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    Regional Meeting Basic - NCS PDF

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    anjelika
    The document provides an overview of basic nerve conduction studies. It discusses nerve anatomy, the purpose and design of studies, motor and sensory nerve conduction parameters and techniques. Motor nerve conduction studies evaluate the compound muscle action potential using larger motor nerves. Sensory studies sum the action potentials of multiple fiber types to measure the sensory nerve action potential. Mixed nerve studies are also described. The interpretation of latency, amplitude, conduction velocity and other parameters is covered. [END SUMMARY]

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    Regional Meeting Basic - NCS PDF

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    anjelika
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    The document provides an overview of basic nerve conduction studies. It discusses nerve anatomy, the purpose and design of studies, motor and sensory nerve conduction parameters and techniques. Motor nerve conduction studies evaluate the compound muscle action potential using larger motor nerves. Sensory studies sum the action potentials of multiple fiber types to measure the sensory nerve action potential. Mixed nerve studies are also described. The interpretation of latency, amplitude, conduction velocity and other parameters is covered. [END SUMMARY]

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    The document provides an overview of basic nerve conduction studies. It discusses nerve anatomy, the purpose and design of studies, motor and sensory nerve conduction parameters and techniques. Motor nerve conduction studies evaluate the compound muscle action potential using larger motor nerves. Sensory studies sum the action potentials of multiple fiber types to measure the sensory nerve action potential. Mixed nerve studies are also described. The interpretation of latency, amplitude, conduction velocity and other parameters is covered. [END SUMMARY]

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    72 views46 pages

    Regional Meeting Basic - NCS PDF

    Uploaded by

    anjelika
    The document provides an overview of basic nerve conduction studies. It discusses nerve anatomy, the purpose and design of studies, motor and sensory nerve conduction parameters and techniques. Motor nerve conduction studies evaluate the compound muscle action potential using larger motor nerves. Sensory studies sum the action potentials of multiple fiber types to measure the sensory nerve action potential. Mixed nerve studies are also described. The interpretation of latency, amplitude, conduction velocity and other parameters is covered. [END SUMMARY]

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    of 46

    Basic Nerve Conduction

    Studies
    Holli A. Horak, MD
    University of Arizona
    August 2015
    Introduction
     Review nerve physiology/ anatomy

     Purpose of testing

     Study design

     Motor NCS

     Sensory NCS

     Mixed NCS

     Interpretation

     Technical considerations

     Summary
    Anatomy
     Motor Neuron
     Axon
     Myelin
     Neuromuscular Junction
     Muscle fibers
    Anatomy
     Dorsal Root ganglion: Bipolar Nerve cell

     One projection central


     Dorsal column
     Other axon distal
     Sensory end organ
     Myelinated: different degrees
    Anatomy
     Neurons
     AHC
     DRG

     Roots

     Rami
     Ventral Rami:
     Plexus
     Dorsal Rami:
     Paraspinals
    Anatomy
     Certain nerves are routinely studied
     Location
     Size
     Important pathology
     Ease of evaluation

     Some are less often studied

     Some are rarely studied


    Study Design
     Answer the clinical question
     Not just routine

     Specifically choose nerve evaluation needed


     Motor NCS
     Sensory NCS
     Repetitive stimulation
     Other (mixed study)

     Least number of NCS needed to answer the clinical


    question
     I.e.. CTS
    Purpose of testing
    Neuropathy Other conditions
    Focal

     Carpal Tunnel Syndrome (CTS)
     Radiculopathy
     Peroneal neuropathy
     Ulnar neuropathy  Neuromuscular junction
    defects
     Generalized
     Diabetic Neuropathy  Myasthenia Gravis
     Guillain Barre syndrome (GBS)
     LEMS

     Axonal  Motor Neuron Disease


     Diabetic Neuropathy
     Nerve transection
     ALS

     Demyelinating  Sensory Neuronopathy


     GBS
     CTS
     Sjogren’s disease
    Motor nerve conduction studies
     Larger

     More reproducible

     Troubleshooting is easier
    Why?
     Compound Muscle Action
    Potential

     Muscle amplifies the


    response
     Stimulate nerve axons
     Causes muscle to contract
     Recording the muscle
    contraction
     Response is in millivolts
     (1000X larger than SNAP)
     Few anatomic variations
     Large motor axons tend to
    be affected late in disease
    states
    Motor NCS
     Belly-Tendon montage
     G1: active
     G2: reference

     Stimulate proximal
     Measure site (s)
     Consistent

     0-60mAmps stimulation
     0.1ms duration
     May need to adjust
    Motor NCS parameters
     Latency
     Onset
     Time (mS)

     Amplitude
     Baseline to peak
     Electrical signal (mV)
     Muscle contraction
    Motor NCS
     Conduction velocity: two
    points in time
     Rate = distance/ time
     So 2 points are needed
     I.e.. CV = 20cm/4ms
     Cannot record a distal
    conduction
     Why?
     Neuromuscular junction
     Cannot accurately
    calculate time
    Conduction Velocity
     Rate = distance/ time  CV = d/ t

     E.g.. Median Nerve:  CV = 20cm/ 8ms-4ms


     Distal latency: 4ms
     CV = 20cm/ 4ms
     Proximal latency: 8ms
     Measure:  CV = 200mm/ 4ms
     20cm between 2 sites
     CV = 200 m/ 4s

     CV = 50 m/s
    Motor NCS parameters
     Area
     Not used frequently
     Used when considering
    conduction block
     Often calculated
    automatically by modern
    machines

     Duration of waveform
     Temporal dispersion
     Demyelinating disease
     Or with severe axonal
    loss
    Sensory Nerve conduction studies
     Summation of all sensory
    nerve fiber action
    potentials
     SNAP (sensory nerve action
    potential)
     Fibers are of mixed type:
     Large/ small
     Myelinated/
    unmyelinated

     Small
     μVolts
    DRG
     External to the spinal cord

     May be located in
    intervertebral foramen
     Lesions may be proximal to
    DRG

     Important consideration
     Distal axon and DRG may be
    spared
     Therefore Sensory NCS
    may be normal
     Despite symptoms!
    Sensory NCS parameters
     Latency (ms)
     Onset
     Peak: more commonly used
     More reproducible/ consistent

     Amplitude (μV)
     Baseline to peak
     Peak to peak

     Duration

     Conduction velocity
     Can calculate a distal velocity
     Use onset latency for CV
     Fastest fibers
    Sensory NCS
     Antidromic
     Anti: “against” or opposite
     I.e.. Against natural
    conduction
     Stimulate proximal, record
    distal

     Orthodromic
     Ortho: “right” or correct
     I.e.. Natural direction of
    sensation
     Stimulate distal; record
    proximal
    Antidromic SNCS
     More common
     Why?

     In general, easier

     Higher amplitude responses


     Sensory nerve is more
    superficial in distal skin
     Easier to obtain and
    record
    Antidromic Sensory NCS
    Orthodromic Sensory NCS
    “Mixed” nerve studies
     Motor is pure motor: belly-tendon montage
     Recording muscle

     Sensory NCS should record only sensory fibers


     Record over skin
     Evaluate SNAP

     But, some nerves recorded are mixed


     Both sensory and motor fibers present
     Stimulation
     Recording site
    “Mixed” nerve studies
     Palmar studies

     Tarsal Tunnel studies (plantar nerve)

     Specialized studies
     Evaluating one specific lesion
     Carpal tunnel syndrome
     Tarsal tunnel syndrome
     Not pure sensory potentials
     Cannot assess integrity of sensory nerve/DRG
    Mixed NCS

     Palmar record over wrist


     Median and ulnar
     Both motor and sensory
    fibers present
     Stimulate in palm
     Both motor and sensory
    fibers present

     Comparison of latencies
     Amplitude is less relevant
    Other considerations in NCS
     Physiologic temporal
    dispersion
     Not all dispersion is
    pathologic
     Proximal amplitudes are
    lower than distal
     Double check your
    results!
     Why?
     Loss of synchrony over
    longer distances
     Proximal nerves are
    deeper and more
    difficult to stimulate
    Averaging
     Used for low amplitude
    sensory nerve potentials
     Additive waveforms confirm
    + presence of SNAP
     Subtracts out artifact

     Lateral antebrachial cutaneous sensory responses


     Effect of averaging: 1, 2, 6, 10 responses
    Routinely evaluated nerves
     Motor:
     Tibial, Fibular (peroneal)
     Median, Ulnar

     Sensory
     Sural
     Median, Ulnar

     Mixed
     Palmars
     Carpal Tunnel syndrome only
    Commonly evaluated nerves
     Motor:
     Radial

     Sensory:
     Superficial Fibular (Peroneal)
     Radial
     Medial antebrachial cutaneous
     Lateral antebrachial cutaneous
     Dorsal Ulnar cutaneous

     Mixed:
     Medial and Lateral plantars (tarsal tunnel)
    Late Responses: F waves/ H reflexes

     Both are used to answer a specific clinical question


     F waves: primarily used to evaluate proximal
    demyelination
     GBS/ CIDP
     Radiculopathy

     H reflex: used to evaluate radiculopathy


     S1 nerve root
    F waves
     Electrical signal travelling
    up to anterior horn cell
     “bounces” back
     NOT a reflex
     Wave traveling up and
    back down motor axons
     Proportion of axons
     Differs with each
    stimulus
     So each waveform
    varies
     Reflects speed of
    conduction
    F-wave utility
     Radiculopathy
     Demyelinating (ie nerve root compression)
     May be prolonged
     Axonal
     May disappear

     Demyelinating disease
     Early: may have no change
     Mid-course: delay in F-wave latency
     Late/ severe: loss of F-wave

     F-wave absent/ not recorded


     Can be normal occurrence
     Especially in median and radial nerves
    F wave parameters
     Latency
     ms

     “Normal”
     Upper limit of normal
     Depends on height
     Either for short or tall
    persons
     Need a normogram
     Calculate expected time
    Late Response: H reflex
     True reflex

     Afferent loop: Ia sensory


    fibers

     Efferent loop: Motor axons

     Actual synapse
    H reflex
     S1 nerve root
     Tibial N. stim
     recording from
    gastrocnemius

     Other H reflex responses


    are difficult to elicit

     H reflex largest with


    submaximal stimulation
     As stimulation increases
     H reflex diminishes
     M-wave (motor response)
    increases
    H reflex utility
     Proximal damage to either sensory or motor pathway
     Radiculopathies
     Avulsion

     Side to side comparison

     Tibial nerve studied most often


     upper limit of normal latency is 35 ms
    NCS: Basic Interpretations
     Amplitude: related to the #
    of axons in a nerve

     Latency: a marker of time;


    therefore, most affected by
    demyelinating processes

     Conduction velocity: speed;


    can be affected by both
    axonal loss and
    demyelination
     Large, fast conducting fibers
    are lost
     Moderate slowing
     Demyelination
     Marked slowing
    Normal Values
     Vary lab to lab  In general

     No universal standards  Conduction velocities


     Motor NCS
     General principles apply  Legs > 40 M/s
     Side to side variability
     Arms > 50 M/s
     < 50% difference
     Sensory NCS
     amplitude
     10 M/s faster
     Physiologic temporal
    dispersion
     <20 % drop in amplitude
     Comparison studies
     < 0.2 or 0.3 ms
    difference
    Conduction Velocity
     Determined by the fastest  Axonal loss can produce
    conducting fibers slowing
     <2/3 LLN
     Motor NCS
     Legs > 30 M/s
     Legs: 40 M/s
     Arms > 40 M/s
     Arms: 50 M/s
     Sensory CV about 10 M/s  Demyelination
    faster  Produces significant slowing
     > 2/3 LLN
     Legs < 30 M/s
     Arms < 40 M/s
    Axonal Loss
     Most Neuropathies
     LE > UE
     Distal > proximal
     Sensory > Motor

     So a NCS study in a patient with Neuropathy


     Low amplitudes, more severe in the legs than arms
     Loss of sensory responses in legs early on
     CV slowing > 2/3 LLN
    Demyelinating Process
    Hereditary Acquired
     Uniform slowing  Non-uniform process
     Across all segments  Conduction block
     Non-compressible
     Uniform waveform shape segments
     CMAPs  Temporal dispersion
     Increased variability in
     Profound slowing
    range of velocities
     Some nerves affected more
    than others
     MMN
    Focal vs. Generalized
     Focal lesion  Generalized
     Either axonal or  More often due to systemic
    demyelinating process
     Compression
     Axonal
     Demyelinating
     Polyneuropathy
     CTS, ulnar neuropathy
     Axonal  Demyelinating
     Mononeuritis  GBS
    multiplex
     CIDP
     Nerve transection
    Safety Considerations
     For NCS
     Generally very safe

     EMG/NCS machine electrically certified


     Checked annually to rule out “leak”
     Grounded outlet

     Do not create an electric circuit through patient


     Ie. Bed unplugged, no other devices attached to pt
     But, studies are done in ICUs routinely, with precautions
     Pacemaker: not a problem if one stays distal and ground is
    near stimulator
     Other devices: turn off if possible (artifact!)
    Technical Problems
     Temperature

     Incorrect measurements

     Inter-electrode distance
    (too far or too close)

     Background interference/
    noise

     Incomplete circuit
     I.e.: check to make sure
    electrodes are plugged in!
    Temperature
     Very important
     Commonly ignored/ missed
     0.2ms/ degree centigrade

     Arms > 31 °C

     Legs > 30 ° C

     Must check distal limb


     Thermistor
     Infrared temperature probe
    Summary: NCS
     Easily tolerated, safe

     Must be consistent in technique


     Intralab normal values

     Monitor for technical issues

     Very sensitive to axonal loss

     Very specific for demyelinating disease

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