Intraspinal Microstimulation using Cylindrical Multielectrodes

A general framework for automatic closed-loop control of bladder voiding induced by intraspinal microstimulation in rats

Individuals with spinal cord injury or neurological disorders have problems in voiding function due to the dyssynergic contraction of the urethral sphincter. Here, we introduce a closed-loop control of intraspinal microstimulation (ISMS) for efficient bladder voiding. The strategy is based on asynchronous two-electrode ISMS with combined pulse-amplitude and pulse-frequency modulation without requiring rhizotomy, neurotomy, or high-frequency blocking. Intermittent stimulation is alternately applied to the two electrodes that are implanted in the S2 lateral ventral horn and S1 dorsal gray commissure, to excite the bladder motoneurons and to inhibit the urethral sphincter motoneurons. Asynchronous stimulation would lead to reduce the net electric field and to maximize the selective stimulation. The proposed closed-loop system attains a highly voiding efficiency of 77.2-100%, with an average of 91.28 ± 8.4%. This work represents a promising approach to the development of a natural and robust motor neuroprosthesis device for restoring bladder functions.

Functional organization of motor networks in the lumbosacral spinal cord of non-human primates

Implantable spinal-cord-neuroprostheses aiming to restore standing and walking after paralysis have been extensively studied in animal models (mainly cats) and have shown promising outcomes. This study aimed to take a critical step along the clinical translation path of these neuroprostheses, and investigated the organization of the neural networks targeted by these implants in a non-human primate. This was accomplished by advancing a microelectrode into various locations of the lumbar enlargement of the spinal cord, targeting the ventral horn of the gray matter. Microstimulation in these locations produced a variety of functional movements in the hindlimb. The resulting functional map of the spinal cord in monkeys was found to have a similar overall organization along the length of the spinal cord to that in cats. This suggests that the human spinal cord may also be organized similarly. The obtained spinal cord maps in monkeys provide important knowledge that will guide the very first testing of these implants in humans.

Effect of anesthesia on motor responses evoked by spinal neural prostheses during intraoperative procedures

OBJECTIVE

The overall goal of this study was to investigate the effects of various anesthetic protocols on the intraoperative responses to intraspinal microstimulation (ISMS). ISMS is a neuroprosthetic approach that targets the motor networks in the ventral horns of the spinal cord to restore function after spinal cord injury. In preclinical studies, ISMS in the lumbosacral enlargement produced standing and walking by activating networks controlling the hindlimb muscles. ISMS implants are placed surgically under anesthesia, and refinements in placement are made based on the evoked responses. Anesthesia can have a significant effect on the responses evoked by spinal neuroprostheses; therefore, in preparation for clinical testing of ISMS, we compared the evoked responses under a common clinical neurosurgical anesthetic protocol with those evoked under protocols commonly used in preclinical studies.

APPROACH

Experiments were conducted in seven pigs. An ISMS microelectrode array was implanted in the lumbar enlargement and responses to ISMS were measured under three anesthetic protocols: (1) isoflurane, an agent used pre-clinically and clinically, (2) total intravenous anesthesia (TIVA) with propofol as the main agent commonly used in clinical neurosurgical procedures, (3) TIVA with sodium pentobarbital, an anesthetic agent used mostly preclinically. Responses to ISMS were evaluated based on stimulation thresholds, movement kinematics, and joint torques. Motor evoked potentials (MEP) and plasma concentrations of propofol were also measured.

MAIN RESULTS

ISMS under propofol anesthesia produced large and functional responses that were not statistically different from those produced under pentobarbital anesthesia. Isoflurane, however, significantly suppressed the ISMS-evoked responses.

SIGNIFICANCE

This study demonstrated that the choice of anesthesia is critical for intraoperative assessments of motor responses evoked by spinal neuroprostheses. Propofol and pentobarbital anesthesia did not overly suppress the effects of ISMS; therefore, propofol is expected to be a suitable anesthetic agent for clinical intraoperative testing of an intraspinal neuroprosthetic system.

Intraspinal microstimulation produces over-ground walking in anesthetized cats

OBJECTIVE

Spinal cord injury causes a drastic loss of motor, sensory and autonomic function. The goal of this project was to investigate the use of intraspinal microstimulation (ISMS) for producing long distances of walking over ground. ISMS is an electrical stimulation method developed for restoring motor function by activating spinal networks below the level of an injury. It produces movements of the legs by stimulating the ventral horn of the lumbar enlargement using fine penetrating electrodes (≤50 μm diameter).

APPROACH

In each of five adult cats (4.2-5.5 kg), ISMS was applied through 16 electrodes implanted with tips targeting lamina IX in the ventral horn bilaterally. A desktop system implemented a physiologically-based control strategy that delivered different stimulation patterns through groups of electrodes to evoke walking movements with appropriate limb kinematics and forces corresponding to swing and stance. Each cat walked over an instrumented 2.9 m walkway and limb kinematics and forces were recorded.

MAIN RESULTS

Both propulsive and supportive forces were required for over-ground walking. Cumulative walking distances ranging from 609 to 835 m (longest tested) were achieved in three animals. In these three cats, the mean peak supportive force was 3.5 ± 0.6 N corresponding to full-weight-support of the hind legs, while the angular range of the hip, knee, and ankle joints were 23.1 ± 2.0°, 29.1 ± 0.2°, and 60.3 ± 5.2°, respectively. To further demonstrate the viability of ISMS for future clinical use, a prototype implantable module was successfully implemented in a subset of trials and produced comparable walking performance.

SIGNIFICANCE

By activating inherent locomotor networks within the lumbosacral spinal cord, ISMS was capable of producing bilaterally coordinated and functional over-ground walking with current amplitudes <100 μA. These exciting results suggest that ISMS may be an effective intervention for restoring functional walking after spinal cord injury.

The Fabrication, Implantation, and Stability of Intraspinal Microwire Arrays in the Spinal Cord of Cat and Rat

Intraspinal microstimulation (ISMS) is currently under investigation for its ability to restore function following spinal cord injury and aid in addressing basic investigations of the spinal cord in feline and murine (rat) models. In this report we describe the procedures for fabricating and implanting intraspinal microwires, with special emphasis on the rat model. We also report our results on targeting success and long-term stability and functionality of the implants. Early targeting with implants fabricated based on general "average" dimensions of the spinal cord was approximately 50% successful in reaching the proper targets within the ventral grey matter in cats. Improvements in insertion technique and the use of multiple contact electrodes have raised the targeting success to 100%. Furthermore, the manufacturing of ISMS arrays has been improved by the use of magnetic resonance imaging to create subject-specific implants for cats and track the location of the arrays post-implant. In the rat, our procedures have produced desirable targeting of all recovered microwires. We speculate this is due to the different targeting parameters and the shorter depth of insertion in the rat spinal cord. Although there is a heightened mechanical mismatch between the 30 μm -diameter microwires and the small rat spinal cord, chronic implantation and stimulation produce limited histological damage and do not compromise function. Furthermore, despite the increased difficulties of implanting into the smaller rat spinal cord, ISMS is effective in activating spinal cord networks in the lumbosacral enlargement in a manner that is safe, stable and reproducible.

A flexible base electrode array for intraspinal microstimulation

In this paper, we report the development of a flexible base array of penetrating electrodes which can be used to interface with the spinal cord. A customizable and feasible fabrication protocol is described. The flexible base arrays were fabricated and implanted into surrogate cords which were elongated by 12%. The resulting strains were optically measured across the cord and compared to those associated with two types of electrodes arrays (one without a base and one with a rigid base connecting the electrodes). The deformation behavior of cords implanted with the flexible base arrays resembled the behavior of cords implanted with individual microwires that were not connected through a base. The results of the strain test were used to validate a 2-D finite element model. The validated model was used to assess the stresses induced by the electrodes of the three types of arrays on the cord, and to examine how various design parameters (thickness, base modulus, etc.,) impact the mechanical behavior of the electrode array. Rigid base arrays induced higher stresses on the cord than the flexible base arrays which in turn imposed higher stresses than the individual microwire implants. The developed flexible base array showed improvement over the rigid base array; however, its stiffness needs to be further reduced to emulate the mechanical behavior of individual microwire arrays without a base.

Restoring stepping after spinal cord injury using intraspinal microstimulation and novel control strategies

The overall objective of this project is to develop a feedback-driven intraspinal microstimulation (ISMS) system. We hypothesize that ISMS will enhance the functionality of stepping by reducing muscle fatigue and producing synergistic movements by activating neural networks in the spinal cord. In the present pilot study, the controller was tested with ISMS and external sensors (force plates, gyroscopes, and accelerometers). Cats were partially supported in a sling and bi-laterally stepped overground on a 4-m instrumented walkway. The walkway had variable friction. Limb angle was controlled to within 10° even in the presence of variable friction. Peak ground reaction forces in each limb were approximately 12% of body weight (12.5% was full load bearing in this experimental setup); rarely, the total supportive force briefly decreased to as low as 4.1%. Magnetic resonance images were acquired of the excised spinal cord and the implanted array. The majority of electrodes (75%) were implanted successfully into their target regions. This represents the first successful application of ISMS for overground walking.

Spinal cord stimulation: therapeutic benefits and movement generation after spinal cord injury

Spinal cord injury (SCI) is a devastating neurological condition that leads to loss of motor and sensory function. It commonly causes impairments in limb movements, respiration, bowel and bladder function, as well as secondary complications including pain, spasticity, and pressure ulcers. Numerous interventions such as neuroprotection, regeneration, pharmacology, rehabilitation training, and functional electrical stimulation are under investigation for improving function after SCI. This chapter discusses the use of spinal cord stimulation (epidural and intraspinal electrical stimulation) for alleviating pain and spasticity, and restoring standing and walking. Epidural stimulation is effective in reducing the intensity of intractable pain, but its effectiveness in the treatment of spasticity remains unclear. It can induce rhythmic, locomotor-like movements in the legs, presumably due to the activation of afferent pathways. Intraspinal microstimulation is a new electrical stimulation approach that activates locomotor-related networks within the ventral regions of the lumbosacral spinal cord. In animals, this approach is capable of producing prolonged, fatigue-resistant standing and stepping of the hindlegs. While the results in animals have been very encouraging, technical advancements are necessary prior to its implementation in humans with SCI. Taken collectively, spinal cord stimulation holds substantial promise in restoring function after neural injury or disease.

Non-invasive method for selection of electrodes and stimulus parameters for FES applications with intrafascicular arrays

High-channel-count intrafascicular electrode arrays provide comprehensive and selective access to the peripheral nervous system. One practical difficulty in using several electrode arrays to evoke coordinated movements in paralyzed limbs is the identification of the appropriate stimulation channels and stimulus parameters to evoke desired movements. Here we present the use of a six degree-of-freedom load cell placed under the foot of a feline to characterize the muscle activation produced by three 100-electrode Utah Slanted Electrode Arrays (USEAs) implanted into the femoral nerves, sciatic nerves, and muscular branches of the sciatic nerves of three cats. Intramuscular stimulation was used to identify the endpoint force directions produced by 15 muscles of the hind limb, and these directions were used to classify the forces produced by each intrafascicular USEA electrode as flexion or extension. For 451 USEA electrodes, stimulus intensities for threshold and saturation muscle forces were identified, and the 3D direction and linearity of the force recruitment curves were determined. Further, motor unit excitation independence for 198 electrode pairs was measured using the refractory technique. This study demonstrates the utility of 3D endpoint force monitoring as a simple and non-invasive metric for characterizing the muscle-activation properties of hundreds of implanted peripheral nerve electrodes, allowing for electrode and parameter selection for neuroprosthetic applications.

Intraspinal microstimulation for the recovery of function following spinal cord injury

Spinal cord injury is a devastating neurological trauma, often resulting in the impairment of bladder, bowel, and sexual function as well as the loss of voluntary control of muscles innervated by spinal cord segments below the lesion site. Research is ongoing into several classes of therapies to restore lost function. These include the encouragement of neural sparing and regeneration of the affected tissue, and the intervention with pharmacological and rehabilitative means to improve function. This review will focus on the application of electrical current in the spinal cord in order to reactivate extant circuitry which coordinates and controls smooth and skeletal muscle below the injury. We first present a brief historical review of intraspinal microstimulation (ISMS) focusing on its use for restoring bladder function after spinal cord injury as well as its utilization as a research tool for mapping spinal cord circuits that coordinate movements. We then present a review of our own results related to the use of ISMS for restoring standing and walking movements after spinal cord injury. We discuss the mechanisms of action of ISMS and how they relate to observed functional outcomes in animal models. These include the activation of fibers-in-passage which lead to the transsynaptic spread of activation through the spinal cord and the ability of ISMS to produce fatigue-resistant, weight-bearing movements. We present our thoughts on the clinical potential for ISMS with regard to implantation techniques, stability, and damage induced by mechanical and electrical factors. We conclude by suggesting improvements in materials and techniques that are needed in preparation for a clinical proof-of-principle and review our current attempts to achieve these.

Muscle plasticity in rat following spinal transection and chronic intraspinal microstimulation

Intraspinal microstimulation (ISMS) employs electrical stimulation of the ventral grey matter to reactivate paralyzed skeletal muscle. This work evaluated the transformations in the quadriceps muscle that occurred following complete transection and chronic stimulation with ISMS or a standard nerve cuff (NCS). Stimulation was applied for 30 days, 4 h/day. Both methods induced significant increases in time-to-peak tension (ISMS 35%, NCS 25%) and half rise-time (ISMS 39%, NCS 25%) compared to intact controls (IC). Corresponding increases in type-IIA myosin heavy chain (MHC) and decreases in type-IID MHC were noted compared to IC. These results were unexpected because ISMS recruits motor units in a near-normal physiological order while NCS recruits motor units in a reversed order. Spinal cord transection and 30 days of stimulation did not alter either recruitment profile. The slope of the force recruitment curves obtained through ISMS following transection and 30 days of stimulation was similar to that obtained in intact animals, and 3.4-fold shallower than that obtained through NCS. The transformations observed in the current work are best explained by the near maximal level of motor unit recruitment, the total daily time of activity and the tonic nature of the stimulation paradigm.

Measurement of the current-distance relationship using a novel refractory interaction technique

It is important to know the spatial extent of neural activation around the stimulating electrodes when using extracellular electrical stimulation for the determination of the structure and function of neural circuit connections or for the restoration of function. The current-distance relationship quantifies the relationship between the threshold current for excitation of a neuron, I(th), and the distance between the electrode and the neuron, r, with two parameters: the offset, I(0), and the current-distance constant, k, with a quadratic equation, I(th)(r) = I(0) + kr(2). We proposed a new method to determine the parameters of the current-distance relationship, and thereby estimate the spatial extent of activation, based on the refractory interaction technique. Refractory interaction is a method that exploits the interaction between the regions of activation produced by two electrodes, when the second stimulus is delivered while neurons activated by the first electrode are in their refractory period. Computer simulations of electrical stimulation of a population of nerve fibers were used to determine the accuracy of the method. The mean relative error in k was 19% and in I(0) was 17%, and the spatial extent of stimulation could be determined with an absolute error of 19 microm and a relative error less than 11%. Subsequently, the method was applied to measure the current-distance properties of peripheral motor nerve fibers and indicated that k = 27 microA mm(-2) and I(0) = 49 microA. This method provided robust estimates of the current-distance properties, and provides a means to determine the spatial extent of activation by extracellular stimulation.

Computational evaluation of methods for measuring the spatial extent of neural activation

Knowing of the spatial extent of neural activation around extracellular stimulating electrodes is necessary to ensure that only the desired neurons are activated or to determine which neurons are responsible for an observed response. Various approaches have been used to estimate the current-distance relationship and thereby the spatial extent of activation resulting from extracellular stimulation. However, these approaches all require underlying assumptions and simplifications, and since the actual extent of activation cannot be directly measured, the impact of deviations from these assumptions cannot be determined. We implemented a computer-based model of excitation of a population of nerve fibers and used the model to evaluate a range of approaches proposed for measuring the spatial extent of neural activation. The estimates with each method were compared with measurements of the true spatial extent of activation that were accessible in the simulations to quantify the accuracy of the estimates and to determine the dependence of accuracy on measurement parameters (interelectrode distance, stimulation amplitude, noise). A newly proposed method, based on the refractory interaction technique, provided the most accurate and most robust estimates of the spatial extent of neural activation.

New functional electrical stimulation approaches to standing and walking

Spinal cord injury (SCI) is a devastating neurological trauma that is prevalent predominantly in young individuals. Several interventions in the areas of neuroregeneration, pharmacology and rehabilitation engineering/neuroscience are currently under investigation for restoring function after SCI. In this paper, we focus on the use of neuroprosthetic devices for restoring standing and ambulation as well as improving general health and wellness after SCI. Four neuroprosthetic approaches are discussed along with their demonstrated advantages and their future needs for improved clinical applicability. We first introduce surface functional electrical stimulation (FES) devices for restoring ambulation and highlight the importance of these devices for facilitating exercise activities and systemic physiological activation. Implanted muscle-based FES devices for restoring standing and walking that are currently undergoing clinical trials are then presented. The use of implanted peripheral nerve intraneural arrays of multi-site microelectrodes for providing fine and graded control of force during sit-to-stand maneuvers is subsequently demonstrated. Finally, intraspinal microstimulation (ISMS) of the lumbosacral spinal cord for restoring standing and walking is introduced and its results to date are presented. We conclude with a general discussion of the common needs of the neuroprosthetic devices presented in this paper and the improvements that may be incorporated in the future to advance their clinical utility and user satisfaction.

Intraspinal microstimulation excites multisegmental sensory afferents at lower stimulus levels than local alpha-motoneuron responses

Microstimulation within the motor regions of the spinal cord is often assumed to activate motoneurons and propriospinal neurons close to the electrode tip. However, previous work has shown that intraspinal microstimulation (ISMS) in the gray matter activates sensory afferent axons as well as alpha-motoneurons (MNs). Here we report on the recruitment of sensory afferent axons and MNs as ISMS amplitudes increased. Intraspinal microstimulation was applied through microwires implanted in the dorsal horn, intermediate region and ventral horn of the L(5)-L(7) segments of the spinal cord in four acutely decerebrated cats, two of which had been chronically spinalized. Activation of sensory axons was detected with electroneurographic recordings from dorsal roots. Activation of MNs was detected with electromyographic (EMG) recordings from hindlimb muscles. Sensory axons were nearly always activated at lower stimulus levels than MNs irrespective of the stimulating electrode location. EMG response latencies decreased as ISMS stimulus intensities increased, suggesting that MNs were first activated transsynaptically and then directly as intensity increased. ISMS elicited antidromic activity in dorsal root filaments with entry zones up to 17 mm rostral and caudal to the stimulation sites. We posit that action potentials elicited in localized terminal branches of afferents spread antidromically to all terminal branches of the afferents and transsynaptically excite MNs and interneurons far removed from the stimulation site. This may help explain how focal ISMS can activate many MNs of a muscle even though they are distributed in long thin columns.

Microfabricated cylindrical multielectrodes for neural stimulation

The effects of spinal cord injuries are likely to be ameliorated with the help of functional electrical stimulation of the spinal cord, a technique that may benefit from a new style of electrode: the cylindrical multielectrode. This paper describes the specifications for, fabrication techniques for, and in vitro evaluation of cylindrical multielectrodes. Four tip shapes were tested to determine which shape required the lowest peak force and would, therefore, be expected to minimize dimpling during implantation. The impedance of the electrode interface was monitored for changes due to insertion as well as repetitive delivery of current pulses. The charge delivery capacity was determined by testing with safe (< or = 0.6 mC/cm2) and damaging levels (> or = 0.8 mC/cm2) of charge density. The results of these tests suggest that this electrode design could be used to stimulate neurons in the ventral horn of the spinal cord.

Intraspinal microstimulation preferentially recruits fatigue-resistant muscle fibres and generates gradual force in rat

Intraspinal microstimulation (ISMS), a novel rehabilitative therapy consisting of stimulation through fine, hair-like microwires targeted at the ventral spinal cord, has been proposed for restoring standing and walking following spinal cord injury. This study compared muscle recruitment characteristics of ISMS with those produced by peripheral nerve cuff stimulation (NCS). Thirty-three minutes of either ISMS or NCS at 1, 20 or 50 s(-1) and 1.2 x threshold (T) amplitude depleted glycogen from muscle fibres of vastus lateralis and rectus femoris. ISMS and NCS were also carried out at 20 s(-1) and 3.0T. Muscle serial sections were stained for glycogen and for myosin heavy chain (MHC)-based fibre types using a panel of monoclonal antibodies. The results of this study show that ISMS recruited fatigue-resistant (FR) fibres at 2.9, 1.9, 1.7 and 2.5 times their relative MHC content at 1, 20 and 50 s(-1) 1.2T and 20 s(-1) 3.0T, respectively. In contrast, NCS recruited FR fibres at 1.2, 1.0, 2.1 and 0.0 times their MHC content at 1, 20 and 50 s(-1) 1.2T and 20 s(-1) 3.0T, respectively. The proportion of FR fibres recruited by ISMS and NCS was significantly different in the 20 s(-1) 3.0T condition (P < 0.0001). We also report that force recruitment curves were 4.9-fold less steep (P < 0.019) for ISMS than NCS. The findings of this study provide evidence for the efficacy of ISMS and further our understanding of muscle recruitment properties of this novel rehabilitative therapy.