Somatosensory Evoked Potential

Presenter: Laxmi Bhattarai

MPT II
Neurological sciences
 CONTENT

• Introduction • Median Nerve SSEPs

• Somatosensory pathways • Tibial Nerve SSEPs
• Spinothalamic tract • Interpretation of abnormalities
• Dorsal column spinal pathways • Clinical implications
• Methods • Clinical application in pathologies
 OBJECTIVE

• What are somatosensory evoked potentials?

• What are its indications and contraindications?
• What are the steps or methods to perform the SSEPs?
• How is the analysis of SSEPs done, according to various waveforms?
• What is the limitation of SSEPs?
 INTRODUCTION

Evoked potentials are the electrical signals generated by the nervous system
in response to sensory stimuli. Auditory, visual, and somatosensory stimuli
are commonly used for clinical evoked potential studies.
These three stimuli give rise to visual evoked potentials (VEPs), brain stem
auditory evoked potentials (BAEPs), and somatosensory evoked potentials
(SEPs), which evaluate functions of their respective sensory systems.
Somatosensory evoked potentials (SEPs) are electric signals generated by
the nervous system following a somatosensory stimulus. SEPs can be
recorded at different levels of the somatosensory pathway and elicited by
almost any somatosensory stimulus.
In clinical practice, SEPs are mostly generated by transcutaneous electrical
nerve stimuli of 0.2–2-ms duration and are applied at the median and
posterior tibial nerves.
The elicited potentials are recorded at the scalp and the cervical spine. The
latency and amplitude of these potentials are analyzed, allowing the
identification and monitoring of impairments of the somatosensory pathway.
 Somatosensory pathways

• Sensory pathways consist of the chain of neurons, from the receptor organ to
the cerebral cortex, responsible for perceiving sensations.
• Somatosensory stimuli activate a chain of neurons starting with the peripheral
first-order (1°) afferent and ending in the cerebral cortex
The 1° afferent is a pseudo-unipolar neuron whose cell body is located in a peripheral (spinal or
cranial) ganglion. It has a peripheral axon that forms or innervates somatosensory receptors and
a central process synapses with 2° afferent neuron(s) in a spinal cord or brain stem nucleus.

The 2° afferent may synapse with 3° afferent neurons in the spinal cord or ascend the neuraxis
to synapse with 3° afferent neurons in the thalamus.

There is a decussation (i.e., axons crossing the midline to the opposite side of the spinal cord or
brain stem) in each somatosensory pathway below the level of the thalamus.
• All somatosensory pathways include a thalamic nucleus. The thalamic
neurons send their axons in the posterior limb of the internal capsule to end in
the cerebral cortex.

• Most somatosensory pathways terminate in the parietal lobe of the cerebral

cortex.
 Spinothalamic Tract

• Is formed by the fibres of second-order neurons of the pathway for crude

touch
• Receptors: Free nerve ending
• Situation: situated in anterior white column
• Origin: The fibres arise from neurons of the chief sensory nucleus of the
posterior gray horn
• Course: These fibres cross obliquely in the anterior white commissure and
enter the anterior white column of the opposite side. The fibres ascend
through other segments of the spinal cord and brainstem.
• Termination: terminate in the ventral posterolateral nucleus of the thalamus
from here , 3rd order neuron fibres relay to the sensory cortex
• Functions: carries the sensory impulses of crude touch
• Effect of lesion:
• B/L - loss of crude touch, itching, tickling on both sides.
• U/L- loss of crude touch sensation in the opposite side below the level of the
lesion
Spinothalamic tracts and pathways for crude touch, pain
and temperature sensations. Anterior spinothalamic tract
(red) carries crude touch sensation. Lateral spinothalamic
tract (blue) carries pain and temperature sensations.
The Dorsal Column-Medial Lemniscal Pathway
• Also know as posterior column-medial lemniscal pathway.
• Divided into 2 tracts: Fasciculus gracilis
• : Fasciculus cuneatus
• This tract are formed by the fibres from the posterior root ganglia and are
constituted by the fibres of the first-order neurons of the sensory pathway.
• Receptors: Meissner corpuscle, Pacinian corpuscle, muscle spindle, tendon
organ.
• Situation: posterior white column of spinal cord .In cervical & upper thoracic
segments of spinal cord, the posterior white column is divided by posterior
intermediated septum into medial fasciculus gracilis & lateral fasciculus
cuneatus.
• Origin: The first-order neuron arises from
the respective receptor and enters the
spinal cord through the posterior root, and
its cell body resides in the dorsal root
ganglia.
• Course: They ascend on the same side of
the spinal cord to relay in nucleus gracilis
and cuneatus present in the medulla.
The fasciculus gracilis contains fibers from
the lower parts of the body whereas
fasciculus cuneatus contains fibers from
upper part of the body.
• Termination: These two tracts terminate in
medulla oblongata. The fibers of fasciculus
gracilis terminate in the nucleus gracilis &
the fibers of fasciculus cuneatus terminate
in the nucleus cuneatus
• The cells of these medullary nuclei form the second-order neurons.
• The axons of second-order neurons form internal arcuate fibers. These fibers
cross the midline from both sides, forming sensory decussation and ascending
through the pons and midbrain as medial lemniscus.
• The medial lemniscus fibres terminate in the thalamus's ventral posterolateral
nucleus, and from here, the third-order neuron relay to the cerebral cortex.
Function: Fine tactile sensation Effect of lesion
1. Loss of fine tactile sensation
Tactile localisation
2. Loss of tactile localisation
Tactile discrimination
3. Loss of two point
Sensation of vibration discrimination
Stereognosis
 METHODS

• Stimulation
• Recording
• Wave labelling, generators
 Stimulation

• To elicit SSEPs, a brief electrical pulse is administered to the distal portion of

a peripheral nerve. In nerves with both motor and sensory components, the
stimulus intensity is raised to just above motor threshold, until slight muscle
twitching is reliably observed.
• For pure sensory nerves, the stimulus intensity is set to 2.5 to 3 times the
sensory threshold. Pulses are given at a rate of 4 to 7 per second. This allows
enough time to prevent distortion of waveforms from cancellation or synergy
of potentials elicited from sequential stimulations. A stimulus duration of 100
to 300 µs is typically used.
 Recording

• Standard surface recording electrodes are placed at key points along each
sensory pathway. Reasonable settings include a wide bandpass with a low-
frequency filter set at 5 to 30 Hz and high-frequency filter set at 2500 to 4000
Hz.
• Evoked potential waveforms are named for the characteristic polarity of their
voltage peak and the characteristic time to maximal amplitude, as measured
in milliseconds after stimulation.
 Wave labelling

• In the nomenclature of SEP waveforms, N or P followed by an integer are

respectively ,used to indicate the polarity and the nominal post-stimulus
latency or typical peak latency (ms) of the recorded wave in the healthy
population (e.g. N20)
• For example, N20 is a negativity that typically peaks at 20ms after the
stimulus.
• The potentials can be recognised by their typical distribution, reflecting the
activation of their generators and can be measured in terms of latency (ms),
amplitude and intervals between peaks.
 Median Nerve SSEPs

• SSEP recording from the median nerve is the most common evoked potential
test to assess the integrity of somatosensory pathways involving the upper
limbs.
• To elicit median nerve SSEPs, stimulation is given 2 cm proximal to the wrist
crease over the median nerve.
• Recording sites for median nerve SSEPs are at Erb’s point, over the cervical
spine, and the scalp.
• Erb’s point is above the clavicle, just lateral to the edge of the
sternocleidomastoid muscle. Proper placement can be assured if stimulation
at Erb’s point induces abduction of a flexed arm.
• A second electrode is placed over the C2 or C5 spinous process. This site is
identified in relation to the prominent spinous process of the C7 vertebra.
• Scalp electrodes are placed 2 cm posterior to the C3 and C4 electrode
placements, as defined by the International 10-20 system. This region overlies
the primary somatosensory cortices. Reference (Ref) electrodes are often
placed at the contralateral Erb’s point (EPc) or at Fz, per the 10–20 system,
although other sites, such as the elbow or distal arm may be used.
• The recording sites are labelled as EPi, Erb’s point (ipsilateral); C2s, C2
spinous process; C5s, C5 spinous process; CPc, centroparietal cortex
(contralateral); CPi, centroparietal cortex (ipsilateral); and Ref (EPc, Fz).
• A standard sequence or pathways used to view median nerve SSEPs involves
channel 1: CPc–CPi, detects near-field cortical potentials; channel 2: CPi–Ref
(Fz), detects subcortical far-field potentials; channel 3: C5s–Ref (Fz), records
cervical cord activation; and channel 4: EPi–Ref (EPc), records activity of
afferents under Erb’s point.
• This sequence allows for the comparison of evoked potentials to a common
reference and emphasizes the comparison of evoked responses between the
ipsilateral and contralateral sensory cortex.
• The relevant median nerve SSEP waveforms typically occur within 4 to 40 ms
after stimulation.
• These include the N9 (displayed best by channel 4), the P13/14 (displayed best in
channel 2), and the N20 from scalp channels (observed best in channels 1 and 2).
Figure 1 shows an example of a normal median nerve SSEP recording.
• Depending on montage and electrode placement, waves generated by
different CNS structures can have the same polarity and latency.
• The areas of the nervous system responsible for generating SSEP waveforms
are mentioned in the table below .
 Interpretation of abnormalities

• Delayed N9 with normal N9-P14 –N20 intervals : Lesion in the

somatosensory nerves at or distal to the brachial plexus.
• Increased N9-P14 interval with normal P14-N20 interval: Lesion between
Erbs point and the lower medulla .
• Increased P14-N20 with normal N9-P14 interval : Lesion between the lower
medulla and the cerebral cortex.
 Posterior Tibial SSEPs
• Posterior tibial nerve SSEPs are elicited by stimulating in between the
Achilles tendon and medial malleolus, using a stimulus intensity just strong
enough to cause plantar flexion of the toes.
• Most of the relevant waveforms appear within 60 ms of stimulation.
• Recording electrodes are placed as CPi, placed at ipsilateral cortex between
C3 and P3 or C4 and P4,SSEP recording, except ipsilateral; CPz, midline,
between Cz and Pz; C5s, same location as for median nerve SSEP recording;
T12s over the T12 spinous process; and Ref, common sites include the iliac
crest, elbow, or Fpz. (frontopolar midline, per 10–20 system).
• A common sequence for posterior tibial nerve SSEPs using these electrodes
is channel 1: Cpi–Ref (Fpz), detects near-field potentials over cortex; channel
2: CPz–Ref (Fpz), detects near-field potentials over cortex; channel 3: Fpz–
Ref (C5s), detects subcortical far-field potentials; and channel 4: T12–Ref
(iliac crest), detects near-field potentials from lumbar cord.
 Interpretation of abnormalities

• Interpretation of tibial SEPs parallels interpretation of median SEPs.

• Prolonged LP with normal LP-P37 interval: Peripheral or distal lesion, peripheral neuropathy
is most likely, but the slowing could be in the cauda equina.
• Normal LP with prolonged LP-P37 interval: Abnormal conduction between the cauda equina
and brain. Median SEP is required to localise the abnormality to the spinal cord. Normal
median SEP indicates a lesion below the mid-cervical cord. Prolonged median SEP indicates
a lesion above the mid-cervical. A second lesion below the cervical cord cannot be ruled out,
however, since the P37 latency is already prolonged by a higher lesion.
• Prolonged LP and prolonged Lp-P37 interval suggest two lesions affecting the peripheral
nerves and central conduction. A single lesion of cauda equina is possible.
 Clinical uses of SEPs

• Evaluation of the peripheral nervous system and the large fiber sensory tracs
in the CNs
• Localization of the anatomic site of somatosensory pathway lesions.
• Identification of impaired conduction caused by axonal loss or demyelination.
• Confirmation of a nonorganic cause of sensory loss.
• To confirm the presence of normal conduction pathways in patients with
conversion disorder , malingering , or other psychological disturbances.
Fustes OJ, Kay CS, Lorenzoni PJ, Ducci RD, Werneck LC, Scola RH. Somatosensory evoked potentials in
clinical practice: a review. Arquivos de neuro-psiquiatria. 2021 Oct 18;79:824-31.
 APPLICATIONS: CORRELATION WITH
VARIOUS PATHOLOGIES

• Numerous pathological mechanisms may impact somatosensory conduction, and these may
all evoke abnormalities in SSEP testing. These include but are not limited to, ischemia,
tumour, spinal cord compression, and demyelination. Individuals with vitamin B12
deficiency, vitamin E deficiency, HIV, amyotrophic lateral sclerosis, myotonic dystrophy,
diabetes, and some hereditary neurodegenerative disorders often exhibit abnormal SSEP
results.
 APPLICATIONS: INTRAOPERATIVE
MONITORING
• Intraoperative monitoring has emerged as one of the major uses for SSEPs, providing a real-
time measure of central nervous system integrity. Many surgeons use SSEP monitoring
routinely for certain spine procedures, such as scoliosis corrections and spinal fusions. Loss
of scalp responses to stimulation alerts the surgeon to potential CNS injury and allows for
adjustment in the operative approach.
• SSEPs can also help to define essential neuroanatomic structures that may not be easily
distinguishable with visual inspection. For instance, SSEPs have been used to define the
primary somatosensory cortex and central sulcus in patients undergoing epilepsy surgery in
the frontoparietal region
 References
• https://www.neurophys.org/wiki/Somatosensory_Evoked_Potentials_(SSEP)
• Passmore SR, Murphy B, Lee TD. The origin, and application of somatosensory evoked
potentials as a neurophysiological technique to investigate neuroplasticity. The Journal of the
Canadian Chiropractic Association. 2014 Jun;58(2):170.
• Fustes OJ, Kay CS, Lorenzoni PJ, Ducci RD, Werneck LC, Scola RH. Somatosensory
evoked potentials in clinical practice: a review. Arquivos de neuro-psiquiatria. 2021 Oct
18;79:824-31.
• Klingner CM, Kattlun F, Krolopp L, Jochmann E, Volk GF, Brodoehl S, Guntinas-Lichius O,
Witte OW, Dobel C. Shaping the sensory–motor network by short-term unresolvable
sensory–motor mismatch. Frontiers in Neurology. 2022 Jan 12;12:793662.
• Klingner CM, Kattlun F, Krolopp L, Jochmann E, Volk GF, Brodoehl S, Guntinas-Lichius O,
Witte OW, Dobel C. Shaping the sensory–motor network by short-term unresolvable
sensory–motor mismatch. Frontiers in Neurology. 2022 Jan 12;12:793662.

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