Nerve proximity and status detection system and method

• US 6,466,817 B1
• Filed: 06/08/2000
• Issued: 10/15/2002
• Est. Priority Date: 11/24/1999
• Status: Expired due to Term

• Current Assignee: Nuvasive Incorporated
• Original Assignee: Nuvasive Incorporated
• Inventors: Kaula, Norbert F., Marino, James F., Blewett, Jeffrey J.
• Primary Examiner(s): Shaver, Kevin
• Assistant Examiner(s): MARMOR II, CHARLES ALAN
• Application Number:
  US09/590,632
• Time in Patent Office: 859 Days
• Field of Search: 600/546, 600/547, 600/548, 600/554, 607/72, 607/115, 607/116, 607/117, 607/118, 606/34, 606/41
• US Class Current: 600/546
• CPC Class Codes: A61B 2017/00039 Electric or electromagnetic phenomena other than conductivity, e.g. capacity, inductivity, Hall effect
• CPC Class Codes: A61B 5/24 Detecting, measuring or recording bioelectric or biomagnetic signals of the body or parts thereof
• CPC Class Codes: A61B 5/296 for electromyography [EMG]
• CPC Class Codes: A61B 5/389 Electromyography [EMG]
• CPC Class Codes: A61B 5/395 Details of stimulation, e.g. nerve stimulation to elicit EMG response
• CPC Class Codes: A61B 5/4893 Nerves

Abstract

A method and system for detecting proximity of a nerve to a proximity electrode and status of nerve. The method of detecting the proximity of the nerve to the proximity electrode applies a first electrical signal with multiple current levels to a calibration electrode. The method applies a second electrical signal with multiple current levels to the proximity electrode. Based on the response of the nerve to the first and second electrical signals, the method determines the proximity of the proximity electrode to the nerve. The method determines the status of the nerve by applying the first electrical signal with multiple signal levels to the calibration electrode.

Claims

1. A method of determining nerve status comprising the steps of:

(a) applying an electrical signal having a plurality of predetermined current levels to a conductive element located near the nerve;

(b) measuring the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(c) mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(d) determining the nerve status based on an interpretation of the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels.

2. The method of claim 1, wherein step c) includes mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for a fixed latency, and wherein step d) includes determining the nerve status based on the mapping of the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for the fixed latency.

3. The method of claim 2, wherein step a) includes placing a conductive element near the nerve, and applying an electrical signal having a plurality of predetermined current levels to the conductive element.

4. The method of claim 3, wherein step a) includes placing a conductive element in the epidural space above the dura of the spinal column in which the nerve is located.

5. The method of claim 2, wherein each response is an EMG.

6. The method of claim 2, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

7. The method of claim 1, wherein step d) of determining nerve status is based on an interpretation of the slope of the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels.

8. The method of claim 1, wherein step d) of determining nerve status is based on an interpretation of a comparison between the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels and known mappings for at least one of healthy and unhealthy nerves.

9. The method of claim 1, wherein step d) of determining nerve status is performed to assess the effect of a surgical procedure on nerve status.

10. The method of claim 1, wherein step d) of determining nerve status is performed intraoperatively to assess the effect of a surgical procedure on nerve status.

11. The method of claim 1, wherein the conductive element is coupled to a medical device.

12. The method of claim 11, wherein the medical device comprises at least one of a cannula, a catheter, and a needle.

13. The method of claim 1, wherein each response is an EMG.

14. The method of claim 1, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

23. The article of manufacture for use in determining nerve status of claim 12, wherein each response is an EMG.

15. A method of determining nerve status comprising the steps of:

(a) applying an electrical signal having a plurality of predetermined current levels to a conductive element located near the nerve;

(b) measuring the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(c) determining the nerve status based on the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels, including the sub-steps of (i) mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for a fixed latency; and

(ii) determining the nerve status based on the mapping of the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for the fixed latency, wherein the fixed latency is a function of peaks in each response of the nerve to the applied electrical signal for the plurality of predetermined current levels.

16. The method of claim 15, wherein the fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(b) selecting the latency having the largest number of peaks located thereabout.

17. The method of claim 15, wherein the fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(b) determining the number of peaks located about each latency having a peak located thereabout; and

(c) selecting the latency having the largest number of peaks located thereabout.

18. The method of claim 15, wherein the fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(b) determining the ratio of the peak level to corresponding current level for each peak;

(c) determining the sum of the ratio of peak level to current level for peaks located about each latency having a peak located thereabout; and

(d) selecting the latency having the largest sum of ratios.

19. The method of claim 18, wherein each response is an EMG.

20. The method of claim 18, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

47. The apparatus of claim 20, wherein each response is an EMG.

21. An article of manufacture for use in determining nerve status, the article of manufacture comprising computer readable storage media including program logic embedded therein that causes control circuitry to perform the steps of:

(a) applying an electrical signal having a plurality of predetermined current levels to a conductive element located near the nerve;

(b) measuring the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(c) mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(d) determining the nerve status based on an interpretation of the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels.

22. The article of manufacture for use in determining nerve status of claim 21, wherein step c) includes mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for a fixed latency, and wherein step d) includes determining the nerve status based on the mapping of the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for the fixed latency.

24. The article of manufacture for use in determining nerve status of claim 21, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

25. The article of manufacture of claim 21, wherein step d) of determining nerve status is based on an interpretation of the slope of the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels.

26. The article of manufacture of claim 21, wherein step d) of determining nerve status is based on an interpretation of a comparison between the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels and known mappings for at least one of healthy and unhealthy nerves.

27. The article of manufacture of claim 21, wherein step d) of determining nerve status is performed to assess the effect of a surgical procedure on nerve status.

28. The article of manufacture of claim 21, wherein step d) of determining nerve status is performed intraoperatively to assess the effect of a surgical procedure on nerve status.

29. The article of manufacture of claim 21, wherein the conductive element is coupled to a medical device.

30. The article of manufacture of claim 29, wherein the medical device comprises at least one of a cannula, a catheter, and a needle.

31. The article of manufacture of claim 21, wherein each response is an EMG.

32. The article of manufacture of claim 21, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

40. The apparatus of claim 21, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

41. The apparatus of claim 31, wherein the determination of nerve status is based on an interpretation of the slope of the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels.

58. The method of claim 30, wherein each response is an EMG.

33. An article of manufacture for use in determining nerve status, the article of manufacture comprising computer readable storage media including program logic embedded therein that causes control circuitry to perform the steps of:

(a) applying an electrical signal having a plurality of predetermined current levels to a conductive element located near the nerve;

(b) measuring the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(c) determining the nerve status based on the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels, including the sub-steps of (i) mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for a fixed latency; and

(ii) determining the nerve status based on the mapping of the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for the fixed latency, wherein the fixed latency is a function of peaks in each response of the nerve to the applied electrical signal for the plurality of predetermined current levels.

34. The article of manufacture for use in determining nerve status of claim 33, wherein the fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(b) selecting the latency having the largest number of peaks located thereabout.

35. The article of manufacture for use in determining nerve status of claim 33, herein the fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(b) determining the number of peaks located about each latency having a peak located thereabout; and

(c) selecting the latency having the largest number of peaks located thereabout.

36. The article of manufacture for use in determining nerve status of claim 33, wherein the fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(b) determining the ratio of the peak level to corresponding current level for each peak;

(c) determining the sum of the ratio of peak level to current level for peaks located about each latency having a peak located thereabout; and

(d) selecting the latency having the largest sum of ratios.

37. An apparatus for determining nerve status, the apparatus comprising:

(a) means for applying an electrical signal having a plurality of predetermined current levels to a conductive element located near the nerve;

(b) means for measuring the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(c) means for mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(d) means for determining the nerve status based on an interpretation of the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels.

38. The apparatus of claim 37, wherein the means for mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels includes means for mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for a fixed latency.

39. The apparatus of claim 38, wherein each response is an EMG.

42. The apparatus of claim 37, herein the determination of nerve status is based on an interpretation of a comparison between the mapped responses of the nerve to the applied electrical signal for the plurality of predetermined current levels and known mappings for at least one of healthy and unhealthy nerves.

43. The apparatus of claim 37, wherein the determination of nerve status is performed to assess the effect of a surgical procedure on nerve status.

44. The apparatus of claim 37, wherein the determination of nerve status is performed intraoperatively to assess the effect of a surgical procedure on nerve status.

45. The apparatus of claim 37, wherein the conductive element is coupled to a medical device.

46. The apparatus of claim 45, wherein the medical device comprises at least one of a cannula, a catheter, and a needle.

48. The apparatus of claim 37, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

49. An apparatus for determining nerve status, the apparatus comprising:

(a) means for applying an electrical signal having a plurality of predetermined current levels to a conductive element located near the nerve;

(b) means for measuring the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(c) means for determining the nerve status based on the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels, including (i) means for mapping the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for a fixed latency, (ii) means for determining the nerve status based on the mapping of the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels for the fixed latency, and (iii) means for determining the fixed latency as a function of peaks in each response of the nerve to the applied electrical signal for the plurality of predetermined current levels.

50. The apparatus of claim 49, further comprising:

(a) means for determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels; and

(b) means for selecting the latency having the largest number of peaks located thereabout as the fixed latency.

51. The apparatus of claim 49, further comprising:

(a) means for determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(b) means for determining the number of peaks located about each latency having a peak located thereabout; and

(c) means for selecting the latency having the largest number of peaks located thereabout as the fixed latency.

52. The apparatus of claim 49, further comprising:

(a) means for determining the peaks in the responses of the nerve to the applied electrical signal for the plurality of predetermined current levels;

(b) means for determining the ratio of the peak level to corresponding current level for each peak;

(c) means for determining the sum of the ratio of peak level to current level for peaks located about each latency having a peak located thereabout; and

(d) means for selecting the latency having the largest sum of ratios as the fixed latency.

53. The apparatus of claim 52, wherein each response is an EMG.

54. The apparatus of claim 52, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

55. A method of determining proximity of a nerve to a second conductive element comprising the steps of:

(a) applying a first electrical signal having a plurality of predetermined current levels to a first conductive element located near the nerve;

(b) measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) applying a second electrical signal having the plurality of predetermined current levels to the second conductive element;

(d) measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) determining the nerve proximity to the second conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels relative to the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

56. The method of claim 55, wherein step e) includes:

(a) mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for a first fixed latency;

(b) mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for a second fixed latency and

(c) determining the nerve proximity to the second conductive element based on the mapping of the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for the first fixed latency and the mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for the second fixed latency.

57. The method of claim 56, wherein step a) includes:

(a) placing a first conductive element near the nerve; and

(b) applying a first electrical signal having a plurality of predetermined current levels to the first conductive element.

59. The method of claim 55, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

60. A method of determining proximity of a nerve to a second conductive element comprising the steps of:

(a) applying a first electrical signal having a plurality of predetermined current levels to a first conductive element located near the nerve;

(b) measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) applying a second electrical signal having the plurality of predetermined current levels to the second conductive element;

(d) measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) determining the nerve proximity to the second conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels and the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels, including the sub-steps of;

(i) mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for a first fixed latency;

(ii) mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for a second fixed latency;

(iii) determining the nerve proximity to the second conductive element based on the mapping of the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for the first fixed latency and the mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for the second fixed latency; and

(iv) determining the first fixed latency as a function of peaks in each response of the nerve to the first applied electrical signal for the plurality of predetermined current levels.

61. The method of claim 60, wherein the first fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels; and

(b) selecting the latency having the largest number of peaks located thereabout as the first fixed latency.

62. The method of claim 60, wherein the first fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(b) determining the number of peaks located about each latency having a peak located thereabout; and

(c) selecting the latency having the largest number of peaks located thereabout as the first fixed latency.

63. The method of claim 60, wherein the first fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(b) determining the ratio of the peak level to corresponding current level for each peak;

(c) determining the sum of the ratio of peak level to current level for peaks located about each latency having a peak located thereabout; and

(d) selecting the latency having the largest sum of ratios as the first fixed latency.

64. The method of claim 63, wherein each response is an EMG.

65. The method of claim 63, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

66. The method of claim 65, wherein the second fixed latency is equal to the first fixed latency.

67. An article of manufacture for use in determining proximity of a nerve to a second conductive element, the article of manufacture comprising computer readable storage media including program logic embedded therein that causes control circuitry to perform the steps of:

(a) applying a first electrical signal having a plurality of predetermined current levels to a first conductive element located near the nerve;

(b) measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) applying a second electrical signal having the plurality of predetermined current levels to the second conductive element;

(d) measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) determining the nerve proximity to the second conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels relative to the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

68. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 67, wherein step e) includes:

(a) mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for a first fixed latency;

(b) mapping the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for a second fixed latency and

(c) determining the nerve proximity to the second conductive element based on the mapping of the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for the first fixed latency and the mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for the second fixed latency.

69. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 67, wherein each response is an EMG.

70. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 67, each response is an EMG measured at a muscle physiologically coupled to the nerve.

71. An article of manufacture for use in determining proximity of a nerve to a second conductive element, the article of manufacture comprising computer readable storage media including program logic embedded therein that causes control circuitry to perform the steps of:

(a) applying a first electrical signal having a plurality of predetermined current levels to a first conductive element located near the nerve;

(b) measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) applying a second electrical signal having the plurality of predetermined current levels to the second conductive element;

(d) measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) determining the nerve proximity to the second conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels and the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels, including the sub-steps of;

(i) mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for a first fixed latency;

(ii) mapping the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for a second fixed latency;

(iii) determining the nerve proximity to the second conductive element based on the mapping of the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for the first fixed latency and the mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for the second fixed latency; and

(iv) determining the first fixed latency as a function of peaks in each response of the nerve to the first applied electrical signal for the plurality of predetermined current levels.

72. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 71, wherein the first fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels; and

(b) selecting the latency having the largest number of peaks located thereabout as the first fixed latency.

73. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 71, wherein the first fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(b) determining the number of peaks located about each latency having a peak located thereabout; and

(c) selecting the latency having the largest number of peaks located thereabout as the first fixed latency.

74. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 71, wherein the first fixed latency is selected by performing the steps of:

(a) determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(b) determining the ratio of the peak level to corresponding current level for each peak;

(c) determining the sum of the ratio of peak level to current level for peaks located about each latency having a peak located thereabout; and

(d) selecting the latency having the largest sum of ratios as the first fixed latency.

75. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 74, wherein each response is an EMG.

76. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 74, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

77. The article of manufacture for use in determining proximity of a nerve to a second conductive element of claim 76, wherein the second fixed latency is equal to the first fixed latency.

78. An apparatus for determining proximity of a nerve to a second conductive element, the apparatus comprising:

(a) means for applying a first electrical signal having a plurality of predetermined current levels to a first conductive element located near the nerve;

(b) means for measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) means for applying a second electrical signal having the plurality of predetermined current levels to the second conductive element;

(d) means for measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) means for determining the nerve proximity to the second conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels relative to the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

79. The apparatus for determining proximity of a nerve to a second conductive element of claim 78, wherein the means for determining the nerve proximity to the second conductive element includes:

(a) means for mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for a first fixed latency;

(b) means for mapping the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for a second fixed latency and

(c) means for determining the nerve proximity to the second conductive element based on the mapping of the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for the first fixed latency and the mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for the second fixed latency.

80. The apparatus for determining proximity of a nerve to a second conductive element of claim 78, wherein each response is an EMG.

81. The apparatus for determining proximity of a nerve to a second conductive element of claim 78, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

82. An apparatus for determining proximity of a nerve to a second conductive element, the apparatus comprising:

(a) means for applying a first electrical signal having a plurality of predetermined current levels to a first conductive element located near the nerve;

(b) means for measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) means for applying a second electrical signal having the plurality of predetermined current levels to the second conductive element;

(d) means for measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) means for determining the nerve proximity to the second conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels and the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels, including;

(i) means for mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for a first fixed latency;

(ii) means for mapping the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for a second fixed latency;

(iii) means for determining the nerve proximity to the second conductive element based on the mapping of the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels for the first fixed latency and the mapping of the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels for the second fixed latency; and

(iv) means for determining the first fixed latency as a function of peaks in each response of the nerve to the first applied electrical signal for the plurality of predetermined current levels.

83. The apparatus for determining proximity of a nerve to a second conductive element of claim 82, further comprising:

(a) means for determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels; and

(b) means for selecting the latency having the largest number of peaks located thereabout as the first fixed latency.

84. The apparatus for determining proximity of a nerve to a second conductive element of claim 82, further comprising:

(a) means for determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(b) means for determining the number of peaks located about each latency having a peak located thereabout; and

(c) means for selecting the latency having the largest number of peaks located thereabout as the first fixed latency.

85. The apparatus for determining proximity of a nerve to a second conductive element of claim 82, further comprising:

(a) means for determining the peaks in the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(b) means for determining the ratio of the peak level to corresponding current level for each peak;

(c) means for determining the sum of the ratio of peak level to current level for peaks located about each latency having a peak located thereabout; and

(d) means for selecting the latency having the largest sum of ratios as the first fixed latency.

86. The apparatus for determining proximity of a nerve to a second conductive element of claim 85, wherein each response is an EMG.

87. The apparatus for determining proximity of a nerve to a second conductive element of claim 85, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

88. The apparatus for determining proximity of a nerve to a second conductive element of claim 87, wherein the second fixed latency is equal to the first fixed latency.

89. A method of determining proximity of a nerve to a conductive element comprising the steps of:

(a) applying a first electrical signal having a plurality of predetermined current levels to the conductive element while the conductive element is disposed at a first location;

(b) measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) applying a second electrical signal having the plurality of predetermined current levels to the conductive element while the conductive element is disposed at a second location;

(d) measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) determining the nerve proximity to the conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels and the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

90. The method of claim 89, wherein step e) includes determining the nerve proximity to the conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels relative to the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

91. The method of claim 89, wherein step e) includes the sub-steps of:

(i) mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(ii) mapping the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(iii) interpreting the mapped responses of the first and second applied electrical signals to determine nerve proximity to the conductive element.

92. The method of claim 91, wherein the step of interpreting the mapped responses involves comparing the slope of the mapped response for the first applied electrical signal to the slope of the mapped response for the second applied electrical signal.

93. The method of claim 91, wherein the step of interpreting the mapped responses involves comparing a current level of the mapped response for the first applied electrical signal to a current level of the mapped response for the second applied electrical signal.

94. The method of claim 89, wherein step e) of determining nerve proximity to the conductive element is performed intraoperatively to guide a real time procedure.

95. The method of claim 89, wherein the conductive element is coupled to a medical device.

96. The method of claim 95, wherein the medical device comprises at least one of a cannula, a catheter, and a needle.

97. The method of claim 89, wherein each response is an EMG.

98. The method of claim 89, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

99. An article of manufacture for use in determining proximity of a nerve to a conductive element, the article of manufacture comprising computer readable storage media including program logic embedded therein that causes control circuitry to perform the steps of:

(a) applying a first electrical signal having a plurality of predetermined current levels to the conductive element while the conductive element is disposed at a first location;

(b) measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) applying a second electrical signal having the plurality of predetermined current levels to the conductive element while the conductive element is disposed at a second location;

(d) measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) determining the nerve proximity to the conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels and the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

100. The article of manufacture of claim 99, wherein step e) includes determining the nerve proximity to the conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels relative to the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

101. The article of manufacture of claim 99, wherein step e) includes the sub-steps of:

(i) mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(ii) mapping the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(iii) interpreting the mapped responses of the first and second applied electrical signals to determine nerve proximity to the conductive element.

102. The article of manufacture of claim 101, wherein the step of interpreting the mapped responses involves comparing the slope of the mapped response for the first applied electrical signal to the slope of the mapped response for the second applied electrical signal.

103. The article of manufacture of claim 101, wherein the step of interpreting the mapped responses involves comparing a current level of the mapped response for the first applied electrical signal to a current level of the mapped response for the second applied electrical signal.

104. The article of manufacture of claim 99, wherein step e) of determining nerve proximity to the conductive element is performed intraoperatively to guide a real time procedure.

105. The article of manufacture of claim 99, wherein the conductive element is coupled to a medical device.

106. The article of manufacture of claim 105, wherein the medical device comprises at least one of a cannula, a catheter, and a needle.

107. The article of manufacture of claim 99,wherein each response is an EMG.

108. The article of manufacture of claim 99, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.

109. An apparatus for determining proximity of a nerve to a conductive element, the apparatus comprising:

(a) means for applying a first electrical signal having a plurality of predetermined current levels to the conductive element while the conductive element is disposed at a first location;

(b) means for measuring the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(c) means for applying a second electrical signal having the plurality of predetermined current levels to the conductive element while the conductive element is disposed at a second location;

(d) means for measuring the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(e) means for determining the nerve proximity to the conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels and the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

110. The apparatus of claim 109, wherein the means for determining the nerve proximity to the conductive element includes means for determining the nerve proximity to the conductive element based on the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels relative to the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels.

111. The apparatus of claim 109, wherein the means for determining the nerve proximity to the conductive element includes:

(i) means for mapping the responses of the nerve to the first applied electrical signal for the plurality of predetermined current levels;

(ii) means for mapping the responses of the nerve to the second applied electrical signal for the plurality of predetermined current levels; and

(iii) means for interpreting the mapped responses of the first and second applied electrical signals to determine nerve proximity to the conductive element.

112. The apparatus of claim 111, wherein the means for interpreting the mapped responses includes means for comparing the slope of the mapped response for the first applied electrical signal to the slope of the mapped response for the second applied electrical signal.

113. The apparatus of claim 111, wherein the means for interpreting the mapped responses includes means for comparing a current level of the mapped response for the first applied electrical signal to a current level of the mapped response for the second applied electrical signal.

114. The apparatus of claim 109, wherein the determination of nerve proximity to the conductive element is performed intraoperatively to guide a real time procedure.

115. The apparatus of claim 109, wherein the conductive element is coupled to a medical device.

116. The apparatus of claim 115, wherein the medical device comprises at least one of a cannula, a catheter, and a needle.

117. The apparatus of claim 109, wherein each response is an EMG.

118. The apparatus of claim 109, wherein each response is an EMG measured at a muscle physiologically coupled to the nerve.