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McIntosh JR, Joiner EF, Goldberg JL, Murray LM, Yasin B, Mendiratta A, Karceski SC, Thuet E, Modik O, Shelkov E, Lombardi JM, Sardar ZM, Lehman RA, Mandigo C, Riew KD, Harel NY, Virk MS, Carmel JB. Intraoperative electrical stimulation of the human dorsal spinal cord reveals a map of arm and hand muscle responses. J Neurophysiol 2023; 129:66-82. [PMID: 36417309 PMCID: PMC9799146 DOI: 10.1152/jn.00235.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although epidural stimulation of the lumbar spinal cord has emerged as a powerful modality for recovery of movement, how it should be targeted to the cervical spinal cord to activate arm and hand muscles is not well understood, particularly in humans. We sought to map muscle responses to posterior epidural cervical spinal cord stimulation in humans. We hypothesized that lateral stimulation over the dorsal root entry zone would be most effective and responses would be strongest in the muscles innervated by the stimulated segment. Twenty-six people undergoing clinically indicated cervical spine surgery consented to mapping of motor responses. During surgery, stimulation was performed in midline and lateral positions at multiple exposed segments; six arm and three leg muscles were recorded on each side of the body. Across all segments and muscles tested, lateral stimulation produced stronger muscle responses than midline despite similar latency and shape of responses. Muscles innervated at a cervical segment had the largest responses from stimulation at that segment, but responses were also observed in muscles innervated at other cervical segments and in leg muscles. The cervical responses were clustered in rostral (C4-C6) and caudal (C7-T1) cervical segments. Strong responses to lateral stimulation are likely due to the proximity of stimulation to afferent axons. Small changes in response sizes to stimulation of adjacent cervical segments argue for local circuit integration, and distant muscle responses suggest activation of long propriospinal connections. This map can help guide cervical stimulation to improve arm and hand function.NEW & NOTEWORTHY A map of muscle responses to cervical epidural stimulation during clinically indicated surgery revealed strongest activation when stimulating laterally compared to midline and revealed differences to be weaker than expected across different segments. In contrast, waveform shapes and latencies were most similar when stimulating midline and laterally, indicating activation of overlapping circuitry. Thus, a map of the cervical spinal cord reveals organization and may help guide stimulation to activate arm and hand muscles strongly and selectively.
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Affiliation(s)
- James R. McIntosh
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Evan F. Joiner
- 2Department of Neurological Surgery, Columbia University, New York, New York
| | - Jacob L. Goldberg
- 4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Lynda M. Murray
- 8Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York,9James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Bushra Yasin
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Anil Mendiratta
- 3Department of Neurology, Columbia University, New York, New York
| | - Steven C. Karceski
- 5Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Earl Thuet
- 6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Oleg Modik
- 5Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Evgeny Shelkov
- 5Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Joseph M. Lombardi
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Zeeshan M. Sardar
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Ronald A. Lehman
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Christopher Mandigo
- 2Department of Neurological Surgery, Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - K. Daniel Riew
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Noam Y. Harel
- 7Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York,8Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York,9James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Michael S. Virk
- 4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Jason B. Carmel
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,3Department of Neurology, Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
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Taylor C, McHugh C, Mockler D, Minogue C, Reilly RB, Fleming N. Transcutaneous spinal cord stimulation and motor responses in individuals with spinal cord injury: A methodological review. PLoS One 2021; 16:e0260166. [PMID: 34793572 PMCID: PMC8601579 DOI: 10.1371/journal.pone.0260166] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/03/2021] [Indexed: 11/18/2022] Open
Abstract
Background Transcutaneous spinal cord stimulation (tSCS) is a non-invasive modality in which electrodes can stimulate spinal circuitries and facilitate a motor response. This review aimed to evaluate the methodology of studies using tSCS to generate motor activity in persons with spinal cord injury (SCI) and to appraise the quality of included trials. Methods A systematic search for studies published until May 2021 was made of the following databases: EMBASE, Medline (Ovid) and Web of Science. Two reviewers independently screened the studies, extracted the data, and evaluated the quality of included trials. The electrical characteristics of stimulation were summarised to allow for comparison across studies. In addition, the surface electromyography (EMG) recording methods were evaluated. Results A total of 3753 articles were initially screened, of which 25 met the criteria for inclusion. Studies were divided into those using tSCS for neurophysiological investigations of reflex responses (n = 9) and therapeutic investigations of motor recovery (n = 16). The overall quality of evidence was deemed to be poor-to-fair (10.5 ± 4.9) based on the Downs and Black Quality Checklist criteria. The electrical characteristics were collated to establish the dosage range across stimulation trials. The methods employed by included studies relating to stimulation parameters and outcome measurement varied extensively, although some trends are beginning to appear in relation to electrode configuration and EMG outcomes. Conclusion This review outlines the parameters currently employed for tSCS of the cervicothoracic and thoracolumbar regions to produce motor responses. However, to establish standardised procedures for neurophysiological assessments and therapeutic investigations of tSCS, further high-quality investigations are required, ideally utilizing consistent electrophysiological recording methods, and reporting common characteristics of the electrical stimulation administered.
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Affiliation(s)
- Clare Taylor
- Department of Anatomy, School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
- * E-mail:
| | - Conor McHugh
- Department of Anatomy, School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
| | - David Mockler
- John Stearne Medical Library, Trinity Centre for Health Sciences, School of Medicine, St. James’s Hospital, Dublin, Ireland
| | - Conor Minogue
- Department of Anatomy, School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
| | - Richard B. Reilly
- Trinity Centre for Biomedical Engineering, Trinity College, The University of Dublin, Dublin, Ireland
- School of Engineering, Trinity College, The University of Dublin, Dublin, Ireland
- School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
| | - Neil Fleming
- Department of Anatomy, School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
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Wu YK, Levine JM, Wecht JR, Maher MT, LiMonta JM, Saeed S, Santiago TM, Bailey E, Kastuar S, Guber KS, Yung L, Weir JP, Carmel JB, Harel NY. Posteroanterior cervical transcutaneous spinal stimulation targets ventral and dorsal nerve roots. Clin Neurophysiol 2019; 131:451-460. [PMID: 31887616 DOI: 10.1016/j.clinph.2019.11.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/24/2019] [Accepted: 11/17/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We aim to non-invasively facilitate activation of spared neural circuits after cervical spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). We developed and tested a novel configuration for cervical transcutaneous spinal stimulation (cTSS). METHODS cTSS was delivered via electrodes placed over the midline at ~T2-T4 levels posteriorly and ~C4-C5 levels anteriorly. Electromyographic responses were measured in arm and hand muscles across a range of stimulus intensities. Double-pulse experiments were performed to assess homosynaptic post-activation depression (PAD). Safety was closely monitored. RESULTS More than 170 cTSS sessions were conducted without major safety or tolerability issues. A cathode-posterior, 2 ms biphasic waveform provided optimal stimulation characteristics. Bilateral upper extremity muscle responses were easily obtained in subjects with SCI and ALS. Resting motor threshold at the abductor pollicis brevis muscle ranged from 5.5 to 51.0 mA. As stimulus intensity increased, response latencies to all muscles decreased. PAD was incomplete at lower stimulus intensities, and decreased at higher stimulus intensities. CONCLUSIONS Posteroanterior cTSS has the capability to target motor neurons both trans-synaptically via large-diameter afferents and non-synaptically via efferent motor axons. SIGNIFICANCE Posteroanterior cTSS is well tolerated and easily activates upper extremity muscles in individuals with SCI and ALS.
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Affiliation(s)
- Yu-Kuang Wu
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Jonah M Levine
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Jaclyn R Wecht
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Matthew T Maher
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - James M LiMonta
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Sana Saeed
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Tiffany M Santiago
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Eric Bailey
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Shivani Kastuar
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Kenneth S Guber
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Lok Yung
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
| | - Joseph P Weir
- University of Kansas, 1301 Sunnyside Avenue, Lawrence, KS 66045, USA
| | - Jason B Carmel
- Columbia University, 650 West 168th Street, New York, NY 10032, USA
| | - Noam Y Harel
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
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