P30 and N33 of posterior tibial nerve SSEPs are analogous to P14 and N18 of median nerve SSEPs

Subcortical somatosensory evoked potentials after posterior tibial nerve stimulation in children

We report our normative data of somatosensory evoked potentials (SEP) after posterior tibial nerve (PTN) stimulation from a group of 89 children and 18 adults, 0.4-29.2 years of age. We recorded near-field potentials from the peripheral nerve, the cauda equina, the lumbar spinal cord and the somatosensory cortex. Far-field potentials were recorded from the scalp electrodes with a reference at the ipsilateral ear. N8 (peripheral nerve) and P40 (cortex) were present in all children but one. N20 (cauda equina) and N22 (lumbar spinal cord) were recorded in 94 and 106 subjects, respectively. P30 and N33 (both waveforms probably generated in the brainstem) were recorded in 103 and 101 subjects, respectively. Latencies increased with age, while central conduction times including the cortical component, decreased with age (up to about age 10 years). The amplitudes of all components were very variable in each age group. We report our normative data of the interpeak latencies N8-N22 (peripheral conduction time), N22-P30 (spinal conduction time), N22-P40 (central conduction time) and P30-P40 (intracranial conduction time). These interpeak latencies should be useful to assess particular parts of the pathway. The subcortical PTN-SEPs might be of particular interest in young or retarded children and during intraoperative monitoring, when the cortical peaks are influenced by sedation and sleep, or by anesthesia.

Fundamental principles of somatosensory evoked potentials

Studies of SSEP provide unique opportunities for investigating physioanatomic substrates of sensory pathway and cognitive functions of the sensory system. Progress of clinical investigation and application of SSEP have been stalled in more recent years, although SSEP still remain a useful tool for diagnosis of various neurologic disorders and for the monitoring of spinal cord function during surgery. Reflecting complex sensory system in human, scalp-recorded SSEP consists of multiple waves, having different distribution, amplitude, and latencies among different electrodes. The physioanatomic significance of these multiple waves, especially the late components, is largely unknown. These should be explored further, especially in relation to cognitive function.

Establishment of standard values for the latency, interval and amplitude parameters of tibial nerve somatosensory evoked potentials (SEPs)

OBJECTIVE

To establish standard values for tibial nerve somatosensory evoked potentials (SEPs).

METHODS

We examined SEPs following left tibial nerve stimulation in 65 normal subjects of various ages, and performed multiple regression analysis using height, age, (age-20)(2) and gender as predictor variables. We objectively selected the latency or interval parameters with less intersubject variability as the standard parameters for evaluation.

RESULTS

Among 3 cortical bipolar derivations investigated, the Cz'-Cc lead gave a more constant and stable P38 component than the Cz'-Fz or Ci-Cc lead. The latencies of the N8o (N8 onset) of the popliteal potential, P15 (P15 peak) in the contralateral iliac crest-ipsilateral greater trochanter lead, N21, N30 and P38o/P38 in the Cz'-Cc lead, as well as the intervals between these components were selected as standard parameters. P15 was easily identified in all of the subjects and is expected to be a new parameter to evaluate the proximal segment of the tibial nerve. The amplitudes of P15 and the other components were also evaluated. We present nomograms for the normal limit values of each parameter.

CONCLUSIONS

We present a thorough set of standard values for tibial SEPs where the subject factors were fully considered, and which is easily applicable to clinical practice.

Sensory and motor interfering influences on somatosensory evoked potentials

The interfering influences by which the different components of the early somatosensory evoked potentials are modified are reviewed from both neurophysiologic and clinical perspectives. Special consideration is given to the specific differences between sensory and motor interferences. In this context, the specific effect of the mental movement simulation task on the frontal N30 component is discussed in relation to the involvement of this evoked wave as a physiologic index of the dopaminergic motor pathways. Relevant interfering approaches, including concurrent events ranging from tactile stimulation to locomotion, are reviewed and discussed insofar as these data provide insights into the neurophysiologic processes of interaction between competing internal models controlling motor acts and sensory information.

Neuroanatomic substrates of lower extremity somatosensory evoked potentials

After stimulation of the lower extremity nerve (tibial nerve), N21 and N23 are recorded from L4 and T12 spine respectively. The far-field potentials of P31 and N35 are registered from Fpz-C5s (fifth cervical spine) or CPi (ipsilateral with respect to the side of stimulation)-ear derivation. Additional far-field potentials of P17 and P24 may be recorded from the scalp when a noncephalic (knee) reference is used. The major positive peak, P40, is registered at the vertex and the CPi. Preceding P40, there is a small negative peak, N37, recorded at the contralateral (CPc) hemisphere. Neuroanatomic substrates of these somatosensory evoked potential (SSEP) components are less well clarified compared with those of upper extremity (median nerve) SSEPs, primarily because clinical application of lower extremity SSEPs is more difficult, and all of the aforementioned potentials but one (P40) are not obligatory components. The concept of "paradoxical lateralization" complicates the issue further. Accumulating evidence, however, suggests that the far-field potentials of P17 and P31 arise from the distal portion of the sacral plexus and brainstem respectively. These correspond to P9 and P14 of the median nerve SSEPs respectively. The spinal potential of N23 is equivalent to the N13 cervical potential of the median nerve SSEP. N35 recorded from the ipsilateral hemisphere is analogous to N18 of the median nerve. Paradoxically lateralized P40 has been thought to represent the positive end of a dipole field, reflected by the negativity at the mesial surface of the contralateral hemisphere, and has commonly been considered to be equivalent to the first cortical potentials (N20) of the median nerve SSEP. However, more recent evidence suggests that the primary positivity is at the mesial cortical surface, and it more likely corresponds to P26 of the median nerve SSEP. Thus the first cortical potential corresponding to N20 is probably a small and inconsistent N37 recorded on the contralateral hemisphere. These assumptions need to be verified further by more extensive clinical studies applied to various neurologic disorders.

Dissociation induced by voluntary movement between two different components of the centro-parietal P40 SEP to tibial nerve stimulation

Whether the two earliest cortical somatosensory evoked potentials (SEPs) to tibial nerve stimulation (N37 and P40) are generated by the same dipolar source or, instead, originate from different neuronal populations is still a debated problem. We recorded the early scalp SEPs to tibial nerve stimulation in 10 healthy subjects at rest and during voluntary movement of the stimulated foot. We found that the P40, which reached its highest amplitude on the vertex at rest, changed its topography during movement, since its amplitude was reduced much more in the central than in the parietal traces. These findings suggest that two different components contribute to the centro-parietal positivity at rest: (1) the P37 response, which is parietally distributed and is not modified by movement, and (2) the 'real' P40 SEP, which is focused on the vertex and is reduced in amplitude during voluntary movement. Since, also, the N37 response did not vary its amplitude under interference condition, it is possible that the N37 and P37 potentials are generated by the same dipolar source. Other later components, namely P50 and N50 were significantly reduced in amplitude during foot movement. Lastly, the subcortical P30 far-field remained unchanged and this suggests that the phenomenon of amplitude reduction during movement (i.e. gating) occurs above the cervico-medullary junction.

Somatosensory evoked potentials after posterior tibial nerve stimulation--normative data in children

We report normative data of somatosensory evoked potentials to posterior tibial nerve stimulation from 47 children 4-15 years of age. We recorded near-field potentials from the peripheral nerve, the cauda equina, the lumbar spinal cord and the somatosensory cortex. Far-field potentials were recorded from the scalp electrodes with a reference at Erb's point and on the earlobe. The near-field potentials N8 (peripheral nerve) and P40 (cortex) were present in all children. N20 (near-field from the cauda equina) was recorded in 38 subjects. N22 (near-field from the lumbar spinal cord), P30 and N37 ( both far-field waveforms probably generated in the brainstem) were recorded in 46 subjects each. The latencies and the peripheral conduction time (N8-N22) increased with age, while the central conduction time (N22-P40) and the intracranial conduction time (P30-P40) both decreased with age (up to about 10 years of age). The spinal conduction time (N22-P30) was relatively independent of age. The interpeak latencies allow the assessment of specific portions of this pathway. The subcortical posterior tibial nerve-somatosensory evoked potentials are of particular interest in children when the cortical peaks are influenced by sedation and sleep, or by anaesthesia.

Abnormalities of somatosensory and motor evoked potentials in adrenomyeloneuropathy: comparison with magnetic resonance imaging and clinical findings

We studied 6 patients with adrenomyeloneuropathy (AMN) showing mild signs of central nervous system involvement. All patients underwent brain and spinal magnetic resonance imaging (MRI) and somatosensory (SEP) and motor (MEP) evoked potential study. Whereas SEPs and MEPs were abnormal in all patients, only 1 patient showed brain MRI abnormalities; spinal MRI showed hypotrophy without focal abnormalities in 4 of 6 patients. Median nerve SEPs, which were recorded with noncephalic reference montage, revealed delayed or absent scalp P14 far-field potential in all patients and abnormal spinal N13 in 2. Moreover, tibial nerve SEPs revealed abnormalities of the subcortical P30 response in all 4 patients in whom scalp-to-ear recording was employed. These findings strongly suggest that in the early stages of disease neurological dysfunction is localized in the spinal cord, where it is difficult to assess using MRI. However, SEPs and MEPs, which show a typical pattern of abnormality in these patients, could be useful in disclosing signs of long tract involvement and in monitoring treatment.

Selective gating of lower limb cortical somatosensory evoked potentials (SEPs) during passive and active foot movements

We evaluated subcortical and cortical somatosensory evoked potentials (SEPs) in response to posterior tibial nerve stimulation in 4 experimental conditions of foot movement and compared them with the baseline condition of full relaxation. The experimental conditions were: (a) active flexion-extension of the stimulated foot; (b) active flexion-extension of the non-stimulated foot; (c) passive flexion-extension of the stimulated foot in complete relaxation; (d) tonic active flexion of the stimulated foot. We analyzed latencies and amplitudes of the subcortical P30 potential, of the contralateral pre-rolandic N37 and P50 responses and of the P37, N50 and P60 potentials recorded over the vertex. Latencies did not vary in any of the paradigms. The amplitude of subcortical P30 potential did not change during any of the paradigms. Among the cortical waves, P37, N50 and P60 amplitudes were significantly attenuated in all conditions except active movement of the non-stimulated foot (b). This attenuation was less during passive (c) than during active movements of the stimulated foot (a and d). The contralateral pre-rolandic waves N37 and P50 showed no significant decrease during any of the paradigms. These results suggest that gating occurs rostrally to the cervico-medullary junction, probably at cortical level. The different behavior of N37, P50 and P37, N50 cortical responses during movement of the stimulated foot provides evidence suggestive of a highly localized gating process occurring at cortical level. These potentials could reflect activation of separate, functionally distinct generators.

Amplitude changes of tibial nerve cortical somatosensory evoked potentials when the ipsilateral or contralateral ear is used as reference

We performed topographical mapping of somatosensory evoked potentials (SEPs) to the posterior tibial nerve using earlobe references both ipsilateral and contralateral to the stimulation side. The voltage of the frontal contralateral N37 and P50 components was enhanced, while the voltage of the parietal ipsilateral P37 and N50 components was reduced when the contralateral earlobe was substituted by the ipsilateral earlobe reference. Maps of the same data documented concomitant changes in negative and positive potential fields, showing an expansion of the pre-Rolandic N37 toward the centrotemporal contralateral regions, and a tendency of the parietal ipsilateral P37, N50 components to be more focally distributed at the vertex. SEPs recorded at each earlobe (Cv6 reference) provided an explanation of these results: The contralateral earlobe detected a negative potential corresponding to the N37 potential recorded over the scalp, followed by a P50 potential that attenuated the contralateral responses and enhanced the ipsilateral ones. The ipsilateral earlobe had no significant effects on scalp SEPs, since it detected only a large N33 negativity. Current source density (CSD) maps were, of course, not influenced by the ear used as reference. Our results suggest that the ipsilateral ear reference is better than the contralateral one for recording "genuine" cortical SEPs. Therefore, it can be recommended in the clinical domain for mapping studies of lower-limb cortical SEPs.

[Somatosensory evoked potentials in rheumatoid polyarthritis with radiologic involvement of the cervical spine]

Somatosensory evoked potentials (SEP) have been recorded in 11 patients with cervical spine involvement, with or without signs of myelopathy due to rheumatoid arthritis (RA). In three patients, SEP have been recorded both before and after cervical spine surgery. In seven cases, the P14 (particularly the P9/P14 amplitude ratio) or P30 potentials were abnormal, whereas other potentials and conduction times were less often modified. Vertebral luxation sites that were predominantly observed at the upper cervical level account for these findings, thus supporting the diagnostic utility of P14 and P30 potentials which respectively take origin in the lower brain stem, close to or into the nuclei cuneatus and gracilis. Postoperative SEP were strongly correlated with the surgical outcome. SEP could be abnormal in the absence of overt clinical myelopathy or vertebral luxations, thus revealing infraclinical damage to the somatosensory pathways. This suggests that SEP recording is useful to discriminate RA patients with upper cervical cord dysfunction from those in whom vertebral lesion proves to have no direct impact on somatosensory conduction.

Neural generators of tibial nerve P30 somatosensory evoked potential studied in patients with a focal lesion of the cervicomedullary junction

The tibial nerve P30 potential was studied in 6 patients with focal lesions located in the vicinity of the cervicomedullary junction. P30 potential was unaffected while cortical P39 was abnormal in the patients with a supramedullary lesion affecting the somatosensory pathway just above its decussation. Conversely, P30 was abnormal in the presence of a lesion situated caudally to the cervicomedullary junction affecting the lower limb sensory fibers just below their decussation. Median nerve P14 behaved similarly to the P30 potential in these cases. These clinical observations suggest that P30 potential, as P14 of median nerve somatosensory evoked potentials, is generated in the lower brain stem probably before the decussation of the sensory fibers; nucleus gracilis and medial lemniscus fibers in the lower brain stem are probably the anatomical structures generating P30 potential. This suggests that P30 potential may be used to study intraspinal and intracranial conduction times separately in the afferent somatosensory pathways.

Estimating reliability of evoked potential measures from residual scores: an example using tibial SSEPs

A normative study of tibial SSEPs was performed in 74 healthy subjects, and the effects of the variables sex, age and height on SSEP parameters were assessed. In a subgroup of 20 subjects a test-retest study was also performed, which allowed us to estimate the reliability of the different parameters by means of the intraclass correlation coefficient. We demonstrated that the intraclass correlation coefficient may be biased by predictable effects of subject-related variables (such as age, height and sex), if it is computed from raw original values. This bias can be eliminated by estimating reliability indices on residual scores calculated as the differences between observed values and those predicted by subject's age, height and sex.

Topographic analyses of somatosensory evoked potentials following stimulation of tibial, sural and lateral femoral cutaneous nerves

Using topographic maps, we studied the scalp field distribution of somatosensory evoked potentials (SEPs) in response to the stimulation of the tibial (TN), sural (SN) and lateral femoral cutaneous (LFCN) nerves in 24 normal volunteers. Cortical peaks, i.e., N35, P40, N50 and P60 were generally dominant in the contralateral hemisphere for the LFCN-SEP, whereas all peaks except N35 had dominance in the ipsilateral hemisphere to TN- and SN-SEPs. The findings imply that ipsilateral or contralateral peak dominance for the lower extremity SEP is determined by where the cortical leg representation occurs. As a result, mesial hemisphere representation results in peak dominance projected to the hemisphere ipsilateral to stimulation. Representations at the superior lip of the interhemispheric fissure or lateral convexity lead to midline or contralateral peak dominance. These findings also suggest that the paradoxically lateralized P40 is not the result of a positive field dipole shadow generated by the primary negative wave in the mesial hemisphere, but is the primary positive wave, analogous to P26 of the median nerve SEP. Accordingly, contralaterally dominant N35 is likely equivalent to the first cortical potential of N20 in the median nerve SEP. The difference in vector directions of potential fields between N35 and P40 may account for the opposite hemispheric dominance for these peaks in TN- and SN-SEPs.

Subcortical P30 potential following tibial nerve stimulation: detection and normative data

Stimulation of the tibial nerve evokes a P30 far-field potential over the scalp which, like the median nerve P14, probably originates in the vicinity of the cervico-medullary junction. Unlike the P14 potential, P30 recording has not been systematically performed in clinical practice, probably because of doubts about the generator of the potential and the possibility of consistently recording it on the scalp after the unilateral stimulation of the tibial nerve. In this study, we tested the reliability of the tibial nerve scalp far-field P30 potential in 34 normal subjects using different montages, of which the Fpz-Cv6 derivation gave the highest signal to noise ratio, making it possible to obtain a P30 potential peaking at 29.2 +/- 1.6 msec in all normal subjects. This suggests that this component should to be included in the routine recording of tibial nerve SEPs in order to evaluate the spinal and intracranial conduction of the somatosensory pathway separately.