Higher electrical stimulus intensities are required to activate chronically compressed nerve roots: Implications for intraoperative electromyographic pedicle screw testing

Study Design. A comparison of the electrical thresholds required to evoke myogenic responses from direct stimulation of normal and chronically compressed nerve roots. Objective. To determine whether intraoperative electromyographic testing to confirm the integrity of instrumented pedicles should be performed at higher stimulus intensities in cases where there is preoperative lumbosacral radiculopathy. Summary of Background Data. Postoperative neurologic deficits may occur as a result of pedicle screw misplacement during spinal instrumentation. The failure to evoke myogenic responses from stimulation of pedicle holes and screws of intensities of 6-8 mA is commonly used to exclude bony pedicular wall perforation. Methods. Direct nerve root stimulation was used to compare the stimulus thresholds of normal and compressed nerve roots in six patients with limb weakness from chronic lumbosacral radiculopathy. Results. The stimulus thresholds of chronically compressed nerve roots significantly exceeded those of normal nerve roots, indicating partial axonal loss (axonotmesis). In most cases, the direct stimulus thresholds of compressed nerve roots exceeded 10 mA. Conclusions. When instrumentation is placed at spinal levels where there is preexisting chronic lumbosacral radiculopathy, holes and screws may need to be stimulated at higher intensities to exclude pedicular perforation and prevent further latrogenic nerve root injury.