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Berwal D, Quintero A, Telkes I, DiMarzio M, Harland T, Paniccioli S, Dalfino J, Iyassu Y, McLaughlin BL, Pilitsis JG. Improved Selectivity in Eliciting Evoked Electromyography Responses With High-Resolution Spinal Cord Stimulation. Neurosurgery 2024; 95:322-329. [PMID: 38376181 DOI: 10.1227/neu.0000000000002878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/29/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES As spinal cord stimulation (SCS) offers a therapy for increasing numbers of patients with chronic pain and spinal cord injury, it becomes increasingly important to better understand its somatotopy. In this prospective study, we investigate whether high-resolution SCS (HR-SCS) offers improved selectivity assessed through elicitation of evoked electromyography (EMG) responses as compared with commercial paddle leads. METHODS Vertical tripole configurations were used to elicit EMG responses in both types of paddles placed for standard-of-care indications between T6 and T10. In HR-SCS, evoked EMG responses in lower extremity/abdominal muscle groups were monitored at 6 to 8 mediolateral sites. All commercial paddle columns were tested. Percentage change in the maximum root mean square value was calculated at a group level. Heat maps were generated to identify responders for each muscle group. Responders were considered patients who had a >50% change in root mean square over baseline. RESULTS We demonstrated significantly greater motor responses across medial and lateral contacts and greater responder rates consistently at the T6 and T9 levels with HR-SCS as compared with commercial paddles in 18 patients. Distal muscle groups (gastrocnemius and tibialis anterior) and proximal muscle groups (biceps femoris and quadriceps) were selectively activated at both levels. CONCLUSION We demonstrate that HR-SCS has greater selectivity in eliciting evoked EMG responses in an intraoperative setting. HR-SCS offers recruitment of muscle groups at lateral contacts concurrently with medial contacts. We provide data that HR-SCS may provide higher spatial resolution, which has the potential to allow for personalization of care and treatment of pain syndromes/symptoms which to date have not been effectively treated.
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Affiliation(s)
- Deepak Berwal
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton , Florida , USA
| | - Alejandra Quintero
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton , Florida , USA
| | - Ilknur Telkes
- Department of Biomedical Sciences, Florida Atlantic University, Boca Raton , Florida , USA
| | - Marisa DiMarzio
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton , Florida , USA
| | - Tessa Harland
- Department of Neurosurgery, Albany Medical College, Albany , New York , USA
| | | | - John Dalfino
- Department of Neurosurgery, Albany Medical College, Albany , New York , USA
| | | | | | - Julie G Pilitsis
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton , Florida , USA
- Department of Neurosurgery, University of Arizona- Tucson, Tucson , Arizona , USA
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Berwal D, Telkes I, Agarwal S, Paniccioli S, McCarthy K, DiMarzio M, McLaughlin B, Pilitsis JG. Investigation of the intraoperative cortical responses to spinal motor mapping in a patient with chronic pain. J Neurophysiol 2023; 130:768-774. [PMID: 37609700 PMCID: PMC10649839 DOI: 10.1152/jn.00221.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/02/2023] [Accepted: 08/15/2023] [Indexed: 08/24/2023] Open
Abstract
Intraoperative neurophysiological monitoring (IONM) in spinal cord stimulation (SCS) surgery for chronic pain is shown to provide effective guidance during device placement. Electromyography (EMG) is used to determine the laterality of the paddle. In some SCS cases, laterality cannot be obtained via EMG due to patient physiology. Electroencephalography (EEG) is already used in IONM to monitor cortical responses. Here, we show proof-of-concept of assessing the responses of epidurally evoked EMGs simultaneously with EEGs to determine laterality during IONM using a high-resolution (HR) SCS paddle. An 8-column HR-SCS paddle was acutely placed at T9-T10 interspace in patients with failed back surgery syndrome. EMG signals from 18 muscle groups were recorded simultaneously with 60-channel EEG signals at various stimulation amplitudes (0-10 mA). Particular attention was paid to regions associated with pain including the somatosensory cortex (S1), prefrontal cortex (PFC), and motor cortex (M1). When left and right lateral contacts were stimulated at low amplitudes (1-2 mA), significant changes were seen in θ, α, and β powers in the contralateral PFC but not in M1 or S1. There was a significant correlation between M1 and contralateral contacts in α power. At higher currents (7-8 mA), right-sided contacts resulted in α power change. We found significant differences in α, θ, and β powers in PFC for contralateral stimulation of the lateral SCS contacts at low amplitudes and in α power at higher amplitudes. The changes in PFC suggest the potential of EEG for understanding a cortical mechanism of action of SCS and provide insight into the pathophysiology of chronic pain.NEW & NOTEWORTHY Here, we present proof of concept of assessing the responses of epidurally evoked electromyography simultaneously with scalp electroencephalography to determine whether both laterality and insights into pain mechanisms can be elucidated. With stimulation, significant changes were seen in θ, α, and β band power in the contralateral prefrontal cortex and in α power in the motor cortex. We provide insight into the mechanism of action of SCS in preventing pain in this patient.
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Affiliation(s)
- Deepak Berwal
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Ilknur Telkes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Shruti Agarwal
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | | | - Kevin McCarthy
- Nuvasive Clinical Services, San Diego, California, United States
| | - Marisa DiMarzio
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, United States
| | | | - Julie G Pilitsis
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
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Fisher LE, Lempka SF. Neurotechnology for Pain. Annu Rev Biomed Eng 2023; 25:387-412. [PMID: 37068766 DOI: 10.1146/annurev-bioeng-111022-121637] [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: 04/19/2023]
Abstract
Neurotechnologies for treating pain rely on electrical stimulation of the central or peripheral nervous system to disrupt or block pain signaling and have been commercialized to treat a variety of pain conditions. While their adoption is accelerating, neurotechnologies are still frequently viewed as a last resort, after many other treatment options have been explored. We review the pain conditions commonly treated with electrical stimulation, as well as the specific neurotechnologies used for treating those conditions. We identify barriers to adoption, including a limited understanding of mechanisms of action, inconsistent efficacy across patients, and challenges related to selectivity of stimulation and off-target side effects. We describe design improvements that have recently been implemented, as well as some cutting-edge technologies that may address the limitations of existing neurotechnologies. Addressing these challenges will accelerate adoption and change neurotechnologies from last-line to first-line treatments for people living with chronic pain.
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Affiliation(s)
- Lee E Fisher
- Rehab Neural Engineering Labs, Department of Physical Medicine and Rehabilitation, and Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA;
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Scott F Lempka
- Department of Biomedical Engineering, Biointerfaces Institute, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA;
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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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/18/2022] [Accepted: 11/21/2022] [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
- Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York
- Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Evan F Joiner
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Lynda M Murray
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Bushra Yasin
- Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York
- Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Anil Mendiratta
- Department of Neurology, Columbia University, New York, New York
| | - Steven C Karceski
- Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Earl Thuet
- New York Presbyterian, Och Spine Hospital, New York, New York
| | - Oleg Modik
- Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Evgeny Shelkov
- Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Joseph M Lombardi
- Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York
- New York Presbyterian, Och Spine Hospital, New York, New York
| | - Zeeshan M Sardar
- Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York
- New York Presbyterian, Och Spine Hospital, New York, New York
| | - Ronald A Lehman
- Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York
- New York Presbyterian, Och Spine Hospital, New York, New York
| | - Christopher Mandigo
- Department of Neurological Surgery, Columbia University, New York, New York
- New York Presbyterian, Och Spine Hospital, New York, New York
| | - K Daniel Riew
- Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York
- Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
- New York Presbyterian, Och Spine Hospital, New York, New York
| | - Noam Y Harel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Jason B Carmel
- Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York
- Department of Neurology, Columbia University, New York, New York
- Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
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