title: The refractory period of fast conducting corticospinal tract axons in man and its implications for intraoperative monitoring of motor evoked potentials.
abstract: OBJECTIVE
  To determine the absolute and relative refractory period (RRP) of fast conducting axons of the corticospinal tract in response to paired high intensity (HI or supramaximal) and moderate intensity (MI or submaximal) electrical stimuli. The importance of the refractory period of fast conducting corticospinal tract axons has to be considered if repetitive transcranial electrical stimulation (TES) is to be effective for eliciting motor evoked potentials (MEPs) intraoperatively.
  
  
  METHODS
  Direct (D) waves were recorded from the epidural space of the spinal cord in 14 patients, undergoing surgical correction of spinal deformities. To assess the absolute and RRPs of the corticospinal tract, paired transcranial electrical stimuli at interstimulus intervals (ISI) from 0.7 to 4.1 ms were applied. Recovery of conditioned D wave at short (2 ms) and long (4 ms) ISI was correlated with muscle MEP threshold. The refractory period for peripheral nerve was tested in comparison to that for the corticospinal tract. In four healthy subjects sensory nerve action potentials of the median nerve were studied after stimulation with paired stimuli.
  
  
  RESULTS
  HI TES revealed a mean duration of 0.82 ms for the absolute refractory period of the corticospinal tract, while MI stimulation resulted in a mean refractory period duration of 1.47 ms. Stimuli of HI produced faster recovery of D wave amplitude during the RRP. Furthermore, short trains of transcranial electrical stimuli did not elicit MEPs when D wave showed incomplete recovery. A similar influence of stimulus intensity on recovery time was found for the refractory period of peripheral nerve.
  
  
  CONCLUSIONS
  The recovery of D wave amplitude is dependent upon stimulus intensity. High intensity produces fast recovery. This is an important factor for the generation of MEPs. When HI TES is used to elicit MEPs, short and long ISIs are equally effective. When MI TES is used to elicit MEPs, only a long ISI of 4 ms is effective.
authors.affiliation: Institute for Neurology and Neurosurgery, Beth Israel Medical Center-Singer Division, 170 East End Avenue, Room 311, New York, NY 10128, USA.
authors.forename: Klaus
authors.initials: K
authors.lastname: Novak
authors.forename: Adauri Bueno
authors.initials: AB
authors.lastname: de Camargo
authors.forename: Michael
authors.initials: M
authors.lastname: Neuwirth
authors.forename: Karl
authors.initials: K
authors.lastname: Kothbauer
authors.forename: Vahe E
authors.initials: VE
authors.lastname: Amassian
authors.forename: Vedran
authors.initials: V
authors.lastname: Deletis
mesh_terms: D000200:Action Potentials / Q000502:physiology; D000293:Adolescent; D000328:Adult; D001369:Axons / Q000502:physiology*; D002648:Child; D004558:Electric Stimulation / Q000379:methods; D019054:Evoked Potentials, Motor / Q000502:physiology*; D005260:Female; D006801:Humans; D008297:Male; D008475:Median Nerve / Q000502:physiology; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D011712:Pyramidal Tracts / Q000502:physiology*; D011930:Reaction Time / Q000502:physiology; D012032:Refractory Period, Electrophysiological / Q000502:physiology*