms involved in the changes in CMAPs and the change in torque output over the time course of stimulation are discussed.

The purpose of this study was to evaluate the effects of botulinum toxin A (BTX‐A, Botox) dilution volume and post‐injection exercise with electrical stimulation on muscle paralysis. We injected 10 units of BTX‐A diluted with 0.1 ml (B1, n=8) or 0.5 ml (B5, n=8) normal saline into both gastrocnemius muscles of 16 New Zealand white rabbits; two controls received no BTX‐A. After BTX‐A injection, all rabbits received calf muscle stretching exercise and electrical stimulation for 2 hours on the left leg. The compound muscle action potential (CMAP) decrease was most pronounced at 1 week and progressive recovery was observed (i.e. recovery from paralysis, increase of CMAP). There was a significant decrease of CMAP amplitudes in the B5 group compared with the B1 group at week 1 and week 4 (p&lt;0.001). Left limbs with stretching exercise and electrical stimulation showed lower CMAP amplitudes compared with control right limbs of all rabbits. To maximize the muscle paralysis effect of BTX‐A, increasing dilution volume and performing post‐injection stretching exercise with electrical stimulation may be a promising strategy for increasing the beneficial effect of BTX‐A treatment. Future studies are needed to investigate the clinical application of this finding.

To facilitate identification and preservation of the auditory nerve during cerebello-pontine angle surgery, bipolar recording of cochlear nerve compound action potentials (CNAPs) was performed. Two silver wires insulated with teflon up to the exposed ends were utilized as electrodes. They were twisted together, the distance between the two tips being 1 mm or less. Rarefaction polarity clicks (31/s) ranging from the psychoacoustical threshold to 120 dB pe SPL were used as stimuli. The investigation was performed in three groups of patients. The first group consisted of 9 patients submitted to vestibular neurectomy and 4 patients operated on by microvascular decompression of the eighth nerve. The second group comprised 8 patients with acoustic tumors smaller than 2 mm and serviceable hearing. Postoperative audiometric results in the subjects in the second group were compared with those obtained in well-matched homogeneous controls consisting of patients with acoustic neuroma operated on without the aid of CNAP recording. Bipolar recording from the eighth nerve was extremely selective, a good response being obtained only when positioning the electrode on the cochlear portion of the eighth nerve. During removal of the acoustic neuroma, repeated bipolar probing of the tumor and eighth nerve facilitated the task of distinguishing the cochlear nerve from other nervous structures and from the tumor, and contributed to preserving hearing in most patients.

The aim of this study was to investigate the relationship between compound muscle action potentials (CMAPs) and neurological impairment in newborn infants with spina bifida. Thirty-one newborn infants (17 males, 14 females, mean gestational age 39 wks [SD 2]; mean birthweight 3336 g [SD 496]) with spina bifida were investigated at a median age of 2 days (range 1-18 d). Motor and sensory impairment and muscle stretch reflexes were assessed and neuroimaging was performed. CMAPs were recorded from the tibialis anterior muscle and the gastrocnemius muscle after percutaneous electrical nerve stimulation. CMAPs were obtained in almost all infants. The area under the curve of the CMAP (CMAP-area) was associated with motor and sensory impairment and with the presence of muscle stretch reflexes, but not with the morphological level of the spinal anomaly. These associations were stronger for the gastrocnemius muscle than for the tibialis anterior muscle. In conclusion, the CMAP-area correlates with neurological impairment in neonatal spina bifida and provides an estimate of residual motor neuron function in affected spinal segments. The assessment of CMAPs after percutaneous electrical nerve stimulation is recommended as an additional instrument to the clinical neurological examination and imaging studies.

Differential effects of stimulus intensity on peripheral and neuromagnetic cortical responses to median nerve stimulation

GLT1 overexpression in SOD1G93A mouse cervical spinal cord does not preserve diaphragm function or extend disease

The purpose of this study is to verify that compound muscle action potentials (CMAPs) generated a stationary potential and to examine extension of the CMAPs away from the stimulated muscle. A referential derivation and/or bipolar derivation to record the stationary potentials were carried out following tibial nerve stimulation at the popliteal fossa in 10 rabbits. After recording a bipolar and/or referential derivation, wave changes were monitored before and after severing the tibial nerve. The change of the wave by compressing or direct electrical stimulation to the calf muscle was also monitored. In referential derivatives, the stationary waves were observed on top of the skull in all the rabbits examined with the peak latency of the potentials from 3.78 msec to 5.04 msec. In bipolar derivations, the upper limits of the stationary waves recorded were the trunks. The peak latencies were from 2.35 msec to 5.46 msec with an average of 4.12 msec. By analyzing the results from severing the tibial nerves, compressing the calf muscles, and direct electrical stimulation of the calf muscle, the origin of these stationary potentials was determined to be CMAPs of the calf muscles. These findings suggest contamination of the stationary potentials originated by CMAPs for recording of any evoked potentials when motor nerves are stimulated.

Focal stimulation of human cerebral cortex with the magnetic coil: a comparison with electrical stimulation

Intraoperative monitoring of corticospinal function is no longer an experimental technique, having been introduced into routine practice in a number of centers, each of which has now accumulated large series of some hundreds of cases. Different techniques have been developed by these centers; each has advantages and disadvantages, and it is clear that no one technique in particular is optimal for all surgical procedures. The corticospinal system can be activated by transcranial stimulation of the motor cortex or by direct stimulation of the spinal cord with electrical or magnetic stimuli delivered singly or as double or multiple pulses. The evoked activity may be recorded directly from the spinal cord using epidural electrode, or as a postsynaptic volley in motor axons ("neurogenic motor evoked potentials," MEP), or as a compound muscle action potential (CMAP) from innervated muscles. For scoliosis surgery, we use transcranial electrical stimulation, recording the evoked volley from the spinal cord using epidural electrodes at two spinal levels. By simultaneously stimulating the tibial nerves in the popliteal fossae, descending corticospinal volleys and ascending somatosensory volleys can be recorded in the same sweep. Accordingly, this technique allows monitoring of two different modalities of function at two separate levels of the nervous system, a goal that is most desirable because it helps identify the earliest evidence of dysfunction and at the same time minimizes false-positive reports to the surgeon. Our technique has the advantage of being relatively immune to the depressant effects of anesthesia, and full muscle relaxation is possible--even desirable. More peripheral recordings of neurogenic MEP or CMAP, are sensitive to the choice of anesthetic, and the latter requires incomplete curarization. However, these techniques may be appropriate when the pathology is in the low spinal cord or nerve roots.

The influences of coil position and coil-nerve distance on compound muscle action potentials (CMAPs), recorded from the first dorsal interosseus muscle during magnetic stimulation of the brachial segment of the ulnar nerve, were studied in 10 healthy volunteers. A 14-cm coil was held tangentially to the skin with the center overlying the nerve. Mapping of the CMAP latencies and amplitudes was made as the coil was displaced laterally in steps of 1 cm and in planes 0-3 cm from the skin surface. Stimulation with the coil center positioned 3 cm laterally to the nerve with the coil current directed proximally yielded the largest amplitudes with minimal variability and the most constant relationship to electrically evoked CMAPs. In this position the interindividual and intraindividual reproducibility of the magnetically evoked latencies were at least as good as those of electric stimulation when coil-skin distance was less than or equal to 2 cm.