title: Triggered electromyographic threshold for accuracy of thoracic pedicle screw placement in a porcine model.
abstract: METHODS
  A porcine model of thoracic pedicle screw insertion was used to determine the effect of screw position on triggered electromyographic response.
  
  
  OBJECTIVE
  To develop a model of intraoperative detection of misplaced thoracic pedicle screws.
  
  
  BACKGROUND
  Triggered electromyographic stimulation has been a valuable aid in determining appropriate placement of lumbar pedicle screws. The use of pedicle screws is increasing in the thoracic spine. Misplaced thoracic pedicle screws may have significant implications if the spinal cord is injured. This study was an attempt to determine whether the established lumbar model can be used for thoracic pedicle screws.
  
  
  METHODS
  Five 120- to 150-lb domestic pigs had 85 pedicle screws placed bilaterally in the thoracic spine at each level from T6 to T15. Screws were inserted entirely in the pedicle (Group A). After removal of the medial pedicle wall, the screws were reinserted in the pedicle with no neural contact (Group B). The screws were then placed with purposeful contact with the neural elements (Group C). The screws were stimulated, eliciting an electromyographic response in the intercostal muscles for each instrumented level. The type of response noted was classified as either primary (response from appropriate nerve root), secondary (response at different root) or no response (response at different root, no response at appropriate root).
  
  
  RESULTS
  Two hundred fifty responses were recorded. A primary response was noted in 72% of recordings. There was a relatively consistent decrease in the triggered electromyographic response from Group A (mean 4.15 +/- 1.80 mA) to Group C (mean 3.02 +/- 2.53 mA) screws (P = 0.0003). There was little difference in the response obtained from Group A to Group B (mean 4.37 +/- 2.48 mA) screws (P > 0.05). When a primary response was recorded, the mean threshold electromyographic response recorded was significantly lower than recordings with secondary and no response recordings (P < 0.05).
  
  
  CONCLUSIONS
  Even though there was a consistent decrease between the A and C screws that was more definitively separated when a primary response was elicited, it was not possible to determine a cutoff trigger electromyographic level that would consistently differentiate intraosseous from epidural pedicle screw placement. Furthermore, this method could not differentiate screws clearly in the pedicle from screws with medial pedicle wall breakthrough. A more direct method of spinal cord monitoring must be established to provide the surgeon with early warning of the potential of neural injury in the placement of thoracic pedicle screws.
authors.affiliation: Division of Orthopaedic Surgery, University of Toronto, and Toronto Western Hospital, Ontario, Canada.
authors.forename: S J
authors.initials: SJ
authors.lastname: Lewis
authors.forename: L G
authors.initials: LG
authors.lastname: Lenke
authors.forename: B
authors.initials: B
authors.lastname: Raynor
authors.forename: J
authors.initials: J
authors.lastname: Long
authors.forename: K H
authors.initials: KH
authors.lastname: Bridwell
authors.forename: A
authors.initials: A
authors.lastname: Padberg
mesh_terms: D000818:Animals; D001863:Bone Screws; D004056:Differential Threshold; D004558:Electric Stimulation; D004576:Electromyography; D007366:Intercostal Muscles / Q000503:physiopathology*; D007432:Intraoperative Period; D009985:Orthopedics / Q000379:methods* / Q000592:standards*; D013552:Swine; D013904:Thoracic Vertebrae / Q000601:surgery*