"Real-Time Neuromonitoring" Increases the Safety and Non-Invasiveness and Shortens the Duration of Idiopathic Scoliosis Surgery.

Introduction: A practical solution to the incidental unreliability of intraoperative neuromonitoring (IONM) may be the simultaneous neurophysiological recording and control of the surgical field through a camera (the concept of "Real-time" IONM). During "Real-time" IONM, the surgeon is immediately warned about the possibility of damage to the neural structures during, but not after, standard idiopathic scoliosis (IS) corrective surgery procedures (the concept of "Surgeon-neurophysiologist" interactive, verbal IONM). This study aimed to compare the advantages, utilities, reliabilities, and time consumption of the two IONM scenarios. Methods: Studies were performed in two similar groups of patients undergoing surgery primarily due to Lenke 2 idiopathic scoliosis (N = 120), when both IONM approaches were applied. Neurophysiological evaluations of the spinal transmission were performed pre- (T0), intra- (before (T1) and after (T2) surgery), and postoperatively (T3), as well as once in healthy volunteers (control, N = 60). Non-invasive and innovative recordings of the motor evoked potentials (MEPs) bilaterally from the peroneal (PER) nerve and tibialis anterior (TA) muscle were performed with surface electrodes as a result of transcranial magnetic stimulation (TMS) or electrical stimulation (TES) at T0-T3. Results: In both groups, the MEP amplitudes and latencies recorded from the PER nerve were approximately 67% lower and 3.1 ms shorter than those recorded from the TA muscle. The MEP recording parameters differed similarly at T0-T3 compared to the control group. In all patients, the MEP parameters induced by TMS (T0) and TES (T1) did not differ. The MEP amplitude parameters recorded from the TA and PER at T1 and T2 indicated a bilateral improvement in the neural spinal conduction due to the surgical intervention. The TMS-induced MEP amplitude at T3 further increased bilaterally. In both IONM groups, an average 51.8 BIS level of anesthesia did not affect the variability in the MEP amplitude, especially in the PER recordings when the applied TES strength was 98.2 mA. The number of fluctuations in the MEP parameters was closely related to the number of warnings from the neurophysiologist during the transpedicular screw implantation, corrective rod implantation, and distraction, derotation, and compression procedures, and it was higher in the "Surgeon-neurophysiologist" IONM group. The average duration of surgery was shorter by approximately one hour in the "Real-time" IONM group. The number of two-way communications between the surgeon and the neurophysiologist and vice versa in the "Real-time" IONM group decreased by approximately half. Conclusions: This study proves the superiority of using "Real-time" IONM over the standard "Surgeon-neurophysiologist" IONM procedure in increasing the safety and non-invasiveness, shortening the time, and lowering the costs of the surgical treatment of IS patients. The modifications of the MEP nerve-conduction-recording technology with surface electrodes from nerves enable precise and reliable information on the pediatric patient's neurological condition at every stage of the applied surgical procedures, even under conditions of slight fluctuations in anesthesia.

Comparison of Motor Evoked Potentials Neuromonitoring Following Pre- and Postoperative Transcranial Magnetic Stimulation and Intraoperative Electrical Stimulation in Patients Undergoing Surgical Correction of Idiopathic Scoliosis.

The relationships between the results of pre- and intraoperative motor evoked potential recordings during neuromonitoring and whether idiopathic scoliosis (IS) surgical correction improves the spinal efferent transmission have not been specified in detail. This study aims to compare the results of surface-recorded electromyography (EMG), electroneurography (ENG, M, and F-waves), and especially motor evoked potential (MEP) recordings from tibialis anterior muscle (TA) bilaterally in 353 girls with right idiopathic scoliosis (types 1-3 according to Lenke classification). It has not yet been documented whether the results of MEP recordings induced by transcranial single magnetic stimulus (TMS, pre- and postoperatively) and trains of electrical stimuli (TES; intraoperatively in T0-before surgery, T1-after pedicle screws implantation, and T2-after scoliosis curvature distraction and derotation following two-rod implantation) can be compared for diagnostic verification of the improvement of spinal cord neural transmission. We attempted to determine whether the constant level of optimal anesthesia during certain surgical steps of scoliosis treatment affects the parameters of MEPs recorded during neuromonitoring procedures. No neurological deficits have been observed postoperatively. The values of amplitudes but not latencies in MEP recordings evoked with TMS in IS patients compared before and after surgery indicated a slight improvement in efferent neural transmission. The results of all neurophysiological studies in IS patients were significantly asymmetrical and recorded worse on the concave side, suggesting greater neurological motor deficits at p = 0.04. The surgeries brought significant improvement (p = 0.04) in the parameters of amplitudes of sEMG recordings; however, the consequences of abnormalities in the activity of TA motor units were still reflected. ENG study results showed the symptoms of the axonal-type injury in peroneal motor fibers improving only on the concave side at p = 0.04, in parallel with F-wave parameters, which suggests that derotation and distraction might result in restoring the proper relations of the lumbar ventral roots in the spinal central canal, resembling their decompression. There were no significant differences detected in the amplitudes or latencies of MEPs induced with TMS or TES when comparing the parameters recorded preoperatively and intraoperatively in T0. The amplitudes of TES-evoked MEPs increased gradually at p = 0.04 in the subsequent periods (T1 and T2) of observation. A reduction in MEP latency at p = 0.05 was observed only at the end of the IS surgery. Studies on the possible connections between the level of anesthesia fluctuations and the required TMS stimulus strength, as well as the MEP amplitude changes measured in T0-T2, revealed a lack of relationships. These might not be the factors influencing the efferent transmission in spinal pathways beside the surgical procedures. Pre- (TMS-evoked) and intraoperative (TES-evoked) recordings are reliable for evaluating the patient's neurological status before and during surgical scoliosis correction procedures. An increase in MEP amplitude parameters recorded on both sides after scoliosis surgery proves the immediate improvement of the total efferent spinal cord transmission. Considering comparative pre- and postoperative sEMG and ENG recordings, it can be concluded that surgeries might directly result in additional lumbar ventral root decompression. We can conclude that MEP parameter changes are determined by the surgery procedures during neuromonitoring, not the anesthesia conditions if they are kept stable, which influences a decrease in the number of false-positive neuromonitoring warnings.

Comparing Parameters of Motor Potentials Recordings Evoked Transcranially with Neuroimaging Results in Patients with Incomplete Spinal Cord Injury: Assessment and Diagnostic Capabilities.

This study aimed to investigate the relationships between the different levels and degrees of incomplete spinal cord injury (iSCI) evaluated with magnetic resonance imaging (MRI) and the results of non-invasive electromyography (mcsEMG), motor-evoked potentials (MEP), and electroneurography (ENG). With a focus on patients with injuries at four different levels, C3-C5, C6-Th1, Th3-Th6, and Th7-L1, this research delved into the intricate interplay of spinal circuits and functional recovery. The study uses MEP, EMG, and ENG assessments to unveil the correlations between the MEP amplitudes and the MRI injury scores. We analysed data from 85 iSCI patients (American Spinal Injury Association-ASIA scale; ASIA C = 24, and D = 61). We compared the MRI and diagnostic neurophysiological test results performed within 1-2 months after the injury. A control group of 80 healthy volunteers was examined to establish reference values for the clinical and neurophysiological recordings. To assess the structural integrity of spinal white and grey matter on the transverse plane reconstructed from the sagittal readings, a scoring system ranging from 0 to 4 was established. The spinal cord was divided into two halves (left and right) according to the midline, and each half was further divided into two quadrants. Each quadrant was assessed separately. MEP and EMG were used to assess conduction in the corticospinal tract and the contraction properties of motor units in key muscles: abductor pollicis brevis (APB), rectus abdominis (RA), rectus femoris (RF), and extensor digitorum brevis muscles (EXT). We also used electroneurography (ENG) to assess peripheral nerve conduction and to find out whether the changes in this system significantly affect patients' scores and their neurophysiological status. The study revealed consistent positive correlations in iSCI patients between the bilateral decrease of the spinal half injury MRI scores and a decrease of the transcranially-evoked MEP amplitudes, highlighting the complex relationship between neural pathways and functional outcomes. Positive correlations are notably pronounced in the C3-C5, C6-Th1, and Th3-Th6 subgroups (mostly rs 0.5 and above with p < 0.05), while Th7-L1 presents distinct patterns (rs less than 0.5 and p being statistically insignificant) potentially influenced by unique structural compensation mechanisms. We also revealed statistically significant relationships between the decrease of the cumulative mcsEMG and MEP amplitudes and the cumulative ENG scores. These insights shed light on the multifaceted interactions between spinal cord injury levels, structural damage, neurophysiological measures, and motor function outcomes. Further research is warranted to unravel the intricate mechanisms driving these correlations and their implications for enhancing functional recovery and the rehabilitation algorithms in patients with iSCI.

Delayed Surgical Treatment in Patients with Chronic Carpal Tunnel Syndrome Is Still Effective in the Improvement of Hand Function.

Background and Objectives: Severe carpal tunnel syndrome (CTS) is the most common compression neuropathy in the upper extremities treated conservatively; later, when advanced, CTS is treated mostly surgically. The most prevalent symptoms comprise numbness, as well as sensation loss in the thumb, index, and middle finger, and thenar muscle strength loss, resulting in impaired daily functioning for patients. Data on the results of CTS treatment in patients with delayed surgical intervention are scarce. The aim of this study was to determine the postoperative results of chronic carpal tunnel syndrome treatment in patients with symptoms lasting for at least 5 years. Materials and Methods: A total of 86 patients (69 females, 17 males) with a mean age of 58 years reporting symptoms of CTS for at least 5 years (mean: 8.5 years) were prospectively studied. The average follow-up time was 33 months. All patients underwent the surgical open decompression of the median nerve at the wrist. A preoperative observation was composed of an interview and a clinical examination. The subjects completed the DASH (the Disabilities of the Arm, Shoulder, and Hand), PRWE (Patient-Rated Wrist Evaluation), and self-report questionnaires. Global grip strength, sensory discrimination, characteristic symptoms of CTS, and thenar muscle atrophy were examined. Postoperatively, clinical and functional examinations were repeated, and patients expressed their opinions by completing a BCTQ (Boston Carpal Tunnel Syndrome Questionnaire). Results: We found improvements in daily activities and hand function postoperatively. Overall, 88% of patients were satisfied with the outcome of surgery. DASH scores decreased after surgery from 44.82 to 14.12 at p < 0.001. PRWE questionnaire scores decreased from 53.34 to 15.19 at p < 0.001. The mean score of the BCTQ on the scale regarding the severity of symptoms was 1.48 and 1.62 on the scale regarding function after surgery. No significant differences were found in the scores between the male and female groups or between age groups (p > 0.05). A significant increase in global grip strength from 16.61 kg to 21.91 kg was observed postoperatively at p < 0.001. No significant difference was detected in the measurement of sensory discrimination (6.02 vs. 5.44). In most of the examined patients, night numbness and wrist pain subsided after surgery at p < 0.001. Thenar muscle atrophy diminished after surgery at p < 0.001. Conclusions: Most patients were satisfied with the results of CTS surgery regarding the open decompression of the median nerve even after 5 years of ineffective conservative treatment. Significant improvement of the hand function was confirmed in the functional studies.

End-to-Side vs. Free Graft Nerve Reconstruction-Experimental Study on Rats.

The long history of regeneration nerve research indicates many clinical problems with surgical reconstruction to be resolved. One of the promising surgical techniques in specific clinical conditions is end-to-side neurorrhaphy (ETS), described and then repeated with different efficiency in the 1990s of the twentieth century. There are no reliable data on the quality of recipient nerve regeneration, possible donor nerve damage, and epineural window technique necessary to be performed. This research attempts to evaluate the possible regeneration after end-to-side neurorrhaphy, its quality, potential donor nerve damage, and the influence of epineural windows on regeneration efficiency. Forty-five female Wistar rats were divided into three equal groups, and various surgical technics were applied: A-ETS without epineural window, B-ETS with epineural window, and C-free graft reconstruction. The right peroneal nerve was operated on, and the tibial nerve was selected as a donor. After 24 weeks, the regeneration was evaluated by (1) footprint analysis every two weeks with PFI (peroneal nerve function index), TFI (tibial nerve function index), and SFI (sciatic nerve function index) calculations; (2) the amplitude and latency measurements of motor evoked potentials parameters recorded on both sides of the peroneal and tibial nerves when electroneurography with direct sciatic nerve electrical stimulation and indirect magnetic stimulation were applied; (3) histomorphometry with digital conversion of a transverse semithin nerve section, with axon count, fibers diameter, and calculation of axon area with a semiautomated method were performed. There was no statistically significant difference between the groups investigated in all the parameters. The functional indexes stabilized after eight weeks (PFI) and six weeks (TFI and SFI) and were positively time related. The lower amplitude of tibial nerve potential in groups A and B was proven compared to the non-operated side. Neurophysiological parameters of the peroneal nerve did not differ significantly. Histomorphometry revealed significantly lower diameter and area of axons in operated peroneal nerves compared to non-operated nerves. The axon count was at a normal level in every group. Tibial nerve parameters did not differ from non-operated values. Regeneration of the peroneal nerve after ETS was ascertained to be at the same level as in the case of free graft reconstruction. Peroneal nerves after ETS and free graft reconstruction were ascertained to have a lower diameter and area than non-operated ones. The technique of an epineural window does not influence the regeneration result of the peroneal nerve. The tibial nerve motor evoked potentials were characterized by lower amplitudes in ETS groups, which could indicate axonal impairment.

Temporary Occlusion of Common Carotid Arteries Does Not Evoke Total Inhibition in the Activity of Corticospinal Tract Neurons in Experimental Conditions.

Temporary occlusion of the common cervical artery is the reason for ischemic stroke in 25% of patients. Little data is provided on its effects, especially regarding neurophysiological studies verifying the neural efferent transmission within fibers of the corticospinal tract in experimental conditions. Studies were performed on 42 male Wistar rats. In 10 rats, ischemic stroke was evoked by permanent occlusion of the right carotid artery (group A); in 11 rats, by its permanent bilateral occlusion (B); in 10 rats, by unilateral occlusion and releasing after 5 min (C); and in 11 rats, by bilateral occlusion and releasing after 5 min (D). Efferent transmission of the corticospinal tract was verified by motor evoked potential (MEP) recordings from the sciatic nerve after transcranial magnetic stimulation. MEPs amplitude and latency parameters, oral measurements of temperature, and verification of ischemic effects in brain slides stained with hematoxylin and eosin staining (H + E) were analyzed. In all groups of animals, the results showed that five minutes of uni- or bilateral occlusion of the common carotid artery led to alterations in brain blood circulation and evoked changes in MEP amplitude (by 23.2% on average) and latency parameters (by 0.7 ms on average), reflecting the partial inability of tract fibers to transmit neural impulses. These abnormalities were associated with a significant drop in the body temperature by 1.5 °C on average. Ten minutes occlusion in animals from groups A and B resulted in an MEP amplitude decrease by 41.6%, latency increase by 0.9 ms, and temperature decrease by 2.9 °C of the initial value. In animals from groups C and D, five minutes of recovery of arterial blood flow evoked stabilization of the MEP amplitude by 23.4%, latency by 0.5 ms, and temperature by 0.8 °C of the initial value. In histological studies, the results showed that ischemia was most prominent bilaterally in sensory and motor areas, mainly for the forelimb, rather than the hindlimb, innervation of the cortex, putamen and caudate nuclei, globulus pallidus, and areas adjacent to the fornix of the third ventricle. We found that the MEP amplitude parameter is more sensitive than the latency and temperature variability in monitoring the ischemia effects course following common carotid artery infarction, although all parameters are correlated with each other. Temporary five-minute lasting occlusion of common carotid arteries does not evoke total and permanent inhibition in the activity of corticospinal tract neurons in experimental conditions. The symptoms of rat brain infarction are much more optimistic than those described in patients after stroke, and require further comparison with the clinical observations.

The Role of Transcranial Magnetic Stimulation, Peripheral Electrotherapy, and Neurophysiology Tests for Managing Incomplete Spinal Cord Injury.

Efforts to find therapeutic methods that support spinal cord functional regeneration continue to be desirable. Natural recovery is limited, so high hopes are being placed on neuromodulation methods which promote neuroplasticity, such as repetitive transcranial magnetic stimulation (rTMS) and electrical stimulation used as treatment options for managing incomplete spinal cord injury (iSCI) apart from kinesiotherapy. However, there is still no agreement on the methodology and algorithms for treatment with these methods. The search for effective therapy is also hampered by the use of different, often subjective in nature, evaluation methods and difficulties in assessing the actual results of the therapy versus the phenomenon of spontaneous spinal cord regeneration. In this study, an analysis was performed on the database of five trials, and the cumulative data are presented. Participants (iSCI patients) were divided into five groups on the basis of the treatment they had received: rTMS and kinesiotherapy (N = 36), peripheral electrotherapy and kinesiotherapy (N = 65), kinesiotherapy alone (N = 55), rTMS only (N = 34), and peripheral electrotherapy mainly (N = 53). We present changes in amplitudes and frequencies of the motor units' action potentials recorded by surface electromyography (sEMG) from the tibialis anterior-the index muscle for the lower extremity and the percentage of improvement in sEMG results before and after the applied therapies. The increase in values in sEMG parameters represents the better ability of motor units to recruit and, thus, improvement of neural efferent transmission. Our results indicate that peripheral electrotherapy provides a higher percentage of neurophysiological improvement than rTMS; however, the use of any of these additional stimulation methods (rTMS or peripheral electrotherapy) provided better results than the use of kinesiotherapy alone. The best improvement of tibialis anterior motor units' activity in iSCI patients provided the application of electrotherapy conjoined with kinesiotherapy and rTMS conjoined with kinesiotherapy. We also undertook a review of the current literature to identify and summarise available works which address the use of rTMS or peripheral electrotherapy as neuromodulation treatment options in patients after iSCI. Our goal is to encourage other clinicians to implement both types of stimulation into the neurorehabilitation program for subjects after iSCI and evaluate their effectiveness with neurophysiological tests such as sEMG so further results and algorithms can be compared across studies. Facilitating the motor rehabilitation process by combining two rehabilitation procedures together was confirmed.

Neurophysiological Evaluation of Neural Transmission in Brachial Plexus Motor Fibers with the Use of Magnetic versus Electrical Stimuli.

The anatomical complexity of brachial plexus injury requires specialized in-depth diagnostics. The clinical examination should include clinical neurophysiology tests, especially with reference to the proximal part, with innovative devices used as sources of precise functional diagnostics. However, the principles and clinical usefulness of this technique are not fully described. The aim of this study was to reinvestigate the clinical usefulness of motor evoked potential (MEP) induced by a magnetic field applied over the vertebrae and at Erb's point to assess the neural transmission of brachial plexus motor fibers. Seventy-five volunteer subjects were randomly chosen to participate in the research. The clinical studies included an evaluation of the upper extremity sensory perception in dermatomes C5-C8 based on von Frey's tactile monofilament method, and proximal and distal muscle strength by Lovett's scale. Finally, 42 healthy people met the inclusion criteria. Magnetic and electrical stimuli were applied to assess the motor function of the peripheral nerves of the upper extremity and magnetic stimulus was applied to study the neural transmission from the C5-C8 spinal roots. The parameters of compound muscle action potential (CMAP) recorded during electroneurography and MEP induced by magnetic stimulation were analyzed. Because the conduction parameters for the groups of women and men were comparable, the final statistical analysis covered 84 tests. The parameters of the potentials generated by electrical stimulus were comparable to those of the potentials induced by magnetic impulse at Erb's point. The amplitude of the CMAP was significantly higher following electrical stimulation than that of the MEP following magnetic stimulation for all the examined nerves, in the range of 3-7%. The differences in the potential latency values evaluated in CMAP and MEP did not exceed 5%. The results show a significantly higher amplitude of potentials after stimulation of the cervical roots compared to potentials evoked at Erb's point (C5, C6 level). At the C8 level, the amplitude was lower than the potentials evoked at Erb's point, varying in the range of 9-16%. We conclude that magnetic field stimulation enables the recording of the supramaximal potential, similar to that evoked by an electric impulse, which is a novel result. Both types of excitation can be used interchangeably during an examination, which is essential for clinical application. Magnetic stimulation was painless in comparison with electrical stimulation according to the results of a pain visual analog scale (3 vs. 5.5 on average). MEP studies with advanced sensor technology allow evaluation of the proximal part of the peripheral motor pathway (between the cervical root level and Erb's point, and via trunks of the brachial plexus to the target muscles) following the application of stimulus over the vertebrae.

The Usefulness of Motor Potentials Evoked Transvertebrally at Lumbar Levels for the Evaluation of Peroneal Nerve Regeneration after Experimental Repair in Rats.

Motor evoked potentials (MEPs) are used in neurology as part of a precise diagnostic method to study the transmission of efferent neural impulses at the central and peripheral levels of the nervous system. Previous attempts have been made to apply MEPs in animal studies for evaluating neural transmission at the motor cortex center level to the muscles of the forelimbs and hindlimbs. In clinical and experimental studies, little attention is focused on the significance of the magnetic stimulation of spinal cord structures with the direct recording of the evoked potentials from peripheral nerve motor fibers. The aim of this paper was to evaluate the usefulness of the motor potentials evoked transvertebrally at lumbar levels in the evaluation of experimental peroneal nerve regeneration in rats. The bilateral transmission of efferent impulses in the distal parts of the peroneal and tibial nerves was verified by recordings of evoked potentials following transvertebral magnetic stimulation at lumbar levels (MEPs) and the electrical stimulation of the sciatic nerve in classical electroneurographic (ENG) tests for comparison. Recordings were performed 24 weeks after grafts on surgically treated hindlimbs as well as on non-operated hindlimbs as controls. Both the MEP and ENG stimulations resulted in evoked potentials with larger amplitude values following the application of the magnetic pulses, with more being recorded on the non-operated hindlimbs than on the operated ones when recordings were taken from peroneal nerve branches. We observed statistically significant correlations between the MEP and ENG results for peroneal and tibial nerve amplitude on the non-operated side and peroneal nerve amplitude on the operated side. The recorded latencies of the evoked potentials were shorter in the ENG studies than in the MEPs for the non-operated side. The results demonstrated the phenomenon of regeneration in the motor fibers of the peroneal nerves 24 weeks after grafting in the experimental conditions. In this study, the MEPs were as useful as the ENG studies for evaluating regeneration in the motor fibers of hindlimb nerves in rats, although they were not significantly different. This paper discusses the clinical importance of transvertebral MEPs induced at the lumbosacral and cervical levels with a magnetic field for the diagnostic evaluation of efferent impulse transmission at different levels of the motor pathway.

Update on neuromonitoring procedures applied during surgery of the spine - observational study.

Introduction: Motor evoked potentials (MEPs) are currently considered as a more useful method for neurophysiological intraoperative monitoring than somatosensory evoked potentials in cases of surgery applied to patients with adolescent idiopathic scoliosis. The non-invasive approach is preferred to modify MEP recordings, criticizing, in many cases, the fundamentalism for neurophysiological monitoring based only on needle recordings. The aim of the review is to provide our own experience and practical guidelines with reference to neuromonitoring innovations. Material and methods: Recordings of MEPs with surface electrodes instead of needle electrodes including nerve instead of muscle combinations during neurophysiological monitoring associated with surgical interventions to the spine have become more relevant for pediatric purposes, avoiding the anesthesiology-related influences. Observations on 280 patients with Lenke A-C types of spine curvature are presented before and after the surgical correction. Results: The MEPs recorded from nerves do not undergo fluctuations at different stages of scoliosis corrections and the anesthesia effect more than MEPs recorded from muscles. The use of non-invasive surface electrodes during neuromonitoring for MEP recordings shortens the total time of the surgical procedure without diminishing the precision of the neural transmission evaluation. The quality of MEP recordings during intraoperative neuromonitoring from muscles can be significantly influenced by the depth of anesthesia or administration of muscle relaxants but not those recorded from nerves. Conclusions: The proposed definition of "real-time" neuromonitoring comprises the immediate warning from a neurophysiologist about the changes in a patient's neurological status during scoliosis surgery (especially during pedicle screws' implantation, corrective rods' implantation, correction, distraction and derotation of the spine curvature) exactly during the successive steps of corrective procedures. This is possible due to the simultaneous observation of MEP recordings and a camera image of the surgical field. This procedure clearly increases safety and limits financial claims resulting from possible complications.

Motor evoked potentials recorded from muscles versus nerves after lumbar stimulation in healthy subjects and patients with disc-root conflicts.

OBJECTIVE: The study aimed to describe properties and to prove diagnostic usefulness of motor evoked potentials (MEPs) recordings from muscles versus nerves of lower extremities when induced at lumbar levels with magnetic field. METHODS: Methodologically similar MEPs recordings from muscles and nerves of lower extremities were performed once in healthy volunteers (N = 43) and patients with disc-root conflicts at lumbar spine levels (N = 43, proven in MRI studies). Simultaneous electroneurographic (ENG) recordings following stimulation of peroneal nerves verified neural impulses transmission in motor fibers peripherally and at L5 ventral roots. RESULTS: ENG studies in patients proven only moderate axonal type of peroneal nerves injury. The mean values of MEPs amplitudes recorded from nerves were significantly different from those recorded in anatomically related muscles, both in controls (1179.6 ± 451.2 vs 1718.3 ± 481.3) and patients (495.6 ± 275.9 vs 1218.2 ± 465.5) (p = 0.0009-0.0000012); they are about 30% and 51% smaller, respectively. In both groups of subjects, latencies of MEPs recorded from nerves were shorter at about 3.0 ms and characterized by a slightly longer duration (3.0-5.0 ms) than those recorded from muscles. Results revealed positive correlations between decrease of amplitudes in sEMG and MEPs recordings from lower extremities muscles indicating consequences of pathology in neural transmission from spinal centers. CONCLUSIONS: Results of this study point to clear-cut characteristics of MEPs induced oververtebrally with the magnetic field in parameters recorded in healthy subjects and patients with consequences of chronic L4-L5 low back pain, which can be easily implemented in clinical practice. Non-invasive method of MEPs recorded from nerves can be helpful for diagnosing of patients with visible atrophic changes in muscles and simultaneous symptoms of only slight pathology in transmission of nerve impulses peripherally.

Monitoring of the pharmacological treatment availability in patients with multiple sclerosis in the Greater Poland population.

Introduction: There is no clear explanation for the availability of multiple sclerosis (MS) pharmacological treatment for patients in Greater Poland and it can be assumed that the same reason is common in most of the developed countries in the United Europe. As an autoimmune disease MS can overlap with other diseases especially rheumatic disease (RD) as well as some feature of RD may mimic MS, such as MS-like syndrome in the course of primary Sjögren's syndrome. Therefore proper diagnosis and sufficient treatment of MS is important not only for neurologists but also for other clinicians including rheumatologists.The study aims to provide insights that could help healthcare managers create more effective logistical guidelines to improve the timely initiation of pharmacological treatment for MS. Materials and methods: The analysis of the treatment of MS patients has been conducted on a group of 500 patients who were under the management of one healthcare center in Greater Poland. Results: The results point to the different factors influencing the delay in the undertaking the pharmacological treatment, among others the age of the patient, waiting time for clinical evaluation and the final diagnosis from first symptoms to diagnosis, and the patient's waiting time from diagnosis to referral for qualification for treatment. Conclusions: The outcomes of this study have the potential to serve as a valuable resource for healthcare managers. The study's findings could be used as a foundation for developing logistical guidelines aimed at enhancing the pharmacological treatment of MS patients.Furthermore, the study suggests that the reasons behind treatment delays in MS patients might be prevalent in many countries across the United Europe region. However, it's important to note that confirming this conclusion requires additional comparative studies.

Relationships between the Clinical Test Results and Neurophysiological Findings in Patients with Thoracic Outlet Syndrome.

A thoracic outlet syndrome (TOS) is the type of brachial plexus disorder most difficult to objectively assess using a clinical examination and differential diagnosis. Its symptoms can be frequently misdiagnosed, especially among others with cervical disc-root conflicts, plexopathies, and peripheral neuropathies. In this study, we aim to identify the correlations between positive Doppler ultrasonography results indicating pathological changes in the subclavian flow velocity, clinical tests, and chosen clinical neurophysiology recordings as proposed alternative or supplementary diagnostic tools for evaluating TOS patients. Sixty TOS patients with positive Doppler ultrasonography and Roos test results and sixty healthy people as a control group were bilaterally examined, and the results were compared. Pain intensity was assessed using a visual analogue scale (VAS). Sensory perceptions within C4-C8 dermatomes were assessed with Von Frey filament (FvF) tests. The activity of motor units in the proximal and distal muscles of the upper extremities was evaluated using surface electromyography (sEMG) during maximal contractions before and after a provocative raised hands test (RHT). An electroneurography (ENG) was used to evaluate the transmission of nerve impulses peripherally. Motor evoked potential (MEP) recordings, induced by the over-vertebral magnetic stimulation of the C5-C7 neuromeres, were used to examine motor transmissions from the cervical motor centres to the upper extremities muscles. The results revealed a relationship between positive Doppler test scores and pathological changes in the subclavian flow velocity through the results of the following diagnostic tools: a VAS score of 1.9 was detected on average, superficial sensory perception abnormalities were found in the innervation areas of the ulnar nerves detected by FvF tests, a decrease in the amplitudes of sEMG recordings was seen in distal rather than proximal muscles (especially following the RHT), a decrease in the motor and sensory peripheral transmissions of nerve impulses in the median, ulnar and cutaneous anterobrachial median nerves was seen, as well as MEP amplitudes recorded from the abductor pollicis brevis muscle. The provocative RHT combined with sEMG and MEP recordings can be considered accurate and objective clinical neurophysiology tools that could supplement the commonly used clinical tests. Such an approach may result in a more precise neurogenic TOS diagnostic algorithm.

Speech arrest by repetitive Transcranial Magnetic Stimulation - does it still work? Old experiences with new improvements.

BACKGROUND: Traditional repetitive Transcranial Magnetic Stimulation (rTMS) remains applicable in speech studies on healthy participants. Although the procedure of inducing speech arrest by rTMS has been used for over 25 years, there are still significant discrepancies in its methodology. OBJECTIVE: The study aimed to simplify and improve the old methodology of triggering speech arrest by (rTMS). Our goal was to establish the best step-by-step algorithm and verify the procedure on a representative group of participants. METHODS: 47 healthy, right-handed volunteers (23 men and 24 women) at a median age of 23 (range 19-34) were included in the study. Handedness was determined using the Edinburgh Handedness Inventory Test. After setting the individual's motor threshold (MT) and heuristic choice of the place of stimulation, which targeted Inferior Frontal Gyrus (IFG), participants were asked to count downwards from 20 to 10. While counting, a series of 2-second pulses was generated at a frequency of 2 Hz at 120% or 150% of MT. The procedure was video-recorded and subsequently assessed by 3 independent reviewers and self-assessed by participants on visual analogue scales for the effect and comfort of stimulation. RESULTS: Speech arrest was induced in 45 people (95.7%). Language dominance was determined to be either left-sided (for 42.2%) or bilateral (55.3%). Total speech arrest was observed more often in participants for whom Broca's area was active exclusively in the left hemisphere. CONCLUSION: In our study, we present the step-by-step procedure for a simplified, as far as possible, methodology of inducing speech arrest using rTMS with its verification on a representative group of right-handed healthy individuals. Our results prove that the chosen stimulation parameters present a good efficacy ratio and seems to be justified. The traditional applications of rTMS in speech studies may be highly broadened if the methods used are further improved and simplified.

Results of a long-term uniform system of neurorehabilitation in patients with incomplete thoracic spinal cord injury.

INTRODUCTION AND OBJECTIVE: The results of kinesiotherapy treatment in patients after incomplete spinal cord injury (iSCI) are inconclusive, mostly due to different, subjective evaluation methods. The study aims to evaluate the range of functional regeneration in long-term 13 months follow-up using comparative neurophysiological tests after uniform kinesiotherapy in patients with thoracic iSCI. MATERIAL AND METHODS: Comparative tests were performed of sensory perception in dermatomes Th1-S1, electromyography (at rest-rEMG and during maximal contraction-mcEMG) in the muscles of the trunk and lower extremities, electroneurography (ENG) of the motor fibres of the lower extremities, and motor-evoked potential induced transcranially (MEP) before and after treatment in 25 iSCI patients. All subjects were treated with the same kinesiotherapeutic procedures. RESULTS: A moderate increase was found in amplitudes in rEMG and mcEMG recordings fromthe rectus abdominis and rectus femoris muscles, MEPs amplitudes, and amplitudes after peroneal nerve stimulations in ENG studies. There was no improvement in sensory perception. CONCLUSIONS: Following the proposed kinesiotherapy algorithm, patients after thoracic iSCI presented a moderate more motor than sensory functions improvement. Applied neurorehabilitation evoked normalization of muscle tension, moderate improvement of rectus abdominis and rectus femoris muscles motor units activity, and motor central and peripheral neural impulses transmission. The comparative neurophysiological assessment provide a more precise and objective insight into the functional status of afferent and efferent systems than the classical clinical approach in iSCI patients.

Electroneurographic Evaluation of Neural Impulse Transmission in Patients after Ischemic Stroke Following Functional Electrical Stimulation of Antagonistic Muscles at Wrist and Ankle in Two-Month Follow-Up.

The available data from electroneurography (ENG) studies on the transmission of neural impulses in the motor fibers of upper and lower extremity nerves following neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy in post-stroke patients during sixty-day observation do not provide convincing results. This study aims to compare the effectiveness of an NMFES of antagonistic muscle groups at the wrist and ankle and kinesiotherapy based mainly on proprioceptive neuromuscular facilitation (PNF). An ENG was performed once in a group of 60 healthy volunteers and three times in 120 patients after stroke (T0, up to 7 days after the incident; T1, after 21 days of treatment; and T2, after 60 days of treatment); 60 subjects received personalized NMFES and PNF treatment (NMFES+K), while the other 60 received only PNF (K). An ENG studied peripheral (M-wave recordings), C8 and L5 ventral root (F-wave recordings) neural impulse transmission in the peroneal and the ulnar nerves on the hemiparetic side. Both groups statistically differed in their amplitudes of M-wave recording parameters after peroneal nerve stimulation performed at T0 and T2 compared with the control group. After 60 days of treatment, only the patients from the NMFES+K group showed significant improvement in M-wave recordings. The application of the proposed NMFES electrostimulation algorithm combined with PNF improved the peripheral neural transmission in peroneal but not ulnar motor nerve fibers in patients after ischemic stroke. Combined kinesiotherapy and safe, personalized, controlled electrotherapy after stroke give better results than kinesiotherapy alone.

Post-Stroke Treatment with Neuromuscular Functional Electrostimulation of Antagonistic Muscles and Kinesiotherapy Evaluated with Electromyography and Clinical Studies in a Two-Month Follow-Up.

The aim of this study was to determine the sustained influence of personalized neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy (mainly, proprioceptive neuromuscular facilitation (PNF)) on the activity of muscle motor units acting antagonistically at the wrist and the ankle in a large population of post-stroke patients. Clinical evaluations of spasticity (Ashworth scale), manual muscle testing (Lovett scale), and surface electromyography recordings at rest (rEMG) and during attempts of maximal muscle contraction (mcEMG) were performed three times in 120 post-stroke patients (T0: up to 7 days after the incidence; T1: after 21 days of treatment; T2: after 60 days of treatment). Patients (N = 120) were divided into two subgroups-60 patients received personalized NMFES and PNF treatment (NMFES+K), and the other 60 received only PNF (K). The NMFES+K therapy resulted in a decrease in spasticity and an increase in muscle strength of mainly flexor muscles, in comparison with the K group. A positive correlation between the increase of rEMG amplitudes and high Ashworth scale scores and a positive correlation between low amplitudes of mcEMG and low Lovett scale scores were found in the wrist flexors and calf muscles on the paretic side. Negative correlations were found between the rEMG and mcEMG amplitudes in the recordings. The five-grade alternate activity score of the antagonists' actions improved in the NMFES+K group. These improvements in the results of controlled NMFES treatment combined with PNF in patients having experienced an ischemic stroke, in comparison to the use of kinesiotherapy alone, might justify the application of conjoined rehabilitation procedures based on neurophysiological approaches. Considering the results of clinical and neurophysiological studies, we suppose that NMFES of the antagonistic muscle groups acting at the wrist and the ankle may evoke its positive effects in post-stroke patients by the modulation of the activity more in the spinal motor centers, including the level of Ia inhibitory neurons, than only at the muscular level.

The Long-Term Effect of Treatment Using the Transcranial Magnetic Stimulation rTMS in Patients after Incomplete Cervical or Thoracic Spinal Cord Injury.

Repetitive transcranial magnetic stimulation (rTMS) may support motor function recovery in patients with incomplete spinal cord injury (iSCI). Its effectiveness mainly depends on the applied algorithm. This clinical and neurophysiological study aimed to assess the effectiveness of high-frequency rTMS in iSCI patients at the C2-Th12 levels. rTMS sessions (lasting 3-5 per month, from 2 to 11 months, 5 months on average) were applied to 26 iSCI subjects. The motor cortex was bilaterally stimulated with a frequency at 20-25 Hz and a stimulus strength that was 70-80% of the resting motor threshold (15.4-45.5% maximal output) during one therapeutic session. Surface electromyography (sEMG) recordings at rest and during maximal contractions and motor evoked potential (MEP) recordings were performed from the abductor pollicis brevis (APB) and the tibialis anterior (TA) muscles. The same neurophysiological studies were also performed in patients treated with kinesiotherapy only (K group, n = 25) and compared with patients treated with both kinesiotherapy and rTMS (K + rTMS). A decrease in sEMG amplitudes recorded at rest from the APB muscles (p = 0.001) and an increase in sEMG amplitudes during the maximal contraction of the APB (p = 0.001) and TA (p = 0.009) muscles were found in the K + rTMS group. A comparison of data from MEP studies recorded from both APB and TA muscles showed significant changes in the mean amplitudes but not in latencies, suggesting a slight improvement in the transmission of spinal efferent pathways from the motor cortex to the lower spinal centers. The application of rTMS at 20-25 Hz reduced spasticity in the upper extremity muscles, improved the recruitment of motor units in the upper and lower extremity muscles, and slightly improved the transmission of efferent neural impulses within the spinal pathways in patients with C2-Th12 iSCI. Neurophysiological recordings produced significantly better parameters in the K + rTMS group of patients after therapy. These results may support the hypothesis about the importance of rTMS therapy and possible involvement of the residual efferent pathways including propriospinal neurons in the recovery of the motor control of iSCI patients.

Treatment of patients with cervical and upper thoracic incomplete spinal cord injury using repetitive transcranial magnetic stimulation.

PURPOSE: To evaluate the short- and long-term effectiveness of repetitive transcranial magnetic stimulation with parameters based on results of comparative neurophysiological studies in patients with incomplete spinal cord injury. Results may help to understand mechanisms responsible for regeneration of the incomplete spinal cord after injury. METHODS: Repetitive transcranial magnetic stimulation sessions (three to five sessions per month for not less than 5 months) to 15 patients with C4-Th2 incomplete spinal cord injury were applied with individually designed parameters. One session consisted of bilateral stimulation of the primary motor cortex (for 10 min each with 800 stimuli in 2-s lasting trains and the inter-train intervals of 28 s) with frequency at 20-22 Hz and stimulus strength that was 70%-80% of the resting motor threshold (0.84-0.96 T). Recordings of surface electromyography at rest and during the attempt of maximal muscle contractions and motor evoked potentials were performed from abductor pollicis brevis and tibialis anterior muscles bilaterally. Amplitude parameters of surface electromyography and motor evoked potentials were used as outcomes. All neurophysiological tests were comparatively applied before and after treatment. RESULTS: Decrease in surface electromyography amplitudes recorded at rest from abductor pollicis brevis (p = 0.009), increase in surface electromyography amplitudes during maximal contraction of abductor pollicis brevis (p = 0.03) and increase in motor evoked potential parameters recorded from abductor pollicis brevis (p = 0.04) were found. CONCLUSION: Proposed repetitive transcranial magnetic stimulation algorithm reduced the increased muscle tension in upper extremity muscles, improved the function of upper extremity muscle motor units and slightly improved the transmission of efferent neural impulses within spinal pathways. Besides functional recovery in descending spinal pathways, repetitive transcranial magnetic stimulation may also inhibit inevitable pathological changes in nerves.

Early results of supervised versus unsupervised rehabilitation of patients with cervical pain.

PURPOSE: Comparison of early effects of supervised (led by physiotherapist) and unsupervised rehabilitation protocols in patients with myofascial pain syndrome, disk-root conflict and degenerative spine disease at cervical level. METHODS: Three groups of patients (n = 60 each) with clinically and neurophysiologically confirmed myofascial pain syndrome, disk-root conflict and degenerative spine disease were randomly subdivided to supervised and unsupervised treatment subgroups (n = 30 each). Thirty healthy subjects with similar demographic and anthropometric properties as patients were enrolled to control group. Patients were examined before and after rehabilitation with visual analog scale of pain, Spurling's test, painful passive elongation and active trigger points detection in trapezius muscle, sensory perception studies and surface electromyography (at rest, during maximal contraction) and electroneurography. RESULTS: Supervised treatment resulted in decrease of pain intensity (P = .001) and Spurling's symptoms incidence (P = .008) in patients from disk-root conflict group. Painful elongation and incidence of trigger points in trapezius muscle were the least observed at P = .009 after supervised therapy of myofascial pain syndrome. Supervised therapy resulted in decrease of resting electromyography amplitude and increase of maximal contraction electromyography amplitude from trapezius muscle (P = .02) in myofascial pain syndrome patients and from biceps and abductor pollicis brevis muscles of patients from other groups (P from .05 to .001). Median nerve electroneurography and sensory perception results improved at P = .05 after supervised treatment in disk-root conflict group. CONCLUSIONS: Twenty-day supervised rehabilitation provides better therapeutic effects than unsupervised one in treatment of muscle dysfunctions in patients with myofascial pain syndrome, degenerative changes and disk-root conflict at cervical spine.