Apparatus and method for polyphasic multi-output constant-current and constant-voltage neurophysiological stimulation

Abstract

The present specification discloses an intraoperative neurophysiological monitoring (IONM) system including a computing device capable of executing an IONM software engine, a stimulation module having multiple ports and various stimulation components and recording electrodes. The system is used to implement transcranial electrical stimulation and motor evoked potential monitoring by positioning at least one recording electrode on a patient, connecting the stimulation components to at least one port on the stimulation module, positioning the stimulation components on a patient's head, activating, using the IONM software engine, at least one port, delivering stimulation to the patient; and recording a stimulatory response on the patient.

Claims

1. A stimulation module configured to generate and deliver an electrical stimulus comprising at least two successive stimulation pulses, the stimulation module comprising: a plurality of output ports adapted to connect to a plurality of stimulation electrodes; a controller, wherein the controller is configured to simultaneously activate any combination of the plurality of output ports, is configured to designate a first portion of the plurality of output ports to being an anode and to designate a second portion of the plurality of output ports to being a cathode for a first of the at least two successive stimulation pulses, and, for a second of the at least two successive stimulation pulses, is configured to change a designation of a third portion of the plurality of output ports to being a cathode and to a designation of a fourth portion of the plurality of output ports to being an anode, wherein output ports in the third portion is different than output ports in the first portion and wherein output ports in the fourth portion is different than output ports in the second portion; a pulse generator in electrical communication with the controller, wherein the pulse generator comprises: a constant current sink adapted to enable a setting of an intensity of an output current of the stimulation module; a current intensity digital-to-analog converter adapted to generate voltage for the constant current sink that is proportional to the set output current intensity; trigger logic adapted to enable the stimulation module to switch between a plurality of current intensities; and a current sense circuit configured to measure delivered current; and a constant voltage source adapted to enable a setting of an intensity of an output voltage of the stimulation module.

2. The stimulation module of claim 1, further comprising an impedance circuit comprising an impedance voltage generator, an impedance pulse generator, and an impedance sense circuit, wherein the impedance circuit is configured to measure impedance of the plurality of stimulation electrodes.

3. The stimulation module of claim 1, further comprising an adjustable voltage converter, wherein the adjustable voltage converter is configured to adjust a voltage to raise or lower the output supply voltage.

4. The stimulation module of claim 1, wherein the stimulation module is operably connected to a computing device of an intraoperative neurophysiological monitoring (IONM) system and wherein the controller comprises an IONM software engine adapted to execute in the computing device.

5. The stimulation module of claim 1, wherein the plurality of outputs ports comprises at least nine output ports.

6. The stimulation module of claim 1, further comprising an adjustable voltage converter, wherein the adjustable voltage converter is a DC to DC voltage converter and is configured to convert a voltage in a range of 200 to 1200 volts.

7. The stimulation module of claim 6, wherein the adjustable voltage converter comprises a digital-to-analog converter and wherein the digital-to-analog converter is configured to vary a voltage in a feedback loop of the DC-DC voltage converter thereby causing a DC-DC controller to adjust a switching duty cycle to raise or lower the output supply voltage.

8. The stimulation module of claim 1, wherein the constant voltage source generates an output voltage using a field-effect transistor.

9. The stimulation module of claim 8, wherein a gate voltage of the field-effect transistor is set by a digital-to-analog converter and wherein the output voltage is proportional to the digital-to-analog converter voltage.

10. The stimulation module of claim 1, wherein the constant current sink comprises two digital-to-analog converters and an amplifier configured to control separate phases of the at least two successive stimulation pulses.

11. The stimulation module of claim 1, wherein the output current is configured to be set by an adjustable voltage converter at an input of an amplifier.

12. The stimulation module of claim 11, wherein the setting of the output current is adapted to force a voltage across a ground referenced transistor.

13. The stimulation module of claim 1, wherein the pulse generator comprises a field-effect transistor and an amplifier, and wherein the pulse generator is adapted to limit and sense an impedance current.

14. The stimulation module of claim 1, wherein the plurality of output ports is configured to be controlled by a gate drive optocoupler and an H-Bridge transformer driver.

15. The stimulation module of claim 1, wherein the controller is configured to monitor voltage values on a first side and a second side of a voltage rail, wherein the controller is configured to monitor a value of current, and wherein the controller is configured to output a measurement of a delivered pulse based upon the monitored voltage values and the monitored current value.

16. The stimulation module of claim 15, wherein the controller is adapted to use the monitored voltage values and the monitored current value to compute an impedance value.

17. The stimulation module of claim 1, wherein the stimulation module is configured to be in time synchronization with a plurality of facilitation stimulators and a plurality of recording electrodes and wherein the plurality of facilitation stimulators and the plurality of recording electrodes are in data communication with a computing device of an intraoperative neurophysiological monitoring (IONM) system.

18. The stimulation module of claim 17, further comprising a digital timing signal and wherein the time synchronization is achieved using the digital timing signal and coordination of a timestamp by the computing device.

19. The stimulation module of claim 1, wherein one of the at least two successive stimulation pulses is polyphasic.

20. The stimulation module of claim 1, wherein the stimulation module is configured to generate the at least two successive stimulation pulses having a voltage in a range of 0 to 1000 Volts and a current in a range of 0 to 1.5 Amps in any combination of single pulses or pulse trains.

21. The stimulation module of claim 1, wherein the controller is configured to modulate at least one of a plurality of stimulation parameters of the at least two successive stimulation pulses.

22. The stimulation module of claim 1, further comprising an impedance circuit configured to measure an impedance of the plurality of stimulation electrodes based upon a plurality of pulses, wherein the plurality of pulses is generated by combination of one of the plurality of output ports being configured as an anode and remaining ones of the plurality of output ports being configured as cathodes.

23. The stimulation module of claim 1, wherein the stimulation module is configured to operate in a constant voltage mode and wherein the output current is limited in the constant voltage mode.

24. The stimulation module of claim 1, wherein the stimulation module is configured to operate in a constant current mode and wherein the output voltage is limited in the constant current mode.

25. The stimulation module of claim 1, further comprising first and second safety circuits.

26. The stimulation module of claim 1, wherein the stimulation module is configured to be powered down if communication is lost between the stimulation module and a computing device of an intraoperative neurophysiological monitoring (IONM) system.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) These and other features and advantages of the present specification will be further appreciated, as they become better understood by reference to the following detailed description when considered in connection with the accompanying drawings:

(2) FIG. 1A is a block diagram illustrating an intraoperative neuromonitoring (IONM) system, in accordance with an embodiment of the present specification;

(3) FIG. 1B illustrates a stimulation module, in accordance with an embodiment of the present specification;

(4) FIG. 2A is a block diagram illustration a first and second safety circuits of the stimulation module shown in FIG. 1B, in accordance with an embodiment of the present specification;

(5) FIG. 2B is a block diagram illustrating a plurality of circuit elements for generating, adjusting and measuring supply voltage of the stimulation module of FIG. 1B, in accordance with an embodiment of the present specification;

(6) FIG. 2C is a block diagram illustrating a plurality of circuit elements for generating, adjusting and measuring output voltage and current, and for measuring electrode impedance of the stimulation module of FIG. 1B, in accordance with an embodiment of the present specification;

(7) FIG. 2D is a block diagram illustration of an output switch of the stimulation module shown in FIG. 1B, in accordance with an embodiment of the present specification;

(8) FIG. 3 is a flowchart describing a plurality of steps of a first use case of the IONM system of the present specification, illustrating transcranial stimulation and motor evoked potential (MEP) monitoring;

(9) FIG. 4 is a flowchart describing a plurality of steps of a second use case of the IONM system of the present specification, illustrating transcranial stimulation and motor evoked potential (MEP) monitoring;

(10) FIG. 5 is a flowchart describing a plurality of steps of a third use case of the IONM system of the present specification, illustrating transcranial stimulation and motor evoked potential (MEP) monitoring;

(11) FIG. 6 is a flowchart describing a plurality of steps of a fourth use case of the IONM system of the present specification, illustrating transcranial stimulation and motor evoked potential (MEP) monitoring;

(12) FIG. 7 is a flowchart illustrating a plurality of steps of a fifth use case of the IONM system of the present specification, illustrating the facilitation of stimulation; and

(13) FIG. 8 is a flowchart illustrating a plurality of steps of a sixth use case of the IONM system of the present specification, illustrating the facilitation of stimulation.

DETAILED DESCRIPTION

(14) A “computing device” is at least one of a cellular phone, PDA, smart phone, tablet computing device, patient monitor, custom kiosk, or other computing device capable of executing programmatic instructions. It should further be appreciated that each device and monitoring system may have wireless and wired receivers and transmitters capable of sending and transmitting data. Each “computing device” may be coupled to at least one display, which displays information about the patient parameters and the functioning of the system, by means of a GUI. The GUI also presents various menus that allow users to configure settings according to their requirements. The system further comprises at least one processor (not shown) to control the operation of the entire system and its components. It should further be appreciated that the at least one processor is capable of processing programmatic instructions, has a memory capable of storing programmatic instructions, and employs software comprised of a plurality of programmatic instructions for performing the processes described herein. In one embodiment, at least one processor is a computing device capable of receiving, executing, and transmitting a plurality of programmatic instructions stored on a volatile or non-volatile computer readable medium. In addition, the software comprised of a plurality of programmatic instructions for performing the processes described herein may be implemented by a computer processor capable of processing programmatic instructions and a memory capable of storing programmatic instructions.

(15) The term ‘user’ is used interchangeably to refer to a surgeon, neuro-physician, neuro-surgeon, neuro-physiologist, technician or operator of the IONM system and/or other patient-care personnel or staff.

(16) The present specification is directed towards multiple embodiments. The following disclosure is provided in order to enable a person having ordinary skill in the art to practice the invention. Language used in this specification should not be interpreted as a general disavowal of any one specific embodiment or used to limit the claims beyond the meaning of the terms used therein. The general principles defined herein may be applied to other embodiments and applications without departing from the spirit and scope of the invention. Also, the terminology and phraseology used is for the purpose of describing exemplary embodiments and should not be considered limiting. Thus, the present invention is to be accorded the widest scope encompassing numerous alternatives, modifications and equivalents consistent with the principles and features disclosed. For purpose of clarity, details relating to technical material that is known in the technical fields related to the invention have not been described in detail so as not to unnecessarily obscure the present invention.

(17) In the description and claims of the application, each of the words “comprise” “include” and “have”, and forms thereof, are not necessarily limited to members in a list with which the words may be associated. It should be noted herein that any feature or component described in association with a specific embodiment may be used and implemented with any other embodiment unless clearly indicated otherwise.

(18) As used herein, the indefinite articles “a” and “an” mean “at least one” or “one or more” unless the context clearly dictates otherwise.

(19) An Intraoperative Neuro-Monitoring (IONM) System

(20) FIG. 1A is a block diagram illustration of an IONM system 100, in accordance with an embodiment of the present specification. In embodiments, the system 100 enables a stimulation-based assessment of nerve proximity, direction, pathways and/or changes to nerve pathology, health or status during physically invasive procedures. The system 100 comprises a computing device 105 configured to implement or execute an IONM software application or engine 110, at least one multi-connection console 115 connected to the computing device 105 using a cable 104, a stimulation module 120 connected to the console 115 using a cable 112, a plurality of stimulation components 135 such as, but not limited to, subdermal, hooked or corkscrew needle electrodes or surface electrodes adapted to be coupled to the stimulation module 120 simultaneously or in any combination thereof via respective cables 133, a plurality of recording or sensing electrodes 125 connected to the console 115 through respective cables 122 and a plurality of surgical instruments, components and accessories 130 coupled to the console 115 via respective accessory cables 128.

(21) In various embodiments, the computing device 105 comprises at least one processor, at least one non-transitory memory, one or more input devices (such as, but not limited to, keyboard, mouse, touch-screen, camera and combinations thereof) and one or more output devices (such as, but not limited to, display screens, printers, speakers and combinations thereof) all of which may be stand-alone, integrated into a single unit, partially or completely network-based or cloud-based, and not necessarily located in a single physical location. The computing device 105 is in data communication with one or more databases 140 that may be co-located with the computing device 105 or located remotely.

(22) The IONM software application or engine 110 implements a plurality of instructions to: deliver a plurality of stimulation protocols or schedules (stored in the one or more databases 140) through any one, any combination or all of the plurality of stimulation components 135, generate a plurality of graphical user interfaces (GUIs) rendered on one or more display screens (that are coupled to the computing device 105) to display a plurality of MEP (Motor Evoked Potential) activity waveforms sensed by the electrodes 125 and extract a plurality of parameters related thereto and enable user-interaction with the system 100 to perform a plurality of functions such as, but not limited to, selecting and activating/initiating one or more stimulation protocols and modulating one or more stimulation parameters of the protocols. The IONM software application or engine 110 is configured to apply one or more stimulation protocols to one or more nerve structures 145 of a patient 150 through the plurality of stimulation components 135 and acquire and record correspondingly MEP activity through the plurality of electrodes 125 positioned within a plurality of muscle sites or locations 148 of the patient 150.

(23) It should be appreciated by those of ordinary skill in the art that, although described herein with reference to transcranial electrical stimulation (TES) and motor evoked potential monitoring (MEP) during cerebrospinal surgical procedures, the system 100 and related methods or use cases of the present specification have application in a plurality of surgical procedures during which tissue having critical neural structures must be approached, retracted, and/or impinged upon. There is a requirement that such physically invasive procedures be planned and executed while preserving critical neural structures or bundles. It should also be appreciated that, although embodiments have been described herein with reference to MEP activity, the system 100 and related methods or use cases of the present specification may, in various alternate embodiments, use a plurality of different types of neural monitoring modalities such as, for example, triggered electromyography, spontaneous electromyography, mechanomyography, somatosensory evoked potential, nerve conduction velocity and/or train of fours.

(24) The Stimulation Module

(25) FIG. 1B illustrates the stimulation module 120, in accordance with an embodiment of the present specification. The module 120 comprises a housing or enclosure 155 connected, in some embodiments, to a distal end of the electrical cable 112 while a proximal end of the cable 112 is connected to the console 115. In alternate embodiments, the proximal end of the cable 112 may be connected directly to the computing device 105 via a connector such as a D-subminiature connector. In other alternate embodiments, the module 120 may be connected to the console 115 through the electrical cable 112 that serves only to deliver power to the module 120, while the module 120 is in wireless data communication with the computing device 105. Also, in some embodiments, the module 120 is configured as a battery-operated and portable hand-held device.

(26) In embodiments, the module 120 comprises a plurality of output channels or ports 160. In accordance with an embodiment, the plurality of output channels comprise nine ports 160a, 160b, 160c, 160d, 160e, 160f, 160g, 160h, 160i. In accordance with an embodiment, any of the nine ports 160a-160i can be configured and flexibly chosen as any combination of anode or cathode per stimulus thereby allowing user-defined stimuli to be delivered to arbitrary anode and cathode outputs. In one embodiment, a plurality of subdermal needle electrodes are connected to the required number of output ports from the available nine ports 160a-160i.

(27) It should be appreciated that there may be scenarios where one or a combination of stimulation modalities may be of value in a surgical procedure, depending on a stage of a surgical procedure and/or based on what anatomical structure is being stimulated. Because an optimal stimulation paradigm may differ across patients and surgical procedure types, the stimulation module 120 allows the user to easily prepare a varied neuro-stimulation setup, without having to physically move electrodes and/or probes and/or adjust the stimulus paradigm via dials and switches on a device at the computing device or near the operating room table. In accordance with various further aspects of the present specification, the stimulation module 120 delivers polyphasic electrical stimulus with an output of 0 to 1000 Volts, amplitude of 0 to 1.5 Amps and is configurable as any combination of single pulses or multiple pulse trains, enables modulation of one or more of a plurality of stimulation parameters digitally using the IONM software engine 110, is operable as a constant-current or constant-voltage stimulator with current and voltage sensing of delivered stimulus, supports electrode impedance measurement and determination of individual electrode impedance, is tightly synchronized with additional one or more stimulators for neural facilitation, supports transformer-coupled output switching without need for high-side voltage charge pump, is a battery-powered, wireless stimulator and supports a power management scheme, has built-in safety features including redundant circuitry, energy limited power supply, non-stimulating mode with loss of communication, self-diagnostic tests, current and voltage limiting, and includes printed-circuit board spacing and trace management for high energy pulse switching as well as low voltage control signals in a single module.

(28) FIG. 2A is a block diagram illustration of first and second safety circuits of the stimulation module 120 of FIG. 1B, in accordance with an embodiment of the present specification. The first safety circuit element 205 comprises a microcontroller providing control signals to perform at least one of the following functions or tasks, but is not limited to said functions or tasks: The safety circuit element 205 microcontroller includes a reset control signal that is an input to a current intensity digital-to-analog (DAC) converter. When the microcontroller asserts the control signal, the current intensity digital-to-analog (DAC) converter is held in reset. The current intensity digital-to-analog converter (DAC) of the stimulation module is held in reset by the microcontroller when the stimulation module is idle. The delivered current is proportional to the DAC voltage. Resetting the DAC sets the voltage to zero volts. The safety circuit element 205 microcontroller further includes a pulse gate control signal that is an input to a current sink logic circuit element 240, as shown in FIG. 2C. The output of the current sink logic circuit element 240 enables or disables a current sink pulse gate 242. The current sink pulse gate 242 comprises an H-Bridge transformer driver, transformer, gate drive optocoupler, and a metal-oxide semiconductor field-effect transistor (MOSFET) acting as a switch. When the pulse gate control signal is asserted by the safety circuit element 205 microcontroller, the current sink logic element 240 activates the output of the gate drive optocoupler of the current sink pulse gate 242. This causes the gate drive optocoupler to switch an isolated DC voltage to the gate of the MOSFET transistor, causing it to conduct and allow the stimulation current sink to deliver current. The pulse gate control signal must be present at the same time a stimulus is fired to deliver the stimulation. The safety circuit element 205 microcontroller further includes a discharge control signal for a 200 to 1200 volt supply circuit that is an input to a discharge circuit. The discharge circuit includes resistors, a negative-positive-negative (NPN) transistor, and a MOSFET transistor acting as a switch. When the safety circuit element 205 microcontroller asserts the control signal, the NPN transistor turns off. This causes a voltage to be applied to the gate of the MOSFET transistor via a pull-up resistor. The voltage at the gate of the MOSFET transistor causes the MOSFET transistor to conduct and discharge the 200 to 1200 volt supply storage capacitors of quadrupler circuit element 219, as shown in FIG. 2B, through current limiting series resistors to circuit ground. The safety circuit element 205 microcontroller further includes a clamp control signal that is an input to a hardware clamp circuit 237, as shown in FIG. 2C. The hardware clamp circuit 237 consists of an optocoupler, a MOSFET transistor and resistors. When the safety circuit element 205 microcontroller asserts the clamp control signal, the optocoupler is disabled causing a voltage to be applied to the gate of the MOSFET transistor via pull-up resistors. The voltage at the gate of the MOSFET transistor causes the MOSFET transistor to conduct and short the positive (anode) and negative (cathode) stimulation nodes together. The hardware clamp circuit 237 is enabled when the stimulation module is idle. The hardware clamp circuit 237 ensures there is zero voltage potential between the positive (anode) and negative (cathode) nodes of the stimulation module.

(29) The second safety circuit element 210 comprises a microcontroller providing control signals to perform at least one of the following functions or tasks, but is not limited to said functions or tasks: The safety circuit element 210 microcontroller includes an internal digital-to-analog converter (DAC) that is connected to an input of a voltage source 230, as shown in FIG. 2C. The voltage source 230 consists of resistors, an operational amplifier and MOSFET transistors. The digital-to-analog converter generates a variable voltage between 0 and 3 volts. This voltage is connected to an input resistor network of the operational amplifier circuit in the voltage source 230. The resistor network provides DC bias and gain. The output of the operational amplifier circuit drives the gate of a first MOSFET transistor. The drain of the first MOSFET transistor is connected to the gate of a second MOSFET transistor. The first MOSFET transistor is operated in a linear region to adjust the voltage at the gate of the second MOSFET transistor. The drain of the second MOSFET transistor is connected to a 200 to 1200 volt supply rail. The source of the second MOSFET transistor is connected to the positive (anode) node of the stimulation module. The second MOSFET also operates in the linear region to vary the voltage across its drain and source. The resulting positive (anode) node voltage is the difference between the 200 to 1200 volt supply rail and the voltage across the drain to source of the second MOSFET transistor. This voltage is proportional to the digital-to-analog (DAC) voltage generated by the safety circuit element 210 microcontroller. The safety circuit element 210 microcontroller further includes a supply voltage control signal and safety circuitry to enable and disable the 200 to 1200 volt supply 221, as shown in FIG. 2B. The safety circuit includes resistors and a MOSFET transistor. When the safety circuit element 210 microcontroller is inactive, a voltage is applied to the gate of the MOSFET transistor via a pull-up resistor, causing the MOSFET transistor to conduct and setting a DC-DC controller 215 ENABLE pin input to circuit ground, thereby disabling the DC-DC controller 215. The safety circuit element 210 microcontroller enables the DC-DC controller 215 by asserting the control signal causing the MOSFET transistor to turn off When the MOSFET transistor is off, a voltage is applied to the DC-DC controller 215 ENABLE pin via a pull-up resistor. This voltage enables the DC-DC controller 215. The safety circuit element 210 microcontroller further includes a self-test load control signal that is an input to a self-test load circuit 235, shown in FIG. 2C. The self-test load circuit 235 consists of an optocoupler, a MOSFET transistor and resistors. When the safety circuit element 210 microcontroller asserts the control signal, the optocoupler is disabled causing a voltage to be applied to the gate of a MOSFET transistor via pull-up resistors. The voltage at the gate of the MOSFET transistor causes the MOSFET transistor to conduct and connect a self-test load between the positive (anode) and negative (cathode) stimulation nodes. The self-test load circuit 235 is disabled when the stimulation module is idle. The safety circuit element 210 microcontroller further includes a pulse enable control signal and two current intensity trigger control signals for a trigger logic circuit element 225 and current sink circuit 227, shown in FIG. 2C. The trigger logic circuit element 225 consists of a digital-to-analog converter (DAC), logic gates and analog switches. The safety circuit element 210 configures two outputs of the digital-to-analog converter (DAC) according to the desired current intensity. The outputs of the digital-to-analog converter are connected to analog switches. The analog switches are controlled by the two current intensity trigger control signals and the logic gates. The safety circuit element 210 can quickly enable and disable an analog switch connected to the outputs of the digital-to-analog converter (DAC) by asserting and de-asserting the current intensity trigger control signals. When a switch is enabled, the digital-to-analog converter (DAC) voltage is presented to the current sink circuit 227. Under control of the safety circuit element 210, different voltages can be switched to the current sink circuit 227 allowing the stimulation module to quickly deliver different current intensities for each phase of a stimulus pulse. The safety circuit element 210 pulse enable control signal is input to the shutdown pin of an operational amplifier. The operational amplifier drives the gate of a MOSFET transistor with a voltage proportional to the digital-to-analog converter (DAC) voltage presented by the trigger logic circuit element 225. The voltage at the gate of the MOSFET causes the MOSFET transistor to conduct and sink a current through a ground referenced transistor. This is the stimulation module delivered current. The safety circuit element 210 pulse enable control signal must be asserted in order for the output pulse to be delivered. The safety circuit element 210 microcontroller further includes high- and low-side control signals for a patient connection circuit 261, shown in FIG. 2D. The patient connection circuit 261 consists of an H-Bridge transformer driver, transformers, gate drive optocouplers, and MOSFET transistors acting as switches. When the high-side patient connection control signal is asserted by the safety circuit element 210 microcontroller, the output of a gate drive optocoupler is activated. This causes the gate drive optocoupler to switch an isolated DC voltage to the gate of a high-side MOSFET transistor, causing it to conduct and connect the positive (anode) node to an output port 160. When the low-side patient connection control signal is asserted by the safety circuit element 210 microcontroller, the output of a gate drive optocoupler is activated. This causes the gate drive optocoupler to switch an isolated DC voltage to the gate of a low-side MOSFET transistor, causing it to conduct and connect the negative (cathode) node to an output port 160. The safety circuit element 210 microcontroller further includes a reset control signal that is an input to the current intensity digital-to-analog (DAC) converter. When the microcontroller asserts the control signal, the current intensity digital-to-analog (DAC) converter is held in reset. The current intensity digital-to-analog converter (DAC) of the stimulation module is held in reset by the microcontroller when the stimulation module is idle. The delivered current is proportional to the DAC voltage. Resetting the DAC sets the voltage to zero volts. The safety circuit element 210 microcontroller further includes a clamp control signal that is an input to the hardware clamp circuit 237. The hardware clamp circuit 237 consists of an optocoupler, a MOSFET transistor and resistors. When the safety circuit element 210 microcontroller asserts the control signal, the optocoupler is disabled causing a voltage to be applied to the gate of a MOSFET transistor via pull-up resistors. The voltage at the gate of the MOSFET transistor causes the MOSFET transistor to conduct and short the positive (anode) and negative (cathode) stimulation nodes together. The hardware clamp circuit 237 is enabled when the stimulation module is idle. The hardware clamp circuit 237 ensures there is zero voltage potential between the positive (anode) and negative (cathode) nodes of the stimulation module. The safety circuit element 210 microcontroller further includes a discharge control signal for the 200 to 1200 volt supply circuit that is an input to the discharge circuit. The discharge circuit includes resistors, an NPN transistor, and a MOSFET transistor acting as a switch. When the safety circuit element 210 microcontroller asserts the control signal, the NPN transistor turns off. This causes a voltage to be applied to the gate of a MOSFET transistor via a pull-up resistor. The voltage at the gate of the MOSFET transistor causes the MOSFET transistor to conduct and discharge the 200 to 1200 volt supply storage capacitors of quadrupler circuit element 219 through current limiting series resistors to circuit ground. Safety circuit element 210 microcontroller further includes internal analog-to-digital converter channels. These channels combined with voltage dividers or current sense resistors and operational amplifier buffers are used to sense the stimulation parameters such as, but not limited to, the delivered current, output voltage, supply voltage, impedance current.

(30) The redundant safety circuits 205, 210 prevent unintended stimulation. Both circuits 205, 210 must be online and configured by the host computer (computing device 105 of FIG. 1A) to allow an output pulse to be delivered. If communication is lost between the stimulation module and the host computer, the stimulation module is powered down. Additionally, a 200 to 1200 volt power supply is designed to limit the available charge for the stimulus. The stimulation module limits the current in constant-voltage mode and limits the voltage in constant-current mode thereby preventing excessive energy from being delivered by the stimulation module when electrode impedance is very low or very high.

(31) FIG. 2B is a block diagram illustration of a plurality of circuit elements for generating, adjusting and measuring supply voltage of the stimulation module 120 of FIG. 1B, in accordance with an embodiment of the present specification. Circuit element 215 is a DC-DC controller. In some embodiments, the DC-DC controller 215 is a flyback controller. Circuit element 217 is a transformer. In some embodiments, the transformer 217 is a flyback transformer. Circuit element 219 is a voltage quadrupler. Circuit elements 215 and 217 comprise a DC-DC flyback converter 218. The DC-DC flyback controller 215 generates a voltage on the secondary side of the transformer 217. This voltage is quadrupled through quadrupler circuit element 219 which contains a series of diodes and storage capacitors to generate a 200 to 1200 volt supply for the stimulation module. The DC-DC flyback controller 215, flyback transformer 217, and quadrupler circuit element 219 are a source of the delivered output voltage and current. Feedback loop circuit element 220 is connected between the output of the voltage quadrupler circuit element 219 and the feedback input on the DC-DC flyback controller 215.

(32) Circuit element 220 consists of a digital-to-analog converter, operational amplifier, resistors and a MOSFET transistor. The digital-to-analog voltage and operational amplifier control the voltage applied to the gate of the MOSFET transistor to operate the MOSFET transistor in its linear region. Varying the digital-to-analog voltage varies the current through the MOSFET transistor and a resistor divider causing a voltage increase or decrease at the feedback node of the DC-DC flyback controller 215. When the feedback voltage is increased above a certain threshold, the DC-DC flyback controller 215 will reduce its duty cycle causing the voltage at the output of the DC-DC flyback converter 218 to decrease until the feedback voltage is within the threshold range. When the feedback voltage is decreased below a certain threshold, the DC-DC flyback controller 215 will increase its duty cycle causing the voltage at the output of the DC-DC flyback converter 218 to increase until the feedback voltage is within the threshold range. This behavior allows the output of the 200 to 1200 volt supply to be adjusted depending on the stimulation parameters. In various embodiments, the adjustable 200 to 1200 volt DC-DC converter 218 uses a digital-to-analog converter to vary the voltage in the feedback loop of the DC-DC flyback converter 218. This causes the DC-DC flyback controller 215 to adjust the switching duty cycle to raise or lower the output voltage. The adjustable nature of the circuit allows for built-in headroom which keeps the output voltage constant while the supply voltage decreases with each pulse. The 200 to 1200 volt supply can be turned off when not in use, reducing power consumption which allows for a battery-powered option. The high voltage sense circuit 222 provides a means of measuring the output voltage of the 200 to 1200 volt supply. High voltage sense circuit 222 consists of resistors, an operational amplifier and analog-to-digital converter. The output voltage of the 200 to 1200 volt supply is measured by dividing the voltage using a resistor divider, buffering the divided voltage and monitoring the buffered voltage with an internal analog-to-digital converter channel of circuit element 210 of FIG. 2A.

(33) FIG. 2C is a block diagram illustration of a plurality of circuit elements for generating, adjusting and measuring output voltage and current, and for measuring electrode impedance of the stimulation module 120 of FIG. 1B, in accordance with an embodiment of the present specification. Trigger logic circuit element 225 comprises current intensity digital-to-analog converter (DAC) and intensity trigger logic of the stimulation module. The current intensity DAC generates voltage for a current sink circuit 227 that is proportional to a requested stimulus current intensity. The trigger logic allows the stimulation module to switch quickly between different current intensities.

(34) Element 230 is a voltage source for setting an output voltage intensity. The 200 to 1200 volt supply discharge circuit 232 discharges the 200 to 1200 volt supply under the control of the safety circuit elements 205 and 210 of FIG. 2A. The 200 to 1200 volt supply discharge circuit includes resistors, an NPN transistor, and a MOSFET transistor acting as a switch. When safety circuit elements 205 or 210 assert a control signal, the NPN transistor turns off. This causes a voltage to be applied to the gate of a MOSFET transistor via a pull-up resistor. The voltage at the gate of the MOSFET transistor causes the MOSFET transistor to conduct and discharge the 200 to 1200 volt supply storage capacitors of quadrupler circuit element 219 through current limiting series resistors to circuit ground. Self-test load circuit 235 is used to test the stimulation module internally to ensure the stimulation module is working as expected.

(35) Hardware clamp circuit 237 is activated under the control of the safety circuit elements 205 and 210 of FIG. 2A. When activated, the hardware clamp circuit 237 keeps the positive (anode) and negative (cathode) nodes of the stimulation module at the same potential. Element 240 is a current sink logic circuit that ensures that a stimulation pulse will terminate if a predefined pulse limit is exceeded.

(36) A current sink pulse gate 242 is controlled by the safety circuit element 205 of FIG. 2A. The current sink pulse gate consists of an H-Bridge transformer driver, transformer, gate drive optocoupler, and a MOSFET transistor acting as a switch. When the pulse gate control signal is asserted by the safety circuit element 205 microcontroller, the output of the gate drive optocoupler is activated. This causes the gate drive optocoupler to switch the isolated DC voltage to the gate of the MOSFET transistor, causing it to conduct and allow the stimulation current sink to deliver current. This pulse gate must be asserted by the safety circuit element 205 at the same time the safety circuit element 210 attempts to fire a stimulus pulse or the pulse will not be delivered. The current setting and trigger logic circuit element 225 enables setting an output current intensity. Element 247 consists of a current sense resistor and operational amplifier buffer. The voltage across the current sense resistor is an input to the operational amplifier buffer. The output of the operational amplifier buffer is an input to a safety circuit element 210 microcontroller analog-to-digital converter channel. Element 247 provides a means of measuring the delivered current. The delivered current is monitored by the safety circuit element 210.

(37) Impedance voltage generator 250 is a constant voltage source used in conjunction with an impedance pulse generator 252 and an impedance sense circuit 255 for measuring electrode impedance. A method of impedance calculation uses both successive approximation and averaging of 9 pulses, where each pulse is a combination of one output channel or port configured as an anode and the remaining channels configured as cathodes.

(38) High voltage plus sense 257 and high voltage minus sense 260 provide means of measuring the delivered voltage. The delivered voltage is monitored by the safety circuit element 210. The voltage source 230 generates the output voltage for the stimulation module using an emitter follower field-effect transistor whose gate voltage is set by a digital-to-analog converter. The output voltage is proportional to the digital-to-analog converter voltage. A precision current sink is controlled by the trigger logic circuit element 225 that consists of two independent digital-to-analog converters and a high speed operational amplifier to control separate phases of a polyphasic pulse. The output current for the stimulation module is set by the digital-to-analog converter voltage at the input of the high speed operational amplifier which then forces the voltage across a ground referenced transistor at the output. The impedance pulse generator 252 and impedance sense circuit 255, consisting of a field-effect transistor, fixed impedance and an amplifier, are used to limit and sense the impedance current.

(39) FIG. 2D is a block diagram illustration of a patient connection circuit, or output switch or port 261 of the stimulation module 120 of FIG. 1B, in accordance with an embodiment of the present specification. Circuit elements 262 and 264 generate voltage and control signals to connect and disconnect the patient connection circuit or output switch 261. Element 266 is a high-side (anode) patient switch while element 270 is a low-side (cathode) patient switch. In embodiments, there are nine output switches or ports, each similar to the patient connection circuit or output switch 261, forming the nine ports of the stimulation module 120. In embodiments, the nine output switches or ports are controlled by a gate drive optocoupler and H-Bridge transformer driver. This simplifies the high side switching circuit because there is no need for a charge pump to drive the high side output switch. Any combination of switches can be enabled simultaneously and all output switches can be set as anode or cathode.

(40) In embodiments, current and voltage sensing are implemented using voltage dividers, amplifiers and analog-to-digital converters. Both sides of a high voltage rail are monitored along with the current to provide an accurate measurement of the delivered pulse. These values can also be used to compute an “on the fly” impedance measurement.

(41) In embodiments, time clock synchronization of the stimulation module and one or more facilitation stimulators is accomplished with a precise digital timing signal and coordination of the timestamp by the host software (computing device 105 of FIG. 1A). This allows all stimulators and data acquisition and recording electrodes to be synchronized to each other within tens of microseconds.

(42) Stimulation Parameters, Protocols or Schedules

(43) The IONM software application of the present specification implements a plurality of stimulation protocols or schedules, comprising a plurality of stimulation parameters, that are available to the user for modulation, control and automatic delivery or application to a patient depending at least upon a neurostimulation and neuromonitoring objective such as, but not limited to, transcranial stimulation, cortical stimulation or direct nerve stimulation and/or a surgical procedure being performed. It should be appreciated that the IONM software application provides the user with a degree of ease, accuracy and automation with respect to delivery of intended stimuli and recordation of the stimuli as well as that of the correspondingly elicited neuromusculature response.

(44) In various embodiments, stimulation protocols or schedules comprise driving a plurality of stimulation parameters such as, but not limited to, duration of the stimulation; time or moment of application of the stimulation sessions; intensity of stimulations, stimulation pulse shape, frequency, width, amplitude and polarity; stimulation duty cycle; stimulation continuity profile. Following are exemplary standard setting ranges for some of the stimulation parameters: Pulse Width: 50 μsec to 500 μsec, and any increment therein Pulse Amplitude: 0 A to 1.5 A, and any increment therein Pulse Frequency: up to 1 Hz, and any increment therein Pulse Shape: Monophasic positive, Monophasic negative, Biphasic, Polyphasic Pulse Voltage: 0V to 1000V, and any increment therein Mode of Stimulation: Single pulse stimulation, multi-pulse train (MPT) stimulation (comprising, for example, 3 to 5 pulses), Repetitive train stimulation Stimulation Method: Constant-voltage, Constant-current Inter-stimulus interval: 1 millisecond to 9.9 milliseconds (ms) and any increment therein Output Ports or Channels: each independently selectable as anode or cathode

(45) In various embodiments, the IONM software application implements a plurality of sub-sets of the aforementioned stimulation parameters and protocols depending at least upon the type of neurostimulation being delivered—such as, but not limited to, transcranial stimulation.

(46) In some embodiments, the stimulation module 120 of FIG. 1B delivers polyphasic, double pulse or paired pulse train stimulation. In a paired pulse train, a first stimulus of each pair is referred to as the “conditioning or priming stimulus” and a second stimulus is referred to as the “test stimulus”. The double pulse or paired pulse train stimulation improves signal acquisition by priming the nervous system with the first stimulus followed by the second stimulus (test stimulus). In some embodiments, the stimulation module 120 is in time synchronization with one or a plurality of facilitation stimulators. In accordance with an aspect of the present specification, the priming stimulus and the test stimulus are either from a single polyphasic pulse or from at least one facilitation stimulator in sync with the stimulation module 120.

(47) In some embodiments, the stimulation module 120 is configured to deliver a lower intensity, longer pulse width stimulus, for example 200V and 500 uS, which reduces the threshold needed to elicit a neurological response. In embodiments, the stimulation module 120 can be operated for constant-current or constant-voltage output which provides a benefit of delivering an intended stimulus regardless of electrode impedance. In embodiments, the stimulation module 120 includes electrode impedance measurement and reports delivered current and voltage allowing the user to select an optimal stimulation method (that is, constant-current or constant-voltage) and determine if the stimulation module is delivering the intended stimulus.

(48) Exemplary Use Cases

(49) In accordance with various aspects of the present specification, the IONM system of the present specification enables the user to apply a plurality of stimulation protocols, patterns or schedules to the patient with none and/or minimal physical or electromechanical intervention, monitoring and management from the user. The IONM system of the present specification has application in a plurality of neurostimulation and neuromonitoring scenarios such as, but not limited to, transcranial stimulation whereby the motor cortex is stimulated using one or more stimulation probes/electrodes to determine functionality of the cortical structure(s), determine proximity to nervous system structures and create stimulation fields of varying size/depth.

(50) The use case process flowcharts, being described henceforth, illustrate neurophysiological electrical stimulation treatment scenarios utilizing configurable and time-synchronized stimulators to elicit the best neurological response with minimal intervention required by a user. In the illustrated use case scenarios, it is assumed that the user has connected at least six of the nine outputs, of the stimulation module 120 of FIG. 1B, to a patient to allow for programmability of the stimulation parameters without the need for moving electrode connections to achieve a desired neurological response. Additionally, one to four independent electrical stimulators (henceforth, also referred to as ‘facilitation stimulators’) may be connected to the extremities of the patient for facilitation stimulation. In various embodiments, the facilitation stimulators may comprise stimulators such as, but not limited to, low-current electrical stimulator, direct cortical stimulator, constant-current electrical stimulator, constant-voltage electrical stimulator, audio evoked potential stimulator, and visual evoked potential stimulator.

(51) The use case process flowcharts, being described henceforth, illustrate a plurality of functional features of the IONM system of the present specification in general and of the stimulation module 120 of FIG. 1B in particular. A non-limiting exemplary set, from the plurality of functional features, comprises: increasing the area of stimulation to improve a desired response and/or stimulate upper and lower extremities of the patient by adding additional anode sites to the montage, changing the stimulation mode from constant voltage to constant current to overcome issues due to electrode impedance, utilizing biphasic stimulation to elicit responses from both sides of the body with one stimulus, and facilitation stimulation to achieve a desired response at lower stimulation intensities.

(52) Exemplary Use Case 1

(53) FIG. 3 is a flowchart illustrating a plurality of steps of a first use case of transcranial stimulation and motor evoked potential (MEP) monitoring, using the IONM system of the present specification. Also shown is the stimulation module 120 of FIG. 1B illustrating exemplary use of six of the nine output ports 160a-160i. The six output ports or channels are identified in FIG. 3 as C.sub.1, C.sub.2, C.sub.3, C.sub.4, C.sub.z and C.sub.z+6.

(54) Referring now to FIGS. 1A, 1B and 3, at step 305, a patient setup is established for transcranial stimulation and MEP recording or monitoring at a right side lower extremity, that is the right leg, of the patient. In an embodiment, MEP recording or sensing electrodes are positioned at muscle sites on the patient's right leg. Also, a plurality of stimulation components are connected to the six ports (of the stimulation module 120) and positioned at appropriate sites on the patient's head.

(55) At step 310, the IONM software engine 105 activates ports C.sub.1 (anode) and C.sub.2 (cathode) of the stimulation module 120 to deliver stimulation. In an embodiment, the stimulation is delivered at a constant voltage of 100V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, no response is recorded at the patient's right leg at step 315. At step 320, the area of stimulation is increased by adding an anode at port C.sub.z+6. At step 325, the IONM software engine 105 activates ports C.sub.1 (anode), C.sub.z+6 (anode) and C.sub.2 (cathode) of the stimulation module 120 to deliver stimulation. The stimulation is delivered at a constant voltage of 100V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 100 μV is recorded at the patient's right leg at step 330. At step 335, the voltage intensity is increased to 200V to achieve a larger response at the patient's right leg. At step 340, the IONM software engine 105 activates ports C.sub.1 (anode), C.sub.z+6 (anode) and C.sub.2 (cathode) of the stimulation module 120 to deliver stimulation. This time, the stimulation is delivered at an increased constant voltage of 200V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 200 μV is recorded at the patient's right leg at step 345.

(56) Exemplary Use Case 2

(57) FIG. 4 is a flowchart illustrating a plurality of steps of a second use case of transcranial stimulation and motor evoked potential (MEP) monitoring, using the IONM system of the present specification. Also shown is the stimulation module 120 of FIG. 1B illustrating exemplary use of six of the nine output ports 160a-160i. The six output ports or channels are identified in FIG. 4 as C.sub.1, C.sub.2, C.sub.3, C.sub.4, C.sub.z and C.sub.z+6.

(58) Referring now to FIGS. 1A, 1B and 4, at step 405, a patient setup is established for transcranial stimulation and MEP recording or monitoring at right side upper and/or lower extremities, that is the right arm and right leg, of the patient. In an embodiment, MEP recording or sensing electrodes are positioned at muscle sites on the patient's right arm and right leg. Also, a plurality of stimulation components are connected to the six ports (of the stimulation module 120) and positioned at appropriate sites on the patient's head. At step 410, the IONM software engine 105 activates ports C.sub.3 (anode) and C.sub.4 (cathode) of the stimulation module 120 to deliver stimulation. In an embodiment, the stimulation is delivered at a constant voltage of 100V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, no response is recorded at the patient's right arm at step 415.

(59) At step 420, the area of stimulation is increased by adding anode at port C.sub.1 in order to improve response at the upper extremity (right arm) and elicit response at the lower extremity (right leg). At step 425, the IONM software engine 105 activates ports C.sub.1 (anode), C.sub.3 (anode) and C.sub.4 (cathode) of the stimulation module 120 to deliver stimulation. The stimulation is delivered at a constant voltage of 100V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 50 μV is recorded at the patient's right arm and right leg, at step 430.

(60) At step 435, the stimulation mode of the stimulation module 120 is changed from constant-voltage to constant-current to reduce effects of electrode impedance and increase response. At step 440, the IONM software engine 105 activates ports C.sub.1 (anode), C.sub.3 (anode) and C.sub.4 (cathode) of the stimulation module 120 to deliver stimulation. This time, the stimulation is delivered at constant current of amplitude 100 mA, using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 200 μV is recorded at the patient's right arm and right leg, at step 445.

(61) Exemplary Use Case 3

(62) FIG. 5 is a flowchart illustrating a plurality of steps of a third use case of transcranial stimulation and motor evoked potential (MEP) monitoring, using the IONM system of the present specification. Also shown is the stimulation module 120 of FIG. 1B illustrating exemplary use of six of the nine output ports 160a-160i. The six output ports or channels are identified in FIG. 5 as C.sub.1, C.sub.2, C.sub.3, C.sub.4, C.sub.z and C.sub.z+6.

(63) Referring now to FIGS. 1A, 1B and 5, at step 505, a patient setup is established for transcranial stimulation and MEP recording or monitoring at lower extremities on both sides, that is the left and right legs, of the patient. In an embodiment, MEP recording or sensing electrodes are positioned at muscle sites on the patient's left and right legs. Also, a plurality of stimulation components are connected to the six ports (of the stimulation module) and positioned at appropriate sites on the patient's head. At step 510, a stimulation protocol is chosen or activated, at the IONM software engine 105, to use a biphasic pulse with a different anode per phase to stimulate both sides of the patient's body with one stimulus. At step 515, in order to deliver stimulation, the IONM software engine 105 activates ports C.sub.1 (anode) and C.sub.z+6 (cathode) of the stimulation module 120 during the first phase of the biphasic pulse and activates ports C.sub.2 (anode) and C.sub.z+6 (cathode) of the stimulation module 120 during the second phase of the biphasic pulse. In an embodiment, the stimulation is delivered at a constant voltage of 100V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, no response is recorded at any of the patient's legs at step 520.

(64) At step 525, the area of stimulation is increased by adding anode at ports C.sub.3 and C.sub.4. At step 530, in order to deliver stimulation, the IONM software engine 105 activates ports C.sub.1 (anode), C.sub.3 (anode) and C.sub.z+6 (cathode) of the stimulation module 120 during the first phase of the biphasic pulse and activates ports C.sub.2 (anode), C.sub.4 (anode) and C.sub.z+6 (cathode) of the stimulation module 120 during the second phase of the biphasic pulse. In an embodiment, the stimulation is delivered at a constant voltage of 100V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 100 μV is recorded at the patient's right leg and a response of amplitude 75 μV is recorded at the patient's left leg, at step 535.

(65) Now, at step 540, the voltage intensity is increased to 200V to achieve larger response at the patient's left and right legs. At step 545, the IONM software engine 105 activates ports C.sub.1 (anode), C.sub.3 (anode) and C.sub.z+6 (cathode) of the stimulation module 120 during the first phase of the biphasic pulse and activates ports C.sub.2 (anode), C.sub.4 (anode) and C.sub.z+6 (cathode) of the stimulation module 120 during the second phase of the biphasic pulse. In an embodiment, the stimulation is delivered at an increased constant voltage of 200V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 200 μV is recorded at the patient's right leg and a response of amplitude 150 μV is recorded at the patient's left leg, at step 550.

(66) Exemplary Use Case 4

(67) FIG. 6 is a flowchart illustrating a plurality of steps of a fourth use case of transcranial stimulation and motor evoked potential (MEP) monitoring, using the IONM system of the present specification. Also shown is the stimulation module 120 of FIG. 1B illustrating exemplary use of six of the nine output ports 160a-160i. The six output ports or channels are identified in FIG. 6 as C.sub.1, C.sub.2, C.sub.3, C.sub.4, C.sub.z and C.sub.z+6.

(68) Referring now to FIGS. 1A, 1B and 6, at step 605, a patient setup is established for transcranial stimulation and MEP recording or monitoring at all extremities, including the left and right arms as well as the left and right legs, of the patient. In an embodiment, MEP recording or sensing electrodes are positioned at muscle sites on the patient's left and right arms as well as left and right legs. Also, a plurality of stimulation components are connected to the six ports (of the stimulation module 120) and positioned at appropriate sites on the patient's head.

(69) At step 610, a stimulation protocol is chosen or activated, at the IONM software engine 105, to use a biphasic pulse with multiple anodes and cathodes per phase to stimulate all extremities of the patient's body with one stimulus. At step 615, in order to deliver stimulation, the IONM software engine 105 activates ports C.sub.3 (anode), C.sub.1 (anode), C.sub.2 (cathode) and C.sub.4 (cathode) of the stimulation module 120 during the first phase of the biphasic pulse and activates ports C.sub.2 (anode), C.sub.4 (anode), C.sub.3 (cathode) and C.sub.1 (cathode) of the stimulation module 120 during the second phase of the biphasic pulse. In an embodiment, the stimulation is delivered at a constant voltage of 100V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, no response is recorded at any of the patient's extremities at step 620.

(70) Now, at step 625, the mode of stimulation is modified from constant-voltage to constant-current to reduce effects of electrode impedance and increase response. At step 630, in order to deliver stimulation, the IONM software engine 105 activates ports C.sub.3 (anode), C.sub.1 (anode), C.sub.2 (cathode) and C.sub.4 (cathode) of the stimulation module 120 during the first phase of the biphasic pulse and activates ports C.sub.2 (anode), C.sub.4 (anode), C.sub.3 (cathode) and C.sub.1 (cathode) of the stimulation module 120 during the second phase of the biphasic pulse. In an embodiment, the stimulation is delivered at a constant current of amplitude 120 mA using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 150 μV is recorded at the patient's left and right legs and a response of amplitude 200 μV is recorded at the patient's left and right arms, at step 635.

(71) Exemplary Use Case 5

(72) FIG. 7 is a flowchart illustrating a plurality of steps of a fifth use case of facilitation stimulation, using the IONM system of the present specification. Also shown is the stimulation module 120 of FIG. 1B illustrating exemplary use of six of the nine output ports 160a-160i. The six output ports or channels are identified in FIG. 7 as C.sub.1, C.sub.2, C.sub.3, C.sub.4, C.sub.z and C.sub.z+6.

(73) Referring now to FIGS. 1A, 1B and 7, at step 705, a patient setup is established for transcranial stimulation using SSEP (Somatosensory Evoked Potential) stimulation and MEP (Motor Evoked Potential) recording or monitoring at lower extremity right side, that is the right leg, of a patient. In an embodiment, MEP recording or sensing electrodes are positioned at muscle sites on the patient's right leg. In accordance with an embodiment, facilitation stimulators 701 and 702 are also positioned at lower extremity right side, that is the right leg, of the patient. Also, a plurality of stimulation components are connected to the six ports (of the stimulation module 120) and positioned at appropriate sites on the patient's head. In accordance with an aspect, the IONM software engine 105 ensures that the stimulation module 120 and the facilitation stimulators 701 and 702 are in time-synchronization with each other.

(74) At step 710, a stimulation protocol is chosen or activated, at the IONM software engine 105, to initiate a facilitation stimulus using the facilitation stimulators 701 and 702 positioned at the lower extremity right side to reduce an intensity of stimulation required (from the stimulation module 120) to elicit an MEP response. Now, at step 715, the IONM software engine 105 activates the facilitation stimulators 701 and 702 to deliver a facilitation stimulus to the patient's right posterior tibial nerve. In one embodiment, the facilitation stimulus is delivered at a constant current of amplitude 25 mA using a train of 3 pulses having an inter-stimulus interval (ISI) of 2 ms. At step 720, the inter-stimulus interval of the facilitation stimulus is modulated in a range of 40 ms to 50 ms.

(75) Now, at step 725, the IONM software engine 105 configures the stimulation module 120 to deliver a stimulation protocol having relatively lower intensities to achieve desired responses. At step 730, in one embodiment, the IONM software engine 105 activates C.sub.1 (anode) and C.sub.2 (cathode) of the stimulation module 120 to deliver stimulation. In one embodiment, the stimulation is delivered at a constant voltage of amplitude 80V using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 200 μV is recorded at the patient's right leg, at step 735.

(76) Exemplary Use Case 6

(77) FIG. 8 is a flowchart illustrating a plurality of steps of a sixth use case of facilitation stimulation, using the IONM system of the present specification. Also shown is the stimulation module 120 of FIG. 1B illustrating exemplary use of six of the nine output ports 160a-160i. The six output ports or channels are identified in FIG. 7 as C.sub.1, C.sub.2, C.sub.3, C.sub.4, C.sub.z and C.sub.z+6.

(78) Referring now to FIGS. 1A, 1B and 8, at step 805, a patient setup is established for transcranial stimulation using SSEP (Somatosensory Evoked Potential) stimulation and MEP (Motor Evoked Potential) recording or monitoring at all extremities, that is the left and right arms as well as the left and right legs, of a patient. In an embodiment, MEP recording or sensing electrodes are positioned at muscle sites on the patient's left and right arms as well as the left and right legs. In accordance with an embodiment, facilitation stimulators 801 and 802 are also positioned at the left and right arms as well as the left and right legs, of the patient. Also, a plurality of stimulation components are connected to the six ports (of the stimulation module 120) and positioned at appropriate sites on the patient's head. In accordance with an aspect, the IONM software engine 105 ensures that the stimulation module 120 and the facilitation stimulators 801 and 802 are in time-synchronization with each other.

(79) At step 810, a stimulation protocol is chosen or activated, at the IONM software engine 105, to initiate a facilitation stimulus using the facilitation stimulators 801 and 802 positioned at all extremities reduce an intensity of stimulation required (from the stimulation module 120) to elicit an MEP response. Now, at step 815, the IONM software engine 105 activates the facilitation stimulators 801 and 802 to deliver facilitation stimulus at the patient's left and right median nerve as well as the left and right posterior tibial nerve. In one embodiment, the facilitation stimulus is delivered at a constant current of amplitude 25 mA using a train of 3 pulses having an inter-stimulus interval (ISI) of 2 ms. At step 820, the inter-stimulus interval of the facilitation stimulus is modulated in a range of 40 ms to 50 ms.

(80) Now, at step 825, the IONM software engine 105 configures the stimulation module 120 to deliver a stimulation protocol having relatively lower intensities to achieve desired responses.

(81) At step 830, in order to deliver stimulation, the IONM software engine 105 activates ports C.sub.3 (anode), C.sub.1 (anode), C.sub.2 (cathode) and C.sub.4 (cathode) of the stimulation module 120 during a first phase of a biphasic stimulation pulse and activates ports C.sub.2 (anode), C.sub.4 (anode), C.sub.3 (cathode) and C.sub.1 (cathode) of the stimulation module 120 during a second phase of the biphasic stimulation pulse. In an embodiment, the stimulation is delivered at a constant current of amplitude 80 mA using a train of 5 pulses having an inter-stimulus interval (ISI) of 2 ms. As a result of the delivered stimulation, a response of amplitude 150 μV is recorded at the patient's left and right legs while a response of amplitude 200 μV is recorded at the patient's left and right arms, at step 835.

(82) The above examples are merely illustrative of the many applications of the system and method of present specification. Although only a few embodiments of the present specification have been described herein, it should be understood that the present specification might be embodied in many other specific forms without departing from the spirit or scope of the specification. Therefore, the present examples and embodiments are to be considered as illustrative and not restrictive, and the specification may be modified within the scope of the appended claims.