Artifact reduction by using alternating polarity stimulus pairs in intraoperative peripheral nerve action potential reco
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ORIGINAL RESEARCH
Artifact reduction by using alternating polarity stimulus pairs in intraoperative peripheral nerve action potential recording Gang Wu1 · Allan Belzberg1 · Jessica Nance2 · Sergio Gutierrez‑Hernandez2 · Eva K. Ritzl2 · Matthias Ringkamp1 Received: 17 June 2020 / Accepted: 23 October 2020 © Springer Nature B.V. 2020
Abstract Intraoperative nerve action potential (NAP) recording permits direct study of an injured nerve for functional assessment of lesions in continuity. Stimulus artifact contamination often hampers NAP recording and interferes with its interpretation. In the present study, we evaluated the artifact reduction method using alternating polarity in peripheral nerve recording. Our study was conducted under controlled conditions in laboratory animals. NAPs were recorded from surgically exposed median or ulnar nerves. For the artifact reduction method with alternating polarity, two sequential recordings, one with normal and one with reversed stimulus polarity, were acquired and the signals from this recording pair were averaged. Simulation was also performed to further evaluate the effects of alternating polarity on the waveforms. The results are as follows: First, we found that this method worked for recordings with unsaturated electrical stimulus artifacts. Second, slightly unequal latencies occurred in an NAP pair, and this inequality contributed to a minimal loss of NAP amplitudes when averaging the two recordings. Third, perfect artifact cancelation and minimal signal loss were also demonstrated by simulation. Finally, we applied the method during nerve inching and demonstrated its usefulness in intraoperative NAP recordings as the method made the recording more resilient to short conduction distances. Thus, our findings demonstrate that this artifact reduction method can be used as a supplemental tool together with our previously described bridge grounding technique or the nonlifting nerve recording configuration to further improve intraoperative peripheral nerve recording. The method can be applied in clinical settings. Keywords Alternating polarity · Artifact reduction · Intraoperative nerve recording · Nerve action potential · Peripheral nerve surgery · Stimulus artifact
1 Introduction Peripheral nerve trauma (PNT) is common and can be debilitating leading to poor quality of life including chronic pain and disability [1]. A frequent result of PNT is a neuroma in continuity in which despite an intact epineurium, there is axonotmesis of some or all of the axons with resultant Wallerian degeneration in the distal nerve. To determine whether axonal regeneration is occurring across the region of injury often requires surgical intervention, aided by intraoperative * Gang Wu [email protected] 1
Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
2
electrophysiological studies. Compared to other intraoperative electrophysiologic
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