SSEP IN PAEDIATRICS

INTRODUCTION
Somatosensory evoked potential (SEP) in pediatric practice is important because
clinical sensory testing in infants and children is often unreliable.

The maturational changes and growth of spinal cord result in dynamic changes in
SEP latency and waveform, especially in neonates and infants.

For proper interpretation of SEP normal values at different age groups are an
essential prerequisite.

The important methodological, interpretive, and application issues of SEP in

pediatric practice are discussed in the following section.
METHODOLOGICAL CONSIDERATIONS
SEP testing is generally well tolerated by infants and children.

Since children are more relaxed during testing, muscle artifacts are less prominent
which results in better waveform delineation compared to adults.

In every child, median, peroneal, and posterior tibial SEP can be recorded.

The stimulation and recording methods are similar to adult SEP

In newborns,

the Erb's potential is best recorded 1 cm above the clavicle and

cervical potential at C, spinous process.

In very young children,

the anode of the stimulator can be placed at the palm and cathode at the wrist.

The stimulation electrodes can also be placed keeping the cathode ventral and anode on the dorsal aspect of wrist .

The lower rate of stimulation (1 Hz) produces higher amplitude of SEP.

In children above 4 months,

the band pass is kept between 30 and 3000 Hz and sweep time 50 ms.

For infants below 4 months,

the pass may be reduced to 5-1500 Hz and sweep time up to 200 ms.

Averaging 50-60 epochs may be adequate .

In prema- ture infants,

bilateral nerve stimulation is required for reproducible SEP recording.

In uncooperative children, sedation (chloral hydrate 50 mg/kg) may be necessary;
however, it may prolong the latency and reduce the amplitude of cortical poten-
tials.

Normal sleep can also alter the latency of SEP in children below 4 months of age.

Comparison of SEP in rapid eye movement (REM) sleep, slow wave sleep and
wake state revealed increased latency in slow wave sleep, but there was no
difference between wake and REM sleep.
MATURATIONAL CHANGES
The maturation in waveform and latency of SEP is an interplay of a number of
factors, which include synaptic expansion, myelination and increased length of
central and peripheral nervous system corresponding to the growth of the child.

Peripheral components of SEP mature faster than the central components

PERIPHERAL COMPONENTS
The Erb's potential latency remains stable in new borns and older children.

Peroneal conduction velocity at birth is half that of the adult value and reaches the
adult value by 3-4 years of age .

The latency of cervical potential on median nerve stimulation remains relatively

constant till 2-3 years of age and then increases to adult value by 14-18 years
CENTRAL COMPONENTS
The central sensory conduction on median stimulation matures by 6-8 years of
age.
The cortical latency of median SEP reduces from 18 ms at 4-8 months of age to
15 ms at 2-3 years of age.
Cortical potential on tibial nerve stimulation is more variable in children compared
to adults.
The cortical sensory conduction time is the highest in infants and young children,
which decreases with age and reaches the adult value by 13-19 years of age.
At 25-28 weeks of gestation, median stimulation results in a long duration negative
peak at or above 200 ms, which matures to newborn response at 37-38 weeks of
gestation .
The absolute latency and interpeak latencies are prolonged in premature
compared to full-term neonates.

But there is no difference in SEP of term infants and premature infants when
evaluated at term
WAVEFORM MORPHOLOGY
Cortical potentials on median and tibial stimulation are broader in children
compared to adults and the duration of waveform decreases with increasing age.

Spinal and cortical potentials are usually of higher amplitude with complex
morphology in early childhood.

Generally, waveform morphology in children becomes adult-like by 5-8 years of

age.
 Some components of SEP may not be consistently recordable during infancy due
to ongoing complex maturation of brainstem and cerebral cortex.
On tibial stimulation, cortical potentials are not recordable below.
Cortical potentials on median SEP are recordable in 66-85% full-term neonates .
Median SEP can be consistently recorded by 6-8 weeks postterm
The principles of measurement and wave identification are same as in adult SEP
It is important to compare the findings with corresponding age-matched normal
values.
For defining abnormality, 2.5 or 3 SD cutoff limit may be used.
CLINICAL APPLICATION
PERINATAL ASPHYXIA

SEP has been used to monitor and predict the prog- nosis of asphyxiated infants.

Delay or absence of cortical potentials on median nerve stimulation at 20 months

is associated with neurologic sequelae .

Serial median SEP study in asphyxiated neonates revealed that SEP at 1 week
has the highest predictive value .

Clinical neurologic deficits and outcome of asphyxiated infants correlated better

with SEP compared to CT scan. No child with bilateral
SEP abnormalities was clinically normal. Six infants with normal CT scan had
abnormal development and four had SIP abnormality .

Corti- cal potential of median SEP below 50 ms was associated with normal motor
development and prolonged latency till day 3 of birth was associated with lower
childhood
HYPOXIA or FOCAL BRAIN DAMAGE
Absence of cortical potentials bilaterally is regarded as a reliable marker of poor
prognosis of brain damage.

This reliability increases in serial recordings.

Circumscribed lesions may transiently result in unrecordable SEP but patient may
ultimately have good outcome and SEP may also become recordable.

In contrast to this, in hypoxic coma with bilaterally unrecordable SEP seems to

predict poor prognosis reflecting a different pathogenesis with diffuse destruction
of cortex and thalamocortical pathways
COMA
SEP studies have been used to predict the prognosis of coma.

Bilateral absence of N-P' responses of median SEP is associated with high

mortality and severe neurologic deficits in the surviving comatose children
irrespec- tive of underlying etiology.

Normal or mildly prolonged cortical potentials were associated with good outcome.
DEMYELINATED DISEASES
Multiple sclerosis is rare but acute disseminated of encephalomyelitis is common
in children.

SEP studies in demyelinating diseases reveal prolongation of central ir sensory

conduction time or in severe cases SEP may be unrecordable
NEURODEGENERATIVE DISEASE
SEP is abnormal in leukodystrophies and the abnormalities are usually in central
components; however in metachromatic leukodystrophy, both central and
peripheral components are affected.

The cortical potentials may d be unrecordable or the central sensory conduction

time prolonged.

These abnormalities are found in all types of leukodystrophies including

metachromatic leukodystrophy,
SPINAL CORD MALFORMATION
There is a good correlation between sensory functions and SEP in patients with
myelodysplasia.
The lumbar potential is recorded lower or it may be absent and SEP may improve
after surgery.
Patients with myelome ningocele have associated brainstem and cervical cord
abnormalities, which may result in abnormal sensory conduction time.
A normal median SEP is reassuring in a patient with Arnold Chiari malformation.
Neonatal spinal cord injury may also result in paraparesis and unrecordable tibial
SEP
LEARNING OUTCOME
1. For median SEP recording in infants above 4 months of age, the band pass is kept at 30-3000
Hz, stimulus rate 1 Hz and sweep time 50 ms, whereas in infants below 4 months band pass is
kept at 5-1500 Hz and sweep time 200 ms. Averaging 50-60 epochs may be adequate.
2. Bilateral nerve stimulation may be required for SEP recording in premature infants.
3. SEP matures by 14-18 years of age; therefore, normative value at different age groups should
be considered during interpretation.
4. In demyelinating or dysmyelinating diseases, central sensory conduction time is prolonged. 5.
Bilateral unrecordable SEP in a comatose child suggest poor prognosis.
6. Hypoxic neonates having median cortical latency of more than 50 ms are likely to have motor
and cognitive deficit at 9-10 years of age.