EMG guidance for probe placement, nearby tissue preservation, and lesion confirmation
A system and method for locating a target nerve associated with a facet joint via nerve stimulation and monitoring of electrical muscle activity in a multifidus muscle adjacent the target nerve are described. The system includes a probe housed within a cannula and comprising a probe electrode; a recording electrode for monitoring electrical muscle activity in a medial fascicle of the multifidus muscle; a signal generator; and a controller coupled to the probe electrode and recording electrode. The controller delivers a nerve stimulation from the signal generator to the nerve via the probe electrode and monitors electrical muscle activity in the medial fascicle via the recording electrode. The probe's proximity to the nerve is determined by the electrical muscle activity in the medial fascicle elicited as a result of the nerve stimulation, where the controller provides feedback to a user to guide placement of the probe adjacent the nerve.
1. A system for locating a first target nerve associated with a facet joint via nerve stimulation and monitoring of electrical muscle activity in a multifidus muscle adjacent the first target nerve, the multifidus muscle comprising a medial fascicle, an intermediate fascicle, and a lateral fascicle, wherein the system comprises:
a first probe comprising an insulated shaft and a first probe electrode located at a distal end of the insulated shaft, wherein the first probe electrode includes an array of independent channels for nerve stimulation, nerve ablation, or a combination thereof, and wherein the first probe is configured to form a lesion on the first target nerve by delivery of radiofrequency ablation energy;
a first recording electrode for monitoring electrical muscle activity in the medial fascicle of the multifidus muscle, wherein the first recording electrode is configured for placement in the medial fascicle of the multifidus muscle;
a signal generator; and
a controller coupled to the first probe electrode and the first recording electrode, wherein the controller delivers a first nerve stimulation from the signal generator to the first target nerve via the first probe electrode, wherein the controller monitors electrical muscle activity in the medial fascicle via the first recording electrode, wherein proximity of the first probe to the first target nerve is determined by the electrical muscle activity, electromyography (EMG) burst area, and amplitude in the medial fascicle elicited as a result of the first nerve stimulation, wherein the controller provides feedback to a user to guide placement of the first probe adjacent the first target nerve, and wherein the controller is configured to selectively activate one or more of the array of independent channels,
wherein the controller is configured to: (i) confirm that the first target nerve is a source of pain based, at least in part, on a detected latency between application of the first nerve stimulation and at least one EMG burst in the electrical muscle activity, and (ii) confirm successful formation of the lesion via the first recording electrode based on a difference in electrical muscle activity, EMG burst area, and amplitude elicited by a post-ablation nerve stimulation.
2. The system of claim 1 , comprising one or more additional recording electrodes for monitoring electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof, wherein the one or more additional recording electrodes are positioned on a first cannula or on a shaft of a needle and configured for placement in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof.
3. The system of claim 2 , wherein the controller is configured to monitor for electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof, wherein proximity of the first probe to the first target nerve is determined by the electrical muscle activity elicited in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof as a result of the first nerve stimulation, and wherein the controller provides feedback to guide placement of the first probe adjacent the first target nerve and prevent placement of the first probe adjacent non-target tissue.
4. The system of claim 2 , wherein the system is configured for locating a second target nerve located at a level cephalad to a level of the first target nerve, wherein the controller is configured to deliver a second nerve stimulation to the second target nerve via the first probe electrode, further wherein the controller is configured to monitor for electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof via the one or more additional recording electrodes, wherein proximity of the first probe to the second target nerve is determined by the electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof elicited as a result of the second nerve stimulation, and wherein the controller provides feedback to guide placement of the first probe adjacent the second target nerve and to prevent placement of the first probe adjacent non-target tissue.
5. The system of claim 2 , further comprising a second probe comprising an insulated shaft and a second probe electrode located at a distal end of the shaft, wherein the second probe is housed within a second cannula, wherein the system is configured for locating a second target nerve located at a level cephalad to a level of the first target nerve, wherein the controller is configured to deliver a second nerve stimulation to the second target nerve via the second probe electrode, further wherein the controller is configured to monitor for electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof via the one or more additional recording electrodes, wherein proximity of the second probe to the second target nerve is determined by the electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof elicited as a result of the second nerve stimulation, and wherein the controller provides feedback to a user to guide placement of the second probe adjacent the second target nerve and to prevent placement of the second probe adjacent non-target tissue.
6. The system of claim 2 , wherein the one or more additional recording electrodes has a monopolar configuration, a bipolar configuration, or a multipolar configuration.
7. The system of claim 2 , wherein the one or more additional recording electrodes are disposed on the shaft of the needle and offset from a tip of the needle.
8. The system of claim 2 , wherein the one or more additional recording electrodes is disposed on an outer surface of the first cannula.
9. The system of claim 2 , wherein the first probe is configured to form a lesion on the first target nerve by delivery of radiofrequency ablation energy,
wherein the system confirms successful formation of the lesion via the first recording electrode, the one or more additional recording electrodes, or a combination thereof,
wherein the one or more additional recording electrodes monitor electrical muscle activity in the medial fascicle, the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof, and
wherein the one or more additional recording electrodes are configured for placement in the medial fascicle, the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof.
10. The system of claim 1 , wherein the first recording electrode has a monopolar configuration, a bipolar configuration, or a multipolar configuration.
11. The system of claim 1 , wherein one or more recording electrodes are disposed on the first probe at the distal end of the insulated shaft, wherein the first recording electrode includes a tine extending from the insulated shaft, and wherein the tine is telescopic or retractable from the insulated shaft to allow the tine to be placed in a desired location.
12. The system of claim 1 , wherein the first probe electrode has a monopolar configuration, a bipolar configuration, or a multipolar configuration.
13. The system of claim 1 , wherein monitoring electrical muscle activity in the medial fascicle comprises measuring changes in electrical muscle activity latency, burst area EMG, and amplitude, wherein the first nerve stimulation is applied at a constant stimulation intensity, wherein: (i) a decrease in the latency, an increase in the EMG burst area, an increase in the amplitude, or a combination thereof between two points in time indicates that the first probe is in closer proximity to the first target nerve, or (ii) when the latency, EMG burst area, and amplitude, are constant between two points in time, a decrease in intensity of the first nerve stimulation indicates that the first probe is in closer proximity to the first target nerve.
14. The system of claim 1 , wherein the system determines if the first target nerve carries a pain signal by monitoring for changes in electrical muscle activity in the medial fascicle elicited as a result of the first nerve stimulation, wherein determining that the first target nerve carries the pain signal comprises measuring electrical muscle activity latency, EMG burst area, and amplitude.
15. The system of claim 1 , wherein the first probe includes a sharp tip at the distal end for navigating through tissue.
16. The system of claim 1 , wherein the first probe is configured to form a lesion on the first target nerve by delivery of radiofrequency ablation energy.
17. The system of claim 16 , further comprising one or more stimulating electrodes which are disposed on the first probe, an outer surface of a first cannula, on a surface of skin, on a percutaneous needle, or a combination thereof,
wherein the system confirms successful formation of the lesion via the first nerve stimulation and the one or more stimulating electrodes, wherein the one or more stimulating electrodes are disposed on the first probe, an outer surface of the first cannula, on a surface of skin, on a percutaneous needle, or a combination thereof,
wherein the controller provides feedback to the user indicating successful formation of the lesion on the first target nerve based on a predefined level of change in electrical muscle activity and wherein delivery of radiofrequency energy from the first probe is discontinued upon confirming successful formation of the lesion on the first target nerve.
18. The system of claim 1 , wherein the first target nerve is a medial nerve branch of a dorsal ramus.
19. The system of claim 1 , wherein the system is configured to generate a sound or visual indicator to indicate electrical proximity to the first target nerve.
20. A method for locating a first target nerve associated with a facet joint via nerve stimulation and monitoring of electrical muscle activity in a multifidus muscle adjacent the first target nerve, the multifidus muscle comprising a medial fascicle, an intermediate fascicle, and a lateral fascicle, the method comprising:
inserting a plurality of recording electrodes for monitoring electrical muscle activity in the medial fascicle of the multifidus muscle, wherein the plurality of recording electrodes are positioned on a first cannula;
positioning a first probe within the first cannula and thereby in proximity to the first target nerve, the first probe comprising an insulated shaft and a first probe electrode located at a distal end of the insulated shaft, wherein the first probe electrode includes an array of independent channels for nerve stimulation, nerve ablation, or a combination thereof, wherein each channel is configured to be selectively activated based on changes in electrical muscle activity latency, EMG burst area, and amplitude in the medial fascicle;
generating a first nerve stimulation from a signal generator;
delivering the first nerve stimulation to the first target nerve via the first probe electrode;
monitoring electrical muscle activity in the medial fascicle of the multifidus muscle via the plurality of recording electrodes on the first cannula;
guiding placement of the first probe adjacent the first target nerve based on the electrical muscle activity elicited in the medial fascicle of the multifidus muscle;
confirming that the first target nerve is a source of pain based, at least in part, on a detected latency between application of the first nerve stimulation and at least one EMG burst in the electrical muscle activity;
forming a lesion on the first target nerve by delivery of radiofrequency ablation energy; and
confirming successful formation of the lesion via at least one recording electrode based on a difference in electrical muscle activity, EMG burst area, and amplitude elicited by a post-ablation nerve stimulation.
21. The method of claim 20 , further comprising:
inserting one or more additional recording electrodes for monitoring electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof; and
monitoring electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof via the one or more additional recording electrodes.
22. The method of claim 21 , further comprising:
guiding placement of the first probe adjacent the first target nerve based on the electrical muscle activity elicited in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof; and
preventing placement of the first probe adjacent non-target tissue.
23. The method of claim 21 , wherein the method comprises locating a second target nerve located at a level cephalad to a level of the first target nerve, wherein the method further comprises:
positioning the first probe near the second target nerve;
generating a second nerve stimulation from the signal generator;
delivering the second nerve stimulation to the second target nerve via the first probe electrode;
monitoring electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof via the one or more additional recording electrodes; and
guiding placement of the first probe adjacent the second target nerve and preventing placement of the first probe adjacent non-target tissue based on the electrical muscle activity elicited in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof.
24. The method of claim 21 , wherein the method comprises locating a second target nerve located at a level cephalad to a level of the first target nerve, wherein the method further comprises:
positioning a second probe comprising an insulated shaft and a second probe electrode located at a distal end of the insulated shaft near the second target nerve, wherein the second probe is housed within a second cannula;
generating a second nerve stimulation from the signal generator;
delivering the second nerve stimulation to the second target nerve via the second probe electrode;
monitoring electrical muscle activity in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof via the one or more additional recording electrodes; and
guiding placement of the second probe adjacent the second target nerve and preventing placement of the second probe adjacent non-target tissue based on the electrical muscle activity elicited in the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof.
25. The method of claim 20 , wherein the first probe electrode includes an array of independent channels for nerve stimulation, nerve ablation, or a combination thereof, each channel having an axial dimension and a radial dimension, wherein each channel is adapted to be separately energized.
26. The method of claim 25 , wherein the method comprises selectively activating one or more of the independent channels in the array to direct nerve stimulation energy to the first target nerve.
27. The method of claim 20 , comprising applying the first nerve stimulation at a constant stimulation intensity, wherein a decrease in latency, an increase in EMG burst area, an increase in amplitude, or a combination thereof indicates that the first probe is in closer proximity to the first target nerve, or comprising maintaining the latency, EMG burst area, amplitude, or a combination thereof at a constant level, wherein a decrease in the first nerve stimulation intensity indicates that the first probe is in closer proximity to the first target nerve.
28. The method of claim 20 , comprising:
delivering a third nerve stimulation; and
monitoring for changes in electrical muscle activity in the medial fascicle elicited as a result of the third nerve stimulation to determine if the first target nerve carries a pain signal, wherein determining that the first target nerve carries the pain signal comprises measuring electrical muscle activity latency, EMG burst area, and amplitude.
29. The method of claim 20 , further comprising:
forming a lesion on the first target nerve by delivering radiofrequency ablation energy from the first probe, wherein successful formation of the lesion is confirmed via the first recording electrode, one or more additional recording electrodes, or a combination thereof, wherein the one or more additional recording electrodes monitor electrical muscle activity in the medial fascicle, the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof, wherein the one or more additional recording electrodes are configured for placement in the medial fascicle, the intermediate fascicle, the lateral fascicle, paraspinal muscles surrounding the multifidus muscle, or a combination thereof.
30. The method of claim 29 , further comprising:
confirming successful formation of the lesion on the first target nerve via a fourth nerve stimulation and one or more stimulating electrodes, wherein the one or more stimulating electrodes are disposed on a probe, an outer surface of the first cannula, on a surface of skin, on a percutaneous needle, or a combination thereof.
31. The method of claim 30 , wherein successful formation of the lesion on the first target nerve is indicated by a predefined level of change in electrical muscle activity, wherein delivering radiofrequency ablation energy from the first probe is discontinued upon confirming successful formation of the lesion on the first target nerve.
32. The method of claim 20 , wherein a sound or visual indicator is generated to indicate electrical proximity to the first target nerve.
33. A system for locating a first target nerve associated with a facet joint via nerve stimulation and monitoring of electrical muscle activity in a multifidus muscle adjacent the first target nerve, the multifidus muscle comprising a medial fascicle, an intermediate fascicle, and a lateral fascicle, wherein the system comprises:
a first probe comprising an insulated shaft and a first probe electrode located at a distal end of the insulated shaft, wherein the first probe electrode includes an array of independent channels for nerve stimulation, nerve ablation, or a combination thereof, wherein the first probe is configured to form a lesion on the first target nerve by delivery of radiofrequency ablation energy;
a plurality of recording electrodes for monitoring electrical muscle activity in the medial fascicle of the multifidus muscle, wherein plurality of recording electrodes is configured for placement in the medial fascicle of the multifidus muscle;
a signal generator; and
a controller coupled to the first probe electrode and the plurality of recording electrodes, wherein the controller delivers a first nerve stimulation from the signal generator to the first target nerve via the first probe electrode, wherein the controller monitors electrical muscle activity in the medial fascicle via the plurality of recording electrodes, wherein proximity of the first probe to the first target nerve is determined by the electrical muscle activity in the medial fascicle elicited as a result of the first nerve stimulation, and wherein the controller provides feedback to a user to guide placement of the first probe adjacent the first target nerve, and wherein the controller is configured to selectively activate one or more of the array of independent channels,
wherein the controller is configured to: (i) confirm that the first target nerve is a source of pain based, at least in part, on a detected latency between application of the first nerve stimulation and at least one electromyography (EMG) burst in the electrical muscle activity, and (ii) confirm successful formation of the lesion via at least one recording electrode based on a difference in electrical muscle activity, EMG burst area, and amplitude elicited by a post-ablation nerve stimulation.