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Somatosensory Evoked Potentials; Cerebral Potentials; Spinal Potentials; Nerve Stimulation; Sensory Lesions Muscle Nerve 21: 277–290, 1998

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Somatosensory Evoked Potentials; Cerebral Potentials; Spinal Potentials; Nerve Stimulation; Sensory Lesions Muscle Nerve 21: 277–290, 1998 Key words: somatosensory evoked potentials; cerebral potentials; spinal potentials; nerve stimulation; sensory lesions Muscle Nerve 21: 277–290, 1998 AAEM MINIMONOGRAPH 19: SOMATOSENSORY EVOKED POTENTIALS MICHAEL J. AMINOFF, MD, FRCP1 and ANDREW A. EISEN, MD2 1 Department of Neurology, University of California at San Francisco, San Francisco, California, USA 2 Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada Received 11 August 1997; accepted 5 September 1997 More than 40 years have elapsed since the first so- sensory threshold. It is also possible to elicit SEPs matosensory evoked potential (SEP) was recorded using a variety of mechanical stimuli.63,105 This al- from humans,21 and 15 years have passed since the lows selective activation of specific sensory modali- clinical role of SEPs was reviewed as an American ties, but the SEPs elicited are often of small ampli- Association of Electrodiagnostic Medicine (AAEM) tude and may require many hundreds of responses minimonograph. At that time, interest in SEPs was to be averaged. This limits the clinical utility of me- reaching its zenith, and a vast literature had already chanically elicited SEPs. accumulated. The subsequent development of so- The SEP is greatly attenuated or abolished when phisticated imaging techniques has impacted on the the dorsal columns are selectively ablated in ani- role of SEPs in the clinical setting, making it timely mals,18 indicating that within the spinal cord the SEP to review this aspect as the end of the century is is mediated predominantly via these tracts. Con- approached. This minimonograph considers current versely, cord lesions that do not interrupt the dorsal concepts of the physiologic basis of the SEP, dis- columns are associated with a relatively normal SEP. cusses the different techniques available to elicit and Loss of posterior column function in humans is al- record it, and critically analyzes its clinical utility. most invariably accompanied by a grossly abnormal The peripheral electrical stimulus routinely used SEP.47 Some SEP components may, however, reflect to elicit an SEP activates predominantly—if not en- extralemniscal activity; they have been evoked in cats tirely—the large-diameter, fast-conducting group Ia 55 after selective dorsal column transection by stimuli muscle and group II cutaneous afferent fibers. Se- that are sufficient to excite small-diameter periph- lective intrafascicular stimulation has provided evi- eral fibers,76 and tourniquet-induced ischemia in hu- dence for a direct muscle afferent fiber (Ia) projec- mans abolishes short-latency before long-latency SEP tion to the human somatosensory cortex.43 However, components, suggesting that they are mediated by when a mixed nerve is stimulated, both group Ia different centrally conducting tracts.119 muscle afferents and cutaneous group II afferents Although in general the SEP is best recorded contribute to the resulting SEP.55 Its amplitude is over the somatosensory cortex, topographic map- almost maximal when the peripheral nerve action ping indicates that several of its components are potential is only 50% of its maximum.35 This trans- widely distributed over the scalp, and some are maxi- lates into a requisite stimulus intensity of about twice mally recorded outside the somatosensory cortex.112 Because the SEP monitors more than just the so- *Correspondence to: American Association of Electrodiagnostic Medi- matosensory pathways, abnormalities recorded in cine, 421 First Avenue S.W., Suite 300 East, Rochester, MN 55902, USA certain primary diseases of the motor system (such as CCC 0148-639X/98/030277-14 © 1998 American Association of Electrodiagnostic Medicine. Published amyotrophic lateral sclerosis) should not cause con- by John Wiley & Sons, Inc. cern. AAEM Minimonograph 19: SEPs MUSCLE & NERVE March 1998 277 STIMULATION TECHNIQUES Dermatomal Stimulation. Dermatomal stimulation Mixed Nerve Stimulation. Because electrical stimu- is even more segmentally specific than cutaneous lation of a mixed nerve initiates a relatively synchro- nerve stimulation, because cutaneous nerve stimula- nous volley that elicits a sizable SEP, it has become tion invariably activates fibers from more than one the standard for clinical use. The stimulus intensity dermatome. However, with dermatomal stimulation required to elicit an SEP of maximum amplitude the ascending volley is very desynchronized, and this need not be supramaximal. The ideal stimulus in- sometimes makes the SEP difficult to interpret. Der- duces a mixed nerve action potential that is just matomal stimulation has been used most often to greater than 50% of its maximum amplitude and assess function of the lumbosacral roots. For L5, the clinically produces a slight muscle twitch. Too high a medial side of the first metatarsophalangeal joint or stimulus is counterproductive, producing occlusion the dorsal surface of the foot between the first and of Ia impulse traffic by other converging afferent second toes is stimulated. For S1, the lateral side of impulses.43 The occurrence of occlusion may de- the fifth metatarsophalangeal joint is stimulated. pend on the limb that is stimulated.44 When occlu- Care must be taken to avoid stimulus spread to sion occurs, a percentage of the initial volley is inef- neighboring dermatomes, underlying muscle (which fective, and the SEP is accordingly lower in induces activity of Ia afferents), and digital cutane- amplitude. A stimulus of short duration (200–300 ous nerves. This can be achieved if the stimulus is µs) is popular, but longer duration (1000 µs) pulses kept at 2.5 × sensory threshold, which gives about of appropriately lower intensity may be appropriate 80% of the maximum amplitude. Normative data for because they preferentially activate the type Ia and II the L5 and S1 dermatomes are well established.4 afferents.113 A repetition rate of 5.1 Hz is conve- nient. Faster rates may be tolerable to the patient Motor Point Stimulation. A single muscle motor and do not alter the SEP until they exceed 15 Hz. point can be stimulated to elicit SEPs.31 This is Troublesome electrocardiographic artifact, achieved by using a monopolar needle electrode for particularly relevant with noncephalic referential re- stimulation. A long-duration (1.0 ms), low-intensity cordings of SEPs elicited from the legs, can be obvi- stimulus preferentially activates the Ia afferents that ated by triggering the stimulus off the electrocardio- exit in the same bundle as the alpha motor fibers at gram. In general, SEPs elicited by lower limb the motor point. This method allows stimulation of stimulation have the added advantage of testing the proximal (large) muscle Ia afferent input. functional integrity of much of the length of the spinal cord, an important consideration in suspected Paraspinal Stimulation. The paraspinal region at multiple sclerosis and other myelopathies that may sequential levels along the vertebral column can be not be detected by imaging techniques. stimulated to elicit SEPs.51 This method ‘‘obviates’’ peripheral input from long nerves in the limbs and Cutaneous Nerve Stimulation. Virtually any acces- more readily identifies lesions of the spinal cord. sible cutaneous nerve can be stimulated to elicit an The stimulus is applied simultaneously to both sides, SEP. With cutaneous nerve stimulation, however, the 2 cm lateral to the midline, at an intensity that in- potentials are smaller than those evoked by mixed duces a small visible muscle twitch. Potentials are nerve stimulation, and the small far-field compo- recorded over the scalp (Cz–Fz). The afferent volley nents are difficult to record.25,30 Use of cutaneous is primarily initiated in the cutaneous branches of nerve stimulation should be considered when it is the primary dorsal root rami, with some contribution necessary to: (1) assess the integrity of specific cuta- from the paraspinal Ia afferents. neous nerves, such as the lateral femoral cutaneous In normal subjects, the value for spinal cord con- nerve,116 which are not readily studied by conven- duction velocity between T12 and T1 is approxi- tional techniques; (2) measure peripheral sensory mately 64 m/s. However, it is better to refer to con- conduction when this is not otherwise possible be- duction time, which over the same segments is 5.4 ± cause the sensory nerve action potential (SNAP) is 1.6 ms.51 either absent or very small25,30; (3) evaluate isolated root function, because of the increased segmental RECORDING AND FILTERING OF SEPs specificity of cutaneous stimulation4,29; and (4) as- Surface or needle electrodes can be used for record- sess dubious patchy numbness for medicolegal rea- ing SEPs. There is no difference in the resultant SEP. sons, by stimulating homologous areas of ‘‘involved’’ The latter, although easily inserted into the scalp, and normal skin supplied through cutaneous termi- are not popular because of their higher impedance, nals.22 the discomfort of their insertion, and the theoretical 278 AAEM Minimonograph 19: SEPs MUSCLE & NERVE March 1998 risk of infection. Recording montages are either ‘‘ce- may be recorded with bipolar cephalic derivations,37 phalic bipolar’’ or ‘‘referential.’’ In a cephalic bipo- but referential recording is required for proper lar montage both electrodes are placed on the head, identification. Far-field potentials are small in ampli- while in a referential montage the reference elec- tude, recorded with equal ease and amplitude over a trode is placed off the head. A cephalic bipolar mon- wide area of the scalp, and usually positive and tage is relatively noise-free and is satisfactory for rou- monophasic at the active electrode, reflecting a mov- tine clinical use. However, there is cancellation of ing front approaching the recording electrode. the small-amplitude, far-field potentials, which can Kimura and coworkers showed that under some cir- only be recorded with noncephalic references (e.g., cumstances far-field potentials may be biphasic and the opposite mastoid, shoulder, arm, hand, or knee, of either polarity.67 The posterior tibial near-field or the linked mastoids or earlobes). Recording with potential is also positive in polarity.
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