INVESTIGATIONS IN NEUROLOGY
Clinical neurophysiology
Adrian J Fowle
Abstract
Clinical neurophysiology is a diagnostic discipline concerned with
measuring electrical activity in the central nervous system, peripheral
nervous system and muscle. Patients of all ages and severities of con-
dition are referred by many different specialties in primary and second-
ary care. Three main categories of investigation are offered, each of
which has basic and more advanced tests. Electroencephalography
(EEG) is usually a recording of cortical activity. Its principal use is in
managing epilepsy, particularly in classification; it has an increasing
role in assessing disorders of consciousness and other brain disor-
ders. Nerve conduction and electromyography (EMG) studies are pri-
marily tests of peripheral nervous system and muscles, and are
often lumped together as ‘EMG’. They are most sensitive to focal
and systemic disorders of large fibre peripheral nerves. They have a
lesser role in small fibre neuropathy, radiculopathy and muscle dis-
ease. Evoked potentials are a small and specialized category with a
variety of infrequently used but important tests. Understanding in
which cases neurophysiology can help and the effect on the patient
is key to a proper collaboration between clinical neurophysiology
and referring departments. There are few adverse effects or
contraindications.
Keywords Electroencephalography; electromyography; encepha-
lopathy; entrapment neuropathy; epilepsy; evoked potentials; intra-
operative monitoring; motor neurone disease; nerve conduction
studies; peripheral neuropathy
Introduction
Clinical neurophysiologists measure electrical activity of the
brain, spinal cord, peripheral nerves and muscles for diagnosis,
monitoring and prognosis. In some countries, including the UK, it
is a medical monospecialty; in other countries, doctors provide
parts of the service to patients whom they also treat. Most de-
partments include healthcare scientists.
Many specialties refer to clinical neurophysiology, chiefly
neurology, paediatrics and musculoskeletal services. Most pa-
tients are outpatients. Patients in intensive therapy units and
operating theatres, and undergoing specialist inpatient assess-
ments of epilepsy, are small in number but high in cost and
complexity. Ages range from premature babies upwards, and
severities from minor ailments to life-threatening illnesses.
The main subdivisions are electroencephalography (EEG),
electromyography and nerve conduction studies (EMG and NCS
Adrian J Fowle FRCP BSc is a Consultant Clinical Neurophysiologist at
the Whittington Hospital, London, UK, Clinical Governance Lead for
Mediservices Healthcare and President of the British Society for
Clinical Neurophysiology. Competing interests: Dr Fowle consults for
a small private medical services firm, Mediservices Healthcare, mainly
as Clinical Governance Lead.
MEDICINE 48:8
Key points
C Electroencephalography measures cortical activity to assess
epilepsy and disorders of consciousness
C Nerve conduction studies and electromyography assess focal
lesions in the peripheral nervous system and generalized
disorders of peripheral nerve and muscle
C Liaison between referrer and clinical neurophysiologist is key
to referring appropriately
C Neurophysiological data must be interpreted in the patient’s
clinical context
C Patients tolerate these tests well if they are explained properly
e or just EMG), and evoked potentials. Intraoperative monitoring
is often considered separately as a particular application of other
techniques.
Neurophysiological tests are cheap, portable and quick in
comparison to many complementary investigations and can have
higher temporal resolution. Interpretation in the patient’s clinical
context is essential.
Electroencephalography
Procedure
Most EEGs are recordings of cortical activity from scalp elec-
trodes. The procedure takes about an hour to obtain a 20-minute
recording. The patient is awake but relaxed and has their eyes
closed.
Hyperventilation and photic stimulation with lights flashing at
different frequencies are common activation procedures to in-
crease sensitivity. These carry slight risks of causing a seizure
and require the patient’s consent. Sleep is the third common
activation procedure and needs a longer recording time e much
longer for a child with autism.
Most recordings are inter-ictal. Generalized toniceclonic sei-
zures are rare in EEG departments.
Variants of EEG
 The multiple sleep latency test consists of four or five
EEGs every 2 hours as a test for narcolepsy.
 In ambulatory EEG, the patient wears a recorder while
they go about their normal routine.
 Video-telemetry as an inpatient or ambulatory procedure
is a recording of one or more days using video to correlate
clinical attacks with electrographic changes.
 Subdural grids or depth electrodes can be used in pre-
surgical work-ups of patients with epilepsy and even dur-
ing surgery (electrocorticography).
What to tell your patients
EEG is a passive test and does not ‘do anything’ to you. There is
sometimes mild discomfort when the electrodes are applied, and
550 Ó 2020 Published by Elsevier Ltd.
 INVESTIGATIONS IN NEUROLOGY

you will want to wash out the adhesive paste. Uncommonly,
longer term recording can cause skin reactions. Activation pro-
cedures can cause seizures, but this is best discussed with the
clinical neurophysiology team.
There are few contraindications other than the above.
Applications
EEG is a tool for measuring both events and states in the brain
(See Figure 1 and Table 1). In epilepsy it is often overused
because of misunderstanding of its sensitivity and specificity.
Nerve conduction studies and electromyography
Procedure
‘EMG’ is often used to cover both NCS and EMG. Patients should
be relaxed and neither shivering or sweating.
Basic nerve conduction studies
The median, ulnar, radial, sural, peroneal and tibial are the most
commonly tested nerves. The amplitude of the response is
mainly determined by the number of axons working, and con-
duction velocity by the integrity of the myelin sheath.
Amplitude asymmetry of up to 50% may be normal in
some circumstances. Velocities are affected by cold,
particularly distally, so the limbs should be warmed first. Com-
parison between results obtained from different departments is
difficult.
In sensory NCS, stimulation and recording are both performed
on a nerve. The resulting potential is of the order of microvolts
and easily swamped by muscle activity. Several samples are
averaged. Velocity is easily calculated from the latency of the
response and the distance travelled.
In motor NCS, the nerve is stimulated and the recording made
over a muscle. Responses are usually in the order of millivolts
and do not need averaging. There is a neuromuscular junction
(NMJ) between the most distal stimulation point and the muscle,
which makes velocity measurements in this segment meaning-
less. Instead the distal motor latency is used as a guide to ve-
locity. It is usual to stimulate at several sites, with the recording
site constant; velocity can be calculated in more proximal
segments.
Only large nerve fibres are assessed. Small fibre techniques
are not uniformly accepted and are not considered here.

10–20 standard Normal EEG

electrode positions

Left Right

Fp1 Fp2

F7 F3 Fz F4 F8

A1 T3 C3 Cz C4 T4 A2

T5 P3 Pz P4 T6

01 02

The international 10–20 system

for electrode placement. Even
numbers on right, z for midline
Fp, prefrontal; F, frontal;
C, central; P, parietal; O, occipital;
The author at about 42 years of age
T, temporal; A, auricular.

Examples of abnormal EEGs

Regular 3 Hz spike wave Focal discharges in Encephalopathy in 70-year-old

discharge in a 17-year-old a 15-year-old female female with postoperative
male with JME with MTS complications

Figure 1

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 INVESTIGATIONS IN NEUROLOGY

Applications of EEG
Indication Utility

Epilepsy diagnosis Usually unhelpful. In most cases, the diagnosis is a clinical one (see text)
Non-epileptic Can help distinguish epilepsy from non-epileptic attack disorder. Some patients have both
attack disorder
Epilepsy classification Main use of EEG is classification of seizure type, epilepsy type and syndrome. Can require several EEGs
Prognosis Stems from classification and number of seizures
Repeat EEG Unhelpful once classification established, unless seizures change
Syncope Contraindicated unless there are clinical features suggesting epilepsy
Daydreaming In children, some have childhood absence epilepsy
Aggression Most aggressive teenagers are just that. It rarely signifies temporal lobe epilepsy
Brain lesions Occasionally useful when neuro-imaging is not available
Agitated or unconscious Some have non-convulsive or subclinical status epilepticus. A good clinical examination is required to make a
useful referral
Anti-epileptic drugs Not useful for monitoring therapy except in status epilepticus. Can help predict successful withdrawal, particularly
in children
Driving, flying The UK’s DVLA for civilian and commercial drivers and CAA for pilots have complex rules. EEG can form part of
assessment
Unconscious or EEG may show encephalopathy or status epilepticus
failure to wean in
intensive care
Cardiac arrest EEG and SSEPs can offer prognosis in hypoxiceischaemic encephalopathy. They have been required more
commonly since the introduction of percutaneous coronary intervention
Encephalopathy, All show slowing of EEG so clinical context is important. EEG has periodic complexes in CreutzfeldteJakob disease,
delirium, dementia, but not in Alzheimer’s disease
sleep
Psychiatry Major illnesses have only non-specific abnormalities. EEG may be useful to exclude epilepsy, encephalopathy and
dementia. Antipsychotic drugs can cause EEG changes that look like epilepsy

CAA, Civil Aviation Authority; DVLA, Driver and Vehicle Licensing Agency; SSEP, somatosensory evoked potential.

Table 1

Variants of nerve conduction studies patient cooperation is required. Interpretation is based on an

 Late responses to motor (f wave) and sensory (h reflex)
stimulation, both recorded over muscle, can give some
indication of proximal disorders and are useful in demye-
linating neuropathies such as GuillaineBarre syndrome.
 Repetitive stimulation of 10 pulses at 3 Hz usually results
in similar responses to each pulse. In NMJ disorders, the
amplitude of the response falls and then rises again.
 Stimulation of the orbital nerve and recording from the
facial muscles is used in the blink reflex to study cranial
nerves and brainstem.
 Magnetic stimulation of the cortex or nerve root, with
recording (see O’Brien in Further reading) over muscles,
extends the NCS concept to include some central nervous
system measurements.
Basic EMG
EMG needles record from a small volume of muscle in contact
with the specialized tip. Recordings are analysed by inspection or
digitally. Examination of each muscle is performed at rest, with
minimal contraction and maximal voluntary contraction, so
understanding of the pathophysiology and time course of nerve
and muscle injury and repair. EMG is more sensitive in neu-
ropathy than myopathy.
Choosing muscles for EMG in focal lesions requires studying
muscles with different nerve and root innervation. In systemic
illnesses, it is more useful to think of proximal and distal. There
is a huge variation between practitioners in the number and sites
of needle insertions used.
Variants of EMG
Single fibre EMG is used for NMJ disorders such as myasthenia
gravis. It examines the ‘jitter’ of a single NMJ. Originally per-
formed with an expensive, complex, reusable needle, the test is
now imitated using ordinary, single use needles with some un-
certainty about performance.
What to tell your patients
NCS are like testing house wiring. A mild electric shock is given
at one end of the nerve and the result measured along the nerve.
Some of them make muscles jump. It may be necessary to put

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 INVESTIGATIONS IN NEUROLOGY

very small needles in your muscles to record natural activity.
Most people find this odd and some find it mildly uncomfortable.
It is rarely very painful. NCS have no after effects. Needle EMG
may cause minor discomfort for 24 hours.
Patients with pacemakers are safe in most situations. Those
with implantable cardiac defibrillators are not known always to be
safe so ideally the defibrillator should be switched off and the test
performed under cardiological monitoring. Warfarin is generally
safe but other anticoagulants are not known to be safe and muscles
should be chosen accordingly. Neither pregnancy nor widespread
skin lesions, such as in a burns unit, are a contraindication.
Applications
EMG/NCS is very good at diagnosing some conditions and poor
at diagnosing others that are apparently similar (See Figure 2 and
Table 2). Consult your local department if in doubt.
Evoked potentials
These are mainly specialized techniques and are not considered
in depth here.
Visual evoked potentials (VEPs) are measured over the occip-
ital cortex in response to light flashes or reversal of a chequerboard
pattern. In ophthalmology they are often combined with surface
recordings of retinal potentials e electroretinography (ERG).
Auditory evoked potentials (AEPs), which are also known as
brainstem auditory evoked potentials (BAEPs) or brainstem
auditory evoked responses (BAERs), are recorded in response to
clicks. Brainstem responses are usually used in audiology and
operative monitoring. The later cortical responses are of interest
to psychologists.
Somatosensory evoked potentials (SSEPs or SEPs) are recor-
ded over the sensory cortex in response to stimulation of a

Sensory Nerve Conduction Traces Data

Studies: Anatomy -Pk
MEDIAN - CTS
Stimulus Recording Amplitude Velocity
On End
+ + +
+Pk+ + +
Site Site Microvolts m/s
+ + + + + +
Index Right Wrist 7.4 41.5
On
-Pk
Little Right Wrist 6.0 55.9
Index Left Wrist 6.2 34.3
+ + + + + +
Little Left Wrist 7.7 50.0
-Pk
On
Ring Right Wrist Biphasic
+Pk
+ + + + + +

S-NCS data showing slight slowing in right median

+

On
+
-Pk + + + + nerve, moderate slowing in left median nerve (index
+Pk
+ + + + + +

+ + + + + +
a biphasic potential in mild carpal tunnel syndrome.
+ + + + + +
Normal velocity in the arms is > 50 m/s
Stimulation of right index
S-NCS recordings from:
Earth strap on palm.

Motor Nerve Conduction

Studies: Anatomy Traces Data
Stimulus Recording Amplitude Latency Velocity
1 +
3 + 5+ + +
Site Site Microvolts ms m/s
4 Wrist Right APB 11.4 3.75
+ + + + +
Elbow Right APB 10.0 57.0
2
Wrist Left APB 9.7 5.20
+ + + + +

1 3 5
Elbow Left APB 8.6 59.7
4
+ + + + +
M-NCS data showing normal latency at right wrist,
increased latency at left wrist. Forearm conduction
+ + + + +

2 velocity is normal on both sides.

1+ 3+ + 5 + +
4
These data show bilateral carpal tunnel syndrome, slight
+ + + + +
(grade 1/6) on Canterbury scale – see Bland) on the right and
moderate (grade 3) on the left side.
+ + 2 + + +

Stimulation of median Stimulation at elbow, 1 3 5

4
nerve at right wrist, recording as before + + + + +

recording over APB

muscle M-NCS recordings from:
Stimulation at right wrist (Top trace)
Stimulation at right elbow (Second trace)
Stimulation at left wrist (Third trace)
Stimulation at left elbow (Bottom trace)

Figure 2

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 INVESTIGATIONS IN NEUROLOGY

Applications of NCS and EMG

Clear indications Utility

Carpal tunnel Commonest referral to EMG departments and often has the biggest effect on patient outcomes. Grading by the
syndrome Canterbury Scale informs treatment by corticosteroid injection or decompression
Ulnar neuropathy Second most common. Distinguish elbow, wrist and other causes and assess severity
Clinically significant If without clear cause and especially if acute, disabling or multifocal. Can distinguish axonal versus demyelinating,
neuropathy acute versus chronic and sometimes hereditary versus acquired
Diseases of EMG is essential in motor neurone disease (MND)). May need repeat examination at intervals. Can distinguish this
motor neurones from radiculopathy and mimics such as MMNCB. No individual feature separates MND from other causes. Essential
in childhood forms
Trauma Crucial role in separating neurapraxia, axonotmesis and neurotmesis, which affects prognosis
Probable indications Neurological assessment before neurophysiology is strongly advised
Other entrapments Many are described. Some are usefully assessed, e.g. common peroneal nerve at the fibular head. Less useful for
others, particularly if only painful, e.g. radial tunnel syndrome
Brachial plexopathies EMG is essential. Distinguishes these from radiculopathy. Can determine prognosis and sometimes cause
Diseases of NMJ EMG is essential
Weakness Focal or generalized weakness of unknown cause. EMG may help
Possible indications Other tests may be preferable
Myopathy Genetic studies and biopsy often more useful, but EMG finding of neuropathy may prevent unnecessary biopsy
Radiculopathy Sensory NCS are usually normal. Neurophysiology often unhelpful in reaching a positive diagnosis in the absence
of wasting and weakness, however bad the pain. Can exclude peripheral entrapment or generalized neuropathy
Focal pain of Limited use
unknown cause

MMNCB, multiple motor neuropathy with conduction block; MND, motor neurone disease.

Table 2

peripheral nerve. SSEPs can assess spinal lesions and meralgia
paraesthetica. In hypoxiceischaemic encephalopathy, such as
after cardiac arrest, bilateral absence of the median nerve SSEP
suggests a poor prognosis. It is technically demanding to record
this, and the presence of one or both potentials does not predict
survival.
Motor evoked potentials (MEPs) are elicited by electrical or
magnetic cortical stimulation and recorded peripherally. They
are used with SSEPs during operative monitoring of spinal
surgery.
Triple EP e VEPs, AEPs and SSEPs e is still sometimes useful
in multiple sclerosis. A
FURTHER READING
Bland JDP. A neurophysiological grading scale for carpal tunnel syn-
drome. Muscle Nerve 2000; 23: 1280e3.
International League Against Epilepsy. Epilepsy diagnosis. https://
www.epilepsydiagnosis.org/ (accessed 20/4/2020).
Neuromuscular Disease Center, Washington University, St Louis, MO
USA. Home page. https://neuromuscular.wustl.edu/ (accessed
20/4/2020).
O’Brien M. Aids to the examination of the peripheral nervous system.
5th edn. Saunders, 2010.

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