title: Intra-operative transdural electric stimulation in awake patient: target refining for motor cortex stimulation.
abstract: BACKGROUND
  Most authors perform the implantation of epidural electrodes for motor cortex stimulation (MCS) under general anesthesia, using navigation merely based on anatomic landmarks or in combination with intra-operative sensory evoked potentials (SEP) for functional localization. However, intra-operative SEP can only provide the localization of central sulcus in patients who present sensory pathways which are at least partially preserved. Conversely, there are massive deafferentation pain syndromes (e.g., brachial plexus avulsion or amputation) in which the peripheral sensory pathways are severely or totally injured, precluding the use of intra-operative SEP. Objective. The authors present a simple technique for functional localization and intra-operative mapping of motor cortex by the implementation of transdural electrical stimulation of cerebral cortex for target refining of motor cortex during cortical electrode implantation procedures.
  
  
  METHODS
  Thirteen patients with complete brachial plexus root avulsion suffering from severe neuropathic pain in the affected limb were included in this report. First, the anatomical location of the motor cortex of the hand was stereotactically determined by the hand knob within the central sulcus. Functional mapping of cortex was performed by transdural bipolar electrical stimulation under local anesthesia, so patients were fully awake during the whole time of cortical mapping. The cortical mapping oriented the placement of epidural electrodes for chronic cortical stimulation for treatment of neuropathic pain.
  
  
  RESULTS
  Stereotactic MR images of the hand knob were considered a satisfactory landmark for the motor area of the hand in all patients. On top of the anatomical landmark, transdural electrical stimulation (4.0-6.0 mA, 30-60 Hz and pulse width of 1 ms) gave vivid sensations of movement in the deafferented hand, forearm, and arm. The phantom sensation was elicited with lower current than usual motor mapping in patients with intact limbs. It was possible to delineate the spatial map of the phantom hand on the cortical surface with acceptable resolution. The sensation of wrist flexion was elicited in all; most of the patients had clear distinction of the thumb and index. The remaining fingers were not perceived individually. The cortical area responsive to the thumb tended to occupy a lateral position related to the areas of the other fingers, following the maps of the normal homunculus. The evoked sensation was restricted to the period of stimulation, and it stopped as soon as that was discontinued. The stimulation also evoked emotional responses related to sensation of limb movement.
  
  
  CONCLUSIONS
  The proposed technique was useful for target refining in implantation of epidural electrode for motor cortex stimulation. Further studies are required to investigate if target refining by intra-operative mapping will significantly improve the results in the treatment of refractory pain.
authors: Pain Center and Division of Functional Neurosurgery, Department of Neurology, School of Medicine of University of São Paulo, Rua Dr. Ovídio Pires de Campos, 785, São Paulo, SP, 01060-970, Brazil.
authors: Manoel Jacobsen
authors: MJ
authors: Teixeira
authors: Daniel Ciampi
authors: DC
authors: de Andrade
authors: Erich Talamoni
authors: ET
authors: Fonoff
mesh_terms: D000328:Adult; D020516:Brachial Plexus Neuropathies / Q000150:complications; D001931:Brain Mapping; D046690:Deep Brain Stimulation / Q000379:methods*; D005073:Evoked Potentials, Somatosensory / Q000502:physiology; D005260:Female; D006225:Hand / Q000294:innervation; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009044:Motor Cortex / Q000502:physiology*; D009437:Neuralgia / Q000209:etiology / Q000628:therapy*; D014057:Tomography, X-Ray Computed; D014851:Wakefulness; D055815:Young Adult