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connections manifests itself by a delay in its appearance and an absence or reduction in amplitude of subsequent waves These effects are more pronounced on the side of the stimulated ear than contralaterally This is dif cult to understand, since a majority of the cochlear-superior olivary-lateral lemniscal-medial geniculate bers cross to the opposite side It is also surprising that a severe lesion of one relay station would allow impulses, even though delayed, to continue their ascent and be recordable in the cerebral cortex As indicated above, BAEPs are a particularly sensitive means of detecting lesions of the eighth cranial nerve (acoustic neuroma and other tumors of the cerebellopontine angle) and of the auditory pathways of the brainstem Almost one-half of patients with de nite multiple sclerosis and a lesser number with a possible or probable diagnosis of this disease will show abnormalities of the BAEPs (usually a prolongation of interwave latencies I to III or III to V), even in the absence of clinical symptoms and signs of brainstem disease The BAEPs are also useful in assessing hearing in infants who have been exposed to ototoxic drugs, in young children who cannot cooperate with audiometry, and in hysterical patients who feign deafness Somatosensory Evoked Potentials Somatosensory evoked potentials (SEPs) are used in most clinical neurophysiology laboratories to con rm lesions in the somatic sensory systems The technique consists of applying 5-per-second painless transcutaneous electrical stimuli to the median, peroneal, and tibial nerves and recording the evoked potentials (for the upper limb) as they pass the brachial plexus over Erb s point above the clavicle, over the C2 vertebra and over the opposite parietal cortex, and (for the lower limb) sequentially over the lumbar roots of the cauda equina, the nuclei over the cervical spine, and the opposite parietal cortex The impulses generated in large touch bers by 500 or more stimuli and averaged by computer can be traced through the peripheral nerves, spinal roots, and posterior columns to the nuclei of Burdach and Goll in the lower medulla, through the medial lemniscus to the contralateral thalamus, and thence to the sensory cortex of the parietal lobe Delay between the stimulus site and Erb s point or lumbar spine indicates peripheral nerve disease; delay from Erb s point (or lumbar spine) to C2 implies an abnormality in the appropriate nerve roots or more frequently in the posterior columns; the presence of lesions in the medial lemniscus and thalamoparietal pathway can be inferred from delays of subsequent waves recorded from the parietal cortex (Fig 2-6) The normal waveforms are designated by the symbols P (positive) and N (negative), with a number indicating the interval of time in milliseconds from stimulus to recording (eg, N 11, N 13, P 13, P 22, etc) As shorthand for the polarity and approximate latency, the summated wave that is recorded at the cervicomedullary junction is termed N/P 13, and the cortical potential from median nerve stimulation is seen in two contiguous waves of opposite polarity is called N 19 P 22 The corresponding cortical wave after tibial or peroneal nerve stimulation is called N/P 37 For purposes of clinical interpretation, the SEPs are assumed to be linked in series, so that interwave abnormalities in latency indicate a conduction defect between the generators of the two peaks involved (Chiappa and Ropper) Normal values are shown in Table 2-4 Recordings with pathologically veri ed lesions at these levels are to be found in the monograph by Chiappa This test has been most helpful in establishing the existence of lesions in spinal roots, posterior columns, and brainstem in disorders such.

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as the Guillain-Barre syndrome, ruptured lumbar and cervical discs, multiple sclerosis, and lumbar and cervical spondylosis when the clinical data are uncertain The central counterpart also pertains namely, that obliteration of the cortical waves (assuming that all preceding waves are unaltered) re ects profound damage to the somatosensory pathways in the hemisphere or to the cortex itself As corollaries, the bilateral absence of cortical somatosensory waves after cardiac arrest is a powerful predictor of a poor clinical outcome; the persistent absence of a cortical potential after stroke usually indicates such profound damage that only a limited clinical recovery is to be expected Evoked potential techniques have also been used in the experimental study of olfactory sensation (see Chap 12)