A comparison of magnetic and electrical stimulation of peripheral nerves

Transverse-field activation mechanism in magnetic stimulation of peripheral nerves

The activating function of peripheral nerves in magnetic stimulation is thought to be the gradient of the induced electric field component parallel to the nerve. This implies that there are several orientations of the coil that should not excite nerves. We show that these orientations, however, often yield high-amplitude and even supramaximal muscle response, indicating that the model of the activating function has to be modified. We propose that the electric field component perpendicular to the nerve is responsible for these unexpected muscle responses. Our conclusion is based on practical experiments with different coils and on computer simulations of the induced electric field and its gradient.

Comparison of various coils used for magnetic stimulation of peripheral motor nerves: physiological considerations and consequences for diagnostic use

We compared the ability of 4 magnetic coils to activate peripheral nerves in healthy subjects. No differences in motor threshold intensities were found between the coils, but the intensities needed to elicit maximum compound muscle action potential (CMAP) amplitudes were different. For superficial nerves maximum CMAPs in comparison with electrical stimulation were usually but not always found. CMAPs were at their maximum only when the direction of induced current flowed from proximal to distal and when a certain part of the coil was over the nerve. Distal nerve stimulation was time consuming. Due to artifacts many stimuli were necessary and sometimes no maximum CMAP could be elicited. CMAPs were much less sensitive to position changes of the coil than to changes in an electrical stimulator. Small circular coils were superior to larger coils in terms of the lower intensities necessary to elicit maximum CMAPs, better focusing of the stimulus, and less artifacts. For deep nerves amplitudes were always submaximal. Coactivation of nearby nerves and underlying muscles was another main drawback especially at proximal sites and for coils of large diameter. Despite better focusing, double coils are less useful due to their great diameter. Magnetic stimulation cannot replace electrical neurography at the moment, even if different coils are used at different sites of stimulation.

Repetitive magnetic nerve stimulation: technical considerations and clinical use in the assessment of neuromuscular transmission

We assessed to what extent repetitive magnetic stimulation can replace the electrical method. Fifteen healthy subjects and 3 patients with myasthenia gravis were investigated using stimulation of the median, ulnar, axillary and accessory nerves. Single, as well as 3/sec repetitive magnetic and electrical stimuli were applied. When comparing the results of magnetic vs. electrical stimulation, amplitudes, areas and shapes of compound muscle action potentials were not significantly different. Although single magnetic stimuli were much less uncomfortable than the electrical stimuli, differences in comfort were much smaller in the repetitive protocol, because muscular contractions under the magnetic stimulation coil caused unpleasant movements of, for example, the neck. Additional problems arose from technical limitations of the prototype magnetic stimulator used: stimulation intensity was significantly limited, resulting in an inability to elicit supramaximal responses in 11 of the 154 investigations. Overheating of the stimulator coil forced us to give the coil extra time to cool down. These problems might be solved in the future by more focused stimulus geometry and introduction of cooling devices. It is concluded that magnetic stimulation can elicit responses which are equivalent to the electrical method in repetitive nerve stimulation. At present due to some shortcomings it cannot replace electrical stimulation in routine repetitive nerve stimulation.

Sensory potentials evoked by magnetic stimulation of the cervical spine

Magnetic stimulation of cervical spinal roots was shown to elicit sensory potentials (MESP) which could easily be recorded at the fingers with ring electrodes. The latency of the MESP recorded at digit I was significantly shorter and the amplitude higher than of digits III and V. The latencies were largely independent of stimulus strength. In an attempt to localize the place of depolarization, the latencies of these potentials were compared with the N11 of the SEP (reflecting the arrival in the spinal cord) and with F-wave latencies and motor evoked potentials (MEP) to abductor pollicis brevis. The MESP latencies showed a very constant difference with the N11, being 0.6 ms faster. The mean difference between F latency and MEP was 1.2 ms. It is concluded that the origin of these MESPs is very near the spinal foramina, possibly in the sensory ganglia.

The value of magnetic stimulation in the diagnosis of radiculopathies

We studied 42 patients with cervical and lumbar radiculopathies using magnetic stimulation. Prolonged latencies following magnetic stimulation of the brain, the paravertebral spinal nerve, or both, showed a highly significant correlation with muscle weakness in clinical testing (24 of 26 patients with weakness had pathological motor evoked potentials) as well as with spontaneous activity of the target muscles in needle electromyography (24 of 25 subjects). The determination of both the central and the peripheral motor conduction time was found to be essential in patients with radiculopathies, because different patterns of latency changes correlated with different morphological results in computed tomography: in patients diagnosed as having a lateral compression of the nerve root the peripheral nerve latency was delayed; whereas, in patients with more medially localized herniations, a prolonged central motor latency was the most frequent finding. This study posits that combined magnetic stimulation of the brain and nerve root is an effective and painless technique for the noninvasive evaluation of nerve root function.

Determining the site of stimulation during magnetic stimulation of a peripheral nerve

Magnetic stimulation has not been routinely used for studies of peripheral nerve conduction primarily because of uncertainty about the location of the stimulation site. We performed several experiments to locate the site of nerve stimulation. Uniform latency shifts, similar to those that can be obtained during electrical stimulation, were observed when a magnetic coil was moved along the median nerve in the region of the elbow, thereby ensuring that the properties of the nerve and surrounding volume conductor were uniform. By evoking muscle responses both electrically and magnetically and matching their latencies, amplitudes and shapes, the site of stimulation was determined to be 3.0 +/- 0.5 cm from the center of an 8-shaped coil toward the coil handle. When the polarity of the current was reversed by rotating the coil, the latency of the evoked response shifted by 0.65 +/- 0.05 msec, which implies that the site of stimulation was displaced 4.1 +/- 0.5 cm. Additional evidence of cathode- and anode-like behavior during magnetic stimulation comes from observations of preferential activation of motor responses over H-reflexes with stimulation of a distal site, and of preferential activation of H-reflexes over motor responses with stimulation of a proximal site. Analogous behavior is observed with electrical stimulation. These experiments were motivated by, and are qualitatively consistent with, a mathematical model of magnetic stimulation of an axon.

Localization of nerve depolarization with magnetic stimulation

The specific location on the magnetic stimulation (MS) coil that may correspond to the area of nerve depolarization has not been determined. In order to localize such an area, MS with 9-cm and 5-cm diameter coils was compared with conventional percutaneous electric stimulation (ES). On the 9-cm coil the distribution of points of nerve depolarization corresponded to that quarter of the coil which was placed over and parallel to the median nerve, whereas on the 5-cm coil, this area also extended outside the coil. The points of median nerve depolarization with MS were distributed over a distance of 7 cm on the stimulator head and was nearly identical for the 2 coil sizes at the wrist and elbow. Ulnar nerve costimulation was less frequent with the smaller coil at the wrist. A calculated reference point on the coil is suggested for more accurate NCV determinations.

Relevance of stimulus duration for activation of motor and sensory fibers: implications for the study of H-reflexes and magnetic stimulation

Electric stimuli with durations of 0.5-1.0 msec are optimal for studies of H-reflexes. It is more difficult to obtain H-reflexes with shorter duration stimuli or with magnetic stimulation. In order to understand this behavior, we studied the excitation thresholds for motor and sensory fibers in the ulnar, median and tibial nerves using both electric and magnetic stimulation. For short duration electrical stimuli (0.1 msec) the threshold for motor fibers is lower than for sensory fibers. For longer duration electric stimuli (1.0 msec) the threshold for sensory fibers is lower. For magnetic stimulation the threshold for motor fibers is much lower than for sensory fibers. Thus, stimulus duration is a critical parameter for sensory fiber excitation, and current magnetic stimulators are not optimal.