A new method for estimating spinal cord function. Refractory period of conductive spinal cord evoked potentials

STUDY DESIGN: This study was designed to examine the possibility of a new spinal cord monitoring method using measurement of the refractory period to monitor spinal cord function. OBJECTIVES: To determine whether measuring the refractory period and the recovery rate of conductive spinal cord evoked potential is a useful method for estimating spinal cord function. BACKGROUND: Measuring the refractory period and constructing the recovery curve have been used to investigate peripheral nerve function. Spinal cord evoked potential elicited by the single stimulus usually is used to evaluate spinal cord function, and it has been said that 50% attenuation of the amplitude is the critical alarm level. METHODS: In anesthetized cats, amplitude, area, and latency were measured on a personal computer from subtracted data collected with a paired-stimulation technique. The authors constructed recovery curves of ascending and descending conductive spinal cord evoked potentials and measured the refractory period during spinal cord compression. RESULTS: When the amplitude of the ascending spinal cord evoked potential began to decrease during spinal cord compression, the amplitude of the response elicited by the second stimulus with interstimulus intervals of 0.8 msec and 1.0 msec decreased more significantly. When the amplitude of the ascending spinal cord evoked potential decreased to 50% of the precompression amplitude, the mean value of the absolute refractory periods of the ascending and descending spinal cord evoked potentials became prolonged from 0.40 +/- 0.007 msec to 0.53 +/- 0.014 msec, and the mean values of their amplitude and area recovery rates decreased from 75% +/- 1% to 35% +/- 2% (interstimulus interval, 0.8 msec) and from 81% +/- 1% to 46% +/- 2% (insterstimulus interval, 1.0 msec). CONCLUSIONS: The change of the responses elicited by the paired stimuli is more sensitive than those elicited by the single stimulus in the spinal cord evoked potentials. The absolute refractory periods and the recovery rate during 50% attenuation of the precompression amplitude is the critical alarm level in spinal cord monitoring.     

Effects of distraction on physiologic integrity of the spinal cord, spinal cord blood flow, and clinical status

The authors determined the effects of distraction of the spine on physiologic integrity of the spinal cord using neurogenic motor evoked potentials (NMEPs), somatosensory evoked potentials (SEPs), spinal cord blood flow measurements, and clinical status in nine hogs. Spinal cord blood flow was measured after each level of distraction using the hydrogen washout technique. The results indicated that blood flow of at least 65% of baseline was required to maintain physiologic integrity of the spinal cord, and that a decrease of blood flow to 12% of baseline was associated with paraplegia. Neurogenic motor evoked potentials always correlated with the animal's postsurgical clinical status, whereas the SEP was falsely negative in one animal.     

Two cases of severe metabolic acidosis after monitoring of evoked spinal cord potential

Evoked spinal cord potential (ESCP) elicited by direct spinal cord stimulation has been applied to monitor the spinal cord function during spinal surgery. We report here two patients who showed excessive muscle contraction and developed severe metabolic acidosis as a result of the stimulation of spinal cord to measure ESCP. These changes were prevented by vecuronium administration prior to ESCP monitoring. These results suggest that excessive muscle contraction by direct spinal cord stimulation may lead to metabolic acidosis. In conclusion, the use of a non-depolarizing muscle relaxant is recommended to prevent the adverse effects of ESCP monitoring.     

Viscoelastic relaxation and regional blood flow response to spinal cord compression and decompression

STUDY DESIGN: To better understand the relationships between primary mechanical factors of spinal cord trauma and secondary mechanisms of injury, this study evaluated regional blood flow and somatosensory evoked potential function in an in vivo canine model with controlled velocity spinal cord displacement and real-time piston-spinal cord interface pressure feedback. OBJECTIVES: To determine the effect of regional spinal cord blood flow and viscoelastic cord relaxation on recovery of neural conduction, with and without spinal cord decompression. SUMMARY OF BACKGROUND DATA: The relative contribution of mechanical and vascular factors on spinal cord injury remains undefined. METHODS: Twelve beagles were anesthetized and underwent T13 laminectomy. A constant velocity spinal cord compression was applied using a hydraulic loading piston with a subminiature pressure transducer rigidly attached to the spinal column. Spinal cord displacement was stopped when somatosensory evoked potential amplitudes decreased by 50% (maximum compression). Six animals were decompressed 5 minutes after maximum compression and were compared with six animals who had spinal cord displacement maintained for 3 hours and were not decompressed. Regional spinal cord blood flow was measured with a fluorescent microsphere technique. RESULTS: At maximum compression, regional spinal cord blood flow at the injury site fell from 19.0 +/- 1.3 mL/100 g/min to 12.6 +/- 1.0 mL/100 g/min, whereas piston-spinal cord interface pressure was 30.5 +/- 1.8 kPa, and cord displacement measured 2.1 +/- 0.1 mm (mean +/- SE). Five minutes after the piston translation was stopped, the spinal cord interface pressure had dissipated 51%, whereas the somatosensory evoked potential amplitudes continued to decrease to 16% of baseline. In the sustained compression group, cord interface pressure relaxed to 13% of maximum within 90 minutes; however, no recovery of somatosensory evoked potential function occurred, and regional spinal cord blood flow remained significantly lower than baseline at 30 and 180 minutes after maximum compression. In the six animals that underwent spinal cord decompression, somatosensory evoked potential function and regional spinal cord blood flow recovered to baseline 30 minutes after maximum compression. CONCLUSIONS: Despite rapid cord relaxation of more than 50% within 5 minutes after maximum compression, somatosensory evoked potential conduction recovered only with early decompression. Spinal cord decompression was associated with an early recovery of regional spinal cord blood flow and somatosensory evoked potential recovery. By 3 hours, spinal cord blood flow was similar in both the compressed and decompressed groups, despite that somatosensory evoked potential recovery occurred only in the decompressed group.     

Electrophysiologic study of trace changes in the excitability of the rat spinal cord

In white rats, retention of the amplitude asymmetry of the monosynaptic reflex responses (MSRR) in the ventral roots of the spinal lumbosacral segments due to removal of half of the cerebellum, was studied. The MSRR asymmetry remained after the consequent spinal cord section at the thoracic level if it had existed over 20 min (fixation period) before this section. When tested with electric stimuli applied to the nerves of muscles-antagonists, the stable MSRR asymmetry could be unidirectional or reciprocal. Prolonged unilateral stimulation of the muscle nerve central end in the spinal rat with stimuli of different frequency and intensity evoked no MSRR amplitude asymmetry during subsequent bilateral testing of the same nerves. But in decerebrated rats the MSRR asymmetry has frequently appeared after such stimulation. Asymmetry of the reticular descending influence is supposed to play a major role in the trace stable changes of excitability of the spinal cord neuronal substrate as well as different capacities of different neurons (or their elements) for fixation and retention of such changes.     

Monitoring of evoked potentials during spinal cord ischaemia: experimental evaluation in a rabbit model

OBJECTIVES: Somatosensory evoked potentials (SEPs), spinal evoked potentials (Spinal-EPs), and motor-evoked potentials (MEPs) were monitored in a rabbit model of spinal cord ischaemia to evaluate their accuracy and relationship to clinical status. METHODS: A modified rabbit spinal cord ischaemia model of infrarenal aortic occlusion for 21 min was employed (30 rabbits). After baseline SEPs, Spinal-EPs, and MEPs were obtained, evoked potentials were recorded continuously during and after clamping of the aorta (30 min). Neurological outcome at 24 h was correlated with evoked potentials, and histopathological findings. RESULTS: Fifteen animals became paraplegic. MEPs were always abolished after clamping of the aorta while Spinal-EPs and SEPs remained. The sensory evoked potentials (SEPs and Spinal-EPs) were the least sensitive to spinal cord ischaemia, and their presence had no correlation with the final clinical status (50% of false negatives). This was consistent with histopathological examination that showed damage almost entirely confined to the anterior horn, while the dorsal columns were generally well preserved. High spine MEPs evoked by twitch stimulation was the best predictor of clinical outcome (0% of false negatives, 0% of false positives). CONCLUSIONS: SEPs and Spinal-EPs cannot be used as safe monitors of ischaemia of the spinal cord. High spine MEPs evoked by twitch stimulation was the most useful for real-time evaluation of spinal cord ischaemia, and the best predictor of neurologic outcome during reperfusion.     

Anesthesia for surgery of degenerative and abnormal cervical spine

A feature common to all congenital or inflammatory abnormalities of the cervical spine is an actual or potential reduction in the lumen of the spinal canal. The spinal cord and nerve roots are at risk. During intubation, and positioning the patient on the table, all untoward movements of the cervical spine may lead to spinal cord compression. Abnormalities of the cervical spine carry the risk of a difficult intubation. If there is much debate as to what constitutes optimum management of the airway, there is no evidence that any one method is the best. Recognizing the possible instability and intubating with care, are probably much more important in preserving neurological function than any particular mode of intubation. During maintenance of anaesthesia, the main goal is to preserve adequate spinal cord perfusion in order to prevent further damage. Spinal cord blood flow seems to be regulated by the same factors as cerebral blood flow. Hypercapnia increases cord blood flow while hypocapnia decreases it. Therefore, normocapnia or mild hypocapnia is recommended. Induced hypotension is frequently used to decrease blood loss. However, in patients with a marginally perfused spinal cord, the reduction in blood flow may cause ischaemia of the spinal cord and may therefore be relatively contraindicated. In addition to standard intraoperative monitoring, spinal cord monitoring is almost mandatory. Monitoring somatosensory evoked potentials is used routinely. However, the major limitation is that this technique only monitors dorsal column function; theoretically, motor paralysis can occur despite a lack of change in recorded signals. Neurogenic motor evoked potentials may now be used to monitor anterior spinal cord integrity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of anode-cathode configuration on paresthesia coverage in spinal cord stimulation

OBJECTIVE: To provide a theoretical basis for the selection of the anode-cathode configuration in spinal cord stimulation for the management pain when one percutaneous epidural electrode or two electrodes in parallel are used. METHODS: A computer model of spinal cord stimulation at T8-T9 was used to calculate the dorsal column areas recruited in stimulation by various configurations used in clinical practice. RESULTS: Tripolar (or bipolar) stimulation by a single electrode, symmetrically placed over the dorsal columns, recruits the largest area and will give the widest paresthesia coverage. Stimulation by two symmetrically placed electrodes connected in parallel to a single channel pulse generator may give similar results, because of their generally smaller distance from the spinal cord, but a "summation effect" does not exist. A smaller dorsal column area is activated when two offset electrodes are used. An electrode placed laterally or transverse bipolar stimulation results in unilateral, usually segmentary, paresthesia. CONCLUSIONS: The relative positions of cathodes and anodes and their distance from the spinal cord are the major determinants of dorsal column/dorsal root activation and paresthesia distribution. The large interpatient variability of the intraspinal geometry is the main cause of differences in paresthesia coverage among patients having optimally placed electrode(s). Changes of paresthesia coverage over time are more probable when multiple electrodes are used.     

Effects of caudal traction of the spinal cord on evoked spinal cord potentials in the cat

This study attempts clarify the mechanism of neurological deficits in tethered cord syndrome using evoked spinal cord potentials (ESCPs). ESCPs in response to both sciatic nerve (SN-ESCP) and spinal cord stimulation (SC-DESCP) were recorded from the dorsal epidural space. With a fixed degree of caudal traction on the spinal cord in ten cats for 2-4 hours, ESCPs were increased in amplitude in the N1 and N2 deflections of the SC-DESCPs to 158% and 154% at L5 and decreased to 91% and 76% after transient augmentation at L3. On the other hand, the amplitude in the N1 deflection of the SN-ESCPs at L3 and L5 was decreased to 40% and 68%. These findings suggest that not only the force but also the duration of traction influence the degree of the spinal cord dysfunction. When the spinal cords of 17 cats received compression with traction and without traction, the SN-ESCPs of the former became positive earlier than that of the latter. The extent of the recovery in amplitude of both SC-DESCPs and SN-ESCPs propagated over compression site was far limited in the former than in the latter. These results would indicate that the spinal cord subjected to traction is vulnerable to compression.     

A case of intrathoracic dumb-bell ganglioneuroma and a surgical approach using spinal evoked potentials (SEP)

A successfully treated case of a seven-year-old girl with a left intrathoracic Dumb-bell ganglioneuroma is reported. The tumor was 10 cm in diameter. Preoperative angiography revealed that the location of tumor was very close to the Adamkiewicz artery. In order to prevent the artery from damaging, spinal evoked potentials (SEP) was used during the surgery and was very useful for monitoring the spinal cord. Although SEP has often been employed in spine surgery, the literature on the use of it for posterior mediastinal tumor is scarce. It is considered that SEP is very useful for not damaging the feeding artery to the spinal cord, and for preventing the postoperative neurologic complications.     

Studies on vesicourethral reflexes. II. Urethral sphincteric responses to spinal cord stimulation

A bipartite bladder model was developed with and without complete muscular separation in order to isolate and analyze separately sphincteric and detrusor responses. Spinal cord stimulation of the sacral micturition center evoked responses in the detrusor compartment as well as in the urethral sphincteric compartment. The micturition center was easily definable in the spinal cord at a variable point lying in the segment L51/2 to L6 vertebral levels. It was not possible to isolate a separate detrusor center from a sphincteric center. They did overlap-with the sphincteric center extending both above and below the detrusor center. Parameters of stimulation were tested and it was noted that 1 to 3 v, frequency of 10 to 15 cps, and duration of 1 msec gave the optimal responses. Complte muscular separation did not alter sphincteric response to spinal cord stimulation. Nerve-mediated impulses resulted in rise in detrusor pressure and a simultaneous rise in urethral pressure that interfered with proper voiding and hindered bladder emptying. This problem remains to be solved before central spinal cord stimulation for the purpose of controlled bladder evacuation becomes fully effective.     

Peripheral inflammation undermines the plasticity of the isolated spinal cord.

Peripheral capsaicin treatment induces molecular changes that sensitize the responses of nociceptive neurons in the spinal dorsal horn. The current studies demonstrate that capsaicin also undermines the adaptive plasticity of the spinal cord, rendering the system incapable of learning a simple instrumental task. In these studies, male rats are transected at the second thoracic vertebra and are tested 24 to 48 hours later. During testing, subjects receive shock to one hindleg when it is extended (controllable stimulation). Rats quickly learn to maintain the leg in a flexed position. Rats that have been injected with capsaicin (1% or 3%) in the hindpaw fail to learn, even when tested on the leg contralateral to the injection. This learning deficit lasts at least 24 hours. Interestingly, training with controllable electrical stimulation prior to capsaicin administration protects the spinal cord against the maladaptive effects. Rats pretrained with controllable stimulation do not display a learning deficit or tactile allodynia. Moreover, controllable stimulation, combined with naltrexone, reverses the capsaicin-induced deficit. These data suggest that peripheral inflammation, accompanying spinal cord injuries, might have an adverse effect on recovery. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A case of idiopathic spinal cord herniation

The authors experienced a case of idiopathic spinal cord herniation with duplicated dura mater. A 63-year-old woman presented right dominant slowly progressive spastic paraplegia and dissociated sensory disturbance. Magnetic resonance imaging (MRI) demonstrated an enlarged dorsal arachnoid space associated with an apparently focally narrowed thoracic cord. The cord was kinked towards the anterior and closely applied to vertebral body at the level of Th3-4. Computed tomographic myelography (CTM) revealed homogeneous filling at dorsal arachnoid space immediately after injection and no defects. At operation multilocular arachnoid cyst and duplicated dura mater was respectively observed dorsally, and ventrally. From defected area of the inner layer, a ventral part of the spinal cord was incarcerated between the two dural layers. After rejection of arachnoid cyst and inner layer was performed, the patient recovered neurologically. Idiopathic spinal cord herniation is a rare disease that shows slowly progressive myelopathy at middle age. The herniations were observed at ventral thoracic cord in all reported cases. The mechanism of this disease is still uncertain. But at least three successive factors seem to be necessary for formation of herniation, 1) abnormal structure of the dura mater such as defect, diverticulum and duplication; 2) adhesion between the cord and the destructive dura mater, and 3) continuous cerebrospinal fluid (CSF) pressure pushing the cord outward from subdural space. In the thoracic spine, mobility is limited compared with the cervical and lumbar spine, and because of physiological curvature the cord situates rather ventrally. For these reasons the incidence of adhesion might be higher at ventral thoracic spine. Although neuroradiological imagings especially MRI and CTM were useful, operative findings were necessary for definitive diagnosis in many reported cases. Considering the effectiveness of surgical treatment, study of the ventral side of the cord should be important to avoid misdiagnosis.     

Antinociceptive action of vaginocervical stimulation in rat spinal cord: 2-DG analysis

Using [14C] 2-deoxyglucose (2-DG) autoradiography with computerized densitometric analysis, unilateral foot pinch was found to significantly increase the relative optical density in laminae I and II of the ipsilateral, compared to the contralateral, spinal cord at lumbar 5 (L5). However, during vaginocervical mechanostimulation applied concurrently with the unilateral foot pinch, no comparable difference was observed. No response to foot pinch was observed in other laminae of the spinal cord at L5, and no effects comparable to the above were observed at L3. These findings indicate that vaginocervical mechanostimulation suppresses neural responses to noxious foot pinch stimulation selectively at the laminae I and II level of the spinal cord at L5, but not at L3.     

The role of motor evoked potentials during surgery for intramedullary spinal cord tumors

OBJECTIVE: This is a prospective study of the methodology and clinical applications of motor evoked potentials (MEPs) during surgery for intramedullary spinal cord tumors. METHODS: Transcranial electrical stimulation was used to activate corticospinal motoneurons, and the traveling waves of the spinal cord were recorded through catheter-electrodes placed epi- or subdurally. Intraoperative MEP monitoring was performed in 32 consecutive patients (age range, 1-50 yr) undergoing resection of intramedullary spinal cord tumors. In 19 patients, MEPs were present before myelotomy (monitorable group), and in 10 patients, MEPs were absent before myelotomy (unmonitorable group). Placement of an epidural electrode was not possible in two patients, and technical problems prevented recording in one. RESULTS: MEP amplitudes decreased intraoperatively by more than 50% of baseline in three patients, all of whom had postoperative paraplegia. Two of these patients recovered within 1 week after surgery, and one remained paraplegic. None of the patients with preserved MEP amplitude (> 50%) sustained immediate significant postoperative deterioration. Motor function was significantly deteriorated 1 week after surgery in one patient in the monitorable group and in five patients in the unmonitorable group. MEP monitorability was significantly associated with good surgical outcome for adult patients (P < 0.05), although not for pediatric patients (P > 0.6). Preoperative motor status and surgical outcome were not significantly associated for the adult (P = 0.13) or pediatric groups (P > 0.4). CONCLUSION: MEP monitorability was a better predictor of functional outcome than the patient's preoperative motor status for the adult group. Significant predictors of MEP monitorability in the adult group were preoperative motor function (P < 0.01), history of no previous treatment (surgery or irradiation) (P < 0.01), and small tumor size (P < 0.05). Weak associations with monitorable MEPs existed for low-grade tumors (P = 0.09), the presence of baseline somatosensory evoked potentials (P = 0.10), and tumor pathological abnormalities (ependymoma) (P = 0.13). No associations were determined for sex (P > 0.4), associated syrinx (P > 0.3), or tumor location (P > 0.5). In the pediatric group, none of the examined factors were associated with MEP monitorability (P > 0.3). A decline of more than 50% in MEP amplitude during tumor removal should serve as a serious warning sign to the surgeon.     

Delayed postoperative tethering of the cervical spinal cord

Tethering of the spinal cord in the lumbar and sacral regions of children with congenital anomalies is a well-recognized problem; however, tethering in the cervical region has rarely been reported. A search of the literature revealed no reports of symptomatic postoperative cervical spinal cord tethering. The authors present five cases of delayed postoperative cervical spinal cord tethering and discuss the benefit of detethering in these patients. All five patients were young (16 to 42 years of age) at presentation. All had done well after an initial surgical procedure but returned between 1 and 31 years postoperatively with symptoms including severe headache, upper-extremity pain, and progressive neurological deficits. In each case, magnetic resonance imaging indicated dorsal tethering of the cord in the cervical region. Surgical exploration with microscopic sharp detethering of the cervical cord was performed on each patient with favorable results. To avoid retethering, wide Tutoplast duraplasty is recommended.     

Spontaneous thoracic spinal cord herniation. A case report

STUDY DESIGN: This is a case report. OBJECTIVE: To focus attention on spontaneous spinal cord herniation as a rare cause of myelopathy that can be diagnosed preoperatively and can be corrected surgically. SUMMARY OF BACKGROUND DATA: A 34-year-old woman presented with spastic paraparesis. Magnetic resonance imaging scan of the thoracic spine revealed anterior displacement and tethering of the cord at T6-T7 and a dorsal intradural arachnoid cyst. Excision of the cyst was performed without improvement in symptomatology. During reoperation the thoracic spinal cord hernia was discovered and was reduced intradurally. METHODS: The authors describe the clinical, radiographic, and surgical findings of this patient and review the findings from other reported cases. They discuss the proposed theories for the pathophysiology of the cord herniation and the surgical management. RESULTS: The patient had idiopathic thoracic spinal cord herniation as there was no history of previous spine surgery or injury. The authors believe that the cord herniated through a congenital dural defect, which resulted in the development of a pseudoarachnoid cyst dorsally to the hernia. The patient improved after intradural reduction of the hernia and closure of the dural defect. CONCLUSION: Idiopathic spinal cord herniation should be recognized as a cause of progressive myelopathy that can be managed successfully with microsurgical techniques.     

Spinal myoclonus complicating spasticity in spinal cord injury: a case study

A case of spinal myoclonus that complicated spasticity management is presented. A 37-year-old man with a C6 American Spinal Injury Association class B spinal cord injury was referred for treatment of spasticity. He had failed previous treatments with baclofen and dantrolene but was partly relieved by diazepam, although with unacceptable side effects. Further evaluation, including simultaneous electroencephalogram, videotaping, and electromyography of the quadriceps, anterior tibialis, posterior tibialis, and medial hamstring suggested myoclonic jerks of spinal origin that initiated episodes of unsustained clonus. During the worst episodes, myoclonic jerks came once every 16 to 22 seconds and persisted for 4 to 5 hours. Each episode of clonus lasted approximately 4 to 6 seconds. Treatment with valproic acid greatly diminished the frequency of myoclonic jerks with minimal side effects. Functionally, the patient was much less fatigued and better able to maintain his full time employment.     

Epidural spinal cord stimulation in the management of spasms in spinal cord injury: a prospective study

Forty-eight spinal cord injury victims were implanted with an epidural spinal cord stimulation system to treat spasms that had not satisfactorily responded to medical therapy. All the patients were at least 6 months after the injury. The protocol included assessment by independent examiners preoperatively and at 3, 6, 12 and 24 months after the implant. Pre- and postoperative data collection included the frequency and severity of the spasms. Combining the frequency and intensity scores into a 'severity' score provided a more accurate clinical picture. No patient observed neurological deterioration following the surgical procedure or the neurostimulation treatment. A statistically significant reduction in the severity of the spasms was observed in the follow-up evaluations, with results that progressively increased in time. It is appears that spinal cord stimulation is an effective and safe alternative in the management of spasms in spinal cord injury victims. Its exact role in relation to intrathecal baclofen infusion and ablative procedures remains to be defined.     

Central and peripheral actions of the NSAID ketoprofen on spinal cord nociceptive reflexes

Ketoprofen is a non-steroidal antiinflammatory drug (NSAID) which provides effective analgesia in situations of pain provoked by tissue inflammation. However, the location of its analgesic effects, (peripheral tissues versus central nervous system), have not been clearly identified and separated. In the present study the effectiveness of ketoprofen was examined in two different types of experiments: (i) Open field behavioural tests in conscious rats, and (ii) spinal cord nociceptive reflexes (single motor units) activated by electrical and thermal stimulation in chloralose anaesthetised rats. The experiments were performed in rats with carrageenan-induced inflammation of one hindpaw, or of one knee joint. The administration of ketoprofen significantly inhibited the reduction of exploratory movements caused by inflammation in open field experiments. Ketoprofen was also effective in depressing reflex activity evoked by electrical and noxious thermal stimulation of the skin, either in inflamed tissue or in normal tissue of monoarthritic animals. It was also effective in the reduction of reflex wind-up; a phenomenon in which the activity of spinal cord neurones increases progressively with high frequency electrical stimulation. We therefore conclude that ketoprofen has central as well as peripheral analgesic activity.