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Segura MJ, Talarico ME, Piantoni L, Noel MA, MacDonald DB. Is Intraoperative Muscle Motor Evoked Potential Variability due to Fluctuating Lower Motor Neuron Background Excitability? J Clin Neurophysiol 2024:00004691-990000000-00174. [PMID: 39354664 DOI: 10.1097/wnp.0000000000001118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2024] Open
Abstract
PURPOSE This pilot study tests the contribution of fluctuating lower motor neuron excitability to motor evoked potential (MEP) variability. METHODS In six pediatric patients with idiopathic scoliosis and normal neurologic examination, cascades of 30 intraoperative H-reflexes (HRs) and MEPs were evoked in the soleus muscle using constant-current stimulators and recorded through surface electrodes with a 20-second interstimulus interval. First, HRs were obtained with an intensity capable of evoking the maximum response. Subsequently, MEPs were obtained with double trains and an intensity of 700 to 900 mA. Coefficients of variation (CVs) of amplitude and area under the curve from HRs and MEPs were compared using a paired two-tailed Student t test. Coefficients of correlation between the mean CVs of HR and MEP parameters were also assessed. RESULTS Pooling the results from the six patients, the mean CV of amplitude from the MEP (24.6 ± 3) was significantly higher than that from the HR (3.5 ± 4.4) (P = 0.000091). The mean CV of the MEP area under the curve (21.8 ± 4.8) was also statistically significantly higher than that from the HR area under the curve (3.4 ± 4.5) (P = 0.00091). The coefficients of correlation of the mean CV of the HR amplitude and area under the curve compared with the corresponding values of the MEP were low (r = 0.29) and very low (r = 0.03), respectively. CONCLUSIONS Our results suggest that fluctuations in lower motor neuron excitability may be less important than previously thought to explain the magnitude of MEP variability. The efficacy of corticospinal volleys to recruit a larger and more stable lower motor neuron population would be critical to obtain reproducible MEPs.
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Affiliation(s)
- Martín J Segura
- Department of Clinical Neurophysiology, National Pediatric Hospital "Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - María E Talarico
- Department of Clinical Neurophysiology, National Pediatric Hospital "Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Lucas Piantoni
- Department of Spine Surgery, National Pediatric Hospital "Dr. Juan P. Garrahan", Buenos Aires, Argentina; and
| | - Mariano A Noel
- Department of Spine Surgery, National Pediatric Hospital "Dr. Juan P. Garrahan", Buenos Aires, Argentina; and
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Manning E, Emerson R. Intraoperative Monitoring of Scoliosis Surgery in Young Patients. J Clin Neurophysiol 2024; 41:138-147. [PMID: 38306222 DOI: 10.1097/wnp.0000000000001058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
SUMMARY Intraoperative neurophysiologic monitoring has added substantially to the safety of spinal deformity surgery correction since its introduction over four decades ago. Monitoring routinely includes both somatosensory evoked potentials and motor evoked potentials. Either modality alone will detect almost all instances of spinal cord injury during deformity correction. The combined use of the two modalities provides complementary information, can permit more rapidly identification of problems, and enhances safety though parallel redundancy should one modality fail. Both techniques are well established and continue to be refined. Although there is room for provider preference, proper monitoring requires attention to technical detail, understanding of the underlying physiology, and familiarity with effects of commonly used anesthetic agents.
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Affiliation(s)
- Erin Manning
- Hospital for Special Surgery, New York, New York, U.S.A.; and
| | - Ronald Emerson
- Weill Cornell Medical Center, Hospital for Special Surgery, New York, New York, U.S.A
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Díaz-Baamonde A, Peláez-Cruz R, Téllez MJ, Lantis J, Ulkatan S. Median nerve somatosensory evoked potential alarm related to head and neck positioning for carotid surgery. J Clin Monit Comput 2023; 37:699-704. [PMID: 35960492 DOI: 10.1007/s10877-022-00904-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
Head positioning in carotid surgery represents an often overlooked but sensitive period in the surgical plan. A 53-year-old male presented a significant decrement in median nerve somatosensory evoked potential (mSEP) following head and neck positioning for carotid pseudoaneurysm repair before skin incision.Neurophysiological monitoring was performed with mSEP and electroencephalography early during the patient's preparation and surgery. Within five minutes after rotation and extension of the head to properly expose the surgical field, the contralateral m-SEP significantly decreased in both cortical (N20/P25) and subcortical (P14/N18) components. Partial neck correction led to m-SEP improvement, allowing to proceed with the carotid repair. We discuss possible underlying pathophysiological mechanisms responsible for these changes and highlight the relevance of an early start on monitoring to avoid neurological deficits.
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Affiliation(s)
- Alba Díaz-Baamonde
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA.
| | | | - Maria J Téllez
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
| | - John Lantis
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
| | - Sedat Ulkatan
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
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4
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Dulfer SE, Gadella MC, Sahinovic MM, Lange F, Absalom AR, Groen RJM, Szelényi A, Drost G. Stimulation parameters for motor evoked potentials during intraoperative spinal cord monitoring. A systematic review. Clin Neurophysiol 2023; 149:70-80. [PMID: 36924672 DOI: 10.1016/j.clinph.2023.02.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/10/2023] [Accepted: 02/08/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The aim of this systematic review was to find the optimal stimulation parameters for muscle recorded transcranial electrical stimulation motor evoked potential (mTc-MEP) and D-wave monitoring during spinal cord monitoring. METHODS A PRISMA systematic search in Medline and EMBASE and a QUADAS-2 quality evaluation was performed to identify studies that compared stimulation parameters consisting of stimulation location, number of pulses, pulse duration, interstimulus interval, double train (DTS) or recurrent train stimulation (RTS) and intertrain interval (ITI) for performing mTc-MEP and D-wave monitoring. Only studies that used total intravenous anaesthesia (TIVA) were included. RESULTS Ten studies that compared stimulation parameters for performing mTc-MEP monitoring (stimulation location n = 4, number of pulses n = 2, pulse duration n = 1, interstimulus interval n = 4, DTS n = 1, RTS n = 2, ITI n = 2) were included. No studies compared stimulation parameters (stimulation location and pulse duration) for performing D-wave monitoring. CONCLUSIONS Few studies examined the optimal stimulation parameters for monitoring mTc-MEPs and no studies were included for D-wave monitoring. There is a need for prospective research to investigate the optimal stimulation parameters for mTc-MEP with the use of TIVA and D-wave monitoring. SIGNIFICANCE For mTc-MEP monitoring, a table is provided in which the recommended stimulation parameters are stated.
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Affiliation(s)
- S E Dulfer
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.
| | - M C Gadella
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - M M Sahinovic
- Department of Anaesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - F Lange
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - A R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - R J M Groen
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - A Szelényi
- Department of Neurosurgery, Hospital of the Ludwig Maximilians University Munich (LMU), Munich, Germany
| | - G Drost
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands; Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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5
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Pasquali C, Basaldella F, Sala F. Updates on Intraoperative Neurophysiology During Surgery for Spinal Dysraphism. Adv Tech Stand Neurosurg 2023; 47:235-272. [PMID: 37640878 DOI: 10.1007/978-3-031-34981-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Spinal dysraphism is a group of disorders resulting from an embryologic failure of spinal cord development which can lead to a radicular-medullary mechanical stretch that generates vascular compromise and hypoxic-ischemic damage to the nervous structures of the conus-cauda region.Thus, the clinical relevance of the different types of spinal dysraphism is related to the possible neurologic deficits resulting from spinal cord tethering. The clinical presentation is heterogenous: from asymptomatic to very compromised patients. The indications and the time of a detethering surgery are still subject of debate, although there is an agreement on the high standards of treatment that have to be offered by the surgery. Intraoperative neurophysiology (ION) contributes to the safety of tethered cord surgery in reducing the risks of iatrogenic neurological damages.
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Affiliation(s)
- Claudia Pasquali
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Federica Basaldella
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
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Journée HL, Journée SL. Transcranial Magnetic Stimulation and Transcranial Electrical Stimulation in Horses. Vet Clin North Am Equine Pract 2022; 38:189-211. [PMID: 35811197 DOI: 10.1016/j.cveq.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Depending on the localization of the lesion, spinal cord ataxia is the most common type of ataxia in horses. Most prevalent diagnoses include cervical vertebral stenotic myelopathy (CVSM), equine protozoal myeloencephalitis (EPM), trauma and equine degenerative myeloencephalopathy (EDM). Other causes of ataxia and weakness are associated with infectious causes, trauma and neoplasia. A neurologic examination is indispensable to identify the type of ataxia. In addition, clinical neurophysiology offers tools to locate functional abnormalities in the central and peripheral nervous system. Clinical EMG assessment looks at the lower motoneuron function (LMN) and is used to differentiate between neuropathy in peripheral nerves, which belong to LMNs and myopathy. As LMNs reside in the spinal cord, it is possible to grossly localize lesions in the myelum by muscle examination. Transcranial (tc) stimulation techniques are gaining importance in all areas of medicine to assess the motor function of the spinal cord along the motor tracts to the LMNs. Applications in diagnostics, intraoperative neurophysiological monitoring (IONM), and evaluation of effects of treatment are still evolving in human medicine and offer new challenges in equine medicine. Tc stimulation techniques comprise transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (TES). TMS was first applied in horses in 1996 by Mayhew and colleagues and followed by TES. The methods are exchangeable for clinical diagnostic assessment but show a few differences. An outline is given on the principles, current clinical diagnostic applications and challenging possibilities of muscle evoked potentials (MEP) from transcranial stimulation in horses.
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Affiliation(s)
- Henricus Louis Journée
- Department of Neurosurgery, University of Groningen, Univ Med Center Groningen, Hanzeplein 1, Groningen 9713 GZ, the Netherlands; Department of Orthopedics, Univ Utrecht, Univ Med Ctr Utrecht, PO-box 85500 NL-3508 GA, Utrecht, Netherlands.
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Abstract
There are many recent advances in intraoperative evoked potential techniques for mapping and monitoring neural function during surgery. In particular, somatosensory evoked potential optimization speeds surgical feedback, motor evoked potentials provide selective motor system information, and new visual evoked potential methods promise reliable visual system monitoring. This chapter reviews these advances and provides a comprehensive background for understanding their context and importance.
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Affiliation(s)
| | - Charles C Dong
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Alberto Uribe
- Department of Anesthesiology, Ohio State University, Columbus, OH, United States
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Galloway G, Sala F. Mapping and monitoring of tethered cord and cauda equina surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:257-270. [PMID: 35772890 DOI: 10.1016/b978-0-12-819826-1.00018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Surgery involving the cauda equina and tethered cord can be associated with significant functional disability including pain, motor and sensory deficits, as well as bladder, bowel, and sexual dysfunction. Neurophysiologic intraoperative monitoring and mapping during these surgeries using a variety of techniques and applications contributes to lessen the risk of permanent injury. This chapter reviews the anatomy of the pelvic floor, describes the techniques involved in monitoring and mapping this area, and describes the limitations of neurophysiology applications. Additionally, this chapter details mapping and monitoring techniques as they apply to tethered cord surgical release in both children and adults with review of outcome studies, and describes complications which can arise from tethered cord repair and injury to the cauda equina despite appropriate neurophysiologic intraoperative involvement.
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Affiliation(s)
- Gloria Galloway
- Department of Neurology, Wexner Medical Center, Ohio State University Medical Center, Columbus, OH, United States.
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
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Busso VO, McAuliffe JJ. How Integrated Anesthesia Communication Leads to Dependable IONM Data. Neurodiagn J 2021; 61:37-45. [PMID: 33945443 DOI: 10.1080/21646821.2021.1875738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Many algorithms, checklists, and escalation pathways have been created to encourage perioperative teams to share a mental model and approach patient care as a team. Respecting and empowering the many voices involved in patient care is crucial to avoid errors and improve patient safety. None of the concepts described herein are novel; however, sustained improvements in operating room culture remain elusive in many organizations. The implementation of practices directed toward driving change in operating room culture has led to improvements in Occupational Safety and Health Administration (OSHA) recordables, perioperative communication, and patient care practices. In this paper, we will review the importance of culture, mutual accountability, and communication in improving patient care, and share several of the processes that have been created at our pediatric tertiary care center.
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Affiliation(s)
- Veronica O Busso
- Department of Anesthesia, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - John J McAuliffe
- Department of Anesthesia, Cincinnati Children's Hospital, Cincinnati, Ohio
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10
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Motor Evoked Potentials Double Train Stimulation: Optimal Number of Pulses per Train. J Clin Neurophysiol 2020; 39:401-405. [PMID: 33079758 DOI: 10.1097/wnp.0000000000000793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE In neurophysiologic intraoperative monitoring, double train transcranial electrical stimulation (dt-TES) for motor evoked potentials (MEP) consists of an initial, facilitating train of stimuli followed by a second, testing, train. The optimal number of pulses per train has not been determined. The authors wanted to determine the optimal combination of pulses per train that produced the highest MEP amplitude. METHODS Dt-TES of 4 + 4, 2 + 7, and 7 + 2 pulses were attempted in 20 patients and compared with single train TES of nine pulses. Latencies of the MEP responses were also compared. Additionally, statistical comparisons were made of the differences between the amplitude and latency measurements within the patients. RESULTS The mean age of the patients was 44.3 years (range, 9-84 years). Dt-TES of 2 + 7 pulses resulted in significantly higher mean amplitudes than dt-TES of 4 + 4 and 7 + 2 pulses and single train TES of nine pulses (p < 0.001). The MEP latency with dt-TES of 2 + 7 pulses was longer than the latencies of single train TES of nine pulses and dt-TES of 4 + 4 and 7 + 2 pulses. CONCLUSIONS Asymmetric dt-TES with 2 + 7 pulses improved MEP amplitudes. This type of stimulation may be preferable to single train TES and dt-TES with symmetric pulse trains.
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11
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Journée SL, Journée HL, Berends HI, Reed SM, de Bruijn CM, Delesalle CJG. Comparison of Muscle MEPs From Transcranial Magnetic and Electrical Stimulation and Appearance of Reflexes in Horses. Front Neurosci 2020; 14:570372. [PMID: 33122992 PMCID: PMC7571265 DOI: 10.3389/fnins.2020.570372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/27/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction Transcranial electrical (TES) and magnetic stimulation (TMS) are both used for assessment of the motor function of the spinal cord in horses. Muscular motor evoked potentials (mMEP) were compared intra-individually for both techniques in five healthy horses. mMEPs were measured twice at increasing stimulation intensity steps over the extensor carpi radialis (ECR), tibialis cranialis (TC), and caninus muscles. Significance was set at p < 0.05. To support the hypothesis that both techniques induce extracranially elicited mMEPs, literature was also reviewed. Results Both techniques show the presence of late mMEPs below the transcranial threshold appearing as extracranially elicited startle responses. The occurrence of these late mMEPs is especially important for interpretation of TMS tracings when coil misalignment can have an additional influence. Mean transcranial motor latency times (MLT; synaptic delays included) and conduction velocities (CV) of the ECR and TC were significantly different between both techniques: respectively, 4.2 and 5.5 ms (MLT TMS --MLT TES ), and -7.7 and -9.9 m/s (CV TMS -CV TES ). TMS and TES show intensity-dependent latency decreases of, respectively, -2.6 (ECR) and -2.7 ms (TC)/30% magnetic intensity and -2.6 (ECR) and -3.2 (TC) ms/30V. When compared to TMS, TES shows the lowest coefficients of variation and highest reproducibility and accuracy for MLTs. This is ascribed to the fact that TES activates a lower number of cascaded interneurons, allows for multipulse stimulation, has an absence of coil repositioning errors, and has less sensitivity for varying degrees of background muscle tonus. Real axonal conduction times and conduction velocities are most closely approximated by TES. Conclusion Both intracranial and extracranial mMEPs inevitably carry characteristics of brainstem reflexes. To avoid false interpretations, transcranial mMEPs can be identified by a stepwise latency shortening of 15-20 ms when exceeding the transcranial motor threshold at increasing stimulation intensities. A ring block around the vertex is advised to reduce interference by extracranial mMEPs. mMEPs reflect the functional integrity of the route along the brainstem nuclei, extrapyramidal motor tracts, propriospinal neurons, and motoneurons. The corticospinal tract appears subordinate in horses. TMS and TES are interchangeable for assessing the functional integrity of motor functions of the spinal cord. However, TES reveals significantly shorter MLTs, higher conduction velocities, and better reproducibility.
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Affiliation(s)
- Sanne Lotte Journée
- Equine Diagnostics, Wyns, Netherlands.,Department of Virology, Parasitology and Immunology, Research Group of Comparative Physiology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Henricus Louis Journée
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Orthopedics, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Department of Orthopedics, University Medical Center Amsterdam, Amsterdam, Netherlands
| | - Hanneke Irene Berends
- Department of Orthopedics, University Medical Center Amsterdam, Amsterdam, Netherlands
| | - Steven Michael Reed
- Rood & Riddle Equine Hospital, Lexington, KY, United States.,M.H. Gluck Equine Research Center, Department of Veterinary Science, University of Kentucky, Lexington KY, United States
| | | | - Cathérine John Ghislaine Delesalle
- Department of Virology, Parasitology and Immunology, Research Group of Comparative Physiology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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Shigematsu H, Kawaguchi M, Hayashi H, Takatani T, Iwata E, Tanaka M, Okuda A, Morimoto Y, Masuda K, Yamamoto Y, Tanaka Y. Post-tetanic transcranial motor evoked potentials augment the amplitude of compound muscle action potentials recorded from innervated and non-innervated muscles. Spine J 2018; 18:740-746. [PMID: 28870837 DOI: 10.1016/j.spinee.2017.08.249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/03/2017] [Accepted: 08/29/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Transcranial electrical stimulation used to produce motor evoked potentials (TES-MEPs) and subsequent compound muscle action potential (CMAP) recording is widely used to monitor motor function during surgery when there is risk of damaging the spinal cord. Nonetheless, some muscles do not produce CMAP amplitudes sufficient for intraoperative monitoring. PURPOSE This study aimed to investigate the utility of tetanic stimulation at single and multiple peripheral nerve sites for augmenting CMAP amplitudes recorded from innervated and non-innervated muscles. STUDY DESIGN/SETTING A retrospective study was carried out. PATIENT SAMPLE The study sample comprised 24 patients with cervical myelopathy who underwent decompression surgery at our department between November 2005 and March 2007. OUTCOME MEASURES Compound muscle action potential amplitude was a physiological measure. METHODS We used two patterns of tetanic peripheral nerve stimulation for each patient. The first pattern consisted of tetanic stimulation of the left tibial nerve only (Pattern 1), and the second pattern consisted of tetanic stimulation of the bilateral median nerves and left tibial nerve (Pattern 2). RESULTS Compound muscle action potential amplitudes from all muscles were augmented by both tetanic stimulation patterns compared with conventional TES-MEP recording; however, Pattern 2 elicited the greatest augmentation of CMAP amplitudes, especially for CMAPs recorded from the bilateral abductor pollicis brevis muscles. CONCLUSIONS Although tetanic stimulation of a single peripheral nerve increased CMAP amplitudes recorded from both innervated and non-innervated muscles, CMAP amplitudes were best augmented when the corresponding nerve received tetanic stimulation. Additionally, tetanic stimulation of multiple nerves rather than a single nerve appears to provide better augmentation.
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Affiliation(s)
- Hideki Shigematsu
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan.
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Hironobu Hayashi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Eiichiro Iwata
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Masato Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Akinori Okuda
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Yasuhiko Morimoto
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Keisuke Masuda
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Yusuke Yamamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 6348522, Japan
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Ushio S, Kawabata S, Sumiya S, Kato T, Yoshii T, Yamada T, Enomoto M, Okawa A. A multi-train electrical stimulation protocol facilitates transcranial electrical motor evoked potentials and increases induction rate and reproducibility even in patients with preoperative neurological deficits. J Clin Monit Comput 2017; 32:549-558. [PMID: 28710663 DOI: 10.1007/s10877-017-0045-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 07/11/2017] [Indexed: 11/28/2022]
Abstract
This study sought to evaluate the facilitation effect of repetitive multi-train transcranial electrical stimulation (mt-TES) at 2 repetition rates on transcranial electrical motor evoked potential (Tc-MEP) monitoring during spinal surgery, and to assess the induction rate in patients with impaired motor function from a compromised spinal cord or spinal nerve. We studied 32 consecutive patients with impaired motor function undergoing cervical or thoracic spinal surgery (470 muscles). A series of 10 TESs with 5 pulse trains were preoperatively delivered at 2 repetition rates (1 and 5 Hz). All peak-topeak amplitudes of the MEPs of the upper and lower extremity muscles elicited by the 10 TESs were measured. The induction rates of the lower extremity muscles were also assessed with muscle and preoperative lower extremity motor function scores. In each of the muscles, MEP amplitudes were augmented by about 2-3 times at 1 Hz and 5-6 times at 5 Hz. Under the 5-Hz condition, all limb muscles showed significant amplification. Also, in all preoperative motor function score groups, the amplitudes and induction rates of the lower extremity muscles were significantly increased. Moreover, the facilitation effects tended to peak in the last half of the series of 10 TESs. In all score groups of patients with preoperative neurological deficits, repetitive mt-TES delivered at a frequency of 5 Hz markedly facilitated the MEPs of all limb muscles and increased the induction rate. We recommend this method to improve the reliability of intraoperative monitoring during spinal surgery.
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Affiliation(s)
- Shuta Ushio
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan. .,Department of Advanced Technology of Medicine, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Shigenori Kawabata
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,Department of Advanced Technology of Medicine, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Satoshi Sumiya
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tsuyoshi Kato
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tsuyoshi Yamada
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Mitsuhiro Enomoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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The Percentage of Amplitude Decrease Warning Criteria for Transcranial MEP Monitoring. J Clin Neurophysiol 2017; 34:22-31. [DOI: 10.1097/wnp.0000000000000338] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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15
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Legatt AD, Emerson RG, Epstein CM, MacDonald DB, Deletis V, Bravo RJ, López JR. ACNS Guideline: Transcranial Electrical Stimulation Motor Evoked Potential Monitoring. J Clin Neurophysiol 2016; 33:42-50. [PMID: 26756258 DOI: 10.1097/wnp.0000000000000253] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Alan D Legatt
- *Departments of Neurology, Neuroscience, and Internal Medicine (Critical Care Medicine), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, U.S.A.; †Department of Neurology, Hospital for Special Surgery, New York, New York, U.S.A.; ‡Department of Neurology, Emory University School of Medicine and the Emory Brain Health Center, Atlanta, Georgia, U.S.A.; §Section of Clinical Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; ‖Laboratory for Human Experimental Neurophysiology, School of Medicine, University of Split, Split, Croatia; ¶Neurophysiology Services, Palomar Medical Center, South Gate, California, U.S.A.; and #Departments of Neurology & Neurological Sciences and Neurosurgery, Stanford University School of Medicine, Stanford, California, U.S.A
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Skinner S. An elegant new test of corticospinal tract function during surgery: More work to be done. Clin Neurophysiol 2016; 127:3376-7. [PMID: 27590207 DOI: 10.1016/j.clinph.2016.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/18/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Stan Skinner
- Abbott Northwestern Hospital, Neurophysiology Department, 800 E 28th Street, Suite 304, Minneapolis, MN 55407, USA.
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Andrews JC, Stein RB, Jones KE, Hedden DM, Mahood JK, Moreau MJ, Huang EM, Roy FD. Intraoperative spinal cord monitoring using low intensity transcranial stimulation to remove post-activation depression of the H-reflex. Clin Neurophysiol 2016; 127:3378-84. [PMID: 27590206 DOI: 10.1016/j.clinph.2016.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/20/2016] [Accepted: 08/10/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate whether low intensity transcranial electrical stimulation (TES) can be used to condition post-activation depression of the H-reflex and simultaneously monitor the integrity of spinal motor pathways during spinal deformity correction surgery. METHODS In 20 pediatric patients undergoing corrective surgery for spinal deformity, post-activation depression of the medial gastrocnemius H-reflex was initiated by delivering two pulses 50-125ms apart, and the second H-reflex was conditioned by TES. RESULTS Low intensity TES caused no visible shoulder or trunk movements during 19/20 procedures and the stimulation reduced post-activation depression of the H-reflex. The interaction was present in 20/20 patients and did not diminish throughout the surgical period. In one case, the conditioning effect was lost within minutes of the disappearance of the lower extremity motor evoked potentials. CONCLUSION Post-activation depression was used to detect the arrival of a subthreshold motor evoked potential at the lower motor neuron. The interaction produced minimal movement within the surgical field and remained stable throughout the surgical period. SIGNIFICANCE This is the first use of post-activation depression during intraoperative neurophysiological monitoring to directly assess the integrity of descending spinal motor pathways.
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Affiliation(s)
- Jennifer C Andrews
- Department of Physiology, University of Alberta, Edmonton, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Richard B Stein
- Department of Physiology, University of Alberta, Edmonton, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Kelvin E Jones
- Department of Physical Education and Recreation, University of Alberta, Edmonton, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | | | - James K Mahood
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, Canada
| | - Marc J Moreau
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, Canada
| | - Eric M Huang
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, Canada
| | - François D Roy
- Department of Surgery, University of Alberta, Edmonton, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada.
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Wang S, Zhang J, Tian Y, Shen J. Rare true-positive outcome of spinal cord monitoring in patients under age 4 years. Spine J 2016; 16:1090-4. [PMID: 27179624 DOI: 10.1016/j.spinee.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/05/2016] [Accepted: 05/07/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intraoperative monitoring (IOM) is becoming an essential component in spinal surgery, but there are many different viewpoints about it in patients under age 4 years. PURPOSE This study aims to report some IOM features in children under age 4 years. DESIGN/SETTING This is a retrospective cases study. PATIENT SAMPLE A total of 37 children (35.76 months±1.47) and 120 patients with adolescent idiopathic scoliosis (AIS, 14.2 years) were recruited between September 2012 and December 2014. OUTCOME MEASURES Relevant monitoring changes were identified as transcranial motor evoked potentials (MEP) or somatosensory evoked potentials (SEP) loss associated with high-risk surgical maneuvers. METHODS Motor evoked potential, SEP, and free-run electromyography (free-run EMG) were used for IOM. The IOM parameters (amplitude, latency, and waveform) and monitoring outcomes (signal changes, true positive, and false positive) were mainly analyzed in the patients under age 4 years. RESULTS All young patients presented stable MEP (90.6 µV±20.3) and SEP (1.01 µV±0.3) baseline. The baseline success rate (100%) was the same as that in patients with AIS; however, the MEP amplitude of young patients was significantly lower than that of patients with AIS (90.6 µV±20.3 vs. 312.1 µV±25.2, n=120; **p<.01) under the same stimulus parameters. Moreover, children under age 4 years have more monitoring changes (18.9%, 7 of 37), but true-positive findings are rare (0%) in our population. CONCLUSIONS Intraoperative monitoring baseline can be obtained satisfactorily in children under age 4 years, but true-positive findings are rare; meanwhile, low MEP amplitude and poor waveforms are common.
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Affiliation(s)
- Shujie Wang
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China.
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China.
| | - Ye Tian
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
| | - Jianxiong Shen
- Department of Orthopedics, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
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Lim SH, Park SK, Han HT. Effective Motor Evoked Potential Waveforms in Patients with Lower Extremity Weakness. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2016. [DOI: 10.15324/kjcls.2016.48.1.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung-Hyuk Lim
- Department of Neurology, Samsung Medical Center, Seoul 06351, Korea
| | - Sang-Ku Park
- Department of Neurology, Samsung Medical Center, Seoul 06351, Korea
| | - Hung-Tae Han
- Department of Neurology, Samsung Medical Center, Seoul 06351, Korea
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Lee JM, Kim DH, Kim HS, Choi BK, Han IH. The Applicability of Intraoperative Neuromonitoring in Patients with Preoperative Motor Weakness during Spine Surgery. KOREAN JOURNAL OF SPINE 2016; 13:9-12. [PMID: 27123024 PMCID: PMC4844661 DOI: 10.14245/kjs.2016.13.1.9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of our study is to evaluate the success rate and feasibility of intraoperative neuromonitoring (IONM) focusing on transcranial motor evoked potential (TcMEP) monitoring for patients with preoperative motor weakness in spine surgery. METHODS Between November 2011 and December 2013, TcMEP and somatosensory evoked potential (SSEP) monitoring were attempted in 130 consecutive patients undergoing spine surgeries for cervical or thoracic cord lesions. Patients ranged in age from 14 to 81 years (mean±standard deviation, 56.7±14.8 years), and 84 patients were male. The success rates of both SSEP and MEPs monitoring were assessed according to the preoperative Medical Research Council (MRC) and Nurick grades. RESULTS TcMEP was recorded successfully in 0%, 28.6%, 72.3%, and 100% of patients with MRC grades 1, 2, 3, 4, and 5, respectively. SSEP was obtained from 0%, 37.5%, 21.5%, 61.4%, and 85.4% of patients with MRC grades 1, 2, 3, 4, and 5, respectively. TcMEP was recorded successfully in 84% of patients with Nurick grades 1-3 and 26% of patients with Nurick grades 4-5. SSEPs were recorded successfully in 76.3% of patients with Nurick grades 1-3 and 24% of patients with grades 4-5. CONCLUSION IONM during spine surgery may be useless in patients with MRC grades 1-2, applicable MRC grade 3, and useful MRC grades 4-5. MRC grade 3 is a critical point of indication for application of MEPs. In unmonitorable cases with MRC grade 3, increasing stimulus intensity or facilitation techniques may be considered to improve the usefulness of TcMEP.
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Affiliation(s)
- Jae Meen Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hwan Kim
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Hwan Soo Kim
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Byung Kwan Choi
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - In Ho Han
- Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
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Tsutsui S, Yamada H. Basic Principles and Recent Trends of Transcranial Motor Evoked Potentials in Intraoperative Neurophysiologic Monitoring. Neurol Med Chir (Tokyo) 2016; 56:451-6. [PMID: 26935781 PMCID: PMC4987444 DOI: 10.2176/nmc.ra.2015-0307] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transcranial motor evoked potentials (TcMEPs), which are muscle action potentials elicited by transcranial brain stimulation, have been the most popular method for the last decade to monitor the functional integrity of the motor system during surgery. It was originally difficult to record reliable and reproducible potentials under general anesthesia, especially when inhalation-based anesthetic agents that suppressed the firing of anterior horn neurons were used. Advances in anesthesia, including the introduction of intravenous anesthetic agents, and progress in stimulation techniques, including the use of pulse trains, improved the reliability and reproducibility of TcMEP responses. However, TcMEPs are much smaller in amplitude compared with compound muscle action potentials evoked by maximal peripheral nerve stimulation, and vary from one trial to another in clinical practice, suggesting that only a limited number of spinal motor neurons innervating the target muscle are excited in anesthetized patients. Therefore, reliable interpretation of the critical changes in TcMEPs remains difficult and controversial. Additionally, false negative cases have been occasionally encountered. Recently, several facilitative techniques using central or peripheral stimuli, preceding transcranial electrical stimulation, have been employed to achieve sufficient depolarization of motor neurons and augment TcMEP responses. These techniques might have potentials to improve the reliability of intraoperative motor pathway monitoring using TcMEPs.
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Affiliation(s)
- Shunji Tsutsui
- Department of Orthopedic Surgery, Wakayama Medical University
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Farajidavar A, Seifert JL, Delgado MR, Sparagana S, Romero-Ortega MI, Chiao JC. Electromagnetic interference in intraoperative monitoring of motor evoked potentials and a wireless solution. Med Eng Phys 2015; 38:87-96. [PMID: 26678325 DOI: 10.1016/j.medengphy.2015.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/31/2015] [Accepted: 10/18/2015] [Indexed: 11/25/2022]
Abstract
Intraoperative neurophysiological monitoring (IONM) is utilized to minimize neurological morbidity during spine surgery. Transcranial motor evoked potentials (TcMEPs) are principal IONM signals in which the motor cortex of the subject is stimulated with electrical pulses and the evoked potentials are recorded from the muscles of interest. Currently available monitoring systems require the connection of 40-60 lengthy lead wires to the patient. These wires contribute to a crowded and cluttered surgical environment, and limit the maneuverability of the surgical team. In this work, it was demonstrated that the cumbersome wired system is vulnerable to electromagnetic interference (EMI) produced by operating room (OR) equipment. It was hypothesized that eliminating the lengthy recording wires can remove the EMI induced in the IONM signals. Hence, a wireless system to acquire TcMEPs was developed and validated through bench-top and animal experiments. Side-by-side TcMEPs acquisition from the wired and wireless systems in animal experiments under controlled conditions (absence of EMI from OR equipment) showed comparable magnitudes and waveforms, thus demonstrating the fidelity in the signal acquisition of the wireless solution. The robustness of the wireless system to minimize EMI was compared with a wired-system under identical conditions. Unlike the wired-system, the wireless system was not influenced by the electromagnetic waves from the C-Arm X-ray machine and temperature management system in the OR.
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Affiliation(s)
- Aydin Farajidavar
- Department of Electrical and Computer Engineering, New York Institute of Technology, Harry Schure Hall, Room #226B, Northern Blvd., Old Westbury, New York 11568-8000, USA.
| | - Jennifer L Seifert
- Department of Bioengineering, University of Texas at Dallas, Dallas, Texas, USA
| | - Mauricio R Delgado
- Neurology Department, Texas Scottish Rite Hospital for Children, Dallas, Texas, USA; Neurology and Neurotherapeutics Department, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Steven Sparagana
- Neurology Department, Texas Scottish Rite Hospital for Children, Dallas, Texas, USA; Neurology and Neurotherapeutics Department, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | | | - J-C Chiao
- Department of Electrical Engineering, University of Texas at Arlington, Arlington, Texas, USA
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Journée SL, Journée HL, de Bruijn CM, Delesalle CJG. Design and Optimization of a Novel Method for Assessment of the Motor Function of the Spinal Cord by Multipulse Transcranial Electrical Stimulation in Horses. J Equine Vet Sci 2015. [DOI: 10.1016/j.jevs.2015.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Monitorage non invasif et sélectif des cordons postérieurs et de la voie pyramidale pendant les chirurgies du rachis et de la moelle épinière. Rev Neurol (Paris) 2015; 171:646-54. [DOI: 10.1016/j.neurol.2015.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 03/27/2015] [Accepted: 04/03/2015] [Indexed: 11/21/2022]
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Using Transcranial Magnetic Stimulation to Evaluate the Motor Pathways After an Intraoperative Spinal Cord Injury and to Predict the Recovery of Intraoperative Transcranial Electrical Motor Evoked Potentials: A Case Report. J Clin Neurophysiol 2015; 33:e8-e11. [PMID: 26061481 DOI: 10.1097/wnp.0000000000000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The authors report a case of unilateral loss of intraoperative transcranial electrical motor evoked potentials (TES MEP) associated with a spinal cord injury during scoliosis correction and the subsequent use of extraoperative transcranial magnetic stimulation to monitor the recovery of spinal cord function. The authors demonstrate the absence of TES MEPs and absent transcranial magnetic stimulation responses in the immediate postoperative period, and document the partial recovery of transcranial magnetic stimulation responses, which corresponded to partial recovery of TES MEPs. Intraoperative TES MEPs were enhanced using spatial facilitation technique, which enabled the patient to undergo further surgery to stabilize the spine and correct her scoliosis. This case report supports evidence of the use of extraoperative transcranial magnetic stimulation to predict the presence of intraoperative TES responses and demonstrates the usefulness of spatial facilitation to monitor TES MEPs in a patient with a preexisting spinal cord injury.
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Tsutsui S, Iwasaki H, Yamada H, Hashizume H, Minamide A, Nakagawa Y, Nishi H, Yoshida M. Augmentation of motor evoked potentials using multi-train transcranial electrical stimulation in intraoperative neurophysiologic monitoring during spinal surgery. J Clin Monit Comput 2014; 29:35-9. [PMID: 24532184 DOI: 10.1007/s10877-014-9565-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 02/12/2014] [Indexed: 11/30/2022]
Abstract
Transcranial motor evoked potentials (TcMEPs) are widely used to monitor motor function during spinal surgery. Improvements in transcranial stimulation techniques and general anesthesia have made it possible to record reliable and reproducible potentials. However, TcMEPs are much smaller in amplitude compared with compound muscle action potentials (CMAPs) evoked by maximal peripheral nerve stimulation. In this study, multi-train transcranial electrical stimulation (mt-TES) was introduced to enhance TcMEPs, and the optimal setting of mt-TES was investigated. In 30 patients undergoing surgical correction of spinal deformities (4 males and 26 females with normal motor status; age range 11-75 years), TcMEPs from the abductor hallucis (AH) and quadriceps femoris (QF) were analyzed. A multipulse (train) stimulus with an individual pulse width of 0.5 ms and an inter-pulse interval of 2 ms was delivered repeatedly (2-7 times) at different rates (2, 5, and 10 Hz). TcMEP amplitudes increased with the number of train stimuli for AH, with the strongest facilitation observed at 5 Hz. The response amplitude increased 6.1 times on average compared with single-train transcranial electrical stimulation (st-TES). This trend was also observed in the QF. No adverse events (e.g., seizures, cardiac arrhythmias, scalp burns, accidental injury resulting from patient movement) were observed in any patients. Although several facilitative techniques using central or peripheral stimuli, preceding transcranial electrical stimulation, have been recently employed to augment TcMEPs during surgery, responses are still much smaller than CMAPs. Changing from conventional st-TES to mt-TES has potential to greatly enhance TcMEP responses.
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Affiliation(s)
- Shunji Tsutsui
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan,
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Roy FD, Bosgra D, Stein RB. Interaction of transcutaneous spinal stimulation and transcranial magnetic stimulation in human leg muscles. Exp Brain Res 2014; 232:1717-28. [PMID: 24531641 DOI: 10.1007/s00221-014-3864-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 01/29/2014] [Indexed: 12/25/2022]
Abstract
Transcutaneous spinal stimulation is a noninvasive method that can activate dorsal and/or ventral roots depending on the location and intensity of stimulation. Reflex root-evoked potentials (REPs) were studied in muscles that traditionally evoke large (soleus) and small H-reflexes (tibialis anterior), as well as muscles where H-reflexes are difficult to study (hamstrings). This study characterizes the interaction of the REP and the motor-evoked potential (MEP). Transcranial magnetic stimulation (TMS) delivered 11-25 ms before spinal stimulation resulted in more than linear summation of the two responses. Because of overlap, the modulation was quantified after subtracting the contribution of the conditioning MEP or REP. At rest, the mean-rectified soleus response was facilitated by up to ~250 μV (21-times the MEP or 161% of the REP). The increases were more reliable during a voluntary contraction (up to ~300 μV, 517% of the MEP or 181% of the REP). At the 13-ms interval, the mean-rectified response in the pre-contracted hamstrings was increased by 227% of the MEP or 300% of the REP. In some subjects, TMS could also eliminate the post-activation depression produced using two spinal stimuli, confirming that the interaction can extend to presynaptic spinal neurons. The spatiotemporal facilitation in tibialis anterior was not significant. However, the large MEP was facilitated when the spinal stimulus preceded TMS by 100-150 ms, presumably because of rebound excitation. These strong interactions may be important for inducing motor plasticity and improved training procedures for recovery after neurological damage.
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Affiliation(s)
- François D Roy
- Department of Surgery, University of Alberta, Edmonton, AB, Canada,
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Macdonald DB, Skinner S, Shils J, Yingling C. Intraoperative motor evoked potential monitoring - a position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol 2013; 124:2291-316. [PMID: 24055297 DOI: 10.1016/j.clinph.2013.07.025] [Citation(s) in RCA: 302] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 07/20/2013] [Accepted: 07/22/2013] [Indexed: 12/12/2022]
Abstract
The following intraoperative MEP recommendations can be made on the basis of current evidence and expert opinion: (1) Acquisition and interpretation should be done by qualified personnel. (2) The methods are sufficiently safe using appropriate precautions. (3) MEPs are an established practice option for cortical and subcortical mapping and for monitoring during surgeries risking motor injury in the brain, brainstem, spinal cord or facial nerve. (4) Intravenous anesthesia usually consisting of propofol and opioid is optimal for muscle MEPs. (5) Interpretation should consider limitations and confounding factors. (6) D-wave warning criteria consider amplitude reduction having no confounding factor explanation: >50% for intramedullary spinal cord tumor surgery, and >30-40% for peri-Rolandic surgery. (7) Muscle MEP warning criteria are tailored to the type of surgery and based on deterioration clearly exceeding variability with no confounding factor explanation. Disappearance is always a major criterion. Marked amplitude reduction, acute threshold elevation or morphology simplification could be additional minor or moderate spinal cord monitoring criteria depending on the type of surgery and the program's technique and experience. Major criteria for supratentorial, brainstem or facial nerve monitoring include >50% amplitude reduction when warranted by sufficient preceding response stability. Future advances could modify these recommendations.
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Affiliation(s)
- D B Macdonald
- Section of Clinical Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital & Research Center, MBC 76, PO Box 3354, Riyadh, Saudi Arabia.
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Intraoperatieve neuromonitoring bij operatie aan de wervelkolom (2). Crit Care 2012. [DOI: 10.1007/s12426-012-0095-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Sarris CE, Tomei KL, Carmel PW, Gandhi CD. Lipomyelomeningocele: pathology, treatment, and outcomes. Neurosurg Focus 2012; 33:E3. [DOI: 10.3171/2012.7.focus12224] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lipomyelomeningocele represents a rare but complex neurological disorder that may present with neurological deterioration secondary to an inherent tethered spinal cord. Radiological testing is beneficial in determining the morphology of the malformation. Specialized testing such as urodynamic studies and neurophysiological testing may be beneficial in assessing for neurological dysfunction secondary to the lipomyelomeningocele. Early surgical intervention may be beneficial in preventing further neurological decline.
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Maruta Y, Fujii M, Imoto H, Nomura S, Oka F, Goto H, Shirao S, Yoshikawa K, Yoneda H, Ideguchi M, Suehiro E, Koizumi H, Ishihara H, Kato S, Kajiwara K, Suzuki M. Intra-operative monitoring of lower extremity motor-evoked potentials by direct cortical stimulation. Clin Neurophysiol 2012; 123:1248-54. [PMID: 22104472 DOI: 10.1016/j.clinph.2011.09.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Revised: 09/09/2011] [Accepted: 09/30/2011] [Indexed: 10/15/2022]
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Yang J, Huang Z, Shu H, Chen Y, Sun X, Liu W, Dou Y, Xie C, Lin X, Hu Y. Improving successful rate of transcranial electrical motor-evoked potentials monitoring during spinal surgery in young children. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 21:980-4. [PMID: 21874623 DOI: 10.1007/s00586-011-1995-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 05/16/2011] [Accepted: 08/16/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION This prospective study was to investigate the successful rate of intraoperative motor evoked potentials (MEP) monitoring for children (<12 years old) with congenital scoliosis. MATERIALS AND METHODS A consecutive series of 27 young children (7 girls and 20 boys; from 1 to 11 years old) between September 2007 and November 2009, were enrolled to this study. 12 patients received general anesthesia based on TIVA, induced with propofol 2-4 mg/kg and fentanyl 3-5 µg/kg followed by a continuous infusion of propofol (20-150 µg/kg/min, at mean of 71.7 µg/kg/min). The other 15 patients received combined inhalation and intravenous anesthesia, induced with sevoflurane and fentanyl 3-5 µg/kg and maintained by sevoflurane (0.5-1%). The maintenance of anaesthesia management was performed with stable physiological parameters during surgery. RESULTS Intraoperative MEP monitoring was successfully performed in all patients, while SEP was successfully performed in 26 of 27 patients. There was no significant difference of successful rates between SEP and MEP monitoring (P > 0.05). As well, no difference in MEP successful rates was observed in two groups with different anesthetic techniques. No wake-up test and no post-operative neurological deficits occurred in this series of patients. CONCLUSION Low dose anesthesia by either TIVA with propofol or sevoflurane-based mixture anesthesia protocol can help the intraoperative spinal cord monitoring to successfully elicit MEP and perform reliable monitoring for patients below 12 years of age.
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Affiliation(s)
- Junlin Yang
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Hoving EW, Haitsma E, Oude Ophuis CMC, Journée HL. The value of intraoperative neurophysiological monitoring in tethered cord surgery. Childs Nerv Syst 2011; 27:1445-52. [PMID: 21538128 PMCID: PMC3155680 DOI: 10.1007/s00381-011-1471-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 04/15/2011] [Indexed: 12/24/2022]
Abstract
PURPOSE The value of intraoperative neurophysiological monitoring (IONM) with surgical detethering in dysraphic patients has been questioned. A retrospective analysis of our series of 65 patients is presented with special focus on technical set-up and outcome. METHODS All patients were diagnosed with a tethered cord (TC) due to spinal dysraphism. A high-risk group (HRG) was determined consisting of 40 patients with a lipomyelomeningocele and/or a split cord malformation sometimes in combination with a tight filum terminale. The surgical procedure was a detethering operation in all cases performed by a single surgeon during a 9-year period (1999-2008). A standard set-up of IONM was used in all patients consisting of motor-evoked potentials (MEP) evoked by transcranial electrical stimulation (TES) and electrical nerve root stimulation. In young patients, conditioning stimulation was applied in order to improve absent or weak MEPs. RESULTS IONM responses could be obtained in all patients. Postoperative deterioration of symptoms was found in two patients of whom one patient belonged to the HRG. Mean maximal follow-up of all 65 patients was 4.6 years (median 4.1 years). Long-term deterioration of symptoms was found in 6 of 65 patients with a mean follow-up of 5 years (median 5.3 years). CONCLUSION The use of IONM is feasible in all TC patients. The identification of functional nervous structures and continuous guarding of the integrity of sacral motor roots by IONM may contribute to the safety of surgical detethering.
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Affiliation(s)
- Eelco W. Hoving
- Department of Neurosurgery, University Medical Centre Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - Esther Haitsma
- Department of Neurosurgery, University Medical Centre Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - Charlotte M. C. Oude Ophuis
- Department of Neurosurgery, University Medical Centre Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - Henricus L. Journée
- Department of Neurosurgery, University Medical Centre Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
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Farajidavar A, Seifert JL, Bell JES, Seo YS, Delgado MR, Sparagana S, Romero MI, Chiao JC. A wireless system for monitoring transcranial motor evoked potentials. Ann Biomed Eng 2010; 39:517-23. [PMID: 20824343 DOI: 10.1007/s10439-010-0152-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 08/21/2010] [Indexed: 11/25/2022]
Abstract
Intraoperative neurophysiological monitoring (IONM) is commonly used as an attempt to minimize neurological morbidity from operative manipulations. The goal of IONM is to identify changes in the central and peripheral nervous system function prior to irreversible damage. Intraoperative monitoring also has been effective in localizing anatomical structures, including peripheral nerves and sensorimotor cortex, which helps guide the surgeon during dissection. As part of IONM, transcranial motor evoked potentials (TcMEPs), and somatosensory evoked potentials (SSEPs) are routinely monitored. However, current wired systems are cumbersome as the wires contribute to the crowded conditions in the operating room and in doing so not only it limits the maneuverability of the surgeon and assistants, but also places certain demand in the total anesthesia required during surgery, due to setup preoperative time needed for proper electrode placement, due to the number and length of the wires, and critical identification of the lead wires needed for stimulation and recording. To address these limitations, we have developed a wireless TcMEP IONM system as a first step toward a multimodality IONM system. Bench-top and animal experiments in rodents demonstrated that the wireless method reproduced with high fidelity, and even increased the frequency bandwidth of the TcMEP signals, compared to wired systems. This wireless system will reduce the preoperative time required for IONM setup, add convenience for surgical staff, and reduce wire-related risks for patients during the operation.
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Affiliation(s)
- Aydin Farajidavar
- Department of Bioengineering, University of Texas at Arlington, 701 S. Nedderman Dr., Arlington, TX 76019, USA.
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Intraoperative neurophysiological monitoring during complex spinal deformity cases in pediatric patients: methodology, utility, prognostication, and outcome. Childs Nerv Syst 2010; 26:523-44. [PMID: 20213189 DOI: 10.1007/s00381-010-1115-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 02/10/2010] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Complex spinal deformity (CSD) problems in pediatric patients result from a wide variety of congenital, acquired, neoplastic, or traumatic abnormalities that result in a combination of spinal deformity and spinal cord impingement. While these problems are rare, decompression, correction, instrumentation, and fusion are quite hazardous. Intraoperative neurophysiological monitoring (IONM) seems particularly beneficial in these patients. METHODOLOGY Somatosensory evoked potentials, transcranial electrical motor evoked potentials (MEPs), direct waves, and electromyography were used in a variety of CSD cases over a period when IONM was routine for most spinal cases. Examples of cases in which IONM provided important intraoperative information and significantly affected the course of the operation are illustrated. RESULTS IONM is a useful tool particularly in CSD cases in pediatric patients but requires special expertise and anesthetic considerations. Loss of MEP appears to have particularly important adverse prognostic information. Conversely, maintenance of IONM provides significant reassurance that the spinal cord function is being maintained. Preserved but persistently diminished MEPs usually predict a neurological injury that will significantly improve and possibly completely recover. Issues concerning training, certification, oversight, standardization of equipment, and technique are partially but incompletely resolved. DISCUSSION IONM is an extremely valuable tool for management of CSD pediatric patients. The utility of IONM is such and the detection of unexpected or unanticipated neurological injury frequent enough that a strong argument that it be used in every spinal surgery case can be made.
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Current World Literature. Curr Opin Anaesthesiol 2008; 21:684-93. [DOI: 10.1097/aco.0b013e328312c01b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Multimodality monitoring of the central nervous system using motor-evoked potentials. Curr Opin Anaesthesiol 2008; 21:560-4. [DOI: 10.1097/aco.0b013e32830f1fbd] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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