Nerve Conduction Study-3

Nerve conduction study
Practical application
Practical application
Electrodes used in nerve conduction studies

Stimulating , recording and ground electrodes
Stimulating electrodes : is bipolar electrode; cathode (-ve polarity) and
anode (+ve polarity). The cathode is an active electrode in most American
EMG machines. The anode is the reference electrode.
Stimulating electrode either surface or needle
Recording electrodes: are two types; surface and needle
Surface electrodes: located on the skin surface and record either nerve
or ms action potential. The most important is to locate the active
electrode on the ms motor point and position the reference off the ms
activated; it is better to place over the ms tendon insertion ( should be
relatively silent electrical area).
Ground electrode: used to
Needle electrode: to be close to thering electrode: are used for recording
antidromically elicited digital SNAPS or as stimulating electrodes.
Needle electrode:
General guidelines for performing nerve conduction studies
1- Explain the procedures to the patient: it is important to explain the
procedure to the patient in a simple language in addition explain to the
patient that the electrical stimulation is a painful.
2- Place the lime to be tested in a relaxed and comfortable position both
for the patient and the examiner, otherwise movement or noise artifacts
affect NCV
3- Measure skin temperature. It's important that the test limb be warm
during measurements NVCs. Motor and sensory NCVs are decreased at
rate of 1.3-2.4m/sec for each centigrade degree drop in skin
temperature .
4- Lower the skin impedance: it's important to reduce skin and electrode
impedances as much as possible by
 Clean the recording and stimulating sites by alcohol
 Applying electrode gel under the electrode
 affixing the electrode to the skin with adhesive tape
5- a ground electrode should be attached to the tested limb and placed
between the stimulating and the recording electrodes
6- perform motor nerve conduction studies first to locate the nerve before
sensory nerve conduction studies as stimulating sites marked exactly.
7- Warn the patient before each stimulation is given.
8- Reduce the pain of stimulation as much as possible before the next
stimulation is given. The stimulus should be of the shortest duration and
1
lowest intensity but adequate to produce the supramaximal response of
the muscle or verve potential.
9- Follow the typical machine settings for the various nerve conductions.
10- Pediatric stimulating electrodes are recommended in infant: use
small stimulating electrode to stimulate the tested nerve without
spreading to other nerves.
Median nerve motor conduction study

1- After application of general guild line
2- Surface recording electrodes are placed over one of the most distal
muscles innervated by the median nerve such as the abductor pollicis
brevis (APB), one recording electrode (active electrode negative polarity )
is placed over the APB motor point, and the secode recording electrode
(reference electrode +ve polarity) is placed 3or 4cm distally over the
insertion of the ms
3- 3rd electrode, ground electrode is placed between stimulating
electrodes and the recoding on a bony area
4- Stimulating electrode is a hand held bipolar electrode (cathode &
anode)connected to stimulator to produce electrical stimulation. The
Cathode of the bipolar probe electrode is distal to the anode over the
median nerve, closest to the most proximal recording electrode over the
ms. Bipolar stimulation is applied at several sits (wrist, elbow, axilla, and
supraclavicular fossa ) where median nerve is superficially located.
 Wrist: between flexor carpi radialis and Palmaris tendon
 Elbow: medial to the biceps tendon in the antecubital fossa over the
brachial artery pulse
 Axilla: midway in the medial side of the arm
 supraclavicular fossa: lateral to the lowe 1/3 of the
sternocleidomastoid ms
5- 1st we attach the ground then recording and finally the stimulating
electrode.
6- Stimulus of increasing magnitude are applied until the amplitude of
the CMAP of the ABP reach a maximum. This signal is evoked CMAP or M
wave and represent the summated electrical activity of all of the ms fibers
in the region of the recording electrodes that are innervated by the
median nerve. To ensure that the maximum amplitude is recorded, a
supramaximal stimulus is apply which is defined as stimulus amplitude
20% greater than that required to obtain the maximal CMAP
7- The characteristics of the CMAP (onset latency, amplitude and MNCV)
measured to provide a quantitative indication of functioning nerve and
ms fibers.
8- To measure for example to determine the motor nerve conduction
velocity in the segment of the median nerve lying between the elbow and
the wrist.
1st stimulation is applied to the median nerve at wrist, 8cm proximal to
the active recording electrode over the ABP. The pointof cathode
2
stimulation at wrist is marked. Latency (L1) between stimulation and
recording CMAP recorded.
Next stimulation would be applied over the median nerve at the elbow
medial to the biceps tendon and just proximal to the elbow crease. the
point of cathode stimulation is also marked at elbow. Latency (L2) at
elbow will be longer than (L1)
Under normal condition CMAP configuration (amplitude, duration and
shape) at elbow stimulation is the same to that at wrist stimulation, this
similarity in configuration ensures that the same group of nerve fibers is
being activated by stimulation at each site so assess conduction over the
same group of nerve fibers. If the configuration is different between 2
point of stimulations this mean that the examiner stimulate different
population of nerve fiber or there is a significant compromise exist
between elbow and wrist.
Then measure the forearm segment length between the two cathode
stimulation points at elbow and wrist. Distance measure by tap
measurement
Conduction velocity elbow to wrist =distance/time=length of forearm segment
(mm)/L1-L2 (ms) fig ()
N.B conduction velocity can't be calculated for segment lying between
distal stimulation point and innervated ms for two resonses 1 st distal
latency measurement includes not only the actual conduction time along
the distal segment but also a synaptic delay across NMJ and a
conduction across ms fibers, 2nd length of the distal segment is difficult
to be accurate.
Test the median nerve in the other site and unlar nerve in the same side.
3
Motor conduction for median nerve
Median nerve sensory conduction studies (Antidromic)

1-After application of general guild line
2-Recording electrode: Ring recording electrodes is placed over a finger
(index or middle finger) supplied mainly by the median nerve
- Active electrode (–ve) polarity is placed over the midpoint of the proximal
phalanx.
- Reference electrode (+ve) polarity) is placed over the distal
interphalangeal crease.
3-Ground electrode the same as MNCV

4-Stimulating electrode : same as MNCV
In Orthodromic study reverse the recording and stimulating electrodes sites, place the
recording electrodes in a position of the stimulating electrodes and vice versa.
4
Sensory orthodromic and antidromic median nerve conduction study
Common Peroneal motor nerve conduction study

1- After application of general guild line
1- Recording electrodes:
 Active electrode (–ve): extensor digitorum bervis (EDB) muscle
 Refrence electrode(+ve): metatarsophalangeal joint of the little toe
2-Stimulating electrode:
 Ankle: anterior ankle, slightly lateral to tibialis anterior tendon
 Below fibular head: one to two fingerbreadths inferior to fibular head
 Popliteal fossa: lateral 1/3 of poptiteal fossa adjacent to external
hamstring tendon.
5
Ground electrode: between stimulating and recording
Follow the same steps as in median motor conduction studies.
Motor conduction studies for common proneal nerve
Common proneal sensory nerve conduction (antidromic)

1- Recording electrodes:
Active electrode (–ve): lateral ankle between the tibials anterior tendon
and lateral malleolu,s 12 cm above lateral malleolus
 Refrence electrode(+ve): placed 3-4cm distally
2-Stimulating electrode: lateral calf. Cathode distally and anode proximal

3-Ground electrode: between stimulating and recording
4-Follow the same steps as in median sensory conduction studies.
Electrodes used in motor and sensory conduction studies:
Stimulating electrode and cable
6
Recording electrodes for MNCVS and cable
Ring electrode for SNCVS
Ground(disc like) electrode and cable
7
Ground (Bracelet) electrode and cable

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Nerve conduction study

Electrodes used in nerve conduction studies

Median nerve motor conduction study

Median nerve sensory conduction studies (Antidromic)

3-Ground electrode the same as MNCV

Common Peroneal motor nerve conduction study

Motor conduction studies for common proneal nerve

Common proneal sensory nerve conduction (antidromic)

 Refrence electrode(+ve): placed 3-4cm distally

2-Stimulating electrode: lateral calf. Cathode distally and anode proximal

Electrodes used in motor and sensory conduction studies:

Stimulating electrode and cable

Ring electrode for SNCVS

Ground(disc like) electrode and cable

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