Conditioning stimulation techniques for enhancement of transcranially elicited evoked motor responses

Journee, H. -L., Polak, H. E. & De Kleuver, M. Dec-2007 In : Neurophysiologie clinique-Clinical neurophysiology. 37, 6, p. 423-430 8 p.

Research output: Contribution to journalArticle

  • H. -L. Journee
  • H. E. Polak
  • M. De Kleuver

Introduction. - In spite of the use of multipulse, transcranial electrical stimulation (TES) is still insufficient in a subgroup of patients to elicit motor-evoked potentials during intraoperative neurophysiological monitoring (IONM). Classic facilitation methods used in awake patients are precluded under general anaesthesia. Conditioning techniques can be used in this situation.

Objective. - To present clinical experimental data and models of motor-neuron (MN) excitability for homonymous and heteronymous conditioning and discuss their applications in IONM.

Material and methods. - Data were obtained in a prospective study on multipulse TES-conditioning of the monosynaptic H-reflex and double multipulse TES.

Discussion. - The principle of facilitation by conditioning stimulation is to apply a test stimulus when motor neurons (MNs) have been made maximally excitable by a conditioning stimulus. Both conditioning and test stimuli recruit separate populations of MNs. The overlapping fraction of MNs controls the efficacy of facilitation. Heteronymous conditioning stimulation, which is performed at a different site from the test stimulus, is illustrated by the TES-conditioned H-reflex (HR). Autonomous conditioning stimulation, which is performed at the same stimulation site, is illustrated by doubte-train TES (dt-TES). The facilitating curves obtained by conditioning stimulation are often 3-modal and show peaks of facilitation at short intertrain intervals (S-ITIs) of 10 ms and between 15 and 20 ms and at longer intertrain intervals (L-ITI) of over 100 ms. The facilitation curves from HR and dt-TES are not always identical since different alpha MN pools are involved. Dt-TES is often successful in neurologically impaired patients whereas facilitation of the HR can be used when conditioned by TES at subthreshold Levels allowing continuous IONM without movement in the surgical field. Alternatively, facilitation by conditioning from peripheral-nerve stimulation can be used for selective transmission of subthreshold TES motor responses to peripheral muscles, permitting motor-monitoring by a so-called selective motor-gating technique.

Conclusions. - Facilitation techniques offer many possibilities in IONM by enhancing low-amplitude TES-MEP responses. They can also selectively enhance responses in a few muscle groups for the reduction of movement. (c) 2007 Elsevier Masson SAS. All rights reserved.

Original languageEnglish
Pages (from-to)423-430
Number of pages8
JournalNeurophysiologie clinique-Clinical neurophysiology
Issue number6
StatePublished - Dec-2007
Event1st European Symposium on Intraoperative Neurophysiology - , Netherlands
Duration: 27-Oct-200628-Oct-2006


1st European Symposium on Intraoperative Neurophysiology



Event: Other


  • H-reflex, facilitation, transcranial stimulation, electrical, selective MEP gating, monitoring, intraoperative, conditioning, stimulation, motor responses, MAGNETIC STIMULATION, CORTEX STIMULATION, SPINAL SURGERY, INTACT MAN, ELECTRICAL-STIMULATION, SPATIAL FACILITATION, SILENT PERIOD, POTENTIALS, MUSCLES, EMG

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