NERVE CONDUCTION STUDIES

Basic Principles
BasharKatirji,M.D.
Professor and Director,
Neuromuscular Center
and EMG Laboratory

Advancing the Vision of the Neurological Institute

May 2013

Spectrumof
Electrodiagnosticstudies
Nerveconduction
studies
Sensory,motor,mixed

NeedleEMG
Concentric
Monopolar

Lateresponses
Fwaves
Hreflexes
Blinkreflexes

Repetitivestimulation
Slow
Rapid
Postexercise

SinglefiberEMG
Quantitativestudies

MUPanalysis
Turnsandamplitudes
MacroEMG
Motorunitnumber
estimate(MUNE)

Advancing the Vision of the Neurological Institute

May 2013

Motorconductionstudies
Bellytendonrecording
Anactivelead(G1)
placedonthebellyof
themuscle
Anindifferentlead(G2)
onthetendon

Musclerecordinghasa
magnifyingeffect.
Eachmotoraxon
innervatesuptoseveral
hundredsmusclefibers
CMAPislarge(inmV)
Adopted from Neal & Katirji, NCS, 2011
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Motorconductionstudies

Adopted from Katirji, in Daroff et al 2012

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Sensoryconductionstudies

Antidromic studiesare
performedbyrecording
potentialsdirectedtoward
thesensoryreceptors
Orthodromic studiesare
obtainedbyrecording
potentialsdirectedaway
fromthesereceptors.
Sensorylatenciesand
conductionvelocitiesare
identicalwitheither
method,butamplitudesare
higherinantidromic
studies.
Adopted from Neal & Katirji, NCS, 207
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Sensoryconductionstudies

Orthodromic median (s)

Onsetlatency isoften
difficulttodetermineand
subjecttodebate.
Peaklatency isvery
accurateandhasreplaced
onsetlatencyinmost
laboratories
Tomeasureconduction
velocity,onsetlatencyis
requiredtoreflectthe
largestconductingfibers
Antidromic median (s)

Adopted from Katirji, in Daroff et al 2012

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Sensorynerveaction
potential(SNAP)

Adopted from Neal & Katirji, NCS, 2011

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SNAPdistinguishesbetweenlesions
proximalvs.distaltoDorsalRoot
Ganglion(DRG)
SNAPisreducedorabsent:
Plexopathies
Mixedmononeuropathies
Ganglionopathies

SNAPisnormal:
Radiculopathies
Caudaequina
Rootavulsions

Spinalcorddisorders
Conusmedullaris
Syringomyelia
Myelitis
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SegmentalrepresentationofSNAPs
Root

SNAP

Root

SNAP

C6

Lateral antebrachial
& Median/ thumb

S1

Sural

L5

Superficial
peroneal

L4

Saphenous

C7

Median/index
& Middle finger

C8

Ulnar/little finger

T1

Medial antebrachial

NoSNAPrepresentationforC5orabove
andL3orabove
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Pathophysiologicalchangesin
focalneuropathies
Demyelination
Focalslowing
Conductionblock

Axonloss
Mixed

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Focaldemyelinativeslowingof
myelinatedaxon

Conductionslowingduetoslowingofnerve
depolarizationacrossthesegment
Itisbestexplainedbywideningofoneormore
nodesofRanvier(Paranodaldemyelination)

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Focal(synchronized)slowing

Mostcommonlyseenwithchronic
entrapments
Carpaltunnelsyndrome
Ulnarneuropathyatelbow
Isduetoparanodaldemyelination
(wideningofthenodesofRanvier)
thataffectallthelargemyelinated
fibersequally
Doesnotcausesymptomsunless
associatedwithotherpathologies

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Internalcomparisontests
inCTS

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FocalslowinginCTS
(Internalcomparisonstudies)

Median

Ulnar

Median/ulnar comparison recording 2nd lumbrical/Interosseous

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DemyelinativeConductionblock
ofamyelinatedaxon

Normal Myelin

Normal Myelin

Demyelinated Segment

Conductionblockoccurswhenactionpotentials
cannotcrossademyelinatednervesegment
Itisbestexplainedbyinternodaldemyelination
(demyelinationofoneormoresegments)andlackof
sufficientNachannelsinthedemyelinatedsegment
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Temporaldispersion
CMAPandSNAP
Thesensorynerveactionpotential(SNAP)andthe
compoundmuscleactionpotential(CMAP)arethe
summatedresponseduetodepolarizationofthousands
ofaxons

Large myelinated
fibers

Small myelinated
fibers
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Temporaldispersion&phase
cancellation CMAP
Short distance

Long distance

Withshortdistance,actionpotentialssummatewellwithlittle
ortemporaldispersionandphasecancellation
Withlongdistance,thereissignificanttemporaldispersion
andphasecancellation

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Temporaldispersion&phase
cancellation SNAP
Short Distance

Long Distance

Temporaldispersion&phasecancellationismoreprominentwith
SNAPthanCMAPfor2reasons:
TheCMAPdurationismuchlongerthantheSNAP
Therangeoffiberconductionvelocityislessspreadinmotorthan
sensoryfibers(12m/secvs.25m/sec).

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May 2013

Areadropisimportantin
assessingconductionblock
Areadropgreater
than50%between
stimulationsites,
regardlessoflength
ofdistance
Overshorter
distances(e.g.10
cm)20%is
acceptable
Rhee RK, England JD, Sumner AJ. Ann Neurol 1990;28:146-159.

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May 2013

Conductionblock
DEFINITE
>50%dropinCMAP
amplitudewith<15%
prolongationofCMAP
duration,or
>50%dropinCMAP
amplitudeandarea,or
>20%dropinCMAP
amplitudeandarea
overashortnerve
segment(10cm)

PROBABLE
2050%dropinCMAP
amplitudewith<15%
prolongationofCMAP
duration,or
2050%dropinCMAP
amplitudeandarea

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Advancing the Vision of the Neurological Institute

May 2013

Conductionblock
Mostcommonwithacute
nervelesions
Peronealatfibularneck
Radialatspiralgroove
Ulnaratelbow

Isduetosegmental
internodaldemyelination
Istheelectrophysiological
correlateofneurapraxia
(firstdegreenerveinjury)
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Radialnerveconductionblockatthe
spiralgroove(Saturdaynightpalsy)

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Ulnar&medianconductionblocksinthe
forearminmultifocalmotorneuropathy

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Identification of conduction block

>50% loss of distal amplitude

Abnormal amplitude reduction

>15% of distal duration

CMAP duration increased

No

Yes

Yes

Area loss >50%

Area loss <50%

Area loss >50%

Pure conduction block (CB)

Temporal dispersion (TD)

CB/TD

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Conductionblockvs.
temporaldispersion

Ulnar neuropathies at the elbow

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Differentialslowing
notconductionblock

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Differential(desynchronized)slowing

Isduetoconduction
slowingalongavariable
numberofthemedium
orsmallnervefibers
(averageorslower
conductingaxons)
Oftenitisassociatedwith
focalslowing

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Axonloss
Themostcommon
mononeuropathiesseen
inclinicalpractice
ResultsinlowCMAP
fromallstimulationsites
Maymanifestwith
conductionblockearly
(beforeWallerian
degeneration)

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DistalSNAPandCMAPamplitudes
duringWalleriandegeneration

CMAP amplitude
SNAP amplitude

100

3 weeks

80
% Amplitude

60
40

2 weeks

20
0

10 11 12

Days from acute axonal injury

Fibrillations
with proximal
/distal gradient

Adopted from Katirji, EMG in clinical practice , 2007

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Earlystudyinaxonlossmononeuropathyisveryusefulin
localization,whileasecondstudyisnecessarytodetermine
pathophysiology

Ulnar nerve lesion in distal arm

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Advancing the Vision of the Neurological Institute

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Considertheraredistaldemyelinatingconduction
blockwhichmaymimicaxonalloss
e.g.acutemedianneuropathyatthewrist

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Electrophysiologicalfindingsin
focalneuropathies
Demyelination
Focalslowing
Conductionblock

Axonloss
Conductionblock
Early(beforeWalleriandegeneration)
Conductionfailure(loworabsentCMAPs)
Late(afterWalleriandegeneration)

Mixed
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CMAPamplitudeandareaarethebest
indicatorofextentofmotoraxonloss
Left

Right

65yearoldwithright
femoralneuropathy
followinganabdominal
hysterectomy
FemoralCMAPs
recordingrectus
femorisisconsistent
withapartialaxonloss
lesion(50%ofaxons
arelost)

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Axonlossandconductionslowing

Normal Nerve

Axon Loss
Largest fibers

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Multiplepathologies
Below elbow

Above elbow

A 45 year man with progressive

ulnar neuropathy
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Anomalies.
MartinGruberanastomosis

Occursinapproximately1520%ofpopulation
Fiberscrossfromthemediantotheulnarnerveinthe
forearm.
Thecommunicatingbranch(es)usuallyconsistsofmotoraxons
thatsupplytheulnarinnervatedintrinsichandmuscles,
thefirstdorsalinterosseousmuscle
thehypothenarmuscles
theulnarthenarmuscles
Acombinationofthesemuscles
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MartinGruberanastomosis
toADMandFDI(UlnarNCS)
Wrist
Bel elbow
Ab elbow
Medwrist
Med elbow
Recording ADM

From Katirji, EMG in clinical practice , 2007

Recording FDI
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Advancing the Vision of the Neurological Institute

May 2013

MartinGruberanastomosis
toulnarthenarwithCTS
(medianNCS)

Adopted from Katirji, EMG in clinical practice , 2007

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May 2013

EDXmeansoflocalizationin
peripheralnervelesions
Nerveconductionstudies
Sensoryconductionstudies
Motorconductionstudies
Lateresponses(Hreflex,Fwaveandblinkreflex)

NeedleEMG
Fibrillationpotentials
Motorunitactionpotentials
Recruitment
Morphology

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Advancing the Vision of the Neurological Institute

May 2013

Fwaves.Values

Testtheintegrityofthemost
proximalmotoraxons
(includingroots)thatarenot
accessiblewithroutineNCS.
IsperformedduringNCS.

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Advancing the Vision of the Neurological Institute

May 2013

Fwaves.Limitations
OnlyminimalFwavelatenciesarereproducible.
Partialaxonallosslesionsareoftenassociatedwith
normallatenciesduetonormalconductioninintact
axons.
Slowingattherootlevelcanbeobscured(diluted)
bythenormalconductionalongthelongaxon.
Sincemostmusclesareinnervatedbytwoormore
roots,normalconductionthroughintactroot(s)in
patientswithsingleradiculopathiesresultsin
normalminimalFwavelatencies.

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Advancing the Vision of the Neurological Institute

May 2013

Hreflex.Values

Theonlytestthatevaluatethe
preganglionicsensoryfibers
TibialHreflexmaybethesole
manifestationofmildS1radiculopathy
TibialHreflexamplitudecorrelatewell
withtheanklejerk
Adopted from Neal & Katirji, NCS, 2011
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Hreflex.Limitations
IsonlyreproduciblefromtheS1
rootthroughthetibialnerve
Iscommonlyabsentbilaterallyin
elderlypatientsorfollowing
spinalsurgery
IsnotalwaysabnormalinS1
radiculopathy
Doesnotaccuratelylocalizethe
lesiontotheS1root,buttothe
S1reflex
Adopted from Neal & Katirji, NCS, 2011
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Blinkreflexes

Adopted from Neal & Katirji, NCS, 2011

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Blinkreflexes

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Blinkreflexes

Facialpalsy:AbsentorprolongedR1andR2ipsilateraltothe
lesionwhilethecontralateralR2recordingswillbenormal.
Trigeminalneuropathy:R1andR2+contralateralR2areabsent
ordelayedwithipsilateralstimulation.Allresponsesarenormal
withcontralateralstimulation.
Lowerbrainstemlesion:Inapontinelesion,theaffectedside
willhaveanabsentorprolongedR1butanormalipsilateraland
contralateralR2.Stimulatingthecontralateralsidewillresultin
normalresponses.AmedullarylesionwillrevealanormalR1
andcontralateralR2whentheaffectedsideisstimulated;
however,theipsilateralR2willbeabsentorprolonged.
DemyelinatingperipheralneuropathiessuchasGBSorCMT1:
MarkedlyprolongedlatenciesinR1andR2dueslowingofthe
sensoryand/ormotorfibers.

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Advancing the Vision of the Neurological Institute

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EDXmeansoflocalizationin
peripheralnervelesions
Nerveconductionstudies
Sensoryconductionstudies
Motorconductionstudies
Lateresponses(Hreflex,Fwaveandblinkreflex)

NeedleEMG
Fibrillationpotentials
Motorunitactionpotentials
Recruitment
Morphology

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LocalizationbyneedleEMG
inaxonlosslesions
Theconceptoflocalizationby
needleEMGissimilarto
clinicallocalizationusing
manualmusclestrengthtesting
thatispartoftheneurological
examination.
Mostoften,muscles
innervatedbybranchesarising
fromthenervedistaltothe
lesionareweak,whilethose
innervatedbybranches
proximaltothelesionare
normal.
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PitfallsofLocalizationbyneedleEMG
1.Nervelesionsalong
segmentswithnomotor
branches.
Theanatomyoftheinjured
nerveplaysanimportant
roleintheprecise
localizationofnerve
lesions.
Manynervestravel
substantialdistances
withoutgivingoutany
motorbranches.

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PitfallsofLocalizationbyneedleEMG
2.Fascicularnervelesions.
Occasionally,peripheral
nervelesionsspareoneor
twonervefascicles
resultinginmusclesthat
escapedenervationdespite
beinglocateddistaltothe
lesionsite.
Thisusuallyresultsinan
erroneouslocalizationthat
ismoredistaltotheactual
siteofthelesion.

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PitfallsofLocalizationbyneedleEMG
3.Chronicnervelesions.
Withmildormodestpartial
axonlosslesions,
regenerationand
reinnervationcanbe
efficientinproximally
locatedmusclesresultingin
remodelingofthemotor
units.
Hence,aneedleEMGdone
severalyearsaftersuch
lesionsmayonlydetectthe
neurogenicchangesinthe
moredistalmuscles

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