Clinical Correlate 6.

Nerve Conduction Studies and Electromyography

Clinical Correlate 6. Nerve Conduction Studies and Electromyography

C. Chalk Click here for other notes on Nerve Conduction Studies and Electromyography.

Introduction
The electrical properties of the nervous system have been recognized at least since the time of Galvani's studies of animal electricity in the 18th century. However, it has only been since the 1940s that developments in electronics have allowed physicians to record and measure the electrical function of the nervous system in patients. The purpose of today's session is to demonstrate some techniques for measuring the electrical function of the peripheral nervous system. These techniques, known as nerve conduction studies and electromyography, are used by neurologists in the evaluation of patients with diseases of the peripheral nerves and muscles.

Nerve Conduction Studies

If a brief electrical shock is applied to a peripheral nerve, the subject will experience two things. First, of course, an electrical sensation will be felt. Second, if the shock is large enough, the muscles innervated by the nerve will make a brief, forceful contraction (a twitch). The effect of the shock is to depolarize some or all of the immediately subjacent axons, causing them to generate action potentials. Unlike action potentials generated normally in the nervous system, which occur rather randomly and which propagate in one direction only, those resulting from the electrical shock travel as a synchronous wave, both up the nerve (towards the brain, experienced as the sensation of a shock) and distally (towards the muscle, causing the twitch). Motor nerve conduction is evaluated by recording the wave of action potentials travelling to the muscle. The muscle twitch is associated with a brief electrical signal, the compound muscle action potential (CMAP). The CMAP is the sum of the action potentials occurring in all the contracting muscle fibres in the muscle. The CMAP is recorded from a pair of electrodes taped to the skin overlying the muscle; because the CMAP is small (millivolts) and brief (milliseconds), it must be amplified electronically and displayed on an oscilloscope.

Clinical Correlate 6. Nerve Conduction Studies and Electromyography

Clinical Correlate 6. Nerve Conduction Studies and Electromyography

The electrical shock is delivered from a hand held stimulator at sites where the nerve of interest is close to the surface (to allow as small a shock as possible to be used). With the electrodes in place, and amplifier and oscilloscope turned on, a single shock is given. On the oscilloscope one sees the shock, followed in a few milliseconds by the CMAP. The time between the shock and the beginning of the CMAP (the latency, in ms) and the size of the CMAP (CMAP amplitude, in mV) are measured from the oscilloscope. The procedure is then repeated, stimulating the nerve at a second site, and again recording the latency and CMAP amplitude. The distance between the two sites of stimulation is measured. The motor conduction velocity (in m/s) between the two sites of stimulation is calculated by: Conduction velocity = Distance Latency A - Latency B

Sensory nerve conduction is evaluated in a slightly different way. Instead of recording the response of a muscle, the sensory nerve action potential (SNAP) is recorded directly from the nerve. The SNAP is the sum of all the action potentials generated in sensory nerve fibres by the electrical shock. The SNAP is about 1000 times smaller than the CMAP, making sensory nerve conduction technically more difficult to measure. In order to ensure that one is recording action potentials from sensory nerve fibres only, the recording electrodes must be placed along a branch of the nerve which contains only sensory fibres. As with motor conduction studies, the SNAP amplitude (in microvolts) and latency (in ms) between the shock and the SNAP are recorded using two sites of stimulation. The sensory conduction velocity (in m/s) is calculated using the equation above. INTERPRETATION OF NERVE CONDUCTION STUDIES: The techniques described above can be applied to almost any peripheral nerve. With the nerve conduction data, the neurologist can determine two main things: 1) Is the nerve normal? 2) If abnormal, does the problem lie in the nerve axon or its myelin sheath? Judging whether a given set of nerve conduction data is normal requires comparing them to values obtained from that nerve in normal subjects. Normal values are well established for motor and sensory conduction in most major peripheral nerves. Of course, the neurologist must select the correct nerve or nerves to test, depending on each patient's clinical problem. If the nerve conduction studies are abnormal, one can also get some idea of how severely a nerve has been damaged or injured. Nerve conduction studies may also allow one to judge whether the main site of damage is the axon or the myelin sheath. Knowing whether a patient has a disease affecting the nerve axons (an "axonal neuropathy") or the myelin sheaths (a "demyelinating neuropathy") helps to guide the physician to a diagnosis among the many causes of peripheral neuropathy. Axonal neuropathies produce a decrease in CMAP and SNAP amplitudes but have relatively little effect on conduction velocities. By contrast, in a demyelinating neuropathy, conduction velocities are significantly slowed, while the CMAP and SNAP amplitudes are little changed.

Clinical Correlate 6. Nerve Conduction Studies and Electromyography

Clinical Correlate 6. Nerve Conduction Studies and Electromyography

Electromyography
Nerve conduction studies are an extremely useful means to study motor and sensory function in the peripheral nervous system. However, nerve conduction studies have some limitations, particularly for examination of motor function. First, motor nerve conduction studies are rather insensitive to small degrees of abnormality. Since the procedure studies the performance of a whole population of axons and muscle fibres, malfunction of small numbers of axons or muscle fibres will produce insignificant changes in parameters like the CMAP amplitude, and may thus go undetected. Second, many motor axons and their muscles are technically impossible to study, mostly because they are too deep to be stimulated or recorded with electrodes on the skin. Third, abnormalities of CMAP amplitude (the most common abnormality which is found in motor nerve conduction studies) may be due to disease of the motor axons or of the muscle fibres. From the motor nerve conduction studies alone, it is often impossible to make the clinically important distinction between these two possibilities. Fortunately, neurologists can also study muscle and nerve function by recording electrical activity with an electrode inserted into a muscle, a procedure known as electromyography. A fine needle electrode is used, and the electrical signals "seen" by the tip of the needle are amplified and displayed visually (on an oscilloscope) and audibly (via a loudspeaker). Unlike motor nerve conduction studies, which evaluate a whole population of motor axons and muscle fibres, electromyography allows one to evaluate individual motor units. (Recall that a motor unit consists of an anterior horn cell, its axon and branches, and all the muscle fibres which it innervates. A large limb muscle like the quadriceps contains several hundred motor units, whereas small muscles like the extraocular muscles contain only a few dozen.) The needle electrode is placed in the muscle, and electrical activity is assessed both with the muscle in a relaxed state and with the patient voluntarily contracting the muscle. In normal muscle innervated by normal nerve, there is no electrical activity at rest. In diseases in which the normal connection between a muscle fibre and its motor axon is broken, the muscle fibre membrane will spontaneously and regularly depolarize and repolarize. This results in tiny electrical signals called "fibrillation potentials", which can be detected by the needle electrode. The detection of fibrillation potentials is a very sensitive means of determining that there are problems in the peripheral motor system. Voluntary contraction of a muscle is accompanied by electrical activity in all the contracting muscle fibres. Each time a motor unit is activated and its constituent muscle fibres contract, a complex electrical signal, the "motor unit potential", can be detected by a needle electrode placed in the midst of the contracting muscle fibres. By assessing the size, duration, and firing pattern of the motor unit potentials in a muscle, the neurologist can evaluate whether the motor units in that muscle are normal or abnormal. If the motor unit potentials are abnormal, the specific pattern allows one to judge whether the problem lies in the anterior horn cell, the motor axon, or the muscle itself. In general, in diseases of muscle fibres, motor unit potentials become small, whereas disease of the anterior horn cell or the motor axons result in enlargement of motor unit potentials.

Clinical Correlate 6. Nerve Conduction Studies and Electromyography

Clinical Correlate 6. Nerve Conduction Studies and Electromyography

WORKSHEET FOR NERVE CONDUCTION STUDIES

MEDIAN NERVE MOTOR CONDUCTION Stimulate Record Latency MEDIAN NERVE MOTOR CONDUCTION Stimulate Record Latency CMAP amplitude Conduction velocity

SNAP amplitude

Conduction velocity

Clinical Correlate 6. Nerve Conduction Studies and Electromyography