NERVE CONDUCTION

VELOCITY

By: mansiPatel

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Introduction
 The Nerve Conduction Study (NCS) is a
electrodiagnostic test commonly used to evaluate
the function, especially the ability of electrical
conduction of the sensory and motor nerves of
the human body.
 These studies assess the ability of peripheral
nerve to conduct electrical impulses by recording
the evoked potential generated by electrical
stimulation of a peripheral nerve.

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Uses of NCS

 To assess the amount of denervation in the

muscle.
 To detect which fiber is
affected.[Sensory/Motor)
 To find out the location of peripheral lesion and
how many peripheral nerves are affected.
 To assess the progression of lesion whether
degenerating or recovering.
 To find out localized nerve block/ axonal
degeneration/ segment demyelination.

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INSTRUMENTATION
 Recording NCV/EMG requires a system that
includes three phases:
1. Input phase
2. Processor phase
3. Output phase

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Input Phase

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ELECTRODES

 Recording electrode
 Active recording electrode
 Reference electrode
 Ground electrode
 Stimulating electrode
 cathode (active) directed towards the recording
muscle
 anode (inactive)

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SURFACE ELECTRODES

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GROUND ELECTRODES

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RING ELECTRODES

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STIMULATING ELECTRODES

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CONCENTRIC NEEDLE
ELECTRODE

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PROCESSOR PHASE- AMPLIFIER

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PROCESSOR PHASE
 DIFFERENTIAL AMPLIFIER

 Small myoelectric signals amplified to be large

enough to be displayed
 Noise is cancelled out

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PROCESSOR PHASE
 FILTERS

 Nerves and muscles respond physiologically at

particular frequency ranges
 “noise” can be removed electronically from

excitable tissue signal by an electronic device

called FILTER

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PROCESSOR PHASE
 Notch filter – eliminates DC and 60Hz AC line
noise. It passes a band of frequencies less than
and greater than 60Hz

 High-pass filter – keeps the high frequency

signals and filters out low frequency signals

 Low-pass filter – keeps the low frequency

signals and rejects the higher frequencies

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PROCESSOR PHASE
 INTEGRATORS

 Calculation of an area under a signal waveform

 Unit – volt-seconds

 Applies to full wave rectified signals, rectified

value is always positive

 Used in quantitative analysis

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OUTPUT PHASE
 Amplified signals displayed on a monitor, heard
on a speaker
 Sample and data can be stored and analyzed

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VARIABLES AFFECTING THE
NERVE CONDUCTION STUDY

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 1) Age: The nerve conduction velocity in a full
term infant is nearly half of the adult value. As
the myelination progresses, the nerve conduction
velocity attains the adult value by 3-5 years of
age.
 2) upper versus lower limb :-The median and
ulnar nerve conduction is higher compared to
tibial and peroneal. An inverse relationship
between height and nerve conduction velocity
suggests that the longer nerves conduct slower
than the shorter nerves (Campbell 1980).

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 3) Temprature:Low temperature results in slowing
of nerve conduction velocity and increases the
amplitude.
 The laboratory temperature, therefore, should be
maintained between 21-23ºC.
 If skin temperature is low , the limb should be
warmed by infrared lamp, by warm water
immersion or making appropriate correction of
the results.

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  Nerve Conduction Study consist of:
1. Motor NCS
2. Sensory NCS
3. F- wave study
4. H- reflex study

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1) Motor NCS
 Motor NCS are performed by electrical stimulation
of a peripheral nerve & recording from a muscle
supplied by the nerve.

 Principles:
 Motor NCS are performed by stimulating a
peripheral nerve at two or more points &
recording muscle action potentials with a pair of
surface electrodes: active placed on the belly of
the muscle and inactive lead placed on the
tendon.

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 The time it takes for electrical impulses to
travel from the stimulation to the recording
site is measured.
◦ This value is called latency which is measured in
milliseconds (ms)
◦ The size of the response called amplitude is also
measured in millivolts (mV)
◦ By stimulating two or more different location along
the same nerve, the NCV across different
segments can be determined

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Recording settings:
 Filter setting= 5Hz-10KHz
 Sweep speed= 2-5 ms/devision
 Wave form= square wave
 Pulse duration= 0.1ms
 Intensity= 5-40mA (Supramax 100 mA)

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Procedure
 Explanation about procedure in brief to the
patient.
 Position the patient comfortably and the part to
be tested to be firmly supported.
 Lower the skin resistance.
 Surface electrode are placed with gel which also
provide an interface between patient and
equipment.
 The surface recording electrode is placed in
muscle belly.

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 The reference electrode is placed over the
tendon distal to active electrode[4cm]
 The ground electrode is placed between the
stimulating and recording electrode.
 Stimulating electrode:
 Cathode [Black] is directed towards the
recording electrode to stimulate the
depolarization towards the muscle.
 Anode [Red] is an inactive electrode.

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 Stimulate the nerve at least two points
along its course.
 It is important to ensure supramaximal
stimulation keeping the cathode close to
active recording electrode, to stimulate
depolarization towards the muscle. This
prevent hyperpolarization effect of anode
and anodal conduction block.
 Stimulus intensity starts low, and is slowly
increased until the action potential is
clearly observed.
 A biphasic action potential with initial
negativity is thus recorded.
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Parameter of MNCS
1) Onset latency: this is the time require for an
electrical stimulus to initiate an action potential
 It is the time from the stimulus to the first
negative deflection of CMAP.
 It measure of conduction in the fastest
conducting nerve fibers.
 It also include neuromuscular transmision time
and propagation time

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2) Amplitude: it is measured from baseline to
negative peak [base to peak] or between
negative and positive peek[peak to peak]
 It correlates with the number of nerve fibers
activated and their synchronicity of firing.
 Nerve pathology decrease the amplitude

3) Duration: it is measured from the onset to

negative or positive peak or final return to
baseline
 It correlate with density of small fiber.
 Nerve pathology increase the duration of CMAP

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Nerve conduction velocity: this is the speed
an impulse travel along a nerve and is
primarily dependent on the integrity of the
myeline sheath
 It is calculated measuring the distance
between two points of stimulation in mm
which is divided by the latency difference in
ms.
 The never conduction velocity is expressed as
m/sec.
 The distance between the two stimulation
points should be measured from cathode to
cathode not from cathode to anode
 Conduction velocity = D (m/sec)
PL-DL
(PL =proximal latency in ms, DL=distal latency in ms
D= distance between proximal and distal stimulation in mm)
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ELECTRODE PLACEMENT

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 UPPER LIMB
◦ 1.Median nerve : Abductor pollicis brevis
◦ 2.Ulnar nerve : Abductor digiti minimi
◦ 3.Radial nerve : EPL / APL
 LOWER LIMB
◦ 1.Common peroneal nerve : Extensor digitorum
brevis
◦ 2.Tibial nerve : Abductor Hallucis

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1) MEDIAN NERVE

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2) ULNAR NERVE

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3) RADIAL NERVE

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4) POSTERIOR TIBIAL
NERVE

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5) COMMON PERONEAL NERVE

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Normal Value of MNCV
◦ UPPER LIMB
 1.Median nerve : 58 to 61 m/s
 2.Ulnar nerve : 59 to 61 m/s
 3.Radial nerve : 62 to 71 m/s
◦ LOWER LIMB
 1.Common peroneal nerve : 48 to 51 m/s
 2.Tibial nerve : 48 to 51 m/s

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2) Sensory NCS
 Sensory conduction can be measured
orthodromically or antidromically
 Orthodromic – distal portion of nerve is
stimulated and SNAP is recorded at a
proximal point along the nerve
 Antidromic – nerve is stimulated proximally
and SNAP recorded distally.
 For orthodromic conduction, ring electrodes
are preferred to stimulate the digital nerve,
whereas surface stimulating electrodes are
commonly used for antidromic stimulation.

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 SNCS recording settings:
◦ Filter settings: 10 Hz - 2 KHz,
◦ Sweep speed 1-2 ms /divison and
◦ Gain 1-5 μv/division.

 Parameter:
◦ Latency
◦ Amplitude
◦ Duration
◦ Conduction velocity

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ELECTRODS PLACEMENT
 UPPER LIMB
◦ 1.Median nerve : Index finger
◦ 2.Ulnar nerve : Little finger
 LOWER LIMB
◦ 1. Sural nerve : 10 cm above LM
◦ 2. Medial plantar nerve : Great toe
◦ 3. Lateral plantar nerve : little toe

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1) MEDIAN NERVE

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2) ULNAR NERVE

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3) SURAL NERVE

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4) Medial and Lateral plantar
nerve

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NORMAL VALUE OF SNCV
 UPPER LIMB
◦ 1.Median nerve : 50-60 m/s
◦ 2.Ulnar nerve : 50-60 m/s
 LOWER LIMB
◦ 1. Sural nerve : 45-55 m/s

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Abnormality findings in NCV
study
 In peripheral nerve injury:
 3 type of nerve injury: if NCV study is

performed within 3-7 days of injury, normal

values will be obtained, as degeneration is
not started.

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Neuropraxia Axonotmesis Neurotmesis
[Type-1] [Type-2] [Type-3]

1) Conduction block: 1) Partial No action potential

Latency: Prolonged denervation is elicited
Amplitude: decreased Reduced
across the site of injury. amplitude with
Velocity: decreased the stimulation
above the level of
2) Demyelination: lesion and normal
Latency: Prolonged Velocity and
Amplitude: Normal latency
Velocity: Reduced
2) Complete
denervation:
Absence of CMAP
in the distribution
of the nerve

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