A finite element investigation of upper cervical instrumentation

STUDY DESIGN

The finite element technique was used to predict changes in biomechanics that accompany the application of a novel instrumentation system designed for use in the upper cervical spine.

OBJECTIVE

To determine alterations in joint loading, kinematics, and instrumentation stresses in the craniovertebral junction after application of a novel instrumentation system. Specifically, this design was used to assess the changes in these parameters brought about by two different cervical anchor types: C2 pedicle versus C2-C1 transarticular screws, and unilateral versus bilateral instrumentation.

SUMMARY OF BACKGROUND DATA

Arthrodesis procedures can be difficult to obtain in the highly mobile craniovertebral junction. Solid fusion is most likely achieved when motion is eliminated. Biomechanical studies have shown that C1-C2 transarticular screws provide good stability in craniovertebral constructs; however, implantation of these screws is accompanied by risk of vertebral artery injury. A novel instrumentation system that can be used with transarticular screws or with C2 pedicle screws has been developed. This design also allows for unilateral or bilateral implantation. However, the authors are unaware of any reports to date on the changes in joint loading or instrumentation stresses that are associated with the choice of C2 anchor or unilateral/bilateral use.

METHODS

A ligamentous, nonlinear, sliding contact, three-dimensional finite element model of the C0-C1-C2 complex and a novel instrumentation system was developed. Validation of the model has been previously reported. Finite element models representing combinations of cervical anchor type (C1-C2 transarticular screws vs. C2 pedicle screws) and unilateral versus bilateral instrumentation were evaluated. All models were subjected to compression with pure moments in either flexion, extension, or lateral bending. Kinematic reductions with respect to the intact (uninjured and without instrumentation) case caused by instrumentation use were reported. Changes in loading profiles through the right and left C0-C1 and C1-C2 facets, transverse ligament-dens, and dens-anterior ring of C1 articulations were calculated by the finite element model. Maximum von Mises stresses within the instrumentation were predicted for each model variant and loading scenario.

RESULTS

Bilateral instrumentation provided greater motion reductions than the unilateral instrumentation. When used bilaterally, C2 pedicle screws approximate the kinematic reductions and instrumentation stresses (except in lateral bending) that are seen with C1-C2 transarticular screws. The finite element model predicted that the maximum stress was always in the region in which the plate transformed into the rod.

CONCLUSIONS

To the best of the authors' knowledge, this is the first report of predicting changes in loading in the upper cervical spine caused by instrumentation. The most significant conclusion that can be drawn from the finite element model predictions is that C2 pedicle screw fixation provides the same relative stability and instrumentation stresses as C1-C2 transarticular screw use. C2 pedicle screws can be a good alternative to C2-C1 transarticular screws when bilateral instrumentation is applied.

Posterior-stabilized and cruciate-retaining total knee replacement: a randomized study

A randomized controlled study was done to compare the clinical, radiographic, and quality of life outcomes between posterior-stabilized and cruciate-retaining primary total knee implants. One hundred forty-three patients were enrolled in the study. Patients ranged in age from 57 to 89 years, had a primary diagnosis of osteoarthritis, and an intact functioning posterior cruciate ligament. Patients were excluded if they had a flexion contracture greater than 15 degrees, a varus deformity greater than 20 degrees, or a valgus deformity greater than 15 degrees. Patients were randomized to one of two study groups, posterior-stabilized AMK total knee implants (76 patients) or cruciate-retaining AMK total knee implants (67 patients). One hundred eight patients have had a minimum 2-year followup including 57 patients in the posterior-stabilized group and 51 patients in the cruciate-retaining group. Seventy-three patients have had a minimum 3-year followup including 37 patients in the posterior stabilized group and 36 patients in the cruciate-retaining group. The overall total Knee Society clinical rating score at 2 years averaged 157.1 points in the posterior-stabilized group and 156.5 points in the cruciate-retaining group. At 3 years, the scores averaged 156.8 points in the posterior-stabilized group and 163.5 points in the cruciate-retaining group. The range of motion component of the Knee Society score averaged 113.6 degrees for the posterior-stabilized group and 108.5 degrees for the cruciate-retaining group at 2 years, and 108.3 degrees in the cruciate-retaining group and 108.5 degrees in the posterior-stabilized group. Based on the various parameters analyzed, there were no notable differences between the groups with a posterior-stabilized and a cruciate-retaining total knee implant at 2 years. This trend seemed to be the same at 3 years.

The Knee Society Index of Severity for failed total knee arthroplasty: practical application

Previous classifications of severity for total knee arthroplasty revisions have been based largely on bone loss of the femur and tibia. These approaches failed to address the more technically difficult issues in revision surgery such as surgical exposure, contractures, extremity alignment, implant removal, soft tissue stability (in the anteroposterior and in the sagittal planes), extensor mechanism integrity, and patellar revisability. Through the Knee Society, the authors developed a severity index that incorporated these latter factors into one measure. The current authors describe the application of the Knee Society Index of Severity for failed total knee arthroplasty and its method of scoring.

The Knee Society Index of Severity for failed total knee arthroplasty: development and validation

Compared with primary knee replacement, total knee arthroplasty revision surgery is a more complex procedure and accounts for greater expenditures of healthcare resources at each clinical stage. Overall, patients having revision procedures have poorer functional outcomes and higher complication rates than patients having primary arthroplasty. Despite the expanded scope of revision problems and the rapidly emerging technology in revision surgery, the long-term success of any method remains in question. Because there is little consensus on the timing of revision surgery, optimal surgical reconstruction, and the type of prosthesis to be implanted, the Knee Society began development of an Index of Severity for Failed Total Knee Arthroplasty. Fifty-four percent of Knee Society members completed an 82-item questionnaire that determined their clinical impression about potential risk factors for the outcomes of revision surgery for failed total knee replacements. Using these results, a consensus group developed the final version of the index. The result of the nominal group process was the Knee Society Index of Severity, which was based on eight distinct domains. Each domain was divided into attributes and weights based on the questionnaire responses and consensus meeting. Actual case scenarios from five institutions were used to test interrater reliability and validity. The interrater reliability of the average score of all ratings was 0.95; the correlation of the criterion rating with the mean rating was 0.77. When three outliers were not included, the Pearson product correlation increased to 0.92. These data support the application of the Knee Society Index of Severity as a critical component of risk factor studies, effectiveness research, and cost-effectiveness analysis involving revisions of total knee replacements.

Cortical network dynamics during verbal working memory function

This study is an exploratory investigation of the regional timing of cortical activity associated with verbal working memory function. ERP activity was obtained from a single subject using a 124-channel sensor array during a task requiring the monitoring of imageable words for occasional targets. Distributed cortical activity was estimated every 2.5 ms with high spatial resolution using real head, boundary element modelling of non-target activity. High-resolution structural MRI was used for segmentation of tissue boundaries and co-registration to the scalp electrode array. The inverse solution was constrained to the cortical surface. Cortical activity was observed in regions commonly associated with verbal working memory function. This included: the occipital pole (early visual processing); the superior temporal and inferior parietal gyrus bilaterally and the left angular gyrus (visual and phonological word processing); the dorsal lateral occipital gyrus (spatial processing); and aspects of the bilateral superior parietal lobe (imagery and episodic verbal memory). Activity was also observed in lateral and superior prefrontal regions associated with working memory control of sensorimotor processes. The pattern of cortical activity was relatively stable over time, with variations in the extent and amplitude of contributing local source activations. By contrast, the pattern of concomitant scalp topography varied considerably over time, reflecting the linear summation effects of volume conduction that often confound dipolar source modelling.

Response of F344 rats to inhalation of subclinical levels of sarin: exploring potential causes of Gulf War illness

Subclinical, repeated exposures of F344 rats to sarin resulted in brain alterations in densities of chlonergic receptor subtypes that may be associated with memory loss and cognitive dysfunction. The exposures also depressed the immune system. The rat appears to be a good model for studying the effects of subclinical exposure to a nerve gas.

Working memory in posttraumatic stress disorder--an event-related potential study

This study examined ERP topography during the updating and the utilization of working memory in subjects with PTSD. Event-related potentials of 18 participants with PTSD and 18 controls were recorded from 32 scalp electrodes during an auditory target detection task requiring the constant updating of target identity. Midline N2 and P3 abnormalities previously noted in PTSD during target detection were replicated. Scalp topographic data revealed sustained reduction in activity over the right hemisphere during working memory updating. Executive processes were associated with brief but widespread right hemisphere reductions during the P3, followed by sustained, bilateral reduction frontally. This study identifies an abnormal pattern of cortical network function during both the updating and use of working memory in PTSD.

The effectiveness of very short scales for depression screening in elderly medical patients

OBJECTIVE

To compare very short scales for screening for depression with longer, widely used scales.

METHODS

Eighty-seven patients over the age of 60 who were admitted to rehabilitation wards or were attending a day rehabilitation facility at a British teaching hospital were screened for depression using the 1-item mental health inventory, and the 4-item, 15-item and 30-item geriatric depression scales. The sensitivity, specificity, and areas under receiver operating characteristic curves were compared, with the diagnostic criteria for research of ICD-10 providing the criterion diagnosis of depressive episode.

RESULTS

All the scales had comparable sensitivity (82.4-100%), specificity (60.0-71.4%), and positive predictive values (33.3-42.9%). Comparison of receiver operating characteristic curves for each scale showed no statistically significant difference between them (range 0.80-0.88).

CONCLUSIONS

The very short scales performed just as well as the widely used longer screening scales in this population. They are worthy of further examination in elderly populations at risk of depression, and may be particularly suitable for older adults due to their brevity and ease of use.

MALDI-ToF/MS as a diagnostic tool for the confirmation of sulfur mustard exposure

The continual threat of chemical and biological warfare has prompted the need for unambiguous analytical methods for the confirmation of agent exposure. In this paper, we have investigated the use of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-ToF/MS) as a diagnostic tool for this purpose. Mass spectral studies of the interaction of sulfur mustard (bis-(2-chloroethyl) sulfide, HD) with hemoglobin and metallothioneine were conducted. In vitro experiments with purified proteins were performed, using both HD and chloroethylethyl sulfide (CEES), in an effort to determine the extent of alkylation and occurrence of HD cross-linking using the MALDI-ToF/MS technique. In a typical experiment, 50 ml of 5 mM HD in acetonitrile was added to an equal volume of 0.5 mM hemoglobin in deionized water followed by vortexing and incubation at room temperature. After 24 h, the samples were analyzed by MALDI-ToF/MS. Mass spectral results indicated the presence of at least two distinct alkylation adducts for both HD and CEES experiments. These results demonstrate that MALDI-ToF/MS is a useful analytical technique to investigate the interaction of HD with biomolecules and may be employed potentially as a diagnostic tool for the confirmation of exposure to chemical warfare agents.

Pathomechanisms of failures of the odontoid

STUDY DESIGN

A finite element investigation to determine the causal mechanisms that lead to odontoid fracture.

OBJECTIVES

To elucidate which loading scenarios, including rotational moments, compression-tension, and lateral and anteroposterior shear, can result in Type I, Type II, and Type III odontoid failures.

SUMMARY OF BACKGROUND DATA

There is considerable controversy about the major loading path that causes odontoid fractures. A review of the clinical and laboratory research literature did not provide a consensus on this issue.

METHODS

A three-dimensional, nonlinear finite element model of the occipito-atlantoaxial (C0-C1-C2) complex was generated from human cadaveric data. Force loads were applied at the posterior margin of the occiput and were applied as lone entities or after the model was prepositioned in flexion, extension, or lateral-bending moments through applied rotation moments. Intraosseous stresses were reported to characterize the probability of fracture due to the applied loadings.

RESULTS

The data indicate that hyperextension can lead to failure of the odontoid at its superior tip (Type I). Finite element model predictions also demonstrated the propensity of loads that induce axial rotation to create relatively high maximum von Mises stress in the Type II fracture region. Flexion prepositioning reduced the stress response of the odontoid.

CONCLUSIONS

Force loading that puts the head in extension coupled with lateral shear or compression leads to Type I fractures, whereas axial rotation and lateral shear can produce Type II fractures. The model failed to elucidate causal mechanisms for Type III fractures. Flexion seems to provide a protective mechanism against force application that would otherwise cause a higher risk of odontoid failure.

The effect of clozapine on the speed and accuracy of information processing in schizophrenia

1. The study aimed to investigate the effects of clozapine on the speed and accuracy of information processing in patients with schizophrenia. Data are reported from 13 subjects with schizophrenia, treated with clozapine for 6.8 (+/- 1.8) months. 2. Reaction time and accuracy of target detection on a tone detection task were measured before and during clozapine treatment, and these results were compared with a matched control group. 3. Symptom severity and performance on three timed tests of cognitive function were also measured prior to clozapine treatment in the schizophrenia group, and these measures were repeated during treatment with clozapine. 4. Treatment with clozapine was found to significantly improve reaction time and the accuracy of target detection in patients with schizophrenia. Despite this improvement their performance remained significantly inferior to that of a matched control group. Both positive and negative symptoms improved with clozapine treatment, as did performance on the WAIS-R digit symbol substitution test. 5. Improved performance on the WAIS-R digit symbol substitution test correlated with reduction in negative symptoms, and faster reaction time showed some correlation with reduction in positive symptoms. 6. The results of this pilot study indicate that treatment with clozapine can produce limited improvement in cognitive function in schizophrenia.

Kinetic origin of the chelate effect. Base hydrolysis, H-exchange reactivity, and structures of syn,anti-[Co(cyclen)(NH3)2]3+ and syn,anti-[Co(cyclen)(diamine)]3+ ions (diamine = H2N(CH2)2NH2, H2N(CH2)3NH2)

The synthesis of syn,anti-[Co(cyclen)en](ClO4)3 (1(ClO4)3) and syn,anti-[Co(cyclen)tn](ClO4)3 (2(ClO4)3) is reported, as are single-crystal X-ray structures for syn,anti-[Co(cyclen)(NH3)2](ClO4)3 (3(ClO4)3). 3(ClO4)3: orthorhombic, Pnma, a = 17.805(4) A, b = 12.123(3) A, c = 9.493(2) A, alpha = beta = gamma = 90 degrees, Z = 4, R1 = 0.030. 1(ClO4)3: monoclinic, P2(1)/n, a = 8.892(2) A, b = 15.285(3) A, c = 15.466(3) A, alpha = 90 degrees, beta = 91.05(3) degrees, gamma = 90 degrees, Z = 4, R1 = 0.0657. 2Br3: orthorhombic, Pca2(1) a = 14.170(4) A, b = 10.623(3) A, c = 12.362(4) A, alpha = beta = gamma = 90 degrees, Z = 4, R1 = 0.0289. Rate constants for H/D exchange (D2O, I = 1.0 M, NaClO4, 25 degrees C) of the syn and anti NH protons (rate law: kobs = ko + kH[OD-]) and the apical NH, and the NH3 and NH2 protons (rate law: kobs = kH[OD-]) in the 1, 2, and 3 cations are reported. Deprotonation constants (K = [Co(cyclen-H)(diamine)2+]/[Co(cyclen)(diamine)3+][OH-]) were determined for 1 (5.5 +/- 0.5 M-1) and 2 (28 +/- 3 M-1). In alkaline solution 1, 2, and 3 hydrolyze to [Co(cyclen)(OH)2]+ via [Co(cyclen)(amine)OH)]2+ monodentates. Hydrolysis of 3 is two step: kobs(1) = kOH(1)[OH-], kobs(2) = ko + kOH(2)[OH-] (kOH(1) = (2.2 +/- 0.4) x 10(4) M-1 s-1, ko = (5.1 +/- 1.2) x 10(-4) s-1, kOH(2) = 1.0 +/- 0.1 M-1 s-1). Hydrolysis of 2 is biphasic: kobs(1) = k1K[OH-]/(1 + K[OH-] (k1 = 5.0 +/- 0.2 s-1, K = 28 M-1), kobs(2) = k2K2[OH-]/(1 + K2[OH-]) (k2 = 3.5 +/- 1.2 s-1, K2 = 1.2 +/- 0.8 M-1). Hydrolysis of 1 is monophasic: kobs = k1k2KK2[OH-]2/(1 + K[OH-1])(k-1 + k2K2[OH-]) (k1 = 0.035 +/- 0.004 s-1, k-1 = 2.9 +/- 0.6 s-1, K = 5.5 M-1, k2K2 = 4.0 M-1 s-1). The much slower rate of chelate ring-opening in 1, compared to loss of NH3 from 3, is rationalized in terms of a reduced ability of the former system to allow the bond angle expansion required to produce the SN1CB trigonal bipyramidal intermediate.

In-vitro hydrolysis, permeability, and ocular uptake of prodrugs of N-[4-(benzoylamino)phenylsulfonyl]glycine, a novel aldose reductase inhibitor

To enhance the ocular uptake of N-[4-(benzoylamino)phenylsulfonyl]glycine (BAPSG), two ester (methyl and isopropyl) prodrugs were synthesized and evaluated for their stability in various buffers (pH 1-9), hydrolysis in rabbit ocular tissues (cornea, conjunctiva, iris-ciliary body, lens, aqueous humor, and vitreous humor), transport across cornea and conjunctiva, and in-vivo uptake following topical administration. Over the pH range of 1-9, the rate constants for degradation ranged from 5.67 to 218.9 x 10(-3) h(-1) for the methyl ester and from 3.14 to 4.45 x 10(-3) h(-1) for the isopropyl ester. At all pH conditions, the isopropyl ester was more stable when compared with the methyl ester. A change in buffer concentration at pH 7.4 did not influence the stability of the prodrugs. The prodrugs were rapidly hydrolysed in the tissue homogenates, with the rate constants for hydrolysis ranging from 1.98 to 7.2x 10(-3) min(-1) for the methyl ester and 3.32 to 6.53 x 10(-3) min(-1) for the isopropyl ester. The in-vitro permeability of the methyl ester was less than the parent drug across cornea and conjunctiva. Isopropyl ester levels were not detectable in the receiver chamber even at the end of the 4-h transport study. Following topical administration of BAPSG and the two prodrugs at a dose of 60 microg/eye, the lowest levels were seen in vitreous humor for parent compound and its methyl ester. In general, the tissue uptake of methyl ester was less than BAPSG. Isopropyl ester levels were below detection limits in all the ocular tissues. Lipophilic ester prodrugs of BAPSG showed good aqueous solution stability in tissue homogenates. However, these prodrugs lacking the free carboxylate anion exhibited reduced in-vitro permeability and in-vivo uptake, suggesting the importance of free carboxylate anion in the delivery of BAPSG.

Chromatographic and mass spectral methods of identification for the side-chain and ring regioisomers of methylenedioxymethamphetamine

The popular drug of abuse 3,4-methylenedioxymethamphetamine (MDMA) is one of a total of 10 regioisomeric 2,3- and 3,4-methylenedioxyphenethylamines of MW 193 that yields regioisomeric fragment ions with equivalent mass (m/z 58 and 135/136) in the electron-impact (EI) mass spectrum. Thus, these 10 methylenedioxyphenethylamines are uniquely isomeric; they have the same molecular weight and equivalent major fragments in their mass spectra. The specific identification of one of these compounds (i.e., Ecstasy or 3,4-MDMA) in a forensic drug sample depends upon the analyst's ability to eliminate the other regioisomers as possible interfering or coeluting substances. This study reports the synthesis, chemical properties, spectral characterization, and chromatographic analysis of these 10 unique regioisomers. The ten 2,3- and 3,4-regioisomers of MDMA are synthesized from commercially available precursor chemicals. In the EI mass spectra, the side-chain regioisomers show some variation in the relative intensity of the major ions, with the exception of only one or two minor ions that might be considered side-chain specific fragments. The position of substitution for the methylenedioxy ring is not easily determined by mass spectral techniques, and the ultimate identification of any one of these amines with the elimination of the other nine must depend heavily upon chromatographic methods. The chromatographic separation of these 10 uniquely regioisomeric amines are studied using reversed-phase liquid chromatographic methods with gradient elution and gas chromatographic techniques with temperature program optimization.

Biomechanical rationale for the pathology of rheumatoid arthritis in the craniovertebral junction

STUDY DESIGN

A finite-element model of the craniovertebral junction was developed and used to determine whether a biomechanical mechanism, in addition to inflammatory synovitis, is involved in the progression of rheumatoid arthritis in this region of the spine.

OBJECTIVES

To determine specific structure involvement during the progression of rheumatoid arthritis and to evaluate these structures in terms of their effect on clinically observed erosive changes associated with the disease by assessing changes in loading patterns and degree of anterior atlantoaxial subluxation.

SUMMARY OF BACKGROUND DATA

Rheumatoid arthritis involvement of the occipito-atlantoaxial (C0-C1-C2) complex is commonly seen. However, the biomechanical contribution to the development and progression of the disease is neither well understood nor quantified. Although previous cadaver studies have elucidated information on kinematic motion and fusion techniques, the modeling of progressive disease states is not easily accomplished using these methods. The finite-element method is well suited for studying progressive disease states caused by the gradual changes in material properties that can be modeled.

METHODS

A ligamentous, nonlinear, sliding-contact, three-dimensional finite-element model of the C0-C1-C2 complex was generated from 0.5 mm thick serial computed tomography scans. Validation of the model was accomplished by comparing baseline kinematic predictions with experimental data. Transverse, alar, and capsular ligament stiffness were reduced sequentially by 50%, 75%, and 100% (removal) of their intact values. All models were subjected to flexion moments replicating the clinical diagnosis of rheumatoid arthritis using full flexion lateral plane radiographs. Stress profiles at the transverse ligament-odontoid process junction were monitored. Changes in loading profiles through the C0-C1 and C1-C2 lateral articulations and their associated capsular ligaments were calculated. Anterior and posterior atlantodental interval values were calculated to correlate ligamentous destruction with advancement of atlantoaxial subluxation.

RESULTS

Model predictions (at 0.3 Nm) fell within one standard deviation of experimental means, and range of motion data agreed with published in vitro and in vivo values. The model predicted that stresses at the posterior base of the odontoid process were greatly reduced with transverse ligament compromise beyond 75%. Decreases through the lateral C0-C1 and C1-C2 articulations were compensated by their capsular ligaments. Anterior and posterior atlantodental interval values indicate that the transverse ligament stiffness decreases beyond 75% had the greatest effect on atlantoaxial subluxation during the early stages of the disease (no alar and capsular ligament damage). Subsequent involvement of the alar and capsular ligaments produced advanced atlantoaxial subluxation, for which surgical intervention may be warranted.

CONCLUSIONS

To the best of the authors' knowledge, this is the first report of a validated, three-dimensional model of the C0-C1-C2 complex with application to rheumatoid arthritis. The data indicate that there may be a mechanical component (in addition to enzymatic degradation) associated with the osseous resorption observed during rheumatoid arthritis. Specifically, erosion of the odontoid base may involve Wolff's law of unloading considerations. Changes through the lateral aspects of the atlas suggest that this same mechanism may be partially responsible for the erosive changes seen during progressive rheumatoid arthritis. Anterior and posterior atlantodental interval values indicate that complete destruction of the transverse ligament coupled with alar and/or capsular ligament compromise is requisite if advanced levels of atlantoaxial subluxation are present.

Treating cognitive dysfunction in patients with schizophrenia

Cognitive dysfunction is a common, chronically disabling component of schizophrenia. It has been proposed that many of the symptoms of schizophrenia can be understood as a result of disruption of fundamental cognitive processes. This paper reviews treatment strategies aimed at improving cognitive function in patients with schizophrenia. Nonpharmacologic interventions include instruction in the performance of tasks such as the Wisconsin Card Sorting Test. Mixed results have been achieved, but it appears that instruction methods involving reinforcement of information held in working memory are more successful. Computer-aided remediation has also been used with variable success. Novel antipsychotic drugs appear to have an advantage over conventional antipsychotic drugs in terms of their effect on cognitive function. The development of more precisely tailored methods of remedial teaching, along with optimal pharmacologic treatment, may lead to more effective treatment of cognitive dysfunction in patients with schizophrenia.

Updating working memory for words: a PET activation study

A PET study of 10 normal individuals was carried out to investigate the cerebral regions involved in the controlled updating of verbal working memory. Subjects viewed single concrete words on a computer monitor and detected occasional target words in an attended color. In the activating condition, a target was defined as a word that was identical to the previous word presented in the attended color. In the control condition, the target was a predesignated word. The same word lists, target probabilities, and target response demands were used for both conditions, with interword intervals constrained to ensure equivalence in the demand for target rehearsal. A comparison of the conditions found bilateral activation of dorsolateral prefrontal (middle frontal gyrus; MFG) and inferior parietal (supramarginal gyrus; SMG) cortical regions. Activation of the MFG is taken to reflect executive control by prefrontal regions over the working memory updating process linking posterior representations of the anticipated target stimulus to anterior representations of the planned response. It is proposed that the updating of the stimulus link is mediated via connections between the MFG and SMG. The role of the SMG as an amodal region binding the various modal representations in posterior association cortex of the word being retained in working memory is considered and reviewed. It is suggested that the combined activation of these regions is related to the executive control of goal-setting in planned behavior.