text:
|Publication number
|Publication type
|Application number
|Publication date
|Nov 29, 2011
|Filing date
|Jan 9, 2004
|Priority date
|Jul 11, 2001
|Fee status
|Also published as
|Publication number
|Norbert Kaula, Jeffrey Blewett, James Gharib, Allen Farquhar
|Original Assignee
|Nuvasive, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (201), Non-Patent Citations (43), Referenced by (53), Classifications (24), Legal Events (4)
|External Links: USPTO, USPTO Assignment, Espacenet
The present application is a continuation of PCT Patent Application Serial No. PCT/US02/22247, filed Jul. 11, 2001 and published on Jan. 23, 2003 as WO 03/005887 A2, the entire contents of which is hereby expressly incorporated by reference into this disclosure as if set forth fully herein.
I. Field of the Invention
This invention relates to nerve monitoring systems and to nerve muscle monitoring systems, and more particularly to systems and methods for determining nerve proximity, nerve direction, and pathology during surgery.
II. Description of Related Art
Systems and methods exist for monitoring nerves and nerve muscles. One such system determines when a needle is approaching a nerve. The system applies a current to the needle to evoke a muscular response. The muscular response is visually monitored, typically as a shake or "twitch." When such a muscular response is observed by the user, the needle is considered to be near the nerve coupled to the responsive muscle. These systems require the user to observe the muscular response (to determine that the needle has approached the nerve). This may be difficult depending on the competing tasks of the user. In addition, when general anesthesia is used during a procedure, muscular response may be suppressed, limiting the ability of a user to detect the response.
While generally effective (although crude) in determining nerve proximity, such existing systems are incapable of determining the direction of the nerve to the needle or instrument passing through tissue or passing by the nerves. This can be disadvantageous in that, while the surgeon may appreciate that a nerve is in the general proximity of the instrument, the inability to determine the direction of the nerve relative to the instrument can lead to guess work by the surgeon in advancing the instrument and thereby raise the specter of inadvertent contact with, and possible damage to, the nerve.
Another nerve-related issue in existing surgical applications involves the use of nerve retractors. A typical nerve retractor serves to pull or otherwise maintain the nerve outside the area of surgery, thereby protecting the nerve from inadvertent damage or contact by the "active" instrumentation used to perform the actual surgery. While generally advantageous in protecting the nerve, it has been observed that such retraction can cause nerve function to become impaired or otherwise pathologic over time due to the retraction. In certain surgical applications, such as spinal surgery, it is not possible to determine if such retraction is hurting or damaging the retracted nerve until after the surgery (generally referred to as a change in "nerve health" or "nerve status"). There are also no known techniques or systems for assessing whether a given procedure is having a beneficial effect on a nerve or nerve root known to be pathologic (that is, impaired or otherwise unhealthy).
Based on the foregoing, a need exists for a better system and method that can determine the proximity of a surgical instrument (including but not limited to a needle, catheter, cannula, probe, or any other device capable of traversing through tissue or passing near nerves or nerve structures) to a nerve or group of nerves during surgery. A need also exists for a system and method for determining the direction of the nerve relative to the surgical instrument. A still further need exists for a manner of monitoring nerve health or status during surgical procedures.
The present invention is directed at eliminating, or at least reducing the effects of, the above-described problems with the prior art, as well as addressing the above-identified needs.
The present invention includes a system and related methods for determining nerve proximity and nerve direction to surgical instruments employed in accessing a surgical target site, as well as monitoring the status or health (pathology) of a nerve or nerve root during surgical procedures.
According to a broad aspect, the present invention includes a surgical system, comprising a control unit and a surgical instrument. The control unit has at least one of computer programming software, firmware and hardware capable of delivering a stimulation signal, receiving and processing neuromuscular responses due to the stimulation signal, and identifying a relationship between the neuromuscular response and the stimulation signal. The surgical instrument has at least one stimulation electrode electrically coupled to said control unit for transmitting the stimulation signal, wherein said control unit is capable of determining at least one of nerve proximity, nerve direction, and nerve pathology relative to the surgical instrument based on the identified relationship between the neuromuscular response and the stimulation signal.
In a further embodiment of the surgical system of the present invention, the control unit is further equipped to communicate at least one of alpha-numeric and graphical information to a user regarding at least one of nerve proximity, nerve direction, and nerve pathology.
In a further embodiment of the surgical system of the present invention, the surgical instrument may comprise at least one of a device for maintaining contact with a nerve during surgery, a device for accessing a surgical target site, and a device for testing screw placement integrity.
In a further embodiment of the surgical system of the present invention, the surgical instrument comprises a nerve root retractor and wherein the control unit determines nerve pathology based on the identified relationship between the neuromuscular response and the stimulation signal.
In a further embodiment of the surgical system of the present invention, the surgical instrument comprises a dilating instrument and wherein the control unit determines at least one of proximity and direction between a nerve and the instrument based on the identified relationship between the neuromuscular response and the stimulation signal.
In a further embodiment of the surgical system of the present invention, the dilating instrument comprises at least one of a K-wire, an obturator, a dilating cannula, and a working cannula.
In a further embodiment of the surgical system of the present invention, the surgical instrument comprises a screw test probe and wherein the control unit determines the proximity between the screw test probe and an exiting spinal nerve root to assess whether a medial wall of a pedicle has been breached by at least one of hole formation and screw placement.
Illustrative embodiments of the invention are described below. In the interest of clarity, not all features of an actual implementation are described in this specification. It will of course be appreciated that in the development of any such actual embodiment, numerous implementation-specific decisions must be made to achieve the developers' specific goals, such as compliance with system-related and business-related constraints, which will vary from one implementation to another. Moreover, it will be appreciated that such a development effort might be complex and time-consuming, but would nevertheless be a routine undertaking for those of ordinary skill in the art having the benefit of this disclosure. The systems disclosed herein boast a variety of inventive features and components that warrant patent protection, both individually and in combination.
The surgical system 10 includes a control unit 12, a patient module 14, an EMG harness 16 and return electrode 35 coupled to the patient module 14, and a host of surgical accessories 20 capable of being coupled to the patient module 14 via one or more accessory cables 22. The surgical accessories 20 may include, but are not necessarily limited to, surgical access components (such as a K-wire 24, one or more dilating cannula 26, and a working cannula 28), neural pathology monitoring devices (such as nerve root retractor 30), and devices for performing pedicle screw test (such as screw test probe 32). A block diagram of the surgical system 10 is shown in
The control unit 12 includes a touch screen display 36 and a base 38. The touch screen display 36 is preferably equipped with a graphical user interface (GUI) capable of communicating information to the user and receiving instructions from the user. The base 38 contains computer hardware and software that commands the stimulation sources, receives digitized signals and other information from the patient module 14, and processes the EMG responses to extract characteristic information for each muscle group, and displays the processed data to the operator via the display 36. The primary functions of the software within the control unit 12 include receiving user commands via the touch screen display 36, activating stimulation in the requested mode (nerve proximity, nerve direction, nerve pathology, screw test), processing signal data according to defined algorithms (described below), displaying received parameters and processed data, and monitoring system status and report fault conditions.
The patient module 14 is connected via a serial cable 40 to the control unit 12, and contains the electrical connections to all electrodes, signal conditioning circuitry, stimulator drive and steering circuitry, and a digital communications interface to the control unit 12. In use, the control unit 12 is situated outside but close to the surgical field (such as on a cart adjacent the operating table) such that the display 36 is directed towards the surgeon for easy visualization. The patient module 14 should be located between the patient's legs, or may be affixed to the end of the operating table at mid-leg level using a bedrail clamp. The position selected should be such that the EMG leads can reach their farthest desired location without tension during the surgical procedure.
In a significant aspect of the present invention, the information displayed to the user on display 36 may include, but is not necessarily limited to, alpha-numeric and/or graphical information regarding nerve proximity, nerve direction, nerve pathology, stimulation level, myotome/EMG levels, screw testing, advance or hold instructions, and the instrument in use. In one embodiment (set forth by way of example only) the display includes the following components as set forth in Table 1:
Screen Component
Menu/Status Bar
The mode label may include the surgical accessory
attached, such as the surgical access components
(K-Wire, Dilating Cannula, Working Cannula),
nerve pathology monitoring device (Nerve Root
Retractor), and/or screw test device (Screw
Test Probe) depending on which is attached.
Spine Image
An image of a human body/skeleton showing the
electrode placement on the body, with labeled
channel number tabs on each side (1-4 on left and
right). Left and Right labels will show the
patient orientation. The Channel number tabs may
be highlighted or colored depending on the
specific function being performed.
Display Area
Shows procedure-specific information.
Myotome & Level
A label to indicate the Myotome name and
corresponding Spinal Level(s)
associated with the channel of interest.
When in the Detection mode, an indication of
"Advance" will show when it is safe to move the
cannula forward (such as when the minimum
stimulation current threshold IThresh
(described below) is greater than a
predetermined value, indicating a safe distance
to the nerve) and "Hold" will show when it
is unsafe to advance the cannula (such as when the
minimum stimulation current threshold IThresh
(described below) is less than a predetermined
value, indicating that the nerve is relatively
close to the cannula) and during proximity
Indicates which function is currently active
(Direction, Detection, Pathology Monitoring, Screw
Dilator In Use
A colored circle to indicate the inner diameter of
the cannula, with the numeric size. If cannula is
detached, no indicator is displayed.
The surgical system 10 accomplishes safe and reproducible access to a surgical target site by detecting the existence of (and optionally the distance and/or direction to) neural structures before, during, and after the establishment of an operative corridor through (or near) any of a variety of tissues having such neural structures which, if contacted or impinged, may otherwise result in neural impairment for the patient. The surgical system 10 does so by electrically stimulating nerves via one or more stimulation electrodes at the distal end of the surgical access components 24-28 while monitoring the EMG responses of the muscle groups innervated by the nerves. In a preferred embodiment, this is accomplished via 8 pairs of EMG electrodes 34 placed on the skin over the major muscle groups on the legs (four per side), an anode electrode 35 providing a return path for the stimulation current, and a common electrode 37 providing a ground reference to pre-amplifiers in the patient module 14. By way of example, the placement of EMG electrodes 34 may be undertaken according to the manner shown in Table 2 below for spinal surgery:
Spinal Level
Right 1
Right Vastus Medialis
Right 2
Right TibialisAnterior
Right 3
Right Biceps Femoris
Right 4
Right Gastroc. Medial
Post Tibialis
Left 1
Left Vastus Medialis
Left 2
Left Tibialis Anterior
Left 3
Left Biceps Femoris
Left 4
Left Gastroc. Medial
Post Tibialis
Although not shown, it will be appreciated that any of a variety of electrodes can be employed, including but not limited to needle electrodes. The EMG responses provide a quantitative measure of the nerve depolarization caused by the electrical stimulus. Analysis of the EMG responses is then used to determine the proximity and direction of the nerve to the stimulation electrode, as will be described with particularity below.
The surgical access components 24-28 are designed to bluntly dissect the tissue between the patient's skin and the surgical target site. An initial dilating cannula 26 is advanced towards the target site, preferably after having been aligned using any number of commercially available surgical guide frames. An obturator (not shown) may be included inside the initial dilator 26 and may similarly be equipped with one or more stimulating electrodes. Once the proper location is achieved, the obturator (not shown) may be removed and the K-wire 24 inserted down the center of the initial dilating cannula 26 and docked to the given surgical target site, such as the annulus of an intervertebral disc. Cannulae of increasing diameter are then guided over the previously installed cannula 26 until the desired lumen is installed. By way of example only, the dilating cannulae 26 may range in diameter from 6 mm to 30 mm. In one embodiment, each cannula 26 has four orthogonal stimulating electrodes at the tip to allow detection and direction evaluation, as will be described below. The working cannula 28 is installed over the last dilating cannula 26 and then all the dilating cannulae 26 are removed from inside the inner lumen of the working cannula 28 to establish the operative corridor therethrough. A stimulator driver 42 is provided to electrically couple the particular surgical access component 24-28 to the patient module 14 (via accessory cable 22). In a preferred embodiment, the stimulator driver 42 includes one or more buttons for selectively activating the stimulation current and/or directing it to a particular surgical access component.
The surgical system 10 accomplishes neural pathology monitoring by electrically stimulating a retracted nerve root via one or more stimulation electrodes at the distal end of the nerve root retractor 30 while monitoring the EMG responses of the muscle group innervated by the particular nerve. The EMG responses provide a quantitative measure of the nerve depolarization caused by the electrical stimulus. Analysis of the EMG responses may then be used to assess the degree to which retraction of a nerve or neural structure affects the nerve function over time, as will be described with greater particularity below. One advantage of such monitoring, by way of example only, is that the conduction of the nerve may be monitored during the procedure to determine whether the neurophysiology and/or function of the nerve changes (for the better or worse) as the result of the particular surgical procedure. For example, it may be observed that the nerve conduction increases as the result of the operation, indicating that the previously inhibited nerve has been positively affected by the operation. The nerve root retractor 30 may comprise any number of suitable devices capable of maintaining contact with a nerve or nerve root. The nerve root retractor 30 may be dimensioned in any number of different fashions, including having a generally curved distal region (shown as a side view in
The surgical system 10 can also be employed to perform screw test assessments via the use of screw test probe 32. The screw test probe 32 is used to test the integrity of pedicle holes (after formation) and/or screws (after introduction). The screw test probe 32 includes a handle 44 and a probe member 46 having a generally ball-tipped end 48. The handle 44 may be equipped with one or more buttons for selectively applying the electrical stimulation to the ball-tipped end 48 at the end of the probe member 46. The ball tip 48 of the screw test probe 32 is placed in the screw hole prior to screw insertion or placed on the installed screw head. If the pedicle wall has been breached by the screw or tap, the stimulation current will pass through to the adjacent nerve roots and they will depolarize at a lower stimulation current.
Upon pressing the button on the screw test handle 44, the software will execute an algorithm that results in all channel tabs being color-coded to indicate the detection status of the corresponding nerve. The channel with the "worst" (lowest) level will be highlighted (enlarged) and that myotome name will be displayed, as well as graphically depicted on the spine diagram. A vertical bar chart will also be shown, to depict the stimulation current required for nerve depolarization in mA for the selected channel. The screw test algorithm preferably determines the depolarization (threshold) current for all 8 EMG channels. The surgeon may also set a baseline threshold current by stimulating a nerve root directly with the screw test probe 32. The surgeon may choose to display the screw test threshold current relative to this baseline. The handle 44 may be equipped with a mechanism (via hardware and/or software) to identify itself to the system when it is attached. In one embodiment, the probe member 46 is disposable and the handle 44 is reusable and autoclavable.
An audio pick-up (not shown) may also be provided as an optional feature according to the present invention. In some cases, when a nerve is stretched or compressed, it will emit a burst or train of spontaneous nerve activity. The audio pick-up is capable of transmitting sounds representative of such activity such that the surgeon can monitor this response on audio to help him determine if there has been stress to the nerve.
Analysis of the EMG responses according to the present invention will now be described. The nerve proximity, nerve direction, and nerve pathology features of the present invention are based on assessing the evoked response of the various muscle myotomes monitored by the surgical system 10. This is best shown in
As shown in
As shown in
As will be explained in greater detail below, the use of the "recruitment curve" according to the present invention is advantageous in that it provides a great amount of useful data from which to make various assessments (including, but not limited to, nerve detection, nerve direction, and nerve pathology monitoring). Moreover, it provides the ability to present simplified yet meaningful data to the user, as opposed to the actual EMG waveforms that are displayed to the users in traditional EMG systems. Due to the complexity in interpreting EMG waveforms, such prior art systems typically require an additional person specifically trained in such matters. This, in turn, can be disadvantageous in that it translates into extra expense (having yet another highly trained person in attendance) and oftentimes presents scheduling challenges because most hospitals do not retain such personnel. To account for the possibility that certain individuals will want to see the actual EMG waveforms, the surgical system 10 includes an Evoked Potentials display that shows the voltage waveform for all 8 EMG channels in real time. It shows the response of each monitored myotome to a current stimulation pulse. The display is updated each time there is a stimulation pulse. The Evoked Potentials display may be accessed during Detection, Direction, or Nerve Pathology Monitoring.
Nerve Detection (Proximity)
The Nerve Detection function of the present invention is used to detect a nerve with a stimulation electrode (i.e. those found on the surgical access components 24-28) and to give the user a relative indication of the proximity of the nerve to the electrode as it is advanced toward the surgical target site. A method of nerve proximity detection according one embodiment of the present invention is summarized as follows: (1) stimulation current pulses are emitted from the electrode with a fixed pulse width of 200 μs and a variable amplitude; (2) the EMG response of the associated muscle group is measured; (3) the Vpp of the EMG response is determined using T1, T2, and Fmax (NB: before T2 is determined, a constant Fsafe is used for Fmax); (4) a rapid hunting detection algorithm is used to determine IThresh for a known Vthresh minimum; (5) the value of It is displayed to the user as a relative indication of the proximity of the nerve, wherein the IThresh is expected to decrease as the probe gets closer to the nerve. A detailed description of the algorithms associated with the foregoing steps will follow after a general description of the manner in which this proximity information is communicated to the user.
The Detection Function displays the value of Ithresh to the surgeon along with a color code so that the surgeon may use this information to avoid contact with neural tissues. This is shown generally in
The threshold-hunting algorithm employs a series of monopolar stimulations to determine the stimulation current threshold for each EMG channel that is in scope. The nerve is stimulated using current pulses with amplitude of Istim. The muscle groups respond with an evoked potential that has a peak to peak voltage of Vpp. The object of this algorithm is to quickly find Ithresh. This is the minimum Istim that results in a Vpp that is greater than a known threshold voltage Vthresh. The value of Istim is adjusted by a bracketing method as follows. The first bracket is 0.2 mA and 0.3 mA. If the Vpp corresponding to both of these stimulation currents is lower than Vthresh, then the bracket size is doubled to 0.2 mA and 0.4 mA. This exponential doubling of the bracket size continues until the upper end of the bracket results in a Vpp that is above Vthresh. The size of the brackets is then reduced by a bisection method. A current stimulation value at the midpoint of the bracket is used and if this results in a Vpp that is above Vthresh, then the lower half becomes the new bracket. Likewise, if the midpoint Vpp is below Vthresh then the upper half becomes the new bracket. This bisection method is used until the bracket size has been reduced to IThresh mA. IThresh is the value of Istim that is the higher end of the bracket.
More specifically, with reference to
The method for finding the minimum stimulation current uses the methods of bracketing and bisection. The "root" is identified for a function that has the value −1 for stimulation currents that do not evoke adequate response; the function has the value +1 for stimulation currents that evoke a response. The root occurs when the function jumps from −1 to +1 as stimulation current is increased: the function never has the value of precisely zero. The root will not be known precisely, but only with some level of accuracy. The root is found by identifying a range that must contain the root. The upper bound of this range is the lowest stimulation current IThresh where the function returns the value +1, i.e. the minimum stimulation current that evokes VThresh response.
The proximity function begins by adjusting the stimulation current until the root is bracketed (
During the bisection state (
During the monitoring state (
When it is necessary to determine the stimulation current thresholds (It) for more than one channel, they will be obtained by time-multiplexing the threshold-hunting algorithm as shown in
The method of performing automatic artifact rejection according to the present invention will now be described. As noted above, acquiring Vpp according to the present invention (based on T1,T2 shown in
The method of automatic artifact rejection is further explained with reference to
According to another aspect of the present invention, the maximum frequency of the stimulation pulses is automatically obtained with reference to
Nerve Direction
Once a nerve is detected using the working cannula 28 or dilating cannulae 26, the surgeon may use the Direction Function to determine the angular direction to the nerve relative to a reference mark on the access components 24-28. This is also shown in
As shown in
After conversion from (x,y) to polar coordinates (r,θ), then θ is the angular direction to the nerve. This angular direction is then displayed to the user as shown in
Insertion and advancement of the access instruments 24-28 should be performed at a rate sufficiently slow to allow the surgical system 10 to provide real-time indication of the presence of nerves that may lie in the path of the tip. To facilitate this, the threshold current IThresh may be displayed such that it will indicate when the computation is finished and the data is accurate. For example, when the detection information is up to date and the instrument is now ready to be advanced by the surgeon, it is contemplated to have the color display show up as saturated to communicate this fact to the surgeon. During advancement of the instrument, if a channel's color range changes from green to yellow, advancement should proceed more slowly, with careful observation of the detection level. If the channel color stays yellow or turns green after further advancement, it is a possible indication that the instrument tip has passed, and is moving farther away from the nerve. If after further advancement, however, the channel color turns red, then it is a possible indication that the instrument tip has moved closer to a nerve. At this point the display will show the value of the stimulation current threshold in mA. Further advancement should be attempted only with extreme caution, while observing the threshold values, and only if the clinician deems it safe. If the clinician decides to advance the instrument tip further, an increase in threshold value (e.g. from 3 mA to 4 mA) may indicate the Instrument tip has safely passed the nerve. It may also be an indication that the instrument tip has encountered and is compressing the nerve. The latter may be detected by listening for sporadic outbursts, or "pops", of nerve activity on the free running EMG audio output (as mentioned above). If, upon further advancement of the instrument, the alarm level decreases (e.g., from 4 mA to 3 mA), then it is very likely that the instrument tip is extremely close to the spinal nerve, and to avoid neural damage, extreme caution should be exercised during further manipulation of the Instrument. Under such circumstances, the decision to withdraw, reposition, or otherwise maneuver the instrument is at the sole discretion of the clinician based upon available information and experience. Further radiographic imaging may be deemed appropriate to establish the best course of action.
Nerve Pathology
As noted above, the surgical system 10 accomplishes neural pathology monitoring by electrically stimulating a retracted nerve root via one or more stimulation electrodes at the distal end of the nerve root retractor 30 while monitoring the EMG responses of the muscle group innervated by the particular nerve.
The surgical system 10 and related methods have been described above according to one embodiment of the present invention. It will be readily appreciated that various modifications may be undertaken, or certain steps or algorithms omitted or substituted, without departing from the scope of the present invention. By way of example only, certain of these alternate embodiments or methods will be described below.
a. Hanging Point Detection Via Linear Regression
As opposed to identifying the stimulation current threshold (IThresh) based on a predetermined VThresh (such as described above and shown in
b. Hanging Point Detection Via Dynamic Sweep Subtraction
With reference to
c. Peripheral Nerve Pathology Monitoring
Similar to the nerve pathology monitoring scheme described above, the present invention also contemplates the use of one or more electrodes disposed along a portion or portions of an instrument (including, but not limited to, the access components 24-28 described above) for the purpose of monitoring the change, if any, in peripheral nerves during the course of the procedure. In particular, this may be accomplished by disposing one or more stimulation electrodes a certain distance from the distal end of the instrument such that, in use, they will likely come in contact with a peripheral nerve. For example, a mid-shaft stimulation electrode could be used to stimulate a peripheral nerve during the procedure. In any such configuration, a recruitment curve may be generated for the given peripheral nerve such that it can be assessed in the same fashion as described above with regard to the nerve root retractor, providing the same benefits of being able to tell if the contact between the instrument and the nerve is causing pathology degradation or if the procedure itself is helping to restore or improve the health or status of the peripheral nerve.
d. Virtual Patient for Evoked Potential Simulation
With reference to
While this invention has been described in terms of a best mode for achieving this invention's objectives, it will be appreciated by those skilled in the art that variations may be accomplished in view of these teachings without deviating from the spirit or scope of the present invention. For example, the present invention may be implemented using any combination of computer programming software, firmware or hardware. As a preparatory step to practicing the invention or constructing an apparatus according to the invention, the computer programming code (whether software or firmware) according to the invention will typically be stored in one or more machine readable storage mediums such as fixed (hard) drives, diskettes, optical disks, magnetic tape, semiconductor memories such as ROMs, PROMs, etc., thereby making an article of manufacture in accordance with the invention. The article of manufacture containing the computer programming code is used by either executing the code directly from the storage device, by copying the code from the storage device into another storage device such as a hard disk, RAM, etc. or by transmitting the code on a network for remote execution. As can be envisioned by one of skill in the art, many different combinations of the above may be used and accordingly the present invention is not limited by the scope of the appended claims.
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|Mapping and ablation of nerves within arteries and tissues
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|Methods for determining neurostimulation electrode configurations based on neural localization
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|Electromyographic lead positioning and stimulation titration in a nerve stimulation system for treatment of overactive bladder
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|High reliability wire welding for implantable devices
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|Implant recharger handshaking system and method
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|Nuvasive, Inc.
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|Implantable lead affixation structure for nerve stimulation to alleviate bladder dysfunction and other indication
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|Neural monitoring sensor
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|U.S. Classification
|607/48, 600/554
|International Classification
|Cooperative Classification
|European Classification
|Dec 20, 2004
Owner name: NUVASIVE, INC., CALIFORNIA
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Owner name: NUVASIVE, INC., CALIFORNIA
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|Sep 26, 2008
Owner name: NUVASIVE, INC., CALIFORNIA
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|May 17, 2017
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Today's bloom is Basket Flower (Centaurea americana)Bloom of the Day for February 1st, 2012:
Type of plant: Annuals
Bloom color: Rose/Mauve, Violet/Lavender, White/Near White
Bloom time of year: Mid Summer, Late Summer/Early Fall
Sun requirements: Full Sun
Cold hardiness: Not Applicable
Height: 36-48 in. (90-120 cm)
Spacing: 12-15 in. (30-38 cm)
View much more information
about this plant at PlantFiles.
2 vendors have this plant for sale.
|Talk about this bloom
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subset: commoncrawl


text:
There are several adages actors should follow when considering a film role: Never work with children, cute barnyard animals, or do movie adaptations of video games. Mark Wahlberg says he had great trepidation in taking on the role of Max Payne because it originated in a 2001 game, but the material was irresistible. He should have resisted. It's not that it's all bad; it's just not as good as it could have been.
Perhaps it's the dark, foreboding mood established by director John Moore (The Omen) that makes Max Payne feel like a mere shadow of The Dark Knight or even The Matrix. The influences are obvious, but the execution is middling. Where the film really goes off track (and deviates from its source material as well) is in the creation of a winged creature that haunts Max and may or may not be a figment of his tortured imagination, representing all the demons plaguing our hero.
Max is a glum DEA agent investigating a series of murders that could be connected to the tragic death of his wife and newborn baby. Along with Russian mobster and assassin Mona Sax (Mila Kunis), whose sister was a victim, he is thrust into the mystery of the killings. Complicating matters for Max is his old mentor and friend, BB (played, appropriately, by another BB — Beau Bridges), a former cop now handling security for a large pharmaceutical firm. BB tries to help Max in his quest along with internal affairs detective Jim Bravura (Chris "Ludacris" Bridges), who seems to sense what's really going on in the mind of Max Payne.
There are plenty of twists and turns and lots of action, but none of it fully connects us to Max's quest. Flashbacks show he was once a happy guy, but the brutal deaths of his wife and baby have brought out his dark side, and that's where he exists as he seeks revenge for the fate that has befallen him. Wahlberg gets to kick a lot of ass and look sullen and grim for most of the running time, but he never gets behind the emotion of a man who has lost everything that ever meant anything to him. It's almost a Death Wish scenario at play here but without the amount of passion required.
As for the other actors, Kunis (Forgetting Sarah Marshall) is gorgeous and acquits herself well as an action heroine. Beau Bridges is all pro as the complex ex-cop who befriends Max but may not be all he seems, while the other Bridges, as in Ludacris, is earnest and helpful. Ukrainian beauty Olga Kurylenko turns up as the thrill-seeking Natasha, younger sister to Mona, and Chris O'Donnell has a small, wimpy role as an executive at the pharmaceutical company that plays a key part in the plot and eventual outcome. Amaury Nolasco (Prison Break) has a minor bit as an extremely tough member of the drug underground Payne encounters.
Certainly there have been worse films of this ilk; for all but the most avid gamers out there, though, this film version of Max Payne may just have you feeling pain to the max.
Genre: Action
Directed by: John Moore
Written by: Beau Thorne
Starring: Mark Wahlberg, Mila Kunis, Olga Kurylenko, Beau Bridges, Chris "Ludacris" Bridges


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I brought this for my newly built system, I didn't really look around to find the best wireless adapter, and really do regret that.
I brought this from our local computer shop, where my brother works, so he got me discount on it. Wasn't badly priced, but I can't remember what it was.
So, I installed the software and drivers, easy enough. After that the problems kick in.
Well, the main problem with this is the signal range. Basicly, it is completely useless unless you are right near to the router. So firstly, if you aren't in the same room as the router, just don't bother with this. Edimax seem to find it funny to provide their customers with useless products, with useless signal ranges.
We had to buy a new router recently as well, as our old reliable Netgear one got killed in a thunderstorm. That router was totaly useless as well.
After deciding that this was the most useless thing going, I took it back, and replaced it with a 'HiGain' one. Now, my laptop, an Acer Aspire 5512WLMi, the build in wireless card is better than what this was! Then it died, so I had to take that one back as well...
So, if you're ever wanting to buy any sort of Networking product, if you see anything to do with Edimax, walk away, and go with a decent brand.
Edimax are juse plain useless.
My household has just recently gone wireless with the help of a wireless box we were given by Orange after they found out we where considering change internet provider. Unfortunately my PC is not wireless enabled so had to buy a wireless receiver so that my machine could pick up a signal in order for me to surf the web.
I didn't have much choice in the receiver for my computer as my dad just went and bought one for me over the internet and he chose one from a company called Edimax. I have never heard of this company so wasn't quite sure how well it would work but I have to say that I have experienced no problems with it at all so far and I have had it for about 2 months now.
I have had a look on the internet and it can be found on Dabs.com for about £12 which I think is pretty good value compared with similar products.
The product comes with a quick installation guide booklet, the USB adapter and a Installation CD which contains a more in-depth installation guide as well as a troubleshooting guide to help you out with any problems you may experience.
The Installation of the product is really easy. Just put in the CD and follow the instructions in the booklet. The booklet also contains screen images for each stage if installation and tells you exactly what boxes to click and press and in total the process takes less than 5 minutes. You then plug in the adapter which is silver in colour and is the size of most memory sticks you but for your computers.
The program that installs from the CD will then search for any wireless internet connections in the area. Its important you know which one is yours so you can connect to the correct connection.
My connection is secured with a WEP code which helps to make it a more secure connection. My signal was picked up straight away by the receiver which has a green light that flashes when a signal is being received and used.
The program also means that it will look for the signal every time your computer is started up so you won't need to search for a signal every time you login.
In conclusion I have to say that I have been really impressed with this product. Its small compact adapter is a definite bonus as it can be plugged into your USB ports without taking up to much room. The installation process is extremely easy and very quick with you being online within about 10 minutes of putting the CD in the drive. I would definitely recommend this product who is wanting to get there computer hooked up to a wireless connection.


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Florida State's late run at another top 10 recruiting class got off the ground running late Monday afternoon. With national signing getting underway in less than 48 hours, the Seminoles' 2005 class is far from filled but there are several elite prospects still out there for the taking. One of those blue-chip recruits took himself off the market by making a commitment to the Tribe.
Many people suspected that four-star linebacker Derek Nicholson would join his brother in Tallahassee and he made it official on Monday.
Article Continues Below
"I was most comfortable there," Nicholson said. "I've been following Florida State since my brother went there and they were the first school to offer."
Not only did the USA Today All-American commit to Bobby Bowden and the Seminoles, he did so before a national television audience on ESPN News.
This past weekend the four-star linebacker completed his official visits with a trip to Florida State where he was hosted by brother A.J. Nicholson. He had also visited North Carolina, Virginia Tech and Texas. When it came time to make his decision he had narrowed his list to FSU, UNC and Texas, but the chance to play for the Garnet and Gold was too much to pass up.
In early January, Nicholson took part in the North Carolina-South Carolina Shrine Bowl and the U.S. Army Bowl. He earned defensive MVP honors in the Shrine Bowl and led the East Squad in tackles in the U.S. Army game. As a result of his outstanding effort in those two games he has skyrocketed up the charts and is now the No. 2 ranked inside linebacker in the nation.
He finished his prep career at Mt. Tabor with over 600 career tackles breaking the old school record held by his brother.
Nicholson is already qualified and carries an overall GPA of 3.8 and scored a 19 on the ACT.
Talk about it on the Premium Recruiting Board or the Regular Recruiting Board


text:
Moms on WIC
How do you use the evaporeted milk that you get every month?
Do you use it to cook? Do you add water and make use it as regular milk?
I have cans of this stuff backed up.
Every now and then Dh will use it in his coffee. I will use it to cook with if we are running low on regulat milk.
Today I mixed a few cans with water in a milk jug. Then I tried it. It didn't taste TOO bad. It tasted like Skim milk but with a funky little after taste. I used chocolate and made some chocolate milke for DS with it. He didn't seem to mind.
Anyways so I was just wondering how you other WIC moms use this stuff?
Edit: For those who are saying you do not get it, do you CHOOSE not to get it or is it not offered to you?
We get both.
Between DS and I (I am pregnant) we get 41/2 gallons of regular (2% milk) and then 4 - 12 oz cans of evaporated milk.
Quoting EthansMomma2010:
You can get regular milk instead right? I used the cans to make milk for my DS. He never cared. I liked that it didn't go bad like a whole gallon would. Now we drink coconut milk which wic doesn't cover.
I know I am not hte only perosn in the world who gets it. My best friend who is also pregnant gets evaported milk as well.
Do you have a recipe to make mac n cheese with it?
Quoting Diva-Mami:
I didnt get wic but the ppl I know that do dont get that. But you can bake with it or make mac n cheese with it.
Here you can get dry or can beans! But those are easy to use just make a big pot of chili or soup.
Quoting Anonymous:
I dont get that.. But I have a while shelf full of various dry beans, peas and lentils lol when it gets totally full u give it to the social mi is tries for a food drive.
I'm not on assistance, but I use it in cooking or in coffee.


text:
Huge congratulations to Henning from your friends here at TAM!!! *Video by Lars Stig Moller http://youtu.be/iW0062RoRiYRead More »
Tag Archives: Henning Jorgensen
JoJo Ackermann: Fear of a Flash Planet
By JoJo Ackermann About six months ago, three guys in their early 20s walked into the shop around opening time with the request to have a heart and the word "Mom" tattooed on their asses. Honestly, I thought they were just screwing around but after a few laughs and some more questions, I realized these dudes were serious about getting it done… Read More »
Gent Stef: 666% – Barcelona and Back
By Stef Pitera I'm one of those guys with that condition, the "Travel Bug." Can't sit my ass in the same place for too long. I'm sure many of you out there will be familiar with what I'm talking about… To spend years constantly on the road, out of a backpack, sometimes changing countries every week. The airport hall, check-in desks and safety procedures become what you may consider more familiar. I don't know where this comes from but when you are on the way to your flight, carrying just the essential to go to tattoo somebody else, somewhere else and to look presentable, you feel light, free. No strings attached, no responsibilities. Some kind of eternal youth. Suspended in that limbo, with that rush you can only feel right after leaving and just before arriving. A new place to see, new people to meet, a new beer to try… Or maybe just running away. Who knows. Ask me in 10 years…Read More »
JoJo Ackermann: That's The Impression That I Get
By JoJo Ackermann "Tattoos are my life!" That is a bold statement. I have heard it from beginners with less than five years and from veteran tattooers with more than 20 years in the craft… Hell, I have even said it myself. It would seem that most people who begin their journey into the world of tattooing understand that it is a lifetime commitment, which reaches far beyond the ability to just apply a tattoo. Listening and being respectful while the older veteran tattooers speak about stories and reflect on experiences, or even share tips and advise is almost like hearing tribal elders pass on the secrets of a world that is still closed off to most…Read More »
Stef Pitera: What It's All About
By Stef Pitera After all these years doing this, suddenly a simple question pops up; What is it all about? It has been underlined many times recently by many people. The industry is changing. And that's a fact. I can't say I have been tattooing 20 or 30 years like a few people I've had the pleasure to meet, work with or learn from. But I've been in this long enough to witness the change…Read More »
Tattoo Artist Magazine: 2011 Ink 'N Iron Video Review (VIDEO)
[youtube http://www.youtube.com/watch?v=A5jNyUnnCxM&w=560&h=349]Read More »
Ink 'N Iron Tattoo Convention, On the Queen Mary in Long Beach (VIDEO)
By Kent Smith I'm going to start this out by saying what an incredibly long week it was leading up to this convention. Crash, John and I all woke at 4 a.m. (well Crash and I did, I think John got up at 5 a.m.) to catch a flight from Atlanta to L.A. on June 3rd…Read More »
Dan Sinnes Article Preview for Tattoo Artist Magazine Issue #24
Wido de Marval: So you spent some time in Barcelona. Do you remember where you went? For different guest spots? You went to The States? Dan Sinnes: Yeah, but I still stayed in Luxembourg a lot. Because I still had a girlfriend at the time, and two dogs. But when I had the opportunity to do guest spots, I'd do it. After I had my break-up and I was by myself, I put it to the max and I went to the United States and traveled as much as I could, alone.Read More »
Milan Tattoo Convention: On the Road in Italy
By Kent Ok, so this blog was supposed to be posted over a week ago, but I could not muster the strength or energy to get it done. It seemed that I somehow got brushed by the black finger of death while in Milan, with the worst illness I have faced to this day. I have no clue what this Italian funk was that I caught, but I do not wish that shit on my worst enemy… Well ok, maybe they too should be struck with it one day…Read More »


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Drug arrests
Pocono Mountain Regional police reported on the following drug-related arrests made by officers.
On Friday, Feb. 24, about 6:16 p.m. officers observed a suspicious vehicle parked at the rear of the parking lot of Summit Lanes, in Pocono Summit, Tobyhanna Township.
Officers stopped to investigate and identified the occupants of the vehicle as Frederick James McConnell, 18, of Pocono Summit, and three juvenile males, all 17, two from Pocono Summit and one from Albrightsville.
Officers found marijuana on one of the juveniles and conducted a search of the vehicle. Found was drug paraphernalia.
McConnell and the three juveniles will have drug counts filed against them, police said.
Also on Friday, about 10 p.m., officers made a traffic stop for a motor vehicle code violation along SR115 near Interstate 80. The driver was identified as John McCabe, 18, of Summerville, N.J. A consent search was made of the vehicle with the use of a K9 unit and found was three mason jars filled with marijuana.
McCabe was placed under arrest and charged with possession of marijuana.
On Saturday, Feb. 25, about 1:06 a.m. officers made a traffic stop along SR115 near a PennDOT shed in Blakeslee, for speeding. The driver was identified as Brian Kurz, 23, of Pocono Lake. While speaking with the driver officers noticed a multi-colored glass pipe in the cupholder on the center console.
The pipe was found to contain residue as it was used to smoke marijuana. Police said Kurz will be charged with possession.


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PREMIUM EXCLUSIVE Thunder Tiger e-MTA Video Review
Aug 23, 2013 No Comments
The heart pounding e-MTA from Thunder Tiger boasts a massive power system, twin LiPo power and huge size and performance. With a cantilever suspension and modular chassis design, this truck is designed to take a beating an then some. Big-time stump pulling power and like this means it can do backflips from a standstill and tons more. See for yourself in this Performance Test.


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The West Norfolk Artists Association's annual exhibition, which is held as part of the King's Lynn Festival, is now open at the Fermoy Gallery and Shakespeare Barn of the Lynn Arts Centre.
The show, which is open until this Saturday, has moved from its traditional home at the St Nicholas Chapel, because of the renovations taking place there.
Pictured above at the opening of the exhibition are association chairman Kit Price-Moss, festival chairman Alison Croose, association member Andrew Schumann and Arts Centre director, and exhibition curator, Liz Falconbridge.


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Aug 12 (Reuters) - Vanguard Group has listed five new exchange-traded funds in Canada as the No. 1 U.S. mutual fund company expands in the region, which last month reached more than $1 billion in assets under management.
The five new equity ETFs, which were to begin trading on the Toronto Stock Exchange on Monday, join Vanguard's roster of 11 ETFs currently listed in Canada.
Valley Forge, Pennsylvania-based Vanguard entered the Canadian market in December 2011.
ETFs track a basket of shares, bonds or commodities and can be traded in real time on exchanges like stocks. They offer access to indexes without having to buy the individual underlying securities.
While exchange-traded products, including ETFs, in Canada have gathered $4.3 billion in net inflows since the start of the year, Canada was the only major region to register outflows for ETPs in July, with $800 million moving out of such Canadian-listed funds, according to BlackRock Inc's latest monthly ETP Landscape report.
The report counted 281 exchange-traded products listed in Canada at the end of July, compared with 1,490 products listed in the United States.
The newly listed ETFs are the Vanguard FTSE Canada All Cap Index ETF ; the Vanguard FTSE Developed ex North America Index ETF ; the Vanguard U.S. Dividend Appreciation Index ETF (hedged to the Canadian dollar) ; the Vanguard U.S. Dividend Appreciation Index ETF ; and the Vanguard U.S. Total Market Index ETF.
Vanguard plans to offer two new fixed-income ETFs in Canada - the Vanguard U.S. Aggregate Bond Index ETF and the Vanguard Global ex-U.S. Aggregate Bond Index ETF, both hedged to the Canadian dollar. It plans to offer the funds "in the near future."
Vanguard manages more than $2.5 trillion in global assets, including $285 billion in global ETF assets.


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Car won from casino still undelivered
Woman claims she was taxed $134,000 for Aston Martin she never got
Don Bauder 3 p.m., Nov. 23
True films lovers have no use for watches; who needs Cartier when you can count cue marks?
Laraine Day & Q. Marks in John Brahm's *The Locket*
I miss cue marks. No, not my third cousin twice removed, but changeover cues, or cigarette burns as they are affectionately called. Whether they are round, oval or, in the case of union butchers, hash marks, these prompts appear in the upper right-hand corner of the frame every 15 to 18 minutes. (Two reels equal forty-minutes, three reels an hour, etc.) They were originally intended to alert the projectionist that a reel was winding to an end and it was time to perform a changeover from one projector to the other. In case the projectionist dozed off, three bells sounded as the cue marks neared the gate.
According to Online Dictionary for Library and Information Science, "The first cue appears 12 feet (eight seconds at 24 frames per second) before the end of the reel, alerting the projectionist to start the motor of the projector on which the next reel is mounted. After another 10 1/2 feet (seven seconds at 24 fps), the change-over cue appears, signaling the projectionist to make the change. When this second cue appears, the projectionist has 1 1/2 feet (one second at 24 fps) to switch projectors before the black leader at the tail of the exhausted reel is projected on the screen."
The platter system rendered cue marks obsolete. Multiplexes began mounting the five or six individual reels that comprise a feature film on one enormous platter. Instead of performing a half-dozen changeovers every two hours, operators are now free to simultaneously project several different films in several different auditoriums simply by re-threading and pushing a few buttons.
The only thing in the frame worth looking at.
Before platters (and the multiplexing of America), audiences were guaranteed a projectionist in the booth during the entire show in case the film hit a bad splice and went out of frame or focus. Nowadays, concession workers doubling as projectionists focus on the trailers and don't return to the booth until it's time to prep for the next show. That's why it takes so long after you've lodged a complaint with an usher to fix a projection problem.
Cue marks can still be seen in 35mm exhibition prints, but not digitally projected features. To make matters worse, computer geeks are electronically camouflaging them on DVD releases of older films because they may be viewed as flaws in the otherwise pristine transfer. Why? We've lived with them for over a century. Cue marks are a part of the fabric of film. Let them be.
From now on I'll have to check the time remaining on the DVD counter or, even worse, buy a watch.
I remember in 1979 and 1980 when we first automated the reel switchovers at the long-gone downtown all-night grindhouse theaters, first at the Aztec and Casino on 5th Avenue and then at the Balboa on 4th and then the company's other SD theaters. It seemed like a space age miracle, to be able to literally flick a light switch (behind the snack bar!) at the buzzer prompt, enabling anyone on duty to seamlessly roll in the next reels.
That early automation was the beginning of absentee projectionists, rather than when platter feeds came in -- after the auto-switches were installed, theater owners Walnut Properties (who also ran moviehouses in Oceanside, El Cajon, and National City) cut the projectionist staff downtown from six people to only two, tho the remaining duo spent a LOT of time sprinting from theater to theater (including the Plaza and Cabrillo in Horton Plaza, the Pussycat on 4th, and the Bijou on 5th) to keep things running smoothly.
BTW, LOVE that you use a pic from a John Brahm film in this blog!! Been lately digging his work on the DVD sets for both Twilight Zone and Boris Karloff's Thriller ---
Love it when the film cinches on the big rotating wheel. Nothing more painful to the eye than oobleck-colored platter scratches.
Brahm's string of noirs in the 40s are remarkable. What I wouldn't give for a clean DVD pressing of "Guest in the House." If nothing else, there's always "Hot Rods to Hell," a film I've seen more times than my feet.
As a small boy, I remember a family movie outing (some crappy 1970s Disney live action movie with Kurt Russell - take your pick) with my parents and maternal grandmother.
After the movie, I overheard my gran talking to my parents: "You'd think they'd have better film projectors - all those holes in the upper right hand corner."
Guess what I was looking for at every screening thereafter? Thanks grandma!
Cue marks should be left on all DVD's of movies made before projectors were automated. That would be a true representation of cinema history.


text:
Some maples along Summit Avenue near the Mississippi River in St. Paul already are beginning to change color, perhaps still stressed from last year's drought.
JIM GEHRZ • jgehrz@star tribune.com,
Anne Kaplan of St. Paul passed a distressed maple tree along Summit Avenue during her daily walk. Some species, such as butternut trees and sumac, are right on time to change color now.
Photos by JIM GEHRZ • jgehrz@star tribune.com,
Gary Johnson, a professor of urban forestry at the University of Minnesota, recommends watering small trees until the first hard freeze.
Feed Loader,
Some leaves are starting to change color in Minnesota
- Article by: Jeff Strickler
- Star Tribune
- August 10, 2013 - 6:57 PM
Was that it? Is summer over already?
With low temperatures dipping into the 50s, it's felt more like September than August recently. Now come sightings around the metro area of trees with their leaves starting to change color, raising concerns that our ultra-late spring is going to be sandwiched with an ultra-early fall.
Don't start looking for your snow shovel. Yes, the trees are trying to send a message, but not that message.
"Any time you see trees changing color early it means that they're stressed," said Gary Johnson, a professor of urban forestry at the University of Minnesota. "It means that the tree has started to shut down."
Not all the bright leaves are early. It's normal for some foliage to have started changing color, said Jim Gilbert, a Twin Cities phenologist.
"Butternut trees, which are native to Minnesota, will start turning as early as July 4th," he said. "Sumac, which is actually a shrub, should start turning any day now, if it isn't already. And there's a vine, the Virginia creeper, that's also changing now — and is right on time."
But with other species, the leaves still should be dark green, said Kent Honl, master arborist at Rainbow Treecare.
The temperatures haven't been cool enough to cause a change in color, he said. "That's more a function of the length of daylight, anyway. And even though the days are getting shorter, they haven't gotten that short."
There are all sorts of things that can put trees under stress, the experts said: disease, insects, improper planting, damage from the storms that have moved through this summer and even residual effects from the drought last summer.
Because of the shortage of rainfall last year, some trees were not able to store up the water they needed before winter, Johnson said. In addition, "droughty soil gets colder and freezes deeper, which can damage roots. The roots near the surface are the least hardy."
Even though we've had plenty of rain this summer, some trees still aren't getting enough water, he said. "Trees on small spaces like boulevards or in parking lots don't have enough ground around them to absorb the rain," he said. "Trees on hills can be affected because the water runs down the hill" before it can be absorbed.
That's assuming that the roots are functioning, said Peter Moe, operations director at the Minnesota Landscape Arboretum. Many trees that turn color early suffer from a condition known as girdling roots. Typically associated with the replanting of container-grown trees, it occurs when the roots grow around the main stem of the tree and cut off the flow of water.
Experts also suggest checking the tree for insects, damage or disease. One disease that often results in early leaf changes is chlorosis, which Honl compared to anemia in people.
"It's the same sort of thing where the body — in this case, the tree — can't absorb the nutrients it needs," he said.
How can you tell if the changing leaves are the result of stress? Look at where the changes are happening, said Ralph Sievert, forestry director for the Minneapolis Park and Recreation Board. If lots of trees in the area are changing color, it's normal. But if it's happening in just one tree — or just one part of a tree — it's not.
"Stress is site-specific," he said. "If you see it in just one place, that's stress, and stress on a tree isn't good."
Even healthy trees need to be watched for signs of stress, Johnson said.
"It's absolutely critical to keep watering trees, especially small trees, and we've had a lot of new trees planted all over the metro this summer," he said. "And keep watering them until the first hard freeze. When the hose finally is so stiff that you can't use it, then you can quit."
Now that we know that the trees aren't forecasting an early fall, what does meteorologist Paul Douglas expect?
"We're sort of careening from one extreme to the other," he said. "But we seem to be moving into a period of longer, warmer autumns. Temperatures should warm up again by the last week of August, and, if I had to wager a guess, I'd expect a warmer-than-usual September."
Keep those T-shirts and shorts handy. Summer isn't over yet.
Jeff Strickler • 612-673-7392
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