Faculty Bibliography

The sciatic nerve in 52 hip arthroplasties was evaluated using intraoperative somatosensory evoked potentials (SSEPs). Twenty-nine of these cases involved the lateral transtrochanteric approach, and 23 involved the posterior approach. A total of 11 incidents of SSEP changes occurred in eight patients. Six episodes occurred during lateral retraction of the proximal femur, and three occurred during anterior retraction of the proximal femur. Tracings returned to baseline with prompt cessation of femoral retraction in each case. One SSEP change occurred in a revision following reduction of the prosthetic components, and this resolved with shortening of the prosthetic neck to less than anatomic length. One change occurred during tightening of cables securing strut allografts to the femur and this resolved spontaneously. No correlation was found between frequency of SSEP changes and age, sex, limb lengthening, or preoperative range of motion. It is concluded that routine lateral or anterior retraction may place the sciatic nerve at risk

Stereotaxic ventral pallidotomy has been employed in the symptomatic treatment of patients with advanced Parkinson's disease (PD). To understand the pathophysiology of clinical outcome following this procedure, we studied 10 PD patients (5 men and 5 women; mean age 60.0 +/- 6.1 years; mean Hoehn and Yahr stage 3.8 +/- 1.0) with quantitative 18F-fluorodeoxyglucose (FDG) and positron emission tomography (PET). All patients were scanned preoperatively; 8 of 10 patients were rescanned 6 to 8 months following surgery. Clinical performance was assessed off medications before and after surgery using standardized timed motor tasks. We found that preoperative lentiform metabolism correlated significantly with improvement in contralateral motor tasks at 1 week, 3 months, and 6 months following unilateral pallidotomy (p<0.03). Postoperatively, significant metabolic increases were noted in the primary motor cortex, lateral premotor cortex, and dorsolateral prefrontal cortex (p<0.01) of the hemisphere that underwent surgery. Improvement in contralateral limb motor performance correlated significantly with surgical declines in thalamic metabolism (p<0.01) and increases in lateral frontal metabolism (p<0.05). Principal components analysis disclosed a significant covariance pattern characterized by postoperative declines in ipsilateral lentiform and thalamic metabolism associated with bilateral increase in supplementary motor control metabolism. Subject scores for this pattern correlated significantly with improvements in both contralateral and ipsilateral limb performance (p<0.005). These results suggest that pallidotomy reduced the preoperative overaction of the inhibitory pallidothalamic projection. Clinical improvement may be associated with modulations in regional brain metabolism occurring remote from the lesion site

Physiological methods such as microelectrode recording of neuronal activity and electrical stimulation of target structures can improve the safety and efficacy of certain stereotactic surgeries. The globus pallidus (GP) was electrically stimulated in 136 patients with Parkinson's disease prior to unilateral posteroventral pallidotomy to identify functional areas and prevent deficits. We found that electrical stimulation of the GP elicited two principal responses: contractions of the contralateral hand and flashing lights. The mean voltage that evoked motor responses was 4.3 V (range 1.7-9.0 V), while higher intensity was necessary to elicit visual responses (mean 6.8 V; range 3.5-9.9 V). Contralateral tremor, speech impairment, paresthesias, and warm sensations were also elicited

The physiologic mechanisms generating the cutaneous silent period (CSP) remain uncertain. It is not known whether the CSP occurs because of inexcitability of the spinal motor neuron. We therefore, assessed excitability of the motor neuron during the CSP using F-wave responses. H-reflexes were also elicited during the CSP. Electrical stimulation to the fifth digit produced the CSP in the voluntarily contracting abductor pollicis brevis muscle (APB). Median nerve stimulation at the wrist elicited control F or H responses during isometric APB contraction (condition 1) and in resting muscle (condition 2). Control amplitudes were compared to those elicited in the midst of the CSP. In Condition 1, F-wave amplitudes and frequency during the CSP were unchanged compared with controls. However, F-waves were increased in amplitude and frequency during the CSP (P < 0.001) relative to responses elicited in resting muscle (condition 2). H-reflexes during the CSP were suppressed (P < 0.001) compared with controls elicited during contraction (condition 1), but facilitated relative to the resting state (condition 2) in which no H-reflexes were elicitable. We conclude that spinal motor neurons remain excitable to antidromic volleys at the same time that the corticospinal volley is inhibited to produce the CSP. Moreover, motor neuron excitability appears to be increased during the CSP compared to the relaxed state.

The use of different paradigms and initial skin and thermode reference temperatures in quantitative thermal testing does not allow strict comparison of results generated from different laboratories. We tested (a) whether the reproducibility of the method of limits is higher for measurement of isolated warm and cold thresholds (WT, CT) as compared to difference limen (DL) thresholds, i.e. values derived from alternating warm and cold stimulation, and (b) whether WT-, CT- and DL-thresholds depend on the value of baseline skin and thermode temperatures. In 20 healthy volunteers WT-, CT-, and DL-thresholds were determined at the volar wrist using a Somedic-Thermotest. In condition A the baseline thermode temperature was set at 30 degrees C, and in conditions B and C at 35 degrees C; in condition C the tested skin area was also warmed to 35 degrees C prior to the test. The randomized tests were repeated within 1-8 days. WT-, CT-, and DL-values were reproducible, but DL-values were more widely spread than WT and CT. CT variability was lowest in condition A, and WT variability in condition C. We conclude that DL determination should be abandoned, since CT and WT better differentiate normal from abnormal thresholds than the coarse DL-values. We recommend the use of the lower baseline thermode temperature (30 degrees C) and elimination of warming of the tested skin area prior to the test