Electrical nerve locators

Phil Dalrymple
Subbiah Chelliah

Key points

Nerve fibres of differing

morphology require differing
minimum pulse widths.
Evidence of a complete
electrical circuit must be
ascertained before needle
advancement.
Incorrect electrode polarity
may increase the required
current strength
considerably.
Muscle twitches obtained at
<0.2 mA may indicate
intraneural needle
placement.

Phil Dalrymple
Specialist Registrar in Anaesthesia and
Intensive Care Medicine
Department of Anaesthetics
University Hospitals of
Leicester NHS Trust
Leicester General Hospital
Gwendolen Road
Leicester LE5 4PW
UK
Subbiah Chelliah
Consultant Anaesthetist
Department of Anaesthetics
University Hospitals of
Leicester NHS Trust
Leicester General Hospital
Gwendolen Road
Leicester LE5 4PW
UK
Tel: 0116 2584661
Fax: 0116 2584661
E-mail: sleepist@hotmail.com
(for correspondence)

32

Electro-physiological factors
affecting nerve stimulation
Current strength and pulse width
In order to propagate a nerve impulse by electrical means, a threshold stimulus of current

must be applied to the nerve. Below this threshold, no impulse is propagated. The relationship
between the strength and duration of current
flow is important in determining whether a
nerve is stimulated. This relationship can be
explained by the terms rheobase and chronaxy.
The rheobase is the minimum current required
to stimulate a nerve and chronaxy is the
duration of the current stimulus required to
stimulate that nerve at twice the rheobase.
From the graph of threshold curves for
different nerve fibres (Fig. 1) and the formula
I Ir (1 C/t), where I is the current required,
Ir is the rheobase, C is the chronaxy and t is the
stimulus duration, it is evident that the current
needed to stimulate the nerve will depend
on the pulse width or duration of stimulus.
This graph also demonstrates that different
nerve fibres will have varying chronaxy. The
chronaxy can be used as a measure of the
threshold for any particular nerve and it is useful when comparing different nerves or fibre
types. Large motor fibres (Aa) have shorter
chronaxy (0.050.1 ms) and can be readily
stimulated with shorter width pulses of current.
It is therefore possible to stimulate the larger
Aa motor fibres without stimulating the
Ad (chronaxy 0.150 ms) or C fibres (chronaxy
0.4 ms) responsible for pain. One potential
cause of block failure is when a longer pulse
width from a greater distance elicits the same
twitching as a shorter pulse width giving a
false sense of proximity to the nerve. It is
also possible to locate sensory nerves using
longer width pulses of current and inducing
paraesthesia (without actually touching the
nerve) in awake, cooperative patients.

Distance from current

stimulus to nerve
The further the needle tip is from the nerve, the
greater the current strength at the tip needs to
be. Coulombs Law states that E K (Q/r2),
where E is the threshold current required at
the nerve, K is a constant, Q is the minimal
current from the needle tip and r is the distance
from the nerve. Since the radius is squared, the

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Knowledge of applied
anatomy, pharmacology,
physics and competent
procedural technique are
essential requirements for
consistently safe peripheral
nerve blockade.

Peripheral nerve blockade for the purposes of

intraoperative and postoperative analgesia has
developed over the years into a common clinical procedure. Successful regional anaesthesia
of this type depends upon precise location of
the peripheral nerve or nerve plexus. Electrical
stimulation of a peripheral nerve usually results
in muscular twitching, paraesthesia or a combination depending on the nerve morphology.
An electrical nerve locator (ENL) will stimulate muscular twitching at a close distance to
the nerve without actually touching it; hence,
providing greater accuracy for local anaesthetic deposition. The term ENL is used in
this review to differentiate from peripheral
nerve stimulators, which use the same principle
to assess the degree of neuromuscular block
during anaesthesia. These machines deliver
much higher currents and have other modalities e.g. train of four, tetanic and double burst
stimulation. However, there are some machines
on the market which can serve both purposes.
Before the availability of ENLs, no
paraesthesia-no anaesthesia was one guide
to a blindly advancing needle, as well as locating fascial planes with anatomical knowledge
and well practised technique. However, seeking
paraesthesia when performing a peripheral
nerve block may increase the risk of postanaesthetic neurological sequelae.1 Needle
and perhaps injection trauma are the probable
aetiology. With the increasing popularity of
regional anaesthesia used either solely or in
conjunction with general anaesthesia, ENLs
have become more readily available. It is
imperative that we understand some of the
electro-physiological principles and the equipment involved in these procedures to improve
anaesthetic technique and avoid the potential
risks of nerve damage and patient harm.

Electrical nerve locators

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Fig. 1 Current threshold curves, rheobase and chronaxy in low and high speed nerve fibres.

Fig. 2 Stimulation current and distance from the nerve, using insulated and non-insulated needles.

further the needle tip is from the nerve, a proportionately greater

current is needed to stimulate the nerve. This principle can be used
to estimate the distance from the needle tip to the nerve using a
constant current stimulus. Alternatively, the lower the threshold
current able to stimulate the nerve, the closer the needle tip is to the
nerve. For example, at 10 mm from the nerve, an insulated needle
will have a current threshold of 4 mA, but at 4 mm from the nerve,
the threshold will be 2 mA (Fig. 2).

Electrode polarity
Significantly less current is required when the stimulating electrode adjacent to the nerve is acting as the cathode, rather than
the anode.2 When the stimulating needle is the cathode, the current
flow alters the resting membrane potential of cells nearby, producing an area of depolarization, which more easily triggers
an action potential. If the stimulating electrode is the anode,
the current causes an area of hyper-polarization adjacent to the

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Electrical nerve locators

needle tip and a ring of depolarization distal to the tip. This

arrangement is much less efficient, requiring an increased current
strength of several times magnitude. Modern ENLs have correct
polarity connections as standard, thus ensuring efficient use.

knob can be attached to some modern current generators. Foot

operated current intensity controllers are also available, which
may bring a more efficient technique to an operator without an
assistant.

Electrical nerve locating equipment

Pulse width

There are several purpose built pieces of equipment, which

together make up an ENL. These include a current generator,
stimulating needle, insulated wire circuitry and extension tubing
connected to the syringe of local anaesthetic. Each component
has several features, which are necessary to improve nerve
location efficiency and safety.

Current generator (Fig. 3)

The set current is delivered between the tip of the needle and the
remote electrode. The resistance in the circuit varies with the tissue
impedance and the position of the electrode from the tip of the
needle. Constant current design of modern ENLs compensates for
the varying impedance to a large extent. It is possible to measure
both the set current and the actual delivered current with some
ENL models.

Current meter
The operator needs to be accurately aware of the current intensity
at which the nerve is being stimulated, since it will give an approximate distance from the needle tip to the nerve. The current meter
provides a digital display of the current delivered in the circuit.
Most ENLs can deliver a maximum current of 5 mA and a minimum current of 0.01 mA.

Current output control

This control allows the operator or assistant to vary the current
passing through the circuit precisely. A steam sterilizable control

Low battery indicator

Pulsation frequency control

Connection/disconnection indicator
This is an important safety feature, since it will indicate when the
current stimulus is not being delivered for whatever reason, for
example, poor electrode contact, loss of circuitry, unit malfunction, battery failure. Connection may be reassuringly signalled to
the operator by pulsating beeps and also a flashing light. Loss of
these signals should alert the operator to avoid advancing the
needle towards the nerve in an otherwise blind fashion.

Nerve blockade specific

Current generators used in assessing recovery of muscle relaxation
should not be used in locating nerves for blockade because of
the possibility of high intensity currents (sometimes >150 mA),
causing neural damage at close approximation to the nerve.

Choice of stimulating frequency

Most ENLs deliver electrical impulses at 1 or 2 Hz frequency.
Using 2 Hz frequency allows more frequent feedback to the operator as the needle tip is advancing, allowing more efficient and
faster manipulation of the needle to the nerve. Reduction of
frequency may be useful if stimulation is causing pain at a
fracture site.

Current meter

Connection
to Patient

Fig. 3 An example of a current generator.

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Connection/
disconnection indicator

Current intensity control

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Constant current output

A pulse width of approximately 50100 ms corresponds to chronaxy of Aa motor fibres, preferentially triggering muscle twitching
over pain fibres of longer chronaxy. It is possible to select longer
pulse widths in some ENLs hence aiding location of sensory
nerves.

Electrical nerve locators

Fig. 4 Stimulation current and distance from the nerve, using pinpoint tip insulated needles (e.g. Stimuplex D, Contiplex D).

Stimulating needles

Performing a nerve block

Before performing a peripheral nerve block, it is important to
make sure that all the necessary equipment is present. The patient
should be monitored, i.v. access obtained and resuscitation facilities readily accessible. The ENL should be turned on and checked
according to the manufacturers recommendations, to ascertain
that it is functioning properly. After applying an antiseptic
solution and taking adequate aseptic precautions, the needle is
inserted through the skin. At this point, it is very important to
check if the electrical circuit is complete. The nerve locator indicates circuit completion by a flashing light and/or an audible
bleep. Incomplete connection and/or a dry electrode are the commonest causes of circuit disconnection. Failure to check for circuit

Percutaneous electrode guidance

Percutaneous electrode guidance is a novel technique whereby
the desired nerve can be non-invasively pre-located.6 The needle
tip is enclosed in a shielded cylindrical electrode with a 1 mm wide
conductive plate at the distal end which converts the needle tip to
a smooth skin surface electrode. A 22G hole at the tip allows
advancement of the insulated needle, once the expected response
to the nonpenetrating stimulation is elicited. This technique is still
in its infancy, and it may decrease the number of invasive needle
passes and hence improve safety.

Acknowledgement
The authors would like to thank B. Braun Medical for permission
to reproduce Figures 1, 2 and 4.

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Purpose designed thin insulated needles are used in conjunction

with the nerve locator to precisely locate the nerve. When a noninsulated needle is used, the current disperses in all directions and
hence a larger current is needed to stimulate the nerve.3 However,
if a needle, which is completely insulated except for the bevel
(Fig. 2) is used, lower currents are required to locate the nerve.
Insulated needles with only the pinpoint tip exposed (e.g. Stimuplex D Needle) may provide even greater accuracy (Fig. 4). However, it may be more difficult to locate the nerve with these needles
as the current density is very focused. The non-cutting tip of the
needle reduces the chance of nerve damage should the needle
accidentally touch the nerve.
Needles are available in varying lengths (commonly 50, 100
and 150 mm) and widths (2220G, respectively), according to the
depth of tissue plane required for a particular block. A superficial
nerve requires only a short, thin needle. The increased width of a
longer needle provides more tensile strength and thus directional
control. Larger diameter needles may be used in particular
circumstances although it may increase the possibility of tissue
damage, for example, 18G Tuohy needles used in catheter kits.
The needle has an insulated cable, which prevents current leakage. This is connected to the cathode end of the ENL. The extension tubing from the needle is necessary to provide an immobile
needle injection technique. This should be connected to the syringe
containing the local anaesthetic and flushed before performing the
block to avoid injecting air, which may cause a patchy block.

completion increases potential for neural damage (especially when

performing nerve blocks in unconscious patients).
Once the desired twitch is obtained, the needle is carefully
manipulated, whilst reducing the current until the twitch disappears. Persistence of twitching at a current <0.2 mA may indicate
possible intraneural needle placement. Obtaining a twitch at a
current <0.4 mA but not <0.2 mA is a popular technique. A recent
study indicated that seeking twitches with currents lower than 0.9
mA may not necessarily increase block success rates.4
The needle is now held immobile and 1 ml of the local anaesthetic is injected. At this point the twitching should disappear. The
mechanism for the immediate disappearance of the twitching is
not a result of the local anaesthetic blocking the nerve, but the
mechanical displacement of the nerve away from the needle tip.5
Failure of the twitching to disappear or severe pain experienced by
the patient who is awake at this stage may indicate intraneural
needle placement. The needle should be withdrawn slightly as
intraneural injection may also result in permanent neural damage.
Failure of twitching to disappear after injection of 1 ml may also
be because of intravascular needle tip placement. Over vigorous
aspiration should therefore be avoided. Once it is confirmed that
the needle tip is not inside a nerve or a vessel, the rest of the local
anaesthetic is injected slowly and the needle is safely removed.
Separate kits are available to place catheters next to the
nerves or plexus after electrical location for continuous infusion
techniques (e.g. Contiplex).

Electrical nerve locators

References

4. Franco CD, Domashevich V, Voronov G, Rafizad AB, Jelev TV. The

supraclavicular block with a nerve stimulator: to decrease or not to
decrease, that is the question. Anesth Analg 2004; 98: 116771

1. Selander D, Edshage S, Wolff T. Paresthesiae or no paresthesiae?

Nerve lesions after axillary blocks. Acta Anaesthesiol Scand 1979; 23:
2733

5. Raj PP, Rosenblatt R, Montgomery SJ. Use of the nerve stimulator for
peripheral blocks. Reg Anesth 1980; 5: 1421

2. Tulchinsky A, Weller RS, Rosenblum M, Gross JB. Nerve stimulator

polarity and brachial plexus block. Anaesth Analg 1993;
77: 1003

6. Urmey W, Grossi P. Percutaneous electrode guidance: a noninvasive

technique for prelocation of peripheral nerves to facilitate peripheral
plexus or nerve block. Reg Anesth Pain Med 2002; 27: 2617

3. Bashein G, Ready LB, Haschke RH. Electrolocation: Insulated versus

non-insulated needles. Anaesth Analg 1984; 63: 91924

Please see multiple choice questions 2529.

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