KONAS PERDOSSI 2019

SURABAYA
WORKSHOP NEUROFISIOLOGI
Nerve Conduction Study
Ahmad Asmedi
Departemen Neurologi FK UGM/ RSUP Dr Sardjito
Purpose and
Role of NCS
• Provides objective assessment without patient participation (nerve,
neuromuscular junction, and muscle fiber).
• Identifies subclinical disease.
• Defines pathophysiologic process (e.g., demyelinating vs. axonal).
• Localizes focal disease.
• Assesses proximal conduction (e.g., F waves).
• Defines severity of a peripheral disease.
• Defines the extent of a neurogenic injury (e.g., length-dependent peripheral
neuropathy vs. mono-neuritis multiplex).
• Provides prognostic information (e.g., facial CMAP amplitude in Bell’s palsy).
• Follows a disease to assess progression or response to treatment.
Motor NCS
•The motor NCS assess the motor
nerve fibers of the PNS from the
lower motor neurons in the
brainstem and spinal cord to the
muscle fibers that they innervate
Results of the NCS reflect on the integrity and
function of

•The myelin sheath (Schwann cell derived

insulation covering an axon), and
•The axon (an extension of neuronal cell
body) of a nerve.
CMAP
• A compound muscle action potential (CMAP)
• is the action potential recorded from muscle when stimulation
anywhere along the motor pathway is sufficient to activate some or
all the muscle fibers in that muscle.
• The CMAP is the summated activity of the synchronously activated muscle fibers
in the muscle innervated by the axons and motor units represented in that
muscle.

• Therefore, a CMAP provides a physiologic assessment of

• (1) the descending motor axons in the pathway below the level of stimulation,
• (2) the neuromuscular junction, and
• (3) the muscle fibers activated by the stimulus.
Stimulation Points Upper Extremities

Plexus
Axillary

Radial
Median Ulnar
Elbow Above Elbow
Ulnar
Ulnar Median Below Elbow
Wrist Wrist

Median - Ulnar
Palmer
Stimulation Points Lower Extremities

Crural

Sciatic

Tibial
Peroneal Peroneal Popliteal Fossa

Sural Posterior
Tibial
Particular attention is paid to

• Is the fastest conduction velocity normal?

• Is the velocity gradient normal. Normally nerves closer to
the neuraxis and more cephalad conduct faster than more
distal and caudal nerves.
• Is the CMAP normal in size and shape?
• Does the CMAP alter in size, shape or duration between
stimulation points?
– giving evidence for temporal dispersion
– giving evidence for conduction block
Stimulation effects
CMAPs were
recorded from
small
electrodes in
multiple
locations in 839
grids over the
thenar and
hypothenar
muscles
Location of Recording Electrode
• Recording electrode type and location in a laboratory should be
consistent and have well-defined normal values. Different types
of recording electrodes should have normal values and should
be used only for defined clinical purposes.
• Active recording electrodes (G1) should be placed at the site of
maximal amplitude with no positivity. G1 electrode is mis-
positioned off the muscle end plate if there is an initial
positivity.
• Inactive (reference) electrodes (G2) should be placed over the
tendon (G1–G2 fixed distance placements are not reliable).
 nervus recording from
1 median thenar eminence
median second lumbrical
2 ulnar hypothenar eminence
ulnar frst dorsal interosseous
3 peroneal extensor digitorum brevis
peroneal tibialis anterior
4 tibial abductor hallucis
tibial digiti quinti pedis
5 the suprascapular infraspinatus
6 axillary the deltoid
7 musculocutaneous biceps
8 proximal radial extensor aspect of the forearm the second
lumbrical
9 distal radial the extensor aspect of the forearm,
extensor pollicis brevis
10 femoral the rectus femoris
Both these traces show demyelination in median motor studies. The trace on the left shows almost complete
conduction block with an absent response with proximal stimulation. The trace on the right shows temporal
dispersion where the CMAP duration increases by almost 40% with proximal stimulation. In both situations the
CMAP amplitude with proximal stimulation is smaller.
Schematic representation of phase cancellation and temporal dispersion in
demyelination. In the normal nerve, the responses are synchronised in time and
therefore summate (amplitude is higher that that of the individual components).
Temporal dispersion results in an increased duration and reduced amplitude of CMAP.
SENSORY NCS
Purpose and Role of SNAPs

• Provide objective evidence of the integrity of the

peripheral sensory nerves.
• Assist in identifying and localizing mononeuropathies.
• Used to assess sensory involvement in generalized
peripheral neuropathies.
• Helps to distinguish lesions of the spinal roots
(preganglionic) from lesions of the plexus
(postganglionic).
•The sensory NCS assesses the
sensory nerve fibers of the PNS
from the dorsal root ganglia (DRG)
to the stimulating or recording
electrodes (whichever set is more
distal).
Sensoric
Neurons
AHC
DRG
Roots
Rami
Ventral Rami: Plexus
Dorsal Rami : Paraspinals
Dorsal Root ganglion: Bipolar Nerve cell

One projection
central
Dorsal column

Other axon distal

Sensory end
organ
• SNAP testing needs to be performed in the distribution of the
sensory deficits.
• The SNAP remains preserved in radiculopathies.
• The SNAP is abnormal in clinically affected distributions in
plexopathies.
• SNAPs are very sensitive at detecting mononeuropathies.
• SNAPs are normal in common myopathies and disorders of
the neuromuscular junction.
• SNAPs are normal in ALS and spinal muscular atrophy;
abnormal SNAP in a male patient with motor neuron disease
should raise suspicion for Spinal and bulbar muscular atrophy
(SBMA).
the disturbance
Typical nerve conduction study abnormalities
seen with axon loss or demyelination
Traumatic nerve injury.
• EDX provides valuable information about prognosis in
traumatic nerve injury.
• Neuropraxic injury presents with conduction failure
without axonal degeneration and carries best
prognosis for recovery
• Axonotmesis and neurotmesis affect the axon and can
not be differentiated during the initial study.
Facial neuropathy
•CMAP amplitude compared to the
contralateral side is the best parameter in
estimating the severity and prognosis of
patients with facial neuropathy (5 to 8 days
after onset)
Radiculopathy.
• Cervical and lumbar radiculopathies are among the most
common diagnoses of patients referred to the
electrophysiology laboratory.
SNAPs are most useful in confirming that the lesion is
preganglionic (i.e., intraspinal).

• EMG and NCSs have little prognostic value in radiculopathy

when compared to clinical and psychosocial factors.
• These studies are used mostly in evaluating for presence of a
superimposed process such as polyneuropathy.
Mononeuropathy
• Focal neuropathies, carpal tunnel syndrome (CTS) and ulnar
neuropathy are precisely evaluated with NCS.
• The severity of CTS is graded based on changes of the sensory and
motor potentials, which aids in determining the need for surgery.
• The NCSs improve with therapeutic interventions for carpal tunnel
syndrome, including splinting, steroid injections and surgery.
• Ulnar neuropathy at the elbow and peroneal neuropathy at the
fibular head are also localized with these studies but their correlation
with clinical improvement after surgery is less well established.
Neuropathy.

NCSs do not contribute significantly in the prognosis of

the axonal polyneuropathies.
However, studies have shown a role in evaluating
the response to therapy in diabetic polyneuropathy.
Similarly, follow-up studies demonstrate recovery from
toxic, alcohol-related and nutritional neuropathies.
Improvement of the conduction velocity and CMAP
amplitude has been used to demonstrate
improvement in clinical trials
Neuromuscular junction disorders
•RNS is much less sensitive and is normal in
remission.
•Abnormal decrement is more likely in
generalized than in ocular MG
Motor neuron disease
• NCSs are important to exclude mimickers of ALS, such
as MMN, radiculopathy, mononeuropathy,
polyneuropathy and others.
• ALS patients have normal sensory studies unless there
is an underlying problem.
• Another typical finding that correlates with the
prognosis but lacks sensitivity is the decrease of the
CMAP amplitude.
 IMPORTANT CONSIDERATIONS

• The EDX must be done in conjunction with a careful

neurological history and examination.
• The study should be tailored depending on the
differential diagnostic possibilities.
• When the examination and the EDX findings are
conflicting, the examiner should re-evaluate the
patient and consider the possibility of a technical
problem.
TERIMA KASIH
CONDUCTING STUDY

• 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
H-reflex/F-wave Testing
• Late response (H-reflex and F-wave testing) testing is a type of NCS usually
performed on nerves more proximal to the spine.
• The H-reflex involves conduction from the periphery to and from the spinal
cord. The H-reflex study involves the assessment of the
gastrocnemius/soleus muscle complex in the calf, and is usually performed
bilaterally due to the need to assess symmetrical results in determining
abnormalities.
• The F-wave study is a late response similar to the H-reflex. F-wave studies
are used to assess the proximal segments of the motor nerve function, and
are performed in combination with the examination of
motor nerves.
F-Waves Ulnaris Nerve
Voluntary
contralateral M F
Rec. motor action
to facilitate F

Stim. F

block

F Latency 30 to 50 ms
Minimum F latency is normally measured
 H reflex
Stimulation: 6.4 mA
6.2
6.0
5.8
5.6
5.4
5.2
5.0
4.8
4.6
4.4
4.2
4.0
3.8
3.6
3.4
3.2
3.0
0.0
Motor
Dur.: 1 ms
Int. from 0 mA
Sensory
H to M Max.

Increment
step 0.2 mA
H Max Ampl.

H Stim.

Rec. M Max Ampl.

Sensory nerves are more sensitive than

motor nerves, they need less current
Latencies M: 10 ms H: 30 ms depends on height
In order to establish the necessity for
special diagnostic testing, one needs to
consider at least the following:

oIs there historical/ physical examination/ suggested?

oFor nerve function tests specifically, was a neurological
examination of reflexes, sensory integrity, and motor
function were findings indicative of nerve insult?
o Would the information or clarification anticipated from the
results of the special tests influence treatment planning?
oIs the test most appropriate to whom the patient should be
referred?
• Motor NCSs are performed by applying electrical stimulation at
various points along the course of a motor nerve while recording the
electrical response from an appropriate muscle. Response parameters
include amplitude, latency, configuration, and motor conduction
velocity.
• Sensory NCSs are performed by applying electrical stimulation near a
nerve and recording the response from a distant site along the nerve.
Response parameters include amplitude, latency, and configuration.
• Mixed NCSs are performed by applying electrical stimulation near a
nerve containing both motor and sensory fibers (a mixed nerve) and
recording from a different location along that nerve that also contains
both motor and sensory nerve fibers. Response parameters include
amplitude, latency, configuration, and motor conduction velocity."
Types of CMAP Recording Electrodes