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Background In remote thyroid surgery, a reliable intraoperative neuromonitoring (IONM) procedure is an important tool for reducing injury to recurrent laryngeal nerve (RLN). This study proposes an alternative or adjunct technique for performing full percutaneous (PC) IONM and confirms its feasibility in animal experiments. Methods This prospective porcine model study enrolled four piglets with eight nerve sides. Evoked electromyography (EMG) was stimulated from PC ball-tip probe, and recorded from EMG endotracheal tube (ETT) and from PC paired long-needle electrodes on the perichondrium of the lateral aspect of thyroid cartilage. Results In all RLNs and vagus nerves, typical laryngeal EMG waveforms were successfully evoked by PC probe stimulation and recorded by both ETT and PC needle electrodes. Conclusions This study confirms the feasibility of the full PC IONM techniques in porcine model. However, further clinical studies are needed to compare the practicality of different remote-access approaches for thyroid surgery.

Study Design: Retrospective review of private neuromonitoring databases. Objectives: To review neuromonitoring alerts in a large series of patients undergoing lateral lumbar interbody fusion (LLIF) and determine whether alerts occurred more frequently when more lumbar levels were accessed or more frequently at particular lumbar levels. Methods: Intraoperative neuromonitoring (IONM) databases were reviewed and patients were identified undergoing LLIF between L1 and L5. All cases in which at least one IONM modality was used (motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), evoked electromyography (EMG)) were included in this study. The type of IONM used and incidence of alerts were collected from each IONM report and analyzed. The incidence of alerts for each IONM modality based on number of levels at which at LLIF was performed and the specific level an LLIF was performed were compared. Results: A total of 628 patients undergoing LLIF across 934 levels were reviewed. EMG was used in 611 (97%) cases, SSEP in 561 (89%), MEP in 144 (23%). The frequency of IONM alerts for EMG, SSEP and MEPs did not significantly increase as the number of LLIF levels accessed increased. No EMG, SSEP, or MEP alerts occurred at L1-L2. EMG alerts occurred in 2-5% of patients at L2-L3, L3-L4, and L4-L5 and did not significantly vary by level ( P = .34). SSEP and MEP alerts occurred more frequently at L4-L5 versus L2-L3 and L3-L4 ( P < .03). Conclusions: IONM may provide the greatest utility at L4-L5, particularly MEPs, and may not be necessary for more cephalad LLIF procedures such as at L1-L2.

It is still a challenge to delay the onset of fatigue on muscle contraction induced by Functional Electrical Stimulation (FES). We explored the use of two stimulation methods with the same total area, single electrode stimulation (SES), and spatially distributed electrical stimulation (SDSS) during isometric knee extension with spinal cord injured (SCI) volunteers. We applied stimulation on the left and right quadriceps of two SCI participants with both methods and recorded isometric force and evoked electromyography (eEMG). We calculated the force-time integral (FTI) and eEMG-time integral (eTI) for each stimulation series and used a linear regression as a measure of decay ratio. Moreover, we also estimated the contribution from each channel from eEMG.

Introduction: Ansa-to-recurrent laryngeal nerve (ANSA-RLN) anastomosis procedures in children with unilateral vocal fold immobility (UVFI) are considered a first-line treatment strategy for long-st...

A diagnostic system from measurement of F-wave of evoked electromyography is expected to be useful because F-waves of patients with cerebral infarction, Parkinson’s disease, or ALS disease are different from those of healthy persons. We found that distributions of numbers of pulses (total 150 pulses) along the height ratio of F-wave vs M-wave (F/M) of evoked electromyography very highly correlate with other distributions of the same person. We show that approximation of a distribution of F-wave with 300 pulses with Poisson distribution and normal distribution useful for diagnosis.

Background Energy-based surgical devices, including electrotome, the Harmonic scalpel, and LigaSure, have been widely applied in thyroid surgery, although a comparison of their safety and efficacy has not been reported yet. In this study, we investigated the feasibility of using hemostatic energy-based surgical devices during thyroid surgery in a canine model. Methods Twenty-four beagle dogs were randomly divided into the following groups: electrotome (30 kW), electrotome (15 kW), the Harmonic scalpel (output level 3), and LigaSure (middle gear). The hemostatic devices were applied on the thyroid surface for 3 seconds and then near the recurrent laryngeal nerve (RLN; distance of 5 mm, 3 mm, or 1 mm) for 3 seconds. Evoked electromyography (EMG) amplitudes were recorded by intraoperative neuromonitoring (IONM). Acute microstructural morphological damage to thyroid tissues and the RLN were evaluated immediately after the procedure by light and electron microscopy. Results Electrotome caused a significant decrease in evoked EMG amplitudes when applied at a vertical distance of 1 mm from the RLN, both at 30 kW (1046 ± 404.3 μV vs 153 ± 245.5 μV; p .05) nor microstructural morphological changes in the RLNs. The electrotome (15 kW) caused more serious thermal damage to thyroid tissues than that caused by either the Harmonic scalpel or LigaSure (thermal damaged depth: 0.951 ± 0.061 vs 0.756 ± 0.074, p < .001; 0.951 ± 0.061 vs 0.724 ± 0.116, p < .001). Nevertheless, there were no differences between the Harmonic scalpel and LigaSure groups (p = .435). Conclusion LigaSure and the Harmonic scalpel might be safer than electrotome when used in thyroid operations. LigaSure generates less heat than the Harmonic scalpel and electrotome. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1078–1085, 2017

Background: Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) has been widely applied during thyroid surgery. However, the safe range of stimulation intensity for IONM remains undetermined. Methods: Total thyroidectomies were performed on twenty dogs, and their RLNs were stimulated with a current of 5–20 mA (step-wise in 5 mA increments) for 1 min. The evoked electromyography (EMG) of vocal muscles before and after supramaximal stimulation were recorded and compared. Acute microstructural morphological changes in the RLNs were observed immediately postoperatively under an electron microscope. Results: The average stimulating threshold for RLNs stimulated with 15 mA and 20 mA showed no significant changes compared to the unstimulated RLNs (15 mA group: 0.320 ± 0.123 mA vs. 0.315 ± 0.097 mA, P = 0.847; 20 mA group: 0.305 ± 0.101 mA vs. 0.300 ± 0.103 mA, P = 0.758). Similar outcomes were shown in average evoked EMG amplitude (15 mA group: 1,026 ± 268 μV vs. 1,021 ± 273 μV, P = 0.834; 20 mA group: 1,162 ± 275 μV vs. 1,200 ± 258 μV, P = 0.148). However, obvious acute microstructural morphological changes were observed in the nerves that were stimulated with 20 mA. Conclusions: A stimulation intensity less than 15 mA might be safe for IONM of the RLN.

Although there is recent evidence for the role of intraoperative neurophysiological monitoring (IONM) in spine surgery, there are no uniform opinions on the optimal combination of the different tools. At our institution, multimodal IONM (mIONM) approach in spine surgery involves the evaluation of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) with electrical transcranial stimulation, including the use of a multipulse technique with multiple myomeric registration of responses from limbs, and a single-pulse technique with D-wave registration through epi- and intradural recording, and free running and evoked electromyography (frEMG and eEMG) with bilateral recording from segmental target muscles. We analyzed the impact of the mIONM on the preservation of neuronal structures and on functional restoration in a prospective series of patients who underwent spine surgery. We observed an improvement of neurological status in 50 % of the patients. The D-wave registration was the most useful intraoperative tool, especially when MEP and SEP responses were absent or poorly recordable. Our preliminary data confirm that mIONM plays a fundamental role in the identification and functional preservation of the spinal cord and nerve roots. It is highly sensitive and specific for detecting and avoiding neurological injury during spine surgery and represents a helpful tool for achieving optimal postoperative functional outcome.

Background: Although stimulus evoked electromyography (EMG) is commonly used to confirm the accuracy of pedicle screw placement. There are no studies to differentiate between solid screws and hollow screws to the electrical resistance of pedicle screws. We speculate that the electrical resistance of the solid and hollow pedicle screws may be different and then a potential source of error with stimulus-evoked EMG may happen. Materials and Methods: Resistance measurements were obtained from 12 pedicle screw varieties (6 screws of each manufacturer) across the screw shank based on known constant current and measured voltage. The voltage was measured 5 times at each site. Results: Resistance of all solid screws ranged from 0.084 Omega to 0.151 Omega (mean = 0.118 +/- 0.024 Omega) and hollow screws ranged from 0.148 Omega to 0.402 Omega (mean = 0.285 +/- 0.081 Omega). There was a significant difference of resistance between the solid screws and hollow screws (P l 0.05). The screw with the largest diameter no matter solid screws or hollow screws had lower resistance than screws with other diameters. No matter in solid screws group or hollow screws group, there were significant differences (P l 0.05) between the 5.0 mm screws and 6.0 mm screws, 6.0 mm screws and 7.0 mm screws, 5.0 mm screws and 7.0 mm screws, 4.5 mm screws and 5.5 mm screws, 5.5 mm screws and 6.5 mm screws, 4.5 mm screws and 6.5 mm screws. The resistance of hollow screws was much larger than the solid screws in the same diameter group (P l 0.05). Conclusions: Hollow pedicle screws have the potential for high electrical resistance compared to the solid pedicle screws and therefore may affect the EMG response during stimulus-evoked EMG testing in pedicle screw fixation especially in minimally invasive percutaneous pedical screw fixation surgery.

Background: Motor nerve function decreases with age and can cause abnormalities in motor function. Using newly designed methods, we used evoked electromyograms to evaluate change in motor nerve function. Material/Methods: Motor function was assessed by grip strength, timed up-and-go test, 5-m normal walk, and 5-m fastest walk. In addition, motor nerve conduction velocity was calculated by measuring latency differences ( NCV) in elderly and young subjects. We also investigated motor nerve conduction velocity by correlation coefficient ( NCVCC) and the difference between NCV and NCVCC (DNCV). Results: Significant differences were observed in the motor function of elderly and young persons in grip strength, the timed up-and-go test, and the 5-m fastest walk; however, no difference was observed in the 5-m normal walk test. NCVCC was lower than NCV in both elderly and young. The correlation coefficient peak of the NCVCC calculation was lower in elderly than in young. A negative correlation was observed between correlation coeffi cient peak and DNCV in elderly subjects. Conclusions: NCVCC compares the overall shape of compound muscle action potential and reflects not only the fastest mo tor unit, but also the motor nerve conduction velocity of other motor unit components. A significant negative correlation between DNCV and the correlation coefficient peak was observed only in elderly subjects, suggest ing that older individuals, including those that maintain a high level of physical strength, experience a loss of motor nerve function. Thus, changes in motor nerve function among elderly persons can potentially be further examined for clinical use.

STUDY DESIGN Expert opinion. OBJECTIVE The objective of this study is to debate the requirement for intraoperative neuromonitoring in 90° lateral transpsoas spine surgery (lateral lumbar interbody fusion [LLIF]) in a point-counterpoint style with an argument made for each side followed by a brief rebuttal of each. Dr. Ivan Cheng will argue in favor of the use of neuromonitoring in LLIF, and Dr. Frank Acosta will argue against the requirement for the use of neuromonitoring in LLIF. SUMMARY OF BACKGROUND DATA The lateral approach to the lumbar spine has been used since at least the 1990s and requires passage near or adjacent to the lumbar plexus. The mini-open lateral transpsoas approach was introduced in the literature in 2006 and uses evoked electromyography integrated into the approach and procedural instrumentation that stimulates in directional orientations and provides discrete threshold responses to avoid the nerves of the lumbar plexus. More recently, lateral transpsoas approaches to the lumbar spine have been developed that do not require or advocate for the use of neuromonitoring, instead relying on direct visualization and avoidance of nerves (shallow-docking). METHODS Two experienced lateral approach surgeons who regularly perform lateral transpsoas approaches with integrated neuromonitoring (IC) and without neuromonitoring (FA) present arguments for and against the requirement for neuromonitoring. RESULTS Advocating for the use of neuromonitoring, points made include the broader literature validation of the lateral transpsoas approach with the use of advanced neuromonitoring and the relatively low rate of neural complications in neuromonitored transpsoas lateral approaches compared to those rates in shallow-docking literature. Advocating against the requirement for neuromonitoring in lateral transpsoas, points made include the potentially higher reliability of nerve avoidance with direct visualization as well as the favorable early results in the literature with respect to both new postoperative motor and sensory deficits. CONCLUSION There are arguments to be made on both sides of this debate. There is substantially more literature describing the use of neuromonitoring in lateral transpsoas surgery though shallow-docking reports continue to emerge. LEVEL OF EVIDENCE 5.

International audience; Time-variant muscle responses under electrical stimulation (ES) are often problematic for all the applications of neuroprosthetic muscle control. This situation limits the range of ES usage in relevant areas, mainly due to muscle fatigue and also to changes in stimulation electrode contact conditions, especially in transcutaneous ES. Surface electrodes are still the most widely used in noninvasive applications. Electrical field variations caused by changes in the stimulation contact condition markedly affect the resulting total muscle activation levels. Fatigue phenomena under functional electrical stimulation (FES) are also well known source of time-varying characteristics coming from muscle response under ES. Therefore, it is essential to monitor the actual muscle state and assess the expected muscle response by ES so as to improve the current ES system in favor of adaptive muscle-response-aware FES control. To deal with this issue, we have been studying a novel control technique using evoked electromyography (eEMG) signals to compensate for these muscle time-variances under ES for stable neuroprosthetic muscle control. In this perspective article, I overview the background of this topic and highlight important points to be aware of when using ES to induce the desired muscle activation regardless of the time-variance. I also demonstrate how to deal with the common critical problem of ES to move toward robust neuroprosthetic muscle control with the Evoked Electromyographically Controlled Electrical Stimulation paradigm.

The evoked electromyographic responses to supramaximal train of four stimulation of three muscles, all innervated by the ulnar nerve, were compared during recovery from non-depolarising neuromuscular blockade. The abductor digiti minimi was the most resistant to neuromuscular blockade (P

Object Because the psoas muscle, which contains nerves of the lumbar plexus, is traversed during the extreme lateral interbody fusion (XLIF) approach, appropriate nerve monitoring is needed to avoid nerve injury during surgery and prevent approach-related neural deficit. This study was performed to assess the effectiveness of dynamically evoked electromyography (EMG) to detect and prevent neural injury during the XLIF approach. Methods One hundred two patients undergoing XLIF at L3–4 and/or L4–5 were enrolled in a prospective, multicenter, nonrandomized clinical study. The EMG threshold values for each of the 3 successive dilators were recorded at the surface of the psoas muscle, mid-psoas, and on the spine. At each location, the dilators were rotated 360°, taking recordings immediately posterior, superior, anterior, and inferior. For each dilator, the authors noted the rotational position (the angle in degrees) at which the lowest threshold was found. Findings of pre- and postoperative neurological examinations were also recorded. Results Nerves were identified within proximity of the dilators (alert-level EMG feedback) in 55.7% of all cases during the XLIF approach. Although nerves were more commonly identified in the posterior margin (63%), there was significant variability in the location of nerves identified. Despite the fact that the posterior half of the disc space was targeted in 90% of cases, no significant long-lasting neural deficits were identified in any case; 27.5% experienced new iliopsoas/hip flexion weakness and 17.6% experienced new postoperative upper medial thigh sensory loss. Transient motor deficits were identified in 3 patients (2.9%), and all had resolved by the 6-month follow-up visit. Conclusions The ability to identify and report a discrete, real-time EMG threshold during the transpsoas approach helps to avoid nerve injury and is required for the safe performance of the XLIF procedure. Additionally, nerve location is variable, thus reinforcing the need for real-time directional and proximity information.

Background: The Harmonic Scalpel (HS) is widely used in thyroidectomy. Determining the safety margin of using the HS near the recurrent laryngeal nerve (RLN) is helpful in preventing the injury to this nerve during thyroidectomy. Methods: The parameters of evoked electromyography (EEMG) of vocal muscles before and after using the HS at a power level of 3 were recorded in a rabbit model. Masson staining was used to determine lateral injury caused by incisions using the HS. Results: After the activated tip of the HS made contact with the RLN for ≥1 s or was placed 1 mm from the nerve for 3 or 5 s or 2 mm from the nerve for 5 s, significant changes were observed in the minimal stimulus current intensity threshold, the optimal stimulus current intensity threshold, the onset latency and the wave amplitude of EEMG. After the activated HS tip touched the RLN or was placed 1 mm to the nerve for ≥1 s or 2 mm to the nerve for 5 s, significant changes were found in peak latency. The thickness of injured lateral tissue was 2 mm when using HS for 1, 3 and 5 s, respectively. Conclusion: When used near the RLN at a power level of 3, the activated HS tip should be ≥2 mm from the nerve and the duration of incision should be ≤3 s.

Functional electrical stimulation (FES) is a neuroprosthetic technique to help restore motor function of spinal cord-injured (SCI) patients. Through delivery of electrical pulses to muscles of motor-impaired subjects, FES is able to artificially induce their muscle contractions. Evoked electromyography (eEMG) is used to record such FES-induced electrical muscle activity and presents a form of [Formula: see text]-wave. In order to monitor electrical muscle activity under stimulation and ensure safe stimulation configurations, closed-loop FES control with eEMG feedback is needed to be developed for SCI patients who lose their voluntary muscle contraction ability. This work proposes a closed-loop FES system for real-time control of muscle activation on the triceps surae and tibialis muscle groups through online modulating pulse width (PW) of electrical stimulus. Subject-specific time-variant muscle responses under FES are explicitly reflected by muscle excitation model, which is described by Hammerstein system with its input and output being, respectively, PW and eEMG. Model predictive control is adopted to compute the PW based on muscle excitation model which can online update its parameters. Four muscle activation patterns are provided as desired control references to validate the proposed closed-loop FES control paradigm. Real-time experimental results on three able-bodied subjects and five SCI patients in clinical environment show promising performances of tracking the aforementioned reference muscle activation patterns based on the proposed closed-loop FES control scheme.

This study compares the amplitude and temporal features of stimulus-evoked electromyography (EMG) of paralyzed muscle, rectus femoris (RF), in both lengthened and shortened positions of six spinal cord injured (SCI) subjects during an electrically elicited fatigue process. The torque output and evoked EMG were fitted by hyperbolic tangent functions from which their amplitude residual levels and temporal inflection times can be extracted. Furthermore, a structural EMG model of Fuglevand et al (1992 Biol. Cybern. 67 143-53) was modified to include type I (slow twitch) and type II (fast twitch) of motor unit (MU) fibers with viable parameters obtained from paralyzed muscles to observe their amplitude and temporal changes. Our results showed that the amplitude of stimulus-evoked EMG decreased earlier in the lengthened muscle with a shorter inflection time (48.53 +/- 8.7 s versus 55.13 +/- 4.03 s) than that of the shortened position during 120 s of stimulation time (p0.05). Similarly, the peak-to-peak duration (PTPd) of the evoked EMG increased faster at an earlier time to a higher asymptotical value in lengthened muscle (2.23 +/- 0.74 versus 1.77 +/- 0.54), compared to that of a shortened one (p0.05). These observations coincided with the higher rising rate and larger final value of the temporal coefficients, i.e., longer duration, in both type I and II MUs of lengthened muscles. From the observation of all parameters, the fatigue process in lengthened muscle proceeds faster than that in shortened muscle.

The purpose of this study was to explore advantages and disadvantages of electrodes used for monitoring of the recurrent laryngeal nerve (RLN) and to determine the postoperative outcome in 135 patients. A pilot study examined 11 patients to compare the clinical performance of two commercially available recording electrodes and three stimulation electrodes for RLN neuromonitoring. After determining the most reliable and consistent stimulating/recording electrode combination, 124 patients were then monitored. In a total of 135 patients there was no permanent iatrogenic nerve damage to the RLN, although 2 patients developed transient vocal hoarseness that resolved shortly postoperatively. An initial "searching" current for evoked electromyography (EMG) was delivered at 0.7 mA and then decreased to a value of 0.35 mA, which reliably elicited RLN stimulation with a minimal incidence of false-positive results. The combination of auditory feedback from the mechanically elicited EMG and a control channel involving EMG monitoring of an additional peripheral muscle improved the detection of artifact and improved the clinical efficacy of intraoperative electromyography. A video camera showed the surgical manipulation on the EMG screen, allowing the neurophysiologist to correlate dissection with RLN status and location. Auditory responses from the nerve helped to determine the type of distress the RLN was encountering.

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Although there is recent evidence for the role of intraoperative neurophysiological monitoring (IONM) in spine surgery, there are no uniform opinions on the optimal combination of the different tools. We analyzed the impact of the multimodal IONM (mIONM) on the preservation of neuronal structures and on functional restoration in a prospective series of our patients who underwent spine surgery. The mIONM approach in spine surgery involves the evaluation of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) with electrical transcranial stimulation, including the use of a multipulse technique with multiple myomeric registration of responses from limbs, and a single-pulse technique with D-wave registration through epi- and intradural recording, and free running and evoked electromyography. We observed an improvement of neurological status in 50% of the patients. The D-wave registration was the most useful intraoperative tool, especially when MEP and SEP responses were absent or poorly recordable. Our preliminary data confirm that mIONM plays a fundamental role in the identification and functional preservation of the spinal cord and nerve roots. It is highly sensitive and specific for detecting and avoiding neurological injury during spine surgery and represents a helpful tool for achieving optimal postoperative functional outcome.

ObjectReports of the accuracy of existing neuromonitoring methods for detecting or preventing medial malpositioning of thoracic pedicle screws have varied widely in their claimed effectiveness. The object of this study was to develop, test, and validate a novel neuromonitoring method for preventing medial malpositioning of pedicle screws in the thoracic spine during surgery.MethodsThis is a prospective, blinded and randomized study using a novel combination of input (4-pulse stimulus trains delivered within the pedicle track) and output (evoked electromyography from leg muscles) to detect pedicle track trajectories that—once implanted with a screw—would cause that screw to breach the pedicle's medial wall and encroach upon the spinal canal. For comparison, the authors also used screw stimulation as an input and evoked electromyogram from intercostal and abdominal muscles as output measures. Intraoperative electrophysiological findings were compared with postoperative CT scans by multiple reviewers blinded to patient identity or intraoperative findings.ResultsData were collected from 71 patients, in whom 802 screws were implanted between the T-1 and L-1 vertebral levels. A total of 32 screws ended up with screw threads encroaching on the spinal canal by at least 2 mm. Pulse-train stimulation within the pedicle track using a ball-tipped probe and electromyography from lower limb muscles correctly predicted all 32 (100%) of these medially malpositioned screws. The combination of pedicle track stimulation and electromyogram response from leg muscles proved to be far more effective in predicting these medially malpositioned screws than was direct screw stimulation and any of the target muscles (intercostal, abdominal, or lower limb muscles) we monitored. Based on receiver operating characteristic analysis, the combination of 10-mA (lower alarm) and 15-mA stimulation intensities proved most effective for detection of pedicle tracks that ultimately gave rise to medially malpositioned screws. Additional results pertaining to the impact of feedback of these test results on surgical decision making are provided in the companion report.ConclusionsThis novel neuromonitoring approach accurately predicts medially malpositioned thoracic screws. The approach could be readily implemented within any surgical program that is already using contemporary neuromonitoring methods that include transcranial stimulation for monitoring motor evoked potentials.

We report a case of Melkersson-Rosenthal syndrome. The case involved an eight-year-old girl. She had experienced left facial paralysis and its spontaneous regression two years before she first came to our clinic with left recurrent facial paralysis and lower lip swelling. Evoked electromyography revealed that the ratio between left and right was 5%. Recovery of facial nerve function was observed after administration of a steroid. Six months later, right facial paralysis occurred, but it disappeared after steroid therapy. Three years after her first visit, right facial paralysis recurred. Because lingua plicata was also exhibited, the diagnosis of Melkersson-Rosenthal syndrome was confirmed. Complete recovery from right facial paralysis was observed after steroid therapy. Although her mother had a history of sarcoidosis, the patient's chest roentgenography, serum angiotensin converting enzyme level, and ophthalmological evaluation for uveitis revealed no signs of sarcoidosis.

Acute facial palsy has significant functional and psychologic impact on affected patients that can adversely affect their quality of life. Early determination of the prognosis for recovery may permit intervention to minimize nerve injury and optimize regeneration. Facial nerve evoked electromyography (EEMG) is currently the most commonly used electrodiagnostic test in acute facial palsy, and a considerable number of studies confirms its utility as a prognostic indicator in this clinical setting. The basic principles and techniques of EEMG are reviewed. The prognostic value of EEMG in acute facial palsy and the limitations of the test are also reviewed in view of the most recent literature.

A consecutive series of twenty-seven patients who had thirty acute unstable (type-C) fractures of the pelvic ring was studied prospectively to evaluate the use of stimulus-evoked electromyography to decrease the risk of iatrogenic nerve-root injury during the insertion of iliosacral screws. A prerequisite for inclusion in the study was a normal neurological status preoperatively; somatosensory evoked potentials were monitored to further document the neurological status both before and after insertion of the screw or screws. A total of fifty-one iliosacral screws were inserted, and a current threshold of more than eight milliamperes was selected as the level that indicated that the drill-bit was a safe distance from the nerve root. Four of the fifty-one screws were redirected because of information obtained with stimulus-evoked electromyography. Postoperatively, all patients had a normal neurological status. Computerized tomography, although not accurate for detailed measurements, demonstrated that all of the screws were in a safe, intraosseous position. Monitoring with stimulus-evoked electromyography appears to provide reliable data and may decrease the risk of iatrogenic injury to the nerve roots during operations on the pelvic ring.

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.

Injury to vital neural structures remains a source of major morbidity in head and neck surgery. Electromyographic (EMG) monitoring has been successfully used during otologic and parotid surgery. However, its use in thyroid and parathyroid surgery has been less than routine even though preservation of recurrent laryngeal nerve function is essential to voice and airway. We describe our technique with the use of a postcricoid surface electrode for evoked EMG monitoring in thyroid and parathyroid surgeries. Technique of insertion of the electrode is described. Operative thyroidectomy is described for either close-capsular dissection or initial nerve location. Equipment required and monitoring technique is described for both methods and outcomes are briefly discussed. These results support evoked EMG by postcricoid surface electrode as a useful practical tool in identification of recurrent nerve in thyroid and parathyroid surgery.

Object Percutaneous pedicle screws have recently become popularized for lumbar spinal fixation. However, successful anatomical hardware placement is highly dependent on intraoperative imaging. In traditional open surgery, stimulus-evoked electromyography (EMG) responses can be useful for detecting pedicle screw breaches. The use of insulated sleeves for percutaneous screws has allowed for EMG testing in minimally invasive surgery; however, no reports on the reliability of this testing modality have been published. Methods A total of 409 lumbar percutaneous pedicle screws were placed in 93 patients. Levels of instrumentation included L-1 (in 12 patients), L-2 (in 34), L-3 (in 44), L-4 (in 120), L-5 (in 142), and S-1 (in 57 patients). Intraoperative EMG stimulation thresholds were obtained using insulating sleeves over a metallic tap prior to final screw placement. Data were compared with postoperative fine-cut CT scans to assess pedicle screw placement. Data were collected prospectively and analyzed retrospectively. Results There were 5 pedicle breaches (3 medial and 2 lateral; 3 Grade 1 and 2 Grade 2 breaches) visualized on postoperative CT scans (1.2%). Two of these breaches were symptomatic. In 2 instances, intraoperative thresholds were the sole basis for screw trajectory readjustment, which resulted in proper placement on postoperative imaging. Thirty-five screw trajectories were associated with a threshold of less than 12 mA. However, all breaches were associated with thresholds of greater than 12 mA. Using thresholds below 12 mA as the indicator of a screw breach, this resulted in a sensitivity of 0.0, specificity of 90.3, positive predictive value of 0.0, and negative predictive value of 0.98. Utilizing a threshold of any decreased stimulus (< 20 mA) would have detected 60% of breaches, with a mean threshold of 16.25 mA. Conclusions While these data are limited by the low number of radiographic breaches, it appears that tap stimulation with an insulating sleeve may not be reliable for detecting low-grade radiographically breached pedicles using typical stimulation thresholds (< 12 mA). Imaging-based modalities remain more reliable for assessing percutaneous pedicle screw trajectories until more robust and sensitive electrophysiological testing methods can be devised.

Ninety-one patients with idiopathic (n = 62) and traumatic (n = 29) facial paralyses were available for evaluation at least 1 year after the onset of paralysis. In nine cases of idiopathic paralysis and in 12 cases of traumatic paralysis, total intratemporal nerve decompression was performed. The remaining patients were treated with steroids alone. All patients underwent evoked electromyography (EEMG) testing within 2 weeks of the onset of paralysis. Facial nerve recovery was graded using the House-Brackmann facial nerve recovery scale. Subjects were grouped according to maximal decline of compound muscle action potential (CAP), as determined by EEMG, and by level of recovery 1 year after onset of paralysis. Among patients who did not undergo surgical decompression of the facial nerve, incomplete clinical recovery (grade III or higher) was significantly associated with CAP decline of greater than 90% (p less than 0.05) for idiopathic paralysis. In contrast, there was no significant association between CAP decline of greater than 90% and clinical outcome in traumatic paralysis. These findings support previous reports of the prognostic value of EEMG in idiopathic facial paralysis, but suggest that this test may have less predictive value in the evaluation of facial paralysis as a result of trauma.

Summary Botulinum toxin (botox) injection into the thyroarytenoid (TA) muscle is currently the most favored treatment for spasmodic dysphonia. However, results are often inconsistent. The purpose of this study was to identify a fast-acting neuromuscular blocking agent that could mimic botox effects to screen patients for therapy while still in the clinic. If the agent was noninteractive, it could also be injected coincidentally with botox and the resulting changes in voice used to predict the delayed effects due to botox. Evoked electromyography responses were recorded from the TA muscle in animal experiments to determine the time course for neuromuscular depression by botox and three fast-acting blocking agents: lidocaine, tubocurarine, and succinylcholine. Tubocurarine and succinylcholine proved to be suitable screening or predictor agents of botox efficacy, since they were reversible and mimicked botox action. In contrast, lidocaine produced irreversible effects.

Pelvic ring fractures that occur as a result of substantial orthopedic trauma are frequently repaired using iliosacral screws to stabilize the fracture. Stimulus evoked electromyography, using pulsed current stimuli provided through the drill bit cathode, has been advocated to prevent nerve root injury during iliosacral screw insertion. Our objective was to examine the effects of anode location, drill bit position, and anatomical structure on the nerve monitoring technique. A three-dimensional finite element model was constructed from computed tomography data to evaluate the effectiveness of five anode locations at four stations of drill bit insertion. Results indicate that the anode location should be at the midline or on the side contralateral to drill bit insertion. Locating the anode at other positions, such that the nerve root is outside of the primary electromagnetic field, leads to an attenuated electromyographic response that will ultimately lead to the failure of the monitoring technique.

We investigated the muscular relaxant properties of propofol in a 54 year-old-man with severe tetanus. Four consecutive boluses of propofol 50 mg i.v. were administered. Mean muscular activity recorded on an electromyography (EMG) decreased from 100 to 10-25 mV within 15 s after each bolus. EMG values were restored to prior levels 10 min after the last bolus. Maximum decrease of muscular activity was observed with propofol blood level between 2.90-3.20 micrograms.ml-1. Neuromuscular function recorded by means of evoked electromyography was not affected by propofol administration.

Purpose: To prevent damage to the recurrent laryngeal nerve during thyroid or parathyroid surgery, spontaneous and evoked electromyography (EMG) can be used to locate the recurrent laryngeal nerve or determine when the nerve is being disturbed. Two commercial electrodes have been introduced to receive laryngeal EMG. This study compares the clinical performance of the two electrodes. Patients and Methods: The Xomed-Treace endotracheal tube electrode (Xomed-Treace, Jacksonville, FL) and the RLN postcricoid laryngeal electrode (RLN Systems, Jefferson City, MO) were placed concomitantly in 11 patients during 14 surgical procedures. Results: The RLN electrode provided feedback as to placement by providing a heart-beat artifact. The RLN electrode was found to be both more sensitive and more electrically noisy. On stimulation, the Xomed tube electrode produced generally higher EMG amplitudes, perhaps because of the different muscles they monitor. In one case, the Xomed tube failed to provide EMG responses. Only at low electrical stimulation intensities could left and right vocalis muscles be identified with the Xomed tube. A laryngologist was needed to place the RLN electrode, whereas the attending anesthesiologist was able to place the Xomed tube. Conclusion: Both electrodes provided useful EMG information and helped confirm the location of the recurrent laryngeal nerve. Who will place the electrode, tumors extrinsic or intrinsic to the larynx, cost, and size requirements should be considered when choosing an electrode.

Investigation of the effects of various factors on nerve regeneration has been compromised by the lack of an accurate and objective technique which can monitor dynamic changes in the status of nerve-muscle innervation over the entire course of regeneration. The approach of evoked electromyography (EEMG) was adopted to obtain temporal and quantitative data during nerve regeneration. Initially, transcutaneous nerve stimulation and percutaneous muscle recording was performed, but the approach was abandoned because of the high interest variability (20% average deviation) and requirement for anesthesia during testing. A new approach using chronically implanted stimulation and recording electrodes was adopted in an attempt to circumvent these problems. Initial acute studies performed in the hindlimb of the anesthetized rat identified stable EEMG recording sites with sciatic nerve stimulation. In a second study conducted in chronically implanted unanesthetized unrestrained animals, EEMG recording from these sites demonstrated remarkable stability with an average interest variability of only 5%. Preliminary results have been obtained with this technique in monitoring the progression of hindlimb reinnervation following crush and transection nerve injuries.

We report our results from the application of evoked electromyography (EEMG) and facial nerve latency testing (FNLT) in 30 children aged 4-14 years with idiopathic facial palsy. Our aim was to define the value of these tests as prognostic tools in Bell's palsy. From the EEMG results we ascertained that, when the amplitude of the compound muscle action potential varied between 51% and 95% of the normal value, the neuronal damage is slight (neurapraxia). When the percentage value of muscle response decreases, the prognosis is worse. The results of the FNLT showed that, when the latency is within normal limits, the damage to the nerve is slight (neurapraxia). If the latency is prolonged, the prognosis is worse. Evaluation of our results and comparison with the index of facial nerve functional recovery showed that those two tests have a high percentage of correctness (100% for the EEMG and 96.7% for the FNLT) and a low percentage of error. We conclude that these tests are excellent for predicting the outcome of facial nerve palsy in childhood and we suggest that young patents undergo both so that the determination of the lesion may be as correct as possible. Childs Nervous System

Using evoked electromyography, Nishimura and Yanagihara [2] found that the orbicularis oris muscle in the vicinity of the midline was innervated by bilateral facial nerves. Figure la shows the evoked electromyograms (EMG) of the orbicularis oris muscle in a normal adult.

A method of recording antidromic evoked potential (AEP) of the facial nerve is supposed to have advantages over conventional tests, such as evoked electromyography (eEMG), electroneuronography, and nerve excitation test, in predicting the prognosis of facial palsy in its early stage. However, a comparison of these tests has not yet been studied. The aim of this paper is to investigate the diagnostic value of AEP in predicting the prognosis of facial palsy in comparison with that of eEMG in animal models.

The dose response relationship for the intermediate-acting non-depolarising muscle relaxant, atracurium besylate in the pig was determined using evoked electromyography. An incremental dose technique was used in seven Large White/Landrace crossbred pigs anaesthetised with nitrous oxide and halothane. ED50 and ED95 were 510 +/- 87 micrograms kg-1 and 1150 +/- 270 micrograms kg-1, respectively. Although these values may represent an overestimate, they provide a reasonable guideline for the use of atracurium by veterinary anaesthetists.

The insertion of pedicle screws monitored by evoked electromyography (EMG) was prospectively evaluated in the 132 consecutive patients. The technique involved constant-voltage stimulation and was statistically evaluated at both the arbitrary 20- and 40-V settings. The patients were postoperatively evaluated clinically and radiographically. Computed tomography (CT) scanning was performed for new neurologic deficits. Results were divided into three groups: type 1, a negative EMG response; type 2, a positive EMG response, but no corrective action taken; and type 3, a positive EMG response and corrective action undertaken. Nonparametric statistics were used to evaluate the results at both the 20- and 40-V settings. In the type 3 group, in which corrective action was undertaken, there were no neurologic injuries or screw removals, a statistically significant result. Looking at the two intensity levels, at 20- and 40-V settings, there were no statistically significant differences in the three classifications at either intensity level. We concluded the evoked EMG for monitoring pedicle screw insertion is an efficacious adjunct. A positive response at < 20 V with the constant-voltage technique warrants corrective action.

An abnormal condition of the facial nerve just before apparent paralysis was detected by evoked electromyography. We now report on 2 patients with herpes oticus and vertigo or tinnitus without apparent facial palsy. This abnormal condition is considered to be a subclinical paralysis (preparalytic condition), and early detection of the condition may prevent ensuing paralysis.

A study was made of the impulse conduction speed by moving recording electrodes at 5 mm intervals, successively, after stimulating facial nerves on one side in normal subjects. The findings showed that the speed of the potentials was fast and the amplitude was large, up to a distance of 0.5 cm across the midline. This makes us believe that there is an intermingling, of approximately one cm, of the left and right superior orbicularis oris muscles. Evoked potentials were recorded up to 1.5 to 2.5 cm across the midline--but as the speed reduced abruptly and the amplitude became small, we believe these potentials were conveyed by volume conductors. Six patients with facial palsy were studied, but in none were these findings indicating any reinnervation from the normal side. However, the conduction speed was delayed in them (as compared to normal subjects).

In another report (this issue) the authors described a method of monitoring intraoperative facial nerve evoked electromyography (IFeEMG) by direct electrical stimulation of the intracranial facial nerve and discussed its usefulness in the identification of the facial nerve during surgery for cerebellopontine angle tumors. This report concerns the usefulness of IFeEMG in making prognoses of postoperative facial nerve function. In 21 patients with acoustic neurinomas the correlation between the results of IFeEMG by stimulation of the morphologically preserved facial nerve and postoperative facial nerve function was determined. Patients with no IFeEMG response at the completion of tumor removal had severe postoperative facial palsy, which did not improve. Patients with a good response had no palsy or, at most, mild palsy. These findings suggest that severe postoperative facial palsy due to neurotmesis can be predicted intraoperatively by IFeEMG monitoring. Early surgical treatment is recommended for patients with morphologically preserved facial nerves but no IFeEMG response.

The 24-hour preservation of amputated rabbit limbs was investigated by perfusion with oxygenated fluorocarbon emulsion (Fluosol-43)using an extracorporeal circulation system. Eighteen limbs amputated at the thigh were immediately stored in ischemic condition at 4℃ for one hour, and were perfused at 10℃ for 21 hours. In 12 limbs, replantation was initiated at the period of 22 hours, and recirculation commenced at the time of 24 hours after amputation. In all cases, the viability of gastrocnemius muscle was confirmed by the evoked potential (M-wave) which was observed at the time of 24 hours after amputation. All rabbits survived more than 9 hours after the limb replantation, and 6 rabbits were alive over 4 months until their sacrifice. In histological examination of muscular tissue through the light and electron microscopes ; severe atrophic change was not observed in spite of the denervated condition. The following conclusions were obtained : 1) It is possible to preserve an amputated limb for 24 hours without serious damage, under perfusion with fluorocarbon emulsion at 10℃. 2) In major limb replantation after 24-hour preservation under FC perfusion, the limb can be totally alive, and the survival of the host is secured without replantation toxemia.

142 patients with Bell’s palsy were monitored by repeated applications of evoked EMG. Detailed and objective information as to the incidence, degree, and progression of denervation in Bell’s palsy was

Monitoring neuromuscular transmission provides valuable information to the anesthesiologist. The aquisition of relevant data contributes to a more predictable and rational approach to the use of muscle relaxants and assures improved patient care during and in the immediate postoperative period.

The effects of gonyautoxins (GTXs) on the neuromuscular system in rabbits were examined. M waves were evoked by electric stimulation on the tibial nerve and recorded mainly from the plantar interosseous muscle. Intravenous administration of GTXs decreased the amplitude and prolonged both latency and duration of M waves, while showed little effect on the motor nerve conduction velocity. These results suggest that GTXs have inhibitory effects on the peripheral neuromuscular system, mainly on the neuromuscular transmission.

We performed contralateral and ipsilateral evoked electromyography (EMG) of the orbicularis oris muscle in 9 normal subjects and 32 patients with facial palsies; 22 with Bell's palsy and 10 with Ramsay Hunt's syndrome. In the normal subjects, the amplitude ratio of the contralateral to the ipsilateral evoked EMG ranged from 1:5 to 1:2. In 15 of the patients with facial palsy, the amplitude ratios exceeded the normal range. The amplitude ratios in the denervated group tended to be larger than those in the nondenervated group. These results suggest that contralateral facial nerve fibers innervating beyond the midline might intensify to assist the function of the affected facial nerve.