Somatosenory Evoked Potentials

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1 Somatosenory Evoked Potentials Ronald Emerson, MD Cornell University Hospital for Special Surgery New York Median SSEPs CPc - Ci CPi - Epc SC5 Epc Medial Lemniscus Epi - Epc Spinal Cord Dorsal Gray Tibial SSEPs CPi CPc CPz Fpz Fpz SC5 Medial Lemniscus T12 - IC Spinal Cord Dorsal Gray 1

2 Clinical Applications of SEPs Provide information about integrity of the large fiber sensory system from peripheral nerve brain. Extension of exam; may reveal or localize a lesion Do not indicate particular disease process. Normal doesn t exclude organic cause for symptoms. Can be useful in documenting multiple lesions in MS VEPs abnormal in 70-80% definite MS SEPs abnormal in 60-70% definite MS BAEPs abnormal in 20-40% definite MS Not specific however; multiple EP abnormalities also occur in other disease, including, e.g. Cerebellar degenerations Hereditary spastic paraparesis SLE Vitamin E deficiency Pernicious Anemia Coma Bilateral absence of N20 is highly predictive of poor neurological outcome or death following anoxic (Brunko 1987; Bassetti 2002) or traumatic (Hume 1981) brain injury. However, presence of cortical responses does not guarantee a good outcome. 2

3 Intraoperative EP Monitoring Detect adverse event in time for effective corrective action Identify structures Identify ways to improve surgical technique Stimulation Nerve: median, tibial Ground on limb, proximal to stimulation site Constant current stimulation Monophasic square wave: usec Intensity: Just above motor threshold Rate: 3 5 Hz (not harmonically related to 60 Hz) Recording Bipolar and referential derivations designed to record signals from: Peripheral Nerve Cord Brainstrem Cortex 3

4 Recording Filters: typically Hz (- 6 db/octave) Avoid 60 Hz notch filter Avoid using the smooth button Analysis time typically 50 msec for UE, 60 msec for LE Number of responses averaged: sufficient, typically Replicate Brainstem SSEPs Conducted Electrically Over Entire Head Recorded using Non-Cephalic Reference * 4

5 Cortical SSEP Is Focal, and Rides Atop Widely Distributed Subcortical Is recorded alone by subtracting the underlying subcortical signal using bipolar derivation Right Parietal Left Parietal Brainstem L Parietal Mauguiere and Desmedt, 1989 Cortical + Brainstem R Parietal Right Left C4 C3 Median SSEPs Standard ACNS Montage CPc - CPi CPi - Epc SC5 - Epc Epi - Epc Common Alternatives: Combine Brainstem and Cervical signals: Less data but more noiseimmune. CPc - Cpi Cpi - SC5 Epi - Epc CPc - Cpi SC5 - Fpz Epi - Epc Tibial SSEPs CPi CPc CPz Fpz Need 2 Channels for Cortical SSEP Because of variations in normal Topography: Normal Subject A Fpz SC5 T12 - IC Normal Subject B = often hard to record without sedation 5

6 Median SSEP Interpretation Presence of waveforms Cortical (N20) Subcortical (P14) Cervical cord Erbs Interpeak latencies Interside interpeak Erbs N20 Erbs P14 P14 N20 = may need sedation to record these, N13 recorded from SC5 Fpz may substitute. Tibial SSEPs Interpretation Presence of waveforms Cortical (P37) Subcortical (P31, N34) Lumbar cord (LP) Interpeak latencies Interside interpeak LP P37 = may need sedation to record. Median SSEP Normal Values EP Erb s point Upper Limit Of Normal (ULN) 12 msec P14 * Brainstem Cervical 16.3 msec N20 Cortical 22.1 msec ULN of R-L diff. EP - P14* 5.2 msec 0.7 msec P14* N msec 1.1 msec EP N msec 0.8 msec * Recorded using Scalp SC5 derivation Chiappa

7 Tibial SSEP Normal Values N22 Lumbar P31 Subcortical P37 Cortical Upper Limit Of Normal (ULN) 25 msec 34.7 msec 43.9 msec ULN of R-L diff. N22 P msec 1.5 msec P31 P msec 1.8 msec N22 P msec IFCN Guidelines y/o Woman with MS CP4 CP3 N20, 19 msec CP3 EPc SC5 EPc EP, 9.5 ms Epi-EPc Left median SSEP N13, P14 and N18 Absent. EP N20 IPL Normal. 47 y/o man with pontine AVM CP4 CP3 CP3 EPc SC5 EPc Epi-EPc P14, 14.3 msec EP, 10 msec Left median SSEP EP P14 IPL normal, N18 ~ absent, N20 absent 7

8 66 y/o man with cervical spondylitic myelopathy CP3-CP4 N20, 22.5 msec Cp3-Epc P14, 18 msec SC5-Epc EP, 10 msec Right median SSEP EP P14 delayed, P14 N20 normal 30 y/o with movement disorder L Median SSEP R Median SSEP Cc Ci Cc - Fpz Ci - Epc Cc - Epc SC5 - FPz SC5 - EPc 1.5 uv / div 5 msec / div Acoustic Neuroma 55 year old woman Ai-Cz Ac-Cz Ai-Ac Cc-Ci Cc-Epc Ci-Epc EPI-Epc 8

9 9 y/o boy with cervical instability Cc -Ci Cc -chin Ci -chin 3 y/o with Chiari Malformation Pre OP Post OP Cc -Ci Ci -Epc Cc -Ci 58 y/o 2 days s/p cardiac arrest L Median SSEP R Median SSEP Cc -Epc Ci -Epc SC5-Epc 0.7 uv / div 5 msec / div 9

10 75 y/o 1 day s/p cardiac arrest L Median SSEP R Median SSEP Cc -Ci Cc -Epc Ci -Epc SC5-Epc 1.0 uv / div 5 msec / div 66 y/o s/p cardiac arrest 14 L Median SSEP 14 R Median SSEP SC5-Epc Day 1 33oC CPi-Epc CPc-CPi Day 2 SC5-Epc 37oC CPi-Epc CPc-CPi 20 2 uv/div 44 y/o man with back pain and left leg numbness L Tibial SSEP R Tibial SSEP Ci Cc Ci - Fpz Cz - Fpz Cz SC5 T10 - IC L1 - IC Pf 1.0 uv / div 10 msec / div 10

11 55 year old man with back pain and right leg numbness L Tibial SSEP R Tibial SSEP Ci - Cc Ci - Fz Cz Fpz Cz SC5 T10 - IC L1 - IC Pf 0.7 uv / div 10 msec / div 85 y/o man with compressive spondylitic myelopathy C3-C4 Weak and numb left am L Median SSEP R Median SSEP Cc Ci Cc - Fpz Ci - Epc Cc - Epc SC5 - Fpz SC5 - Epc 1.0 uv / div 5 msec / div 1.5 uv / div 5 msec / div 69 y/o woman with sensory loss both legs L Tibial SSEP R Tibial SSEP Ci - Cc Cz - Fz Fz SC5 T10 - IC L1 - IC Pf 1.5 uv / div 10 msec / div 11

12 66 y/o man with spinal stenosis, difficulty walking L Tibial SSEP R Tibial SSEP Ci - Cc Ci - Fz Cz Fpz Cz SC5 T10 - IC L1 - IC Pf 0.7 uv / div 10 msec / div 38 y/o man with leg numbness L Tibial SSEP R Tibial SSEP Ci - Cc Cz - Fz T10 - IC L1 - IC Pf 2 uv / div 10 msec / div 12

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