Introduction To Nerve Conduction Studies
Introduction To Nerve Conduction Studies
Introduction To Nerve Conduction Studies
Jennifer Bowers
To cite this article: Jennifer Bowers (1993) Basic Introduction to Nerve Conduction Studies:
Technical Aspects and Pitfalls, American Journal of EEG Technology, 33:1, 35-48
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INTRODUCTION
Many neurodiagnostic technologists are asked to learn laboratory tasks that
cover multiple disciplines. One of the most difficult aspects of any new procedure
is translating the new terminology into a familiar language. In this discussion of
nerve conduction studies (NCS), a correlation, where possible, between periph-
eral nervous system (PNS) terminology and central nervous system (CNS) ter-
minology will be drawn. The PNS works essentially in the same way physiolog-
ically as the CNS. The neurophysiology and overall anatomy will not be covered
here in an attempt to compress this topic to a manageable length, but excellent
resource materials are Grey's Anatomy of the Human Body, Peripheral Nerve
Injuries, and Electrodiagnosis in Diseases of the Nerve and Muscle. All these
resources are listed in the Bibliography of this paper. Good working knowledge
of the peripheral anatomy must accompany all topics in nerve conduction studies.
35
36 INTRODUCTION TO NCS
Without knowing the physiology and the anatomy, one cannot successfully test
the system.
----+
FIG. 1. The top train schedule is an example of a normal, nondelayed schedule. The
bottom schedule is an example of a delay due to blockage between Roanoke, VA and
Charlotte, NC. (Reprinted with permission from Technical Synapse, Inc.)
INTRODUCTION TO NCS 37
Train Schedule
8:00AM. 0
Washington, DC
12:00 Noon
5:00P.M.
Charlotte, NC
8:00P.M.
12:00Noon
8:00A.M.
J.-oc
8:00P.M.
11:00 P.M. 0
Atlanta, GA
38 INTRODUCTION TO NCS
I-
FILE ID: V2.1.4 13 FEB 92 11:12
A1r-----1"J. .~ ,..--,S'""T~IKJ::-::L"""Us:;:--:,sr=-=TE=--,.L:-:::;!,....'r:ru==••
=-R -r:::':"=v--.-::::=-=~~~
· · · A1: Above Elbow 7.5 8.0 11.67~9.77
A2: Below Elbow 6.0 7.9 11.~6~9.38
A2 l. · · · · ~ov
5 a\
A3: Wrist 2.9 7.512.10u8.~6
11
1
·
5
·~ Above Elbow-Below Elbow 100 1.5 67
Below Elbow-Wrist 180 3.1 58
Wrist-Axi I\ a
"5 ~ Axi 1\a-Erb's Point
FIG. 2. This is a normal ulnar nerve study with the schedule from wrist (Atlanta) to
above the elbow (Washington) intact. The velocity is normal from wrist to below elbow
and from below elbow to above elbow. (Reprinted with permission from Technical Syn-
apse, Inc.)
A2 ·A/~
0 E
'+OOV
2 •
A2: Below Elbow
A3: Wrist
7.7 7.0 6.068 120.00
3.8 7.2 7.227 18.76
A'l: Axi II a
AS: Erb's Point
35'+U
A ff
flL
Atlanta
110 3.1 35
cv
m/s
FIG. 3 . This is an abnormal ulnar nerve study revealing a delay in conduction and an
amplitude drop across the elbow segment. Note the slowing of velocity above the el-
bow, 35m/sec, and the drop in amplitude to 2 . 1 mV as compared to FIG. 2. (Reprinted
with permission from Technical Synapse, Inc.)
is innervated by a specific nerve and nerve root. By testing muscles of each nerve
root of interest, the physician may isolate the area of the spine, plexus, and/ or
distal nerve that has been damaged. EMG testing is performed by inserting a
needle electrode into the muscle and recording motor unit action potentials
during contraction and normal quiet baseline or abnormal positive sharp waves,
fibrillations, and occasionally fasciculations during rest. The EMG combined
40 INTRODUCTION TO NCS
with the nerve conduction study will give a clear picture of the amount and
location of PNS damage.
nerve injury. In traumatic cases, always test the opposite side for comparison
regardless of whether the nerve is a commonly tested one.
Entrapment Neuropathies
Entrapment neuropathy simply means that a nerve is being impinged or
smashed at a certain anatomical point along its course. Entrapment neuropathies
include carpal tunnel syndrome (CTS) involving the median nerve at the wrist;
cubital tunnel entrapment involving the ulnar nerve at the elbow; peroneal palsy
or foot drop involving the peroneal nerve, usually at the knee; Saturday night
palsy or wrist drop involving the radial nerve above the elbow; tarsal tunnel
syndrome involving the tibial nerve at the ankle; and multiple pressure point
entrapments seen in weight lifters. Entrapment neuropathies can be superim-
posed on generalized peripheral neuropathies or they may stand alone. The
crucial factor in evaluating the patient presenting with a possible entrapment
neuropathy is to test nerves that should not be involved as part of the routine
investigation. For instance, if a patient presents with complaints of index finger
and thumb numbness worse at night, relieved by shaking the hands, and is a
full time data entry operator you will expect an entrapment of the median nerve
at the wrist (carpal tunnel syndrome). If the patient is an unknown diabetic,
however, you could be dealing with a more generalized peripheral neuropathy.
If you test only the median nerve you could miss a more generalized peripheral
neuropathy, send the patient to surgery for a mild carpal tunnel syndrome, and
have the patient back in the lab four months later with the same complaints.
Peripheral Neuropathies
Nonspecific peripheral neuropathies are generalized neuropathies affecting
more than one nerve and usually associated with some chronic problem such as
diabetes mellitus, alcohol abuse, toxic substances including medications, hered-
itary diseases, infectious processes, or in some cases just plain old age. These
neuropathies can manifest themselves in myriad ways and can indeed have
entrapment neuropathies superimposed on them. For example, femoral entrap-
ment neuropathy is a frequent harbinger of a full diabetic neuropathy; a diabetic
radiculopathy can present with the same features as a herniated disc; often
alcoholics will present with a wrist drop when the entire system is involved. As
in EEG, the technologist's role is extremely helpful not only in the investigation
of the physical complaint, but in the history we are able to obtain. Patients often
reveal to us information they will not admit to the physician. If the technologist
sees a decreased amplitude, slowing of conduction velocities, or multiple en-
42 INTRODUCTION TO NCS
Infectious Neuropathies
The most prevalent infectious nervous system disorder seen recently is the
peripheral neuropathy associated with acquired immunodeficiency syndrome
(AIDS). Other common infectious neuropathies include Guillain-Barre syn-
drome (GBS), diphtheria, post-polio syndrome, and chronic inflammatory pe-
ripheral disease (CIPD). These may present in the electrodiagnostic lab with
slowed velocities and diminished amplitude just as any other peripheral neu-
ropathy but are more often seen in the acute state. The most unusual aspect of
GBS is the extremely prolonged latencies of the late responses, F-waves and
H-reflexes. See Nerve Conduction Studies and Electrodiagnosis in Diseases ofthe
Nerve and Muscle, listed in the Bibliography, for a thorough discussion ofH-re-
flexes (monosynaptic reflex arcs) and F-responses (antidromic motor neuron
discharges). These responses will be severely delayed or absent. The latency of
an F-wave in the lower extremity of a patient with GBS might be 80 msec as
opposed to 50 msec in a normal subject. The technologists must adjust the sweep
speed accordingly for a patient with sudden onset "creeping" weakness and
numbness. Often the late responses are the only abnormality on the electrical
exam. The neuropathy caused by human immunodeficiency virus (HIV) is cur-
rently classified as an infectious viral neuropathy. It does differ somewhat from
the others in its electrical presentation. In HIV-positive patients, all distal la-
tencies will be prolonged and often will have very slowed conduction velocities
with relatively normal amplitudes. Acute AIDS patients may present in the
electrophysiologicallaboratory to rule out GBS. A finding of note in these patients
is that their nerve conduction studies are normal with no prolonged late re-
sponses. In this clinical setting, with normal nerve conduction study results, the
spinal fluid has been found to be the only reactive HIV test.
Neuromuscular Junction
There are diseases which affect the chemical conversation between the ter-
minal branch of the nerve and the muscle fiber. These diseases are specific to
the neuromuscular junction. The two syndromes of neuromuscular junction
dysfunction tested with nerve conduction studies are myasthenia gravis (post-
synaptic) and myasthenic syndrome (presynaptic). These are investigated with
repetitive stimulation techniques fraught with technical difficulties and pitfalls
and should be covered as a separate topic. There are several excellent references
INTRODUCTION TO NCS 43
0 • • • •
Recording Site : fllH
.1. • • • •
AI :'0011
STIIIILUS SITE L:!1 DUR AREA
5 •\
•• '= .v••
AI: Above Elbow 7.5 8.0 11.67 ~9.77
A2: Below Elbow 6.0 7.9 11.~6 ~9.38
II' ~ ~011
A3: Wrist 2.9 7.5 12.10 ~8.~6
~: Axilla
fll .5 II\
Above Elbow-Below Elbow 100 1.5 67
Below Elbow-Wrist 180 3.1 58
Wrist-Axilla
~ .5 1111 Axilla-Erb's Point
FIG. 4. This is a normal ulnar nerve study, with distances and latencies measured
accurately. (Reprinted with permission from Technical Synapse, Inc.)
listed in the Bibliography. This subject is too complex to be covered in this brief
article, a task akin to covering epilepsy techniques with a four page article.
FIG. 5. The same normal ulnar nerve study as in FIG. 4. The study has now been
made abnormal by measurement errors. The below elbow latency has been changed by
.2 msec from 6 msec to 5 .8 msec and the below elbow to above elbow limb measure-
ment changed by 2 em from 10 em to 8 em. This results in a 20m/sec slowing across
the elbow and could result in a normal study being interpreted as abnormal. (Reprinted
with permission from Technical Synapse, Inc.)
normal nerve conduction study of the ulnar nerve with the correct measurements.
Figure 5 is the same study but the below elbow to above elbow segment distance
has been changed by 2 em and the latency measurement of the below elbow site
has been changed by .2 msec. Note the apparent chance in conduction velocity
from 67 m/sec to 47 m/sec. This results in a change from normal to severely
abnormal and could send the patient to surgery.
INTRODUCTION TO NCS 45
Neurophysiology Laboratory
FILE ID: V2.1.4 11 MAR 92 13:01
Recording Site .
.l, 392V
AI
~r STIIIILUS SITE LAT1
I
•• ':3'
IIJR AREA
•s llll•s
Rl: ULNAR ELBOW 7.~ 5.8 1~.51 ~3.23
J 109U
:1 ...
A2: MEDIAN WRIS'I 3.5
A3: MEDIAN ELBm 7.0
R'/: MEDIAN WRIS~ 3.5
5.8 9. 792 32.16
6.0 10.25 33.23
5.8 9.883 32.93
RS:
A
flll . . . . . . 160U
SEGIENT
-
DIST DIFF
•• .
.,cv
J.. . . . . . . . . :J . .
RI-A2 MEDIAN TO
A2·R VELOCITY.
3
R3-R'I MEDIAN TO
ULNAR
VOLUM:
MEDIAl
220 3.9 56
3.5
220 3.5 63
fPt·frfELOCITY
·~ 1111
FIG. 6. Volume conduction of the stimulus can result in these findings. Traces A4
and A3 are from normal, correct median nerve stimulation at the wrist and elbow. Traces
A2 and A 1 demonstrate volume conduction at the elbow site from median to ulnar
nerve. Note the change in waveform morphology and the difference in velocity. This error
was produced by moving the cathode 2 em medially. (Reprinted with permission from
Technical Synapse, Inc.)
nerves at the elbow site. Note in the upper traces that the waveform morphology
changes and the elbow waveform no longer looks like the wrist waveform.
Anatomical Variants
There are two major anatomical variants which cause difficulties in the
study of the PNS. One, called Martin Gruber anastomosis, consists of some of
the median nerve fibers crossing over to the ulnar nerve in the forearm. This
causes amplitude changes in the workup of the upper extremity; the ability to
assess this anomaly must be part of your lab criteria. There are three major
presentations of Martin Gruber which are very well described in most of the
publications listed in the Bibliography. In the lower extremity, an accessory
peroneal nerve may also be present and again will give you amplitude differences.
The accessory peroneal nerve amplitude changes are less likely to cause inter-
pretation difficulties than the Martin Gruber anastomosis.
Temperature
Limb temperature is crucial to accurate NCS. A diminished temperature
will slow velocities and latencies and increase amplitudes. If we are evaluating
the speed and amplitude of responses, obviously we should pay attention to
factors affecting these two parameters. If the patient's arms and legs are cold,
warm them up. A limb temperature of34-37° C. is optimal. Surface temperature
may affect sensory latencies up to 1 msec although 0.5 msec is more common.
This can radically affect interpretations of palmar latencies, in which some lab-
oratories consider a 0.2 msec difference between ulnar and median palmars as
abnormal.
valved. A patient presenting with thumb and index finger numbness and pain
may have a carpal tunnel syndrome and/or a CS-6 herniated disc.
SETTING UP A LABORATORY
Setting up an EMG laboratory is very similar to setting up an evoked
potential laboratory. Normal values for the instrument, patient population, and
technique must be gathered in both instances. Published data will vary widely,
just as in evoked potential testing. Different instruments, often from the same
manufacturer, will have different recording characteristics; interinstrument dif-
ferences also need to be documented. The following are general environmental
and instrument needs: an instrument on rollers; disposable items; a sink; incan-
descent lighting; a wide, wooden bed; and necessary storage. There are numerous
instruments available to perform EMG and NCS. As with any other instrument
purchase, you should choose the company and instrument based on the needs
of your laboratory. Do you expect to do single fiber, quantitative motor unit
analysis, facial nerve monitoring in the operating theater, evoked potential test-
ing, or any combination of these tests in addition to routine studies? These are
questions you need to answer and then specify to the vendor. One word of
caution: there are many instruments designed for dual purposes, i.e., evoked
potential testing and EMG testing. Be cautious in trying to equip your EMG and
EP needs with one instrument. Scheduling problems abound as the EMG must
be done when the physician is present and the EP series can take much longer
than predicted. Just the image of a neurologist waiting to perform an EMG while
you finish an EP series on a patient with multiple sclerosis should give you the
picture. Having an instrument with the ability to perform both EP and EMG is
theoretically a good idea. While it requires learning only one instrument, provides
backup for both procedures, and allows your facility to deal with only one
manufacturer, do not expect to get all your EMGs and EPs done on one unit.
Buy two unless you do only a few procedures! As with any instrument purchase,
there will be aspects you like and dislike about all of them.
Disposables in the lab consist primarily of surface electrodes (reusable),
disposable needle electrodes, measuring tapes, conductivity gel (do not use EEG
paste), and alcohol preps. Most instrument manufacturers carry disposables as
do other companies dedicated to accessories only. Instrument manufacturers
usually supply some startup disposables with the instrument, but rarely enough
to work for a week. When purchasing disposable needle electrodes for the first
time, you should make certain testing has been done by the manufacturer to
assure acquisition integrity between the older types of needles and the newer
disposables. Technologists are often asked to purchase and maintain an inventory
48 INTRODUCTION TO NCS
of needle electrodes, and since we do not use them, the manufacturer must be
our source for intemeedle integrity.
A wide wooden bed is almost a necessity in the EMG laboratory. We must
position the patient comfortably, but in a position which allows accurate mea-
surement oflong legs and arms. A stretcher is suboptimal and a recliner is out
of the question. Wood prevents many problems, e.g., interference from metal
touching electrodes, and it increases patient safety. Wood tables, however, are
difficult to find and often must be custom made. Do not use carpet in the room;
the instrument will need to be moved from head to toe along the bed during the
study.
The following items are helpful in the EMG lab and should be present prior
to your needing them. An emesis basin, washcloths, cold water, and Gatorade
all assist with those patients who get a little green around the edges during the
EMG. Vasovagal responses have occurred and you should be prepared to deal
with these problems quickly. A professional attitude and explanation ofthe test
you are about to perform will always assist both you and your patient through
this and all other diagnostic procedures.
As new avenues of professional opportunity open to the technologists of the
1990s we must continue our historical attention to good technique, professional
testing protocol, and reliable results. Nerve conduction study testing is no dif-
ferent from other modalities you face daily and are a dynamic change of pace
for the professionals performing them.
Address reprint requests to: Jennifer Bowers, R.ED T., Atlanta Neurological
Clinic PC, 105 Collier Road NW, Atlanta, GA. 30309
BIBLIOGRAPHY
Aminoff, M.J. (1986): Electrodiagnosis in Clinical Neurology. 2nd ed. Churchill-Livingstone,
New York, 755 pp.
Dawson, D.M., Hallett, M., and Millender, L. ( 1990): Entrapment Neuropathies. 2nd ed. Little,
Brown and Co, Boston-Toronto.
Delagi, E.F. and Perotto, A. ( 1980): Anatomic Guide for the Electromyographer. 2nd ed. Charles
C Thomas, Springfield, IL.
Dong, M.M. and Levison, J .A. ( 1983): Nerve Conduction Handbook. F. A. Davis, Philadelphia.
Goodgold, J. (1974): Anatomical Correlates of Clinical Electromyography. Williams and Wil-
kins, Baltimore-London.
Gross, C. (&l.Xl959): Grey's Anatomy ofthe Human Body. 27th ed. Lea and Febiger, Phila-
delphia.
Hammer, K. (1982): Nerve Conduction Studies. Charles C. Thomas, Springfield, IL.
Haymaker, W. and Woodall, B. (1953): Peripheral Nerve Injuries. 2nd ed. Saunders, Phila-
delphia.
Kimura, J. Electrodiagnosis in Diseases ofNerve and Muscle. 2nd ed. F. A. Davis, Philadelphia.
Wellborn, A. (1991): Brachial Plexus Lesions. Lecture in the AAET Symposium, Vancouver,
BC.