Nerve Conduction Studies

Nerve Conduction Studies and Somatosensory Evoked Potentials
Study Guide
Instructor-William Aldrich, Ph.D., CCC-A
4
Cadwell Educational Programs
Copyright 1992 by Cadwell Laboratories, Inc. All rights reserved. Revised January 1993. Cadwell is a registered trademark of Cadwell Laboratories, Inc. Cadwell Laboratories, Inc. 909 North Kellogg Street Kennewick, Washington 99336 Phone:
Fax:
(509) 735-6481 or (800) 245-3001 (509) 783-6503
Nerve Conduction Studies and Somatosensory ~voked Potentials

-
Study Guide
Educational Programs
Neuromuscular Electricity and Instrument Basics
Table of Contents
Neuromuscular Electricity and Instrument Basics ................................................................... I Upper Extremity Motor Studies ................................................................................................. 7 Practicum: Collecting Motor and F Responses in Median a n d Ulnar Nerves .....................1 9 Sensory NCV Measurement ......................................................................................................25 Upper Extremity Sensory Studies ............................................................................................29 Practicum: Collecting Upper Extremity Sensory Responses
................................,... ............35
8
Lower Extremity Motor Studies ................................................................................................4 1 Practicum: Collecting Motor NCV. F Wave. and H Reflex Responses from t h e Lower Extremity ................................................................................................................... 55 Sensory Studies o f the Leg ...................................................................................................... -63 < Practicum: Collecting Sensory NCV Responses from t h e Lower Extremity ........................69 Applications for Nerve Conduction Studies ........................................................................... 73 Averaged Evoked Potential Fundamentals ........................................................................... 77 Somatosensory Evoked Potentials .......................................................................................... 89 Upper Extremity SEP Protocols .......................................................................................... 103 Practicum: Collecting Upper Extremity SEP Responses ....................................................
115
Lower Extremity SEP Protocols ..............................................................................................119 Practicum: Collecting Lower Extremity SEP Responses .....................................................131 References ............................................................................................................................ 135
Cellular Basis of Bioelectricity

Every cell is a battery. The inside is negative (-) and the outside is positive (+).
Nerve and muscle cells are electrically excitable. They can be depolarized by extwnal stimuli. When a large number of cells become electrically active, their combined voltage depends on the number of cells and their distance from the measuring electrode.
Notes
fl
1.
American Electroencephalographic Society: American ElectroencephalographicSociety Guidelines for Clinical Evoked Potential Studies. American Electroencephalographic Society, l992. Aminoff M: Electrodiagnosis in Clinical Neurology, e d 3. Churchill-Livingstone, 1986. Blackhouse KM, Hutchings RT: Color Atlas of Surface Anatomy. Williams a n d Wilkins, 1986. Chiappa K: Evoked Potentials in Clinical Medicine, ed 2. Raven Press, 1990 Chu-Andrews I, Johnson RI: Electrodiagnosis: An Anatomical and Clinical Approach. Lippincott, 1986. Curtis B: Neurosciences: The Basics. Lea a n d Fibiger, 1990. DeGroot 1: Correlative Neuroanatomy, 21 ed. Appleton a n d Lang, 1991.
I
2.
3.
4.
5.
6.
7.
8.
Delisa IA, e t al: Manual of Nerve Conduction Velocity and Somatosensory Evoked Potentials, e d 2. Raven Press, 1987.
1
9.
lohnson EW: Practical Electromyography, e d 2. Williams a n d Wilkins.
10. Kimura 1: Electrodiagnosis in Diseases oJ Nerve and Muscle. F.A. Davis, 1989.
11. Liveson I: Peripheral Neurology, ed 2. F.A. Davis. 1990.

12. Liveson I, Ma DM: Laboratory Referencefor Clinical Neurophysiology. k
. ~Davis. . 1992.
13. Ma DM, Liveson 1: Nerve Conduction Handbook. F.A. Davis, 1983. O u t o f print. 14. McMinn RMH, Hutchings RT: Color Atlas of Human Anatomy. Year Book Medical Publishers, 1979.
15. Oh Shin 1: Clinical Electromyography: Nenre Conduction Studies. University Park Press, 1984.
O u t of print. 16. Pansky, House: Review of Gross Anatomy, Macmillan. 17. Sethi RK, Thompson LL: The Electromyographer's Handbook, e d 2. Little. Brown, 1989. 18. Spehlmann R: Evoked Potential Primer, Butterworth, 1985.
4.
Proceed to test the dermatomes and segmentals for L4,L5,and S I . Use the saphenous nerve at the ankle for L4. Try the sural nerve at the small toe and lateral on the ankle for SI. all responses.
5. Change subject and repeat testing until each member of your group has obtained
11 NISCFILE
10
3.4
RR 2.78
RUE(
250):
250
REJECT
ex
SWEEP 10
Posterior tibia! nerve SEP resporrse.
GRIN/SCALE : RR 2.78 18 6.0 ,.'FIVE( 250):
I
250
REJECT
Sx
SWEEP
10
:
:I
Common peroneal nerve SEP response.
Lower Extremity SEPs

Prepare subject with a single recording channel to midline cortex at Cz'. Channel Active Reference Forehead
Set the appropriate instrument parameters.

Gain
High-cut filter
Low-cut filter Scale Sweep speed Pulse width Repetition rate
10 pvldiv 300 Hz I0 Hz
4
5 msldiv 200 ps 2.71s
Obtain responses from the posterior tibia1 nerve at the ankle and the common peroneal at the popliteal fossa.
Collecting Lower Extremity SEP Responses
Measurements
Measure latencies for both sides at each level and compute the side differences. Side differences greater than 6 ms are abnormal.
Normal Values
I Cutaneous nerve
Lat. fem. cutaneous Saphenous Saphenous Super peroneal Sural
Stim site
Thigh
Segment
Lat
CV
Knee Ankle Above ankle Ankle
Montage
Active Reference Ground
Cz'
FP~
Proximal leg
Stimulation
L4, L5,and S1 nerve roots
Notes
Lower Extremity Dermatomal SEPs (L4, L5, and SI)

Instrument Parameters
Gain High-cut filter Low-cut filter Sweep speed Scale Averages Pulse width Repetition rate
Electrode Placement
Cz'
Fpz
Ground the leg proximal to the stimulation site
Normal Values
Wave
Lat.
CV
30.3 12.6 18.4
Dif
CV
1.69
Cz'
LAS (Cauda equina)
CZ'
27.3 10.8
0.59 0.99 0.6
1.27
1.70
- T12S
1 6 . 5
1 26
Stimulation
Common peroneal nerve at the popliteal fossa Stimulate with sufficient strength to produce a toe twitch
athode node
Common Peroneal Nerve SEP Normal Response

\IN/SCRLE
10 6.0
RR 2,78
RUE(
250):
258
REJECT
5x
Montage
Channel
1
Active
Reference Forehead
Cz'
Stimulated limb proximal to cathode
Common Peroneal Nerve SEP

Gain High-cut filter Low-cut filter Scale Sweep speed Pulse width Repetition rate
I 0 pV/d iv 300 Hz 1 0 Hz
4 5 msldiv
200 ps 2.7/s
Electrode Placement
I
Fpz Cz' T12S TlOS L4S L2S Ground-shin or calf ipsilateral to stimulated leg
Cz'
- -Fpz
Normal Values
1 wave
Cz'
Tl2S L4S (Cauda equina)
PF (Peripheral nerve)
CZ'
Lat.
38.5
2 1.6
18.0 8.4 16.0
Dif.
CV
- T12S
Posterior Tibia1 ~ e r v e at / the Ankle

50
49
Latency vs. ~elght

Legend
--
47-44-
--- m.val
4s-
3 42-3 a . *I-40
1:I:
--
39--
38-37
--
#--
as-.
Height (Meters)
Stimulation
Posterior tibia1 nerve at the ankle Stimulate with sufficient strength to produce a toe twitch.
Ground
Posterior Tibia1 Nerve SEP Normal Response

'GFIIN ~ S C A L E
le
3.4
RR 2.70
A u ~ t 258):
zse
REJECT
ex
SWEEP
1e
Montage
Channel Active
Reference Forehead
o'
I
-.-Stimulated limb proximal to cathode
Posterior Tibia1 Nerve SEP

Gain High-cut filter Low-cut filter Scale Sweep speed Pulse width Repetition rate
10 pV/div 300 Hz 10 Hz 4 5 ms/div 200 ps 2.7/s
Electrode Placement
Fpz
Cz'
Tl2S
TlOS
L4S L2S Popliteal fossa Ground-shin or calf ipsilateral to stimulation site
- Fpz
Lower Extremity SEP Protocols
RINISCALE
10
5.0
RR 2.70
RUE(
250) :
250
REJECT
62
SWEEP
5
SSEP
Ulnar nerve SEP response.
4. Switch from 3 channel to single cortical channel recording and obtain dermatomal
responses from C6, C7, and C8.

5. Change subject and repeat testing until each member of your group has obtained
all responses.
r s and connect the subject to the 2. Set the appropriate instrument paramet 3
preamplifier.
Gain High-cut filter Low-cut filter Sweep speed Pulse width Repetition rate Scale
10 pvldiv 500 kHz 10 Hz 5 msldiv 200 ps 2.71s 2 to4
3. Obtain responses from both the median and ulnar nerves. To save time, only connect for unilateral testing. Remember that in actual testing both sides are always studied.
~FIIN / ~ C A L E
10
2.0
RR 2.70
AWE(
250):
149
REJECT
iz
SWEEP
5
SSEP
Median nerve SEP response.
Median and Ulnar Nerve SEPs

1. Connect t h e recording and ground electrodes for an upper extremity SEP protocol.
Erb's point (ipsilateral)
2 Channel
I Channel
Active
Reference
Channel
- -
Active
C3' or C4' plus lpsi
Reference Fpz
Erb's
2
Spine
3 Channel
Channel
1
FPZ
Active C3' or C4' Spine lpsi Erb's
Reference Forehead
2
3
Channel
Channel
1
Active C3' or C4' C3' or C4' Spine lpsi Erb's
Reference FP~ Contralateral Erb's FP~ Contralateral Erb's
2
3
4
Collecting Upper Extremity SEP Responses
Measurements
Measure latencies for both sides at each level and compute the side differences. Side differences greater than 6 ms are abnormal.
Normal V a l u e s
I
I Cutaneous nerve
Musc. cutaneous Median Median Ulnar
Stim site
Segment
C5 C6
Forearm Thumb Fingers 2 G 3 Finger 5
C7
C8
Notes
Montage
CY dr ~ 4 '
FPz
,
~roxirnal arm
Stimulation
C6, C7,and C8 nerve roots
Notes
Upper Extremity Dermatomal SEPs (C6, C7, a n d C8)

Gain
High-cut filter Low-cut filter Sweep speed Scale Averages Pulse width Repetition rate
Electrode Placement
C3' C4' Fpz
Ground the arm proximal to the stimulation site
Ulnar N e r v e SEP Normal desponse
Normal V a l u e s
Wave Ulnar Nerve
CV
S i d e Diff
CV
Erb's
Cervical Spinc Cortical
S p i n e - Cortex
Erb's S p i n e
Erbvs Cortex
Stimulation
Ulnar nerve at wrist Stimulate with sufficient strength to produce a thumb twitch
Notes
Montage
2 Channel
I Channel
1 2
r
Active
C3' or C4' Spine
Referenc'e
lpsilaterdl Erb's
Channel
Active
C3' o r C4' plus lpsi Erb's
Spine
Reference
Fpz
or
3 Channel
I
.
Active
C3' or C4' Spine lpsi Erb's
I
FPz
Channel
1
Reference
Forehead
4
3
4
Channel
Channel
1
Active
C3' or C4'
Reference
FPz Contralateral Erb's FP~ Contralateral Erb's
I
2
3
4
r C4' C3' o
Spine lpsi Erb's
I
Ch l
rn
J
Ch 2
Ch3
?
\
?
I
?
I
Ch4
Ground Corn Ref
\
Contralateral COrtex (hand area)
Forehead
I
Spine
I
J
I
(C2. ' 3 . or C7)
lpsilaterali
'
Erb's
Contralateral Db's
Ulnar Nerve SEP

Gain High-cut filter Low-cut filter Scale Sweep speed Pulse width Repetition rate 10 pVldiv 500 Hz 10 Hz 2 to 4 5 ms/div 200 ps 2.71s
Electrode Placement
I
Cervical Spine C2, C5, or C7

\
Erb's point (ipsilateral)
Erb's point on the right and left Back of the neck in the midline at C7, C5, or C2 (operator's discretion) Fpz-forehead in the center, at the hairline C3' and C4' (2 cm behind C3 and C4) Ground the arm proximal to the stimulation site
Median Nerve SEP Notmal esponse

, k~l1 MISCALE
k
I
I
18
2.8
RR 2.70
AUE(
250):
i49
REJECT
1x
SWEEP
SSEP
Normal Values
1 Wave
Erb's
Cervical S p i n e
1 Median N e n e
Cortical
Erb's S p i n e
S p i n e Cortex
Erb's Cortex
Stimulation
Median nerve at wrist Stimulate with sufficient strength to produce a thumb twitch,
Notes
Montage
2 Channel
I Channel
1 2
Active
Reference
Channel
Active
Reference
Fpz
Erbs CY o r ~ 4 ' lpsi~ated~ Spine
C3'o r C4'
plus lpsi
Fpz
Erb's
Spine
FPZ
3 Channel
I Channel I
1 2
Active
C3' or C4'
Reference
Forehead
I
Spine lpsi Erb's
4 Channel
Channel
1
Active
C3' o r C4' C3' or C4'
Reference
FPZ
2 3
4
Conttalateral E F P Z
i
Ground Com Ref
Spine lpsi Erb's
Ch 2
Ch3
Ch 4
LContralateral coltex (hand area) Spine lpsilateral Erb's (C2,C5. or C7) Forehead 1 , Contralateral Erb's
Median Nerve SEP

Gain
High-cut filter Low-cut filter
10 pV1div 500 Hz 10 Hz 2 to 4 5 msldiv 200 p i 2.71s
Scale
Sweep speed Pulse width Repetition rate
Electrode Placement
C3' (C4' o n right)
. '
c e r v i c a l Spine C2, C5, o r C7 Erb's point (ipsilateral)
Erb's point o n t h e right and left Back of t h e neck in t h e midline a t C7, C5, o r C2 (operator's discretion) Fpz-forehead in t h e center, a t the hairline C3' and C4' ( 2 cm behind C3 a n d C4) Ground t h e arm proximal to t h e stimulation site
Upper Extremity SEP Protocols
Absolute Latencies
The last step is to assemble the calculations into a convenient table. Assume CV = 2.33 (s.d.). All latencies are in milliseconds.
x
I
1
I
CV
I DIF I
I I
CV
1 Right
The latencies for a particular patient can be entered into the table in the colbmn for right and left side, and the difference between the sides is computed.
To obtain the mean latency, use:
To obtain the sample standard deviatibn (s.d. use:
The critical value for each peak is obtained I ing:
where CV is critical value x is the mean latency s.d. is the standard deviation from the norms z is the normal deviate select'ed to establish the desired false positive role. (See table.)
I
False positive rate

12.33
Calculation: Interpeak Latencies

N19 - N13 N19 - N9
DIF
N13 - N9
DIF
Subject
1 2
R
6.0 5.4
L
6 . 2 5 . 2
R
7 . 8 9 . 0
L
7.5 10.0
R
1 . 8 3 . 6
L
1 . 3 3 . 9
DIF
. 2
.2
.3 1.0
.5 . 3
Note I : These values are obtained by subtraction. Note 2: The s.d. is used to calculate the limit o f normal referred to here as a critical value.
Example SEP ~ d r m s (Median Nerve at WI

Measurements
Defining Abnormal
The following development is based on the assumption of normally distributed values. When this is not so, the analysis of abnormality is more complex. The concept is simple. Normal is a range of values. Anything outside that range is abnormal. The problem comes when attempting to determine the limit of normal. No matter where the limit is set there will always be some normal values outside the limit and some abnormal values inside the limit. These values will be judged in error. When a normal value is outside the limit and judged abnormal, the error is called jake positive. When an abnormal value is inside the limit and judged to be normal. the error is called a false negative. Selection of the limit of normal causes a trade off between these two errors. USually the limit is set by defining the acceptable rate of false positive. Cutoff in s.d. 2.0 s.d. 2.33 s.d.
2.5 s.d.
% Observed
outside cutoff
Rate of false positives '
3.0 s.d. Converting the range of normal specified in standard deviations to a cutoff latency is done with a simple relationship, It is: assume a limit of 2.33 standard deviations (s.d.) then cutoff latency = mean + 2.33(s.d.) where "cutoff latency" is the latency above which the measure is judged abnormal, "mean" is the average latency of the norm, and s.d. is the standard deviation calculated from the normative data. The best way to digest all this is to run through an example data set and compute a complete set of norms. (See pages 96- 101.)
Using Existing ~ o r r n a l v a l d s
If it were necessary to determine every clinical norm needed for all applications, the process would be prohibitive indeed both in cost and time. Fortunately, it is possible to simplify the process but not avoid it entirely.
Absolute latencies must be determined forleach instrument and parameter. I Measurements based on differences are nok instrument dependent and if care is used the following can be used from the literatu~e:
I
Interpeak latencies Side differences Gender differences Standard deviations
The following pages show how to (These are essentially in the definition of abndrrna~ity.) incorporate literature norms in the values used at a local lab.
Notes
Normal Values
The Need for Normal V a l u e s
The parameters of evoked potentials are inherently statistical. Not only do they vary within and across subjects but also from lab to lab and from test to test. The definition of normal for a given parameter requires a mean value and a measure of dispersion. O f equal importance is that the definition of normal must be in the context of a standard method with consistent technique. The task for each lab is to establish its particular method and technique and tben determine by experiment the mean and standard deviation for each parameter intended for use.
Obtaining Local Lab N o r m s

Select volunteers from persons with no significant neurological history. Use 20 to 30 subjects and obtain data from both right and left sides. The numbers collected are specificto a : given modality, but there are some generalities. Determine the absolute latencies of relevant peaks and compute the interpeak latencies. Then calculate the differences between the measures on the right and left sides. These interside differences are the most sensitive detectors of abnormality. See pages 96-101 for example calculations.
Notes
Segmental and berr latoma1 SEPs

Overview o f Root and Spinal Nerve ~ n a t o r n ~ Overview o f Radiculopathy Pathophysiology Evaluation Clinical Electrophyslological
1
I
SEP technique adapted for robt study
The cortical recording Root-specific stimulation Dermatomal system Sensory nerve system Norms Interpretation
Notes
Anatomical Pathway
The SEP pathway begins with the stimulation of a peripheral nerve. While any mixed or sensory nerve can be used, the study is usually performed using the posterior tibia1 nerve at the ankle for the lower extremity and either the median nerve or the ulnar nerve for the upper extremity. The action potential volley travels toward the central nervous system in the peripheral nerve, traverses the appropriate plexus, and enters the spinal cord. There it turns rostral and travels in the posterior columns to synapse in the appropriate posterior column nucleus. At this level, the second order neuron crosses to the contralateral side of the neuraxis and continues rostral through the medial lemniscus to the posterior ventral nucleus of the thalamus. From there the third-order neuron follows the internal capsule to the somatosensory cortex in the post central g y m . The following figure shows the functional diagram of the pathway.
dorsal root ganglion
lower
G
dorsal root ganglion
splne
initiate action potentials in axons, a basic For details on how an electric field in purpose, it should be sufficient to recall physiology text can be consulted. For that the depolarization occurs in the region ofithe cathode and that the resulting action potential propagates in both directions away fbom the site of stimulation. Only those action potentials that are conducted orth~dromicall~~with respect to the relevant pathway are of interest because they alone produce the evoked potential. It is the Group 11 fibers that are responsible for/theSEP.Croup I fibers generally do not go to the cortex, and Group 111 and fibers a n ciibicu~t to stirnulate--necessary currents would be too painful and would damage tissue. The following figure shows the expected respoise when one records from a mixed nerve that has received an electrical stimulus. Since only mild stimuli are used, only the first peak is actually seen in EP recordings of peripheral nerves.
?
Stimulus Artifact
Stim
Time
Neuroscience of the SEP

Fibers in Peripheral Nerves
Motor efferents to muscles Sensory divided into groups by size and myelination
As a general rule, larger fibers conduct faster and have a lower threshold for stimulation while smaller fibers conduct more slowly and have higher thresholds for stimulation.
Sensory Group
Conduction Velocity
70 to 120 Ws Large, myelinated
40 to 70 M/s
Modallty
Primary muscle spindle Colgi tendon organ Secondary muscle spindle Joint receptor Cutaneous mechanorpc. Generalized touch Prickly pain (discriminative) Deep pain Thermal sensation
Medium, myelinated 5to 15 M/s Small, myelinated

0.2 to 2.3 M/s
Small, unmyelinated
Notes
Somatosensory Evoked potentials
Clinical Test Procedure

1. Attach the electrodes.
2. Test the electrodes.

3. Position the patient.
4. Connect the montage.
5. Set the instrument parameters.
6. Check input signals.

7. Control averages (no stimulus).
8. Stimulus runs (minimum two).

9. Collect data.
Notes
Assessing the Adequacy o l the Preparation

Mechanical
Electrodes must be securely attached to min mize relative movement of electrode and skin.
Impedance
Impedance should be measured using an elc $rode impedance meter and kept as low as possible. This usually means about 2,000 oh 1s or less for the best work. When low impedances are not achibved for \Y reason, it is desirable to Have the impedances matched to within a few thoqsand ohb; in any given channel. Be advised thatthe impedance of the ground electrode must be'as low as all others for optimal performance of the preamplifiers.
h
Quality of Input
Both the visual appearance and sound of th incoming signal should be noted for possible problems before commencing avergging. The input should be &ell behaved as well as not showing evidence of periodic interference. Any periodic interference component can be detected by the presence of a perceived pitgh when listening to the input.
' 1
Notes
Evoked Potential Technique

Electrode Types
The primary electrode for clinical evoked potentials is the concave metal disc. The most common are made from gold and tin. The subdermal needle is often used for intraoperative applications. The disposable, pre-gelled silverlsilver chloride electrode is well suited for nonscalp locations. It is self adhesive and uses a snap connector.
Electrode Application
Location
I
For the sake of consistency and quality control, it is advisable to define the exact electrode positions to be used in a given protocol and use a measuring tape to place the electrodes according to the defined location.
Skin Preparation
This consists of first cleaning the site with a solvent to remove surface oils (alcohol and acetone are popular) and then abrading the surface with a skin prep product such as HP redux, Omniprep, or equivalent.
Fixation
Tape, adhesive cream, and collodion are three common methods used to affix electrodes to the skin. Use of these methods are described in detail in texts of EEG technology.
Notes
There are, however, two assumptions under ring this theory: random noise and invariant signal. These assumptions are nevei strictly met in clinical applications. The following departures should be noted: Noise Transience Periodic interference Signal Amplitude variability Latency variability Departures of the noise from the assumed I mdomness can make EPs difficult to interpret. still superimposed upbn the averaged This is because the residual noise after avel ~ging, EP, may be much larger than theory would ' redid and also unstable from trial to trial. When the average obtained appears difficul to deal with, it I s advisablk to test the validity of the random noise assumpti&. This can be accomplished in two ways. The first is to obtain averages with the stimulus absent. This, in effect, renders the EP component equal to zero so that the averaged waveform displayed is simply the average of the background noise. The second is to perform multiple tribls and superimpose them on the screen to enable a determination of their siniilarity.
11
Notes
The figure below shows the effectof averaging on a BAER.Theory tells us that each time the number of sweeps in an average is doubled the signal-to-noise ratio is bettered by 3 decibels.
Sweeps per average
Averaging Process
Notes
The key assumption is that the noisC is a G average o f the noise is zero. Under this circ screen shows the average of the input sign signals. Actually, the noise does not avers( of samples. What does happen is the noise posed on the evoked signal average but re( tiny evoked potential component. The folk
ssian-distributed random variable so that the Istance, at the end of averaging, the display uhich should be the average of the evoked :ozero. This would require an infinite number rerages to a residual amount still superim:ed significantly in size so as to unmask the ng figure illustrates this theory.
Signal
Notes
Signal ~veraging
While differential amplification and analog filtering have significant impact on the overall signal-to-noise ratio, their effects are never enough to reveal the tiny evoked potentials we seek. The major burden o f signal-to-noise improvement is left to the computer and signal averaging. The process is actually quite simple. The epoch of data following each stimulus is averaged point for point to produce an averaged waveform. The key requirement in this process is that each epoch of data points must bear the same relationship to the stimulus presentation. This usually means that the stimulus and the sweep start at the same instant, but it is equally effective if the stimulus precedes or succeeds the sweep onset by a constant time delay. When this condition is met, the evoked signal component always occurs at the same time within the sweep epoch while the noise component varies randomly. The signal component thus reinforces itself while the noise component averages to zero.
L
W e have already noted that the evoked potential signal is added to the electrical and physiological background noise. This implies that the input signal collected in the epoch followingeach stimulus presentation has two component parts. The first is the evoked signal, and the second is the noise component which is superimposed on it and is obscuring its presence. The following equation expresses this relationship!
E.in (t)= EeP(t) + En (t)

Statistics assure us that if the above is correct, the following relationship is also true:
ZE. tn (t)
Notes
q(tI
Stimuli vs. Sweeps

Every sweep of the averager starts with the pi :sentation of a stimulus. However, when artifact reject is being employed, every sweep may not be included in the actual average. The artifact reject function detects when inpu to the AID convertor is larger than its allowable range. Under these circumstances, the ir put is peak clipped and therefore distorted. When the artifact reject function detkcts the i lput "over-scalecondition" it does not allow the sweep to be included in the averpge. Thei .fore, when the average is completed more stimuli may have been delivered thah total st eeps in the average.
Display Scale
The input sensitivity, which expresses the lected, is specified prior to commencing the vertical scale of the input as during acquisition. In evoked division. The evoked microvolt or less. if input, its For this definition,the input waveform salt waveform is expressed as a multipld of it. N with the gain of the preamplifier while data the computer and factors can be altkred at \ from the input. Operators must exercise car interpretation. of the instrument when data is being colThis sensitivity alsq tells the operator when set to view the input signal 10 microvolts per vertical in the range of one scale factor as the to define a
s defined as a unit, and the averaged e that this scale factor has nothing to do 's being collected. Rather, it is calculated by ill even after the subiect is disconnected in using the display scale as it can confuse
Notes
Basic EP Terminology
Stimulus a n d Sweep Onset
It is fundamental to the averaging process that there be a synchrony between the stimulus and the onset of data collection by the AID convertor. The term "sweep" is used to refer to all the data collected for a given time after the delivery of any single stimulus. This time is referred to as an epoch or sweep.
Sweep Time a n d Sweep Rate

The width of the waveform display in time units is a very important parameter. It represents the maximum latency that can be assigned to a pictured waveform. The width of a sweep can be specified in two ways. First, the total time in milliseconds and, secodd, the rate at which the sweep proceeds across the screen in milliseconds per division. These two methods are equivalent. Since the screen is divided into 10 equal divisions, the sweep time is 10 times the sweep rate.
Stimulus Repetition Rate

Multiple stimuli must be presented to obtain a final averaged EP. Under most circunistances, these stimuli are presented at a fixed rate with a constant time interval between stimuli. Note also that the rate at which stimuli are presented affects the total time required to obtain a single averaged response. This rate must be specified to the instrument and it must conform to acceptable techniques for a particular test protocol.
Samples p e r Average (Total Sweeps)

The final averaged response is based on a given number of stimulus presentations. This number is influenced by the desired signal-to-noise ratio improvements as well as other factors. The instrument must be given the desired value prior to the start of data collection. When it has collected the given number of sweeps, it automatically terminates averaging and displays the final waveform.
Impact o f Noise
All electricity at any point on the body fro n separate sources sums linearly. The evoked potential is superimposed on all other background noise. Muscle evoked potentials, such qs those ecorded in nerve conduction studies. are often substantially larger than tlje backgrbund electrical noise upon which they are superimposed. It is therefore unnecessa j to use anything but straightforward recording techniques to reveal them. Nerve, spinal cord, and brain evdked pot ntials of microvolt and submicrovolt amplitude are virtually always "buried': under t ie background noise. These evoked potentials are invisible to simple biorecording tech iques.
Signal Averaging
The technique of signal averaging is used to mmask the tiny evoked potential from the background noise that obscures it. ''
Comparison of EP to EKG
I EKG I Immediate Result I continuous D

I
I3
I
EP
Delayed Results
~amAled ~atd
Comparison of EP to Bloo Chemistry

l
d
I
Blood Chem. Sampled
Delaied ~ e s u k s
Instant
I EP Sampled
Delaied ~ e s u h
Averaged
Evoked Potential Fundamentals

An evoked potential (EP) is any change in electrical activity of the nervous system in response
to an external stimulus. Examples include: Stimulate a nerve, record from a muscle. Stimulate a nerve, record from a nerve. Stimulate a nerve, record from the spine. Stimulate the eye, record from the brain.
EP Amplitudes
Extracellular voltages recorded from muscle tissue are in the range of tens of millivolts. Extracellular voltages evoked from the spine and brain range from less thanbonemicrovolt to tens of microvolts.
Electrical Noise
<
Evoked potentials in organisms do not occur in isolation. They occur simultaneously with potentials produced by other tissues and with electrical voltages of nonbiological origin. For the purposes of averaged evoked potentials, we will define "noise"as all electrical activity sensed by the electrodes that is not of interest.
Notes
Averaged Evoked Potential Fundamentals
Radiculopathy (cervical)
Motor, sensory, and mixed NCV of median and ulnar in symptomatic arm Dermatomal SEPs for C5, C6, C7, and C8 bilaterally
Radiculopathy (lumbosacral)
Tibial and peroneal motor NCV in the symptomatic leg Sural sensory NCV of the symptomatic leg H reflex bilaterally Bilateral dermatomal or segmental SEPs for L4, L5, and S1
Anterior Horn Cell Diseases

Motor, sensory, and mixed NCV of median and ulnar nerves in one arm Sural sensory NCV in one leg Motor NCV of tibia1 and peroneal nerves in one leg
Z
Myopathy
Motor, sensory, and mixed NCV in one median nerve Sensory NCV in one sural nerve Motor NCV in one peroneal nerve
Minimal Workup for Specific Conditions

Peripheral Neuropathy
Motor, sensory, and mixed NCV i n one ulr Brand one median nerve Sensory study of bilateral sural n+rves Bilateral motor study o f tibial and perone' I nerves F waves in median, ulnar, tibial, and perol eal nerves
Carpal Tunnel Syndro'me

Motor, sensory, and mixed NCV in mediar and ulnar of the symptomatic arm When confirmed in the symptomatic arm. he opposite side should be studied
Tardy Ulnar Nerve Palsy

Motor, sensory, and mixed NCV ip mediar and ulnar nervesdn involved arm Ulnar tests should emphasize conduction ,cross the elbow-the distance of which should be about 10 centimeters If one limb tests positive, the opdosite s h
Peroneal Nerve ~ a l s y i
Motor NCV in peroneal and tibial netves dith attention to the peroneal velocity across the fibular head
General Rationale for Using NCVs

The NCV tests are used primarily for the peripheral nervous system. The Fwave and H reflex project more proximal and to the spinal cord.
NCV studies are essential to verify and localize mononeuropathy.
N C V studies are essential in distinguishing between mono- and poly-neuropathy. It is common that a symptom can be explained by either a central or peripheral site of lesion. NCV tests are used to rule out peripheral sites and focus attention on the central possibilities.
Applications for Nerve conduction Studies
2. Set the appropriate instrument!parame ers and connect the subject to the , preamplifier.
Gain ~igh-cut filter Low-cut filter Sweep speed Pulse width
20 pV/div
2 HZ
I
I
30 Hz
5
ms/div 1
100 to 200 p
3. Stimulate the sural nerve belo&the gas :roc. Measure the latency.
SURAL SENSORY N(
RHP (uU)
1 2 3 4 5
P-T
356 0 0 0 0
4. Use 10, I 4, I 7, or 20 centimeted as the I ieasured distance from cathode to active. This allows you to compare yout data to normative data.
Sural Nerve Sensory NCV (Antidromic)

I . Connect the recording and ground electrodes t o the subject for a sural sensory
NCV protocol.
Active
Reference
Ground
Over the sural nerve posterior and inferior to the medial malleolus 3 crn distal Above ankle
3. Stimulate the tibia1 nerve at the ankle ar d popliteal fossa. Obtain responses from
both locations.
2-R 48.8 4-R

5-R
NCUT (cn) (n&) 1-R 9 . 5 ' 11.5

8.0 0.8 0.0
DIST
29.1
3-R
0.8 0.0 0.0
4. Measure the distance from cathode to active and between cathodes.
I the following formula: 5. Calculate the NCV for both segments using
Tibia1 N e r v e Sensory NCV (Antidromic)

I . Connect recording and ground electrodes to the subject for a tibia1 nerve sensory NCV protocol.
Reference Active
Proximal at base o f big toe Distal to active Dorsum of foot
2. Set the appropriate instrument parameters and connect the subject to the
preamplifier.
Gain High-cut filter Low-cut filter Sweep speed Pulse width 20 pV/div 2 kHz 30 Hz 5 ms/div I00 to 200 ps
Collecting Sensory NCV Responses from the Lower Extremity
Stimulation
10 or 14 cm proximal to recording active over the sural nerve.
Measurements
Measure the latency and compare to norm for the chosen distance.
Sural Nerve Sensory NCV Response

--
SURAL SENSORY NCV
SWEEP 2
. . . . " . . ..... . I
I
......".I._.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........I"...
.......................... . . - . . .................................................. I . . .
. . . . . . . . . I . . . .
v.:;
I " I
.............. ...... ... ....... .....
;A; ;
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
................. ............... ..................................
R ~ P (uU)
1 2
P-T
.............-.
............................................. "...."............".... ............................
3 4
5
356 8 0 0 8
NCV (Antidromic) Sural Nerve ~ e n $ o r y

Gain
High-cut filter Low-cut filter Sweep speed Pulse width 20 pV/div 2 kHz 30 Hz
5 ms/div
I
I
100 to 200 ps
Electrode Placement
+ Anode
- Cathode
Active
Reference Ground
Over the surd nerve Asterior and inferior to the medial malleolus 3 cm distal Above ankle
I
I
!
I
Stimulation
Tibial nerve at ankle and poplitea fossa Obtain ten responses from each lbcation
1
i I
I
Measurements
Measure the distance between the dthode a
active in mil!imeters.
Calculations
Calculate the nerve conduction velocity usinr le following formula:
Notes
Tibia1 Nerve Sensory NCV Using t h e
Medial Plantar Sensory Nerve (Antidromic)

Gain
High-cut filter Low-cut filter Sweep speed Pulse width
20 Wdiv 2 kHz 30 Hz
5 msldiv
100 to 200 ps
Electrode Placement
Reference
Active
Proximal at base of big toe Distal to active Dorsum o f foot
Sensory Studies of the Leg
ossa while watching for an abductor hallicus 3. Stimulate the tibia1 nerve at the pbp~itea~ r o m the contraction to verify the stimulatidn site. , Iso look for the M response f gastroc-soleous. rulation at low subthreshold levels and 4. When sure of the stimulation site, kart sti~ slowly increase the stimulus. Watch for an H reflex before the M response appears. At higher levels the H reflex will disappea and then an F wave will appear. Remember to place cathode proxihal! Thl H reflex is remarkably stable in
repeated trials. Measure its latendy.
Lower Extremity H Reflex

I . Conned the recording and ground electrodes for an H reflex protocol.

preamplifier.
Gastroc-soleous Achilles tendon Between stimulation site and active
Gain High-cut filter Low-cut filter S w e e p speed Pulse width
500 to 1,000V/div 10 kHz 10 Hz 10 msldiv 200 to 500 ps
6. Reverse the stimulus polarity, inc ase the gain (200 to 500 pV/div), and obtain F-wave responses with supramaximal stimuli. Using the TI2 distance measurement and F and M latencies, calculate the F-wave delocity and F ratio.
,
3. Stimulate at sites 1 (ankle),2 (fibular head), and 3 (popliteal crease). Use low
stimulator current to start and gradually increase intensity to produce a maximal amplitude response. Pay attention to the shape of the waveform. Reconnect the active if necessary.
AIN
C u
RR 2.11
SWEEP
PERONEAL MOTOR N.CVi
Pi'-: ; ;
"..""." "..".""a-.".. t."t...t...~:.. ................. ." "............
I . . "
. . I
I........-. ~."""_i...""...-.L.."" ....i.... "....i .....-..... ";..."""..".i"".i ...... "i .-.."..
:
"
tl8r:l-
. ... "...'... . i l i .".. at
2-1 40.0 3-2 Or0 4-3 0 . 0 5-4 0.0
DIST ,SEC-0 NCV (cn) (ns) (n/s) 1-R 5.5

8.8 0.8 0.0 0.8
45.5 0.0 0.8
0.0
4. Measure the SNAP latencies and inter-electrode distances.
5. Calculate the segment conduction velocities and compare to norms.
59
Peroneal Motor MCV and F Wave Using Extensor Digitorum Brevis

I
I . Connect the recording and ground electrodes to the subject using the peroneal motor
NCV protocol.
Lateral small toe Top of foot
2. Set the appropriate instrument paratneters i nd connect the subject to the preampliff er.
Gain High-cut filter Low-cut filter Sweep s p e e d Pulse width
5,000 pvldiv 10 kHz

10 Hz 5 msldiv I00 to 200 p
5. Using the same setup, perform the F-wave test. Remember to reverse the stimulator polarity and increase the gain setting (200 to 500 pV/div).
ITIBIAL
NERVE F WAVE
SWEEP G
3. Obtain compound muscle action potential
(popliteal fossa). Use low stimulator curre produce a maximal amplitude response. Reconnect the active if necessary.
stimulating at sites I (ankle) and 2 start and gradually increase intensity to to the shape of the waveform.
R NCV
Drsr SEC-0 NCV

10.0 2-1 39.0 .3-2 8.0 4-3 8.0 5-4 0.0
1-R
(cn) (ns)
(Wd
9.2 8.0 0.0 0.0
42.4
0.0 0.8 0.0
1...............!...............i...
4. Calculate the motor NCV for the lower leg.
Tibia1 Nerve Motor NCV and F Wave Using Abductor Hallucis

I . Connect recording and ground electrodes to the subject for a tibia1 nerve motor NCV protocol.
Motor point of abductor hallucis Medial big toe Below medial malleolus or tip of foot
2. Set the appropriate instrument parameters and connect the subject to the preamplifier. Gain High-cut filter Low-cut filter Sweep speed Pulse width
5,000 pvldiv 10 kHz 10 Hz 5 ms/div I00 to 200 ps
Collecting Motor NCV, F Wave, and H ~ e f l e x Responses from the Lower Extremity
Stimulation
Tibial nerve at the popliteal fossa Place cathode proximal Patient in prone position with foot suspended-ankle can rest on a pillow Use single stimulus and start with a low intensity. Gradually increase intensity until responses are obtained.
Tibial Nerve H Reflex Response

H REFLEX OF LOWER EXTREMITY
..
DIST
f-R
2-1 3-2
4-3
5-4
SEG-0 NCU (cn) ( n d (H&) 0.0 8.0 18.7 0.0 8.8 2.7 8.0 0.0 2.8 0.0 8.8 8.0 0.0
Notes
Tibia1 Nerve H
fled
I
uses the tibia1 nerve and the gastrocfrom muscle tissue. At certain
I
The H reflex should be viewed as a motor soleous. The recording - consists of M stimulus levels an F wave can also be noted.
Instrument Parameters /
Gain
500 to 1,000 &div 10 kHz 10 Hz I

I
10 msldiv
,
1
I
200 to 5 0 0 p
Electrode Placement
Active
I
<
cast roc-soleous;1
Achilles tendon I Between stimuldtion sit and active
Reference Ground
Lower Extremity Hoffmann Reflex

What i s an H Reflex?
The H reflex is an eledrophysiological analog of the monosynaptic ankle jerk reflex. It is present in all muscle at birth but is restricted to the gastroc-soleous after the first year. Afferent access is made through the posterior tibial nerve. The posterior tibial nerve consists of afferent la fibers and efferent alpha motor fibers of the S 1 root. The H reflex is elicited by a low intensity stimulus and produces a response larger than the M response. Care must be exercised in distinguishing between the H reflex and the F wave.
Peroneal Nerve F Wave ~
e bnse s ~
Notes
Stimulation
Stimulate the peroneal nerve at the ankle and knee Reverse stimulus polarity as in figure Stimulate until a supramaximal response is achieved Obtain ten responses and take the minimum latency
Measurements
Measured distance is the stimulation cathode to TI2 in millimeters
Calcul
Notes
e Peroneal Nerve 6 ~ a b Using Brevis (EDB) Extensor ~ i g i t o r u m

Instrument Parameters /
Gain High-cut filter Low-cut filter Sweep speed Pulse width
II
200 to 500 p~ld'iv 10 kHz 10 Hz 5 msldiv 100 to 200 ms
Electrode Placement
I I
Motor point o fE B Lateral small toe Top of foot
Stimulation
S1, medial ankle S2, midline poptiteal fossa Patient in prone position Reverse stimulus polarity as in figure Stimulate until a supramaximal response is achieved Obtain ten responses and take the minimum latency
Measurements
Distance is measured from stimulation sites using the T12 spinous process
*
Calculations
Fve, - ( F - M - l)ms
- (Djmm(2)
Tibia1 Nerve F Wave Response
Tibia1 Nerve F Abductor H a l l u c i ~ Instrument Parameters j

I
Gain H i g h t u t filter Low-cut filter Sweep speed Pulse width
200 to 500 pV/di~ 10 kHz I 10 Hz 5 ms/div 1 l00to200ps

I
Electrode Placement
I
Motor point o f
Stimulation
Measurements
Distal latency from ankle ~ake-off latencies from stimulation sites Distances between stimulation cathodes
Calculations
Peroneal Nerve Motor NCV Response
SEG-D NCU
8.8 0.0 0.8 0.0
(ns) (nld 45.5 0.8 8.0 0.8
I"""""..""..."." ............, ....... ...".."..................... .... "....""..."."."..."." ...."".""...--""."""
Peroneal Nerve ~ o t d NCV r Using Extensor Digitorum Brevis (EDB)

5.000 pvldiv 10 kHz
10 Hz 5 msldiv I00 t o 2 0 0 ~
Electrode Placement
Motor point o f EDB Lateral small toe Topoffoot

!
Stimulation
.s
I , medial ankle ~ 2midline , popliteal ~ O S S ~
Patient in prone position stimulate until a supramaximal response is achieved
Measurements
Distal latency from ankle Take-off latency from ankle and popliteal fossa Distance between stimulation cathodes
Calculations
Tibia1 Nerve Motor NCV Response
Tibia1 Nerve Moto NCV Using Abductor Hahcis

Gain High-cut filter Low-cut filter Sweep speed Pulse width 5,000 pV/div 10 kHz 10 Hz 5 msldiv 100 to 200 ps
Electrode Placement
Active Reference
Ground
Motor point of a uctor hallucis Medial big toe Below medial rnallkolus or tip of foot
Neuroanatomy of the Leg

Lumbar plexus and nerves
Sacral plexus and nerves
\j
Lateral Femoral Cutaneous (NCVS) Femorald
,
C. ~eroneal mF Lateral Sural
Saphenous U,Ld (NCVS. SEP) Motor to Quads (NCVM to Vastus Medialis) Superficial Pemeal L4, W, S1 (NCVS)
t
Deep Peroneal --sensory L5 (DSSEP) --motor to ED0 (NCVM)

Surd Nerve (S1, S2) -sensory (NCVS) : -sensory S1 (DSSEP)
S2
Medial Plantar -sensoly first toe (NCVS) (L5, S1, S2) --motor to AH (NGVM) Lateral Plantar --motor to ADQ (NCVM) -sensory fifth toe (NCVS) (L5, S1, S2)
S3
Lower Extremity Motor Studies
5. Stimulate the forearm to obtain maximal esponse. Measure the distal latency.
DIST
1-R
NCV (CHI (n/d 16.8 61,8
Notes
Radial Nerve Distal Sensory Latency (Antidromic)

I . Connect recording and ground electrodes to the subject for a radial sensory study.
Ref.
Act.
Ground
I
Major branch o f the sensory nerve as it croqes the extensor pollicis longus tensdon Lateral side o f the head of the second metacarpal Between stimulating site and active
preamplifier.
Gain High-cut filter Low-cut filter Sweep speed Stim pulse width
10 pV/div 3 kHz 30 Hz 2 ms/div 100 p
3. Locate the forearm stimulation site used during the radial nerve motor study.
4. Measure the distance in millimeters between the cathodes at the stimulation sites
and recording active.
5. Stimulate at sites I (wrist), 2 (di
(proximal elbow) to obtain maximal responses. Use the take-off for latency and measure distances from cathode to recording active.
), and 3
(qn) 14.0 2-R 37.0 3-R 45.8 1-R
DIST SEG-0 NCU
(ns) (Wr) 2.13 65.7 5.28 70.1

6.88 65.4
I
6. Record latencies and compare to nbrms. Calculate the velocities in the arm segments. Distal conduction velocity is based on d = 140 millimeters.
Ulnar Nerve Sensory NCV (Antidromic)

I . Connect recording and ground electrodes t o the subject for an ulnar sensory study.
Ad.
&f.
k-
14 cm
<
Active Reference Ground preamplifier. Gain High-cut filter Low-cut filter Sweep s p e e d Pulse width S t i m level for this study.
f fifth digit Proximal at base o

4 cm distal t o active
Dorsum o f hand
2. Set the appropriate instrument parameters and connect t h e subject to the
20 W d i v 2 kHz 30 Hz 2 or 5 msldiv 100 ps Supramaximal
3. Use t h e wrist and elbow stimulation sites marked during t h e ulnar nerve motor study
4. Measure the distance in millimeters between t h e cathodes at t h e stimulation sites
and recording active.
5. Stimulate at sites I (wrist) and 2 (bbow) td obtain maximal responses. Use the take-
off for latency and measure distankes fromicathode t o recording active.
1-R 5 . 0 1.03 48.5 2-R 14.0 2.72 51.5

3-R 30.8 6.53 50.2
Drsr SEG-0NCU (CHI (ns) W s )
6. Calculate NCY using the following ebuation:
7. Perform palmar stimulation and reco d laten .

I
I d Y
Notes
Median Nerve Sensory NCV (Antidromic)

I . Connect recording a n d ground electrodes t o the subject for a median sensory NCV study.
Palmar Stim
- +
Wrist Stim
Active
Proximal at base of first digit

4 cm distal to active
Reference Ground
Dorsum o f hand
2. Set the appropriate instrument parameters and connect t h e subject t o t h e preamplifier.

20 pV/div High-cut filter 2 kHz Low-cut filter 30 Hz Sweep speed 2 o r 5 ms/div Stim pulse width 100 ps Stim level Supramaximal
Gain
3. Use t h e wrist and elbow stimulation sites marked during the median nerve motor
study for this study.

4. Measure the distance in millimeters between t h e cathodes a t t h e stimulation sites and recording active.
Collecting Upper Extremity Sensory Responses
Measurements
Distal latency to negative peak
I
1
Radial Nerve Sensory dCV desponse
NCU Wr) 61.8
AHP (vU 1
1 15.6
P-T
Notes
Radial Nerve Distal Sensory Latency (Antidromic)

Gain
H i g h t u t filter Low-cut filter Sweep speed Pulse width
10 pldiv 3 kHz 30 Hz 2 msldiv 100 ps
Electrode Placement
Ref.
Act.
Ground
Active
Reference
Ground
Major branch of the sensory nerve as it crosses the extensor pollicis longus tendon Lateral side of the head of the second metacarpal Between stimulating site and active
Notes
Measurements
iI
Distal latency from wrist stimu~atidn site Take-off latency for each response Distance between stimulation site4
Calculations
U h a r Nerve Sensory N ~ Rekponse V
Wrist
ten) (ns) (Wr) I - R 14.8 2.1365.7 2-R 37.0 5.28 78.1 3-R 45.8 6.88 65.4
Dxct SEG-0 MeV
Dist elbow
Prox elbow
Ulnar Nerve Sensory NCV (Antidromic)

Gain High-cut filter Low-cut filter Sweep speed Pulse width Stim level
20 pV/div 2 kHz 30 Hz 2 or 5 ms/div
I00 p Supramaximal
Electrode Placement
P,
Ground
Active
Reference Ground
Proximal at base of fifth digit to active Dorsum of hand

4 cm distal
Stimulation
Wrist
Proximal elbow Distalelbow Axilla Erb's
Measurements
Distal latency from wrist stirnulation site Take-off latency for each response Distance between stimulation sites
Calculations
Median Nerve Sensory NCV pesponse

RICHT NED: AN SENSORY ONSET LITENCY ~ N D Drc (ns) PRLH 1.03
ELBOH
krcr
2.72 6,53
SEC-0 NCV (ns) (n&) 1-R 5.0 1.03 48.5 2-R 14.0 2.72 51.5 3-R 38.0 6.53 58.2
(cn)
Flnp
DIST
(W I
46.8 33.6 37.6
P-T

Gain High-cut filter Low-cut filter Sweep speed Pulse width S t h level
20 pV/div 2 kHz 30 Hz 2 or 5 ms/div I00 p
Supramaximal
1
Electrode Placement
r\
Ref. Act.
\> I
-
Palmar Stim
+
Wrist Stim CaS?de Anode
Distal Crease
Proximal at base of first digit Dorsum of hand

Stimulation
Wrist Palmar Elbow Forearm Axilla Erb's
Upper Extremity Sensory Studies
Sensory NCV ~ e a s u r e d e n t
A mixed
nerve such as the median or posterior Each type of fiber has a different conduction tant to have an independent assessment of tively recording from the appropriate selectively stimulating or recording
both motor and sensory fibers. clinical context it is often imporfibers can be isolated by seleccan be isolated by either distal sensory branch.
When performing motor studies, the latency of the is not the result of nerve conduction only. To avoid this problem, two used and the calculation is based upon the conduction between nerve action potentials rather than compound muscle site is necessary and latencies reflect only neural conductidn times.
Notes
Sensory Nerve Assessment

Distal Latencies
Since NCV = distanceltime, it is apparent that time means something only if distance is held constant. Distal latency refers to the latency for the most distal segment which is usually wrist to digit. When distal latencies are compared, the distance between the recording active and the stimulus cathode are fixed at 14 centimeters but a conduction velocity can still be computed.
Conduction Velocities
There are two different methods for performing sensory NCV studies. They are called orthodromic and antidromic. In orthodromic studies, the sensory distab branch of a nerve is stimulated while the recording is made more proximal over the nerve. The direction of conduction is the same as it would be under physiological circumstances. In antidromic studies, the nerve is stimulated proximally and the sensory action potential (SNAP) is recorded from the distal sensory branch. In either case the distance is measured from the stimulus cathode to the recording active electrode. c The sensory response is isolated by recording from distal sensory fibers when using an antidromic technique. These velocities can be over any length depending on the location of the stimulus. The stimuli are applied at mixed fiber locations on the nerve. The responses are called sensory because only the distal APs from sensory fibers are measured. To isolate segments of the sensory pathway, one must use an orthodromic technique in which the sensory fibers are isolated by selectively stimulating the distal sensory branches. Recording at more proximal locations over mixed fibers produces a sensory response because only sensory fibers were stimulated. For this introductory work, the antidromic approach will be shown. It is popular because the SNAPS are large and thus the technique is less demanding. The orthodromic technique, also important, is preferred by many and has several advantages.
NCV
d(mrn)
t(mm)
SNAP
Notes
M e a s u r e m e n t of t h e SNAP Latency
When using the orthodromic technique, the SNAP often shows an initial positive peak which reflects the activity of the fastest fibers. The negative peak represents an average of fibers. When used, the distance is measured to a point halfway between the active and recording electrodes.
( duration
The antidromic SNAPSare larger and often do not show the initial positivity. Therefore, it is necessary to use the initial take-off to reflect the fastest fibers.
Notes
<
Sensory NCV Measurement
9. Reverse the polarity of the stim Jlator an stimulate at t h e wrist using supramaximal current. Observe t h e F wave. 0t)tain ten responses and measure the minimum
latency. Anode
I
I
Reference
Cathode
Ground
10. Move the stimulus t o the elbow ~drepei :.Remember to reverse t h e stimulus polarity. Maintain t h e location a the cath de. Measure f p m cathode to C7 with the
palm up.
I 1. Calculate t h e F wave conduction 4elodty i ~dt h e F ratio.
(F-M1 )(ms)
F ratio =
Notes
(F- M - I ) 2M
3.
Begin with the wrist stimulation site. Use low stimulator current to start and gradually increase to produce a maximal amplitude response. Pay attention to the shape of the waveform. Reconnect the active if necessary. Remember that the distance from the active to the cathode is 8 centimeters.
RIN . .
RR 2,11
Wrist Dist elbow Prox elbow Upper arm
4.
Mark the stimulation site when an adequate response is obtained.
5. Move the stimulation to the elbow and obtain responses as above. Mark the stimulation site and measure between the two cathode sites. 6.
7.
Measure the latency to the take-off point. Calculate the NCV.
8.
Reset the instrument parameters for an F wave test.

Gain High-cut filter Low-cut filter Sweep speed
200 Wdiv 10 kHz 10 Hz 5 or 10 msldiv
Ulnar Nerve Mot r N V a n d F Wave

I.
1k
1
Connect recording and ground elbctrode to the subject far an ulnar nerve study.
Reference
Ground
I
Set the appmprlate instrument parameted and conned the subject to the preamplifier.
I00 ps
9.
Reverse t h e polarity of t h e stimulator and stimulate a t t h e wrist using supramaximal current. Observe t h e F wave. Obtain ten responses a n d measure t h e minimum latency.
Ground
.LIVG
Reference
< 10. Move the stimulus t o t h e elbow and repeat. Remember to reverse t h e stimulus polarity. Maintain t h e location of the cathode. Measure from cathode t o C7 with t h e palm up. I I . Calculate t h e F wave conduction velocity and t h e F ratio.
(F-M- 1 )(ms)
Median Nerve Motor NCV and F Wave

1,
Connect recording and ground electrodes to the subject for a median nerve motor NCV study. Ground

2.
Motor point o f APB Distal phalanx o f thumb Dorsum o f hand
Set the appropriate instrument parameters and connect the subject to the preamplifier.
5,000 Wdiv 10 kHz 10 Hz 5 mddiv 100 p
Supramaximal
Collecting Motor and F Responses in Median
Median Nerve F Wave Response
Notes
Measurements
with The distance between the site of s;timulation ar d the C7 spinous process is mea~sured the arm out 90 degrees from the body. The me ian nerve is measured with the palm up while the ulnar nerve is measured with the pal down.
Minimum F-wave latency for the proximal stim
response For the same site are recorded. Reme for the measurement of the M response. It is the motor NCV tests. Make measurements when reversing the stimulation.
site (elbow)and latency of the M reverse the stimulating electrodes the stimulation sites while doing and keep the cathode the same
Calculations
1
Two calculations can be used, the F wa"e condu
on velocity (FWCV) and the F ratio.
FWCV =
2D(mm) (F-M- l )(ms)
atio =
(F-M- I ) 2M
Notes
200 pV/div High-cut filter 10 kHz Low-cut filter 10 Hz Sweep speed 5 or 10 ms/div
Gain
Electrode Placement
The F wave connections are the same as those used for the median and ulnar nerve motor studies.
Stimulation
The polarity of the stimulus is reversed for F waves. The cathode is proximal rather than distal as it is in the motor N C V using the M response. The Fwave may be enhanced by slight voluntary contraction of the target muscle. The standard sites of stimulation for routine studies are the wrist and elbow. Supramaximal stimulations must be used to assure that the response is an Fwave and not an H reflex.
Data Collection
There is some variability in latency from response to response with F waves. To account for this, it is common to elicit ten responses and take the earlier latency. This reflects the function o f the faster fibers. The longest latency can be measured to provide an indication of dispersion.
Notes
F Waves
A supramaximal stimulus to a motor nerve wii cause two vollies of action potential. One
-- will be in the direction toward the muscle (o odromic) and another toward the spinal cord (antidromic). When the antidrornic volley r aches the anterior horn cell bodies they
depolarize. This starts another orthodromic vo ley back down the same fibers toward the muscle. When this secondary volley reaches t muscle it produces the F wave. Since a synapse is not involved it is not a reflex.
Horn, Cell
Notes
Ulnar Motor NCV Response
Drct SEC-0NCV
Wrist
Dist elbow
1
Prox elbow Upper arm
3-2 4-3 ' 5-4

:
2-1
1-R
(en) (NS) W c ) 0.0 21.0 3 , 9 53.8 '8.4 1 , 9 4 2 . 1 9,8 1.7 52.9 0.8 8.0 0.0
Notes
Stimulation
Site 1 Site 2 Site 3 Site 4
8 cm from active
Distal to elbow Proximal to elbow Upper arm
Measurements
Distal latency Take-off latencies of responses Distances between stimulation sites
Calculations
NCV for segments
II
Notes
Ulnar Nerve Motor NCV

Gain
High-cut f i l t e r Low-cut filter Sweep speed Pulse width Stim level 5,000 CLV/div 10 kHz 10 Hz 5 msldiv I00 ps
Supramaximal
Electrode Placement
Motor point o f abductor digiti minimi (ADM) 5th digit Dorsum o f the hand
Notes
Median Motor Response
Wrist
El bow
Upper arm
Notes
Stimulation
Site1 Site 2 Site 3 Site 4
Cathode(-)8cmfromactiverecordingelectrode,anode(+)proximal
Elbow Upper arm Axilla
Measurements
Distal latency from Site 1 Take-off latency at Sites 1 , 2 , and 3 Distance between the cathodes (-) of the stimulation sites
Calculations
Notes
Gain High-cut filter Low-cut filter Sweep speed Pulse width Stlm level 5,000 Wdiv 10 kHz 10 Hz 5 rns/div 100 ps
Supramaximal
Electrode Placement
I
Motor point of abductor pc Distal phalanx of thumb Dorsum of hand
:is brevis (APB)
<
Motor NCV Measurement

Potentials are obtained by stimulating a netve and recording the response from a muscle. The stimulating electrodes are placed over the nerve. The recording electrodes are placed over the muscle. The recorded potential is called a compound muscle action potential (CMAP).
Motor NCV Concept

NCV= d (m)
m t l m 2
az
t* t, (ms)
dlm 1
- -+0
Stim 1 Stim2
Upper Extremity Motor Studies
Filters
The analog filters are used to reject uhwantec noise. High-cut filters reject higher frequencies and low-cut filters reject lower frqquencic . Filter cutoff frequencies are set by the operator in accordance with the signal being easured.
CRT Display
The display is a two-dimensional graph with ti e on the horizontal axis and voltage on the vertical axis.
The presentation of a stimulus marks the start c :he display trace across the screen. The trace deflects up or down according to the relat ike! polarities of the two preamplifier inputs. Time markers indicate the time from the onset ( khe trace. Amplitude markers indicate the difference in voltage between the two markers.
Stimulus Generation
Stimuli may be presented singly or in p/llse trai ; of constant repetition rate. Either way one stimulus will occur at the onset of the tract :are must be taken to properly locate the cathode and anode according to the measurem t protocol. Stimulus duration is also determined by the application.
Measurement of Bioelectricity
Electrodes
Purposes-Stimulating, recording. and ground Types-Metal cups or plates, springs, needles, and pre-gelled disposable
Differential Amplifier
The preamplifier provides variable amplification of the recorded signal beaus; voltages may vary widely-from microvolts to hundreds of millivolts. The sensitivity (related to gain) is usually expressed in microvolts or millivolts per vertical division on the CRT display. Each channel of a multichannel instrument has its own preamplifier.
Each preamp has two inputs, an inverting input (-) and a noninverting input (+). There are several nomenclatures for the inputs. The most common are:
Inverting Noninverting
Active Reference
GI
G2
The normal physiological way that nerve and m scle are stimulated is by chemical neurotransmitter at the synapse or neruomuscular ju ction. Excitable membranes have voltage sensitive ion channels that can be opened by a external electric field. Clinical tests make use of this to stimulate nerve tissue where and hen it is needed. Stimulators operate by providing a DC pulse of electrical potential (vol age) at its terminals for a specified and selectable duration and delivered to tissue thro ;h percutaneous electrod&.
Tissue Anode Cathode
+
,
The electric field in the tissue opens the voltage mitive channels, depolarizes the membrane, and produces an action potential.
Notes
Action Potentials in Nerve and Muscle

An action potential (AP) starts at a region of membrane that becomes depolarized. The
essence of the AP is that it does not remain stationary. A depolarized region of membrane further depolarizes adjacent membrane, This causes the depolarized region to move along the membrane. A wave of depolarization will follow. The speed at which an action potential moves along the membrane is its conduction velocity. In nerve axons the conduction velocity varies with fiber diameter and amount of myelin sheath. Disease processes can slow the conduction velocity.
Notes
Electric Fields of Bio plectric Sources

Y
A region o f depolarized membrane produces a ipole field. A dipole field results from a separation of positive (+) and negative (-) cha les.
When many cells are depolarized. the fields off ch cell add if {hey are oriented in the same direction. More cells yield a stronger field. New and muscle cells are often oriented so their fields reinforce and may depolarize simult ~eously.
Notes
Electric Fields of Bioelectric Sources

A region of depolarized membrane produces a dipole field. A dipole field results from a
separation of positive (+) and negative (-) charges.
When many cells are depolarized, the fields of each cell add if hey are oriented in the same direction. More cells yield a stronger field. Nerve and muscle cells are often oriented so their fields reinforce and may depolarize simultaneously.
Notes
Stimulation o f Nerve and Muscle

The normal physiological way that nerve and muscle are stimulated is by chemical neurotransmitter at the synapse or neruomuscular junction. Excitable membranes have voltage sensitive ion channels that can be opened by an external electric field. Clinical tests make use of this to stimulate nerve tissue where and when it is needed. Stimulators operate by providing a DC pulse of electrical potential (voltage)at its terminals for a specified and selectable duration and delivered to tissue through percutaneous electrodes.
Tissue
Cathode &,Ode
, +
The electric field in the tissue opens the voltage sensitive channels, depolarizes the membrane, and produces an action potential.
Notes
Filters
The analog filters are used to reject unwanted noise. High-cut filters reject higher frequencies and low-cut filters reject lower frequencies. Filter cutoff frequencies are set by the operator in accordance with the signal being measured.
CRT Display
The display is a two-dimensional graph with time on the horizontal axis and voltage on the vertical axis.
The presentation of a stimulus marks the start of the display trace across the screen. The trace deflects up or down according to the relative polarities of the two preamplifierinputs. Time markers indicate the time from the onset of the trace. Amplitude markers indicate the difference in voltage between the two markers.
Stimulus Generation
Stimuli may be presented singly or in pulse trains of constant repetition rate. Either way one stimulus will occur at the onset of the trace. Care must be taken to properly locate the cathode and anode according to the measurement protocol. Stimulus duration is also determined by the application.
Potentials are obtained by stimulating a nerve and recording the response from a muscle. The stimulating electrodes are placed over the nerve. The recording electrodes are placed over the muscle.The recorded potential is called a compound muscle action potential (CMAP).
Motor NCV conc&t
Stim l Stim2
CMAC
J
Notes
Median Nerve Motor NCV

Gain High-cut filter Low-cut filter Sweep speed Pulse width Stim level 5,000 pV/div 10 kHz 10 Hz 5 ms/div 100 p Supramaximal
q
Electrode Placement
I
Motor point of abductor pollicis brevis (APB) Distal phalanx of thumb Dorsum o f hand
Stimulation
Site 1 Site 2 Site 3 Site 4 Cathode (-) 8 c m from active recording ( lectrode, anode (+) proximal Elbow Upper arm Axilla
Measurements
Distal latency from Site 1 Take-off latency at Sites I,2, and 3 Distance between the cathodes (-) o f the stimuli tion sites
9
Calculations
Notes
Median Motor R e s p o n s e
Wrist
El bow
Upper arm
Notes
Stimulation
Site 1 Site 2 Site 3 Site 4
8 cm from active
Distal to elbow Proximal to elbow Upper arm
Measurements
Distal latency Take-off latencies of responses Distances between stimulation sites
Calculations
NCV for segments
Notes
Upper Extremity F Waves

F Waves
A supramaximal stimulus to a motor nerve will cause two vollies of action potential. One
..
will be in the direction toward the muscle (ortkodmmic) and another toward the spinal cord {untidmmic). When the antidromic volley reaches the anterior horn cell bodies they depolarize. This starts another orthodromic volley back down the same fibers toward the muscle. When this secondary volley reaches the muscle it produces the F wave. Since a synapse is not involved it is not a reflex.
Notes
Measurements
The distance between the site o f stimulation and the C7 spinous process is measured with the arm out 90 degrees from the body. The median nerve is measured with the palm up while the ulnar nerve is measured with the palm down.
Minimum F-wave latency for the proximal stimulation site (elbow)and latency of the M response for the same site are recorded. Remember to reverse the stimulating electrodes for the measurement of the M response. It is best to mark the stimulation sites while doing the motor NCV tests. Make measurements from the cathode and keep the cathode the same when reversing the stimulation.
I
Calculations
b
Two calculations can be used, the F wave conduction velocity (FWCV) and the F ratio.
FWCV =
2D(mm)
F Ratio = 2M
(F-M- 1 )
Notes
3. Begin with the wrist stimulation site. Use low stimulator current to start and gradually
increase to produce a maximal amplitude response. Pay attention to the shape of the waveform. Reconnect the active if necessary. Remember that the distance from the active electrode to the cathode is 8 centimeters.
Wrist
El bow
Upper arm
i ViMEDtAN MOTOR NCV~ . *.
4.
Mark the stimulation site when an adequate response is obtained. Move the stimulation to the elbow and obtain responses as above. Mark the stimulation site and measure between the two cathode sites.
5.
6. Measure the latency to the take-off points.

7:
Calculate the NCV.
8.
Reset the instrument parameters for an F wave test. Gain High-cut filter Low-cut filter Sweep speed
200 pV1d iv I 0 kHz 10 Hz 5 or 10 rnsldiv
Ulnar Nerve Motor NCV and F Wave

I. C o n n e d recording a n d ground electrodes to t h e subject for an ulnar nerve study.
Cathode Reference
f ADM Motor point o 5th digit Dorsum o f hand
<
Set the appropriate instrument parameters and connect t h e subject to t h e preamplifier. Gain High-cut filter Low-cut filter S w e e p speed Pulse width Stim level
5,000Wdiv 1 0 kHz 10 Hz 5 msldiv 100 p Supramaximal
9. Reverse t h e polarity o f t h e stimulator a n d stimulate at t h e wrist using supramaximal current. Observe t h e F wave. Obtain ten responses a n d measure t h e minimum latency.
Anode
Reference
Ground
10. Move t h e stimulus t o t h e elbow and repeat. Remember t o reverse t h e stimulus
f t h e cathode. Measure f p m cathode to C7 with t h e polarity. Maintain the location o palm up.
I I . Calculate t h e F wave conduction velocity a n d t h e F ratio.
FWCV =
2D(mm) (F-M- 1 )(ms)
F ratio =
Notes
(F- M - 1 ) 2M
Sensory NCV Concept
NCV
= d(mm) /
t(ma)
Notes
Sensory NCV Measurement

A mixed nerve such as the median or posterior tibia1 has both motor and sensory fibers.
Each type of fiber has a different conduction velocity. In a clinical context it is often important to have an independent assessment of the two. Motor fibers can be isolated by selectively recording from the appropriate muscle. Sensory fibers can be isolated by either selectively stimulating or recording from a sensory nerve or a distal sensory branch. When performing motor studies, the latency of the M response is not the result of nerve conduction only. To avoid this problem, two stimulation sites are used and the calculation is based upon the conduction between them. Sensory studies involve nerve action potentials rather than compound muscle potentials. Therefore, only one stimulation site is necessary and latencies reflect only neural conductian times.
Notes
I

20 pvldiv 2 kHz 30 Hz 2 or 5 ms/div 100 ps Supramaximal
Electrode Placement
P ,
Palmar Stir I
Wrist Stim :athode Anode
Distal Crease Ground (dorsum)
Active Reference
Proximal at base of first digit

Ground
Dorsum of hand
Stimulation
Wrist Palmar
Elbow
Forearm Axilla Erb's
Measurements
Distal latency from wrist stimulation site Take-off latency for each response Distance between stimulation sites
Calculations
Median Nelve Sensory NCV Response
Measurements
Distal latency from wrist stimulation site Take-off latency for each response Distance between stimulation sites
Calculations
Ulnar Nerve Sensory NCV Response
Wrist
DIST ten) 1-R 14.0 2-R 37.8
3-R 45.0 6.00 65.4
Src-0 NCV (ms) (R/s) 2.13 65.7 5.28 78.1
Dist elbow
AMP tuU)
Prox el bow
1 28.8 2 17.6 3 26.0
P-T
Measurements
Distal latency to negative peak
Radial Nerve Sensory NCV Response
1-R
DI& NCU (CHI (n&) 16.0 61.0
1 15.6
(UU) P-T
AMP
Notes
Stimulate at sites I (wrist) and 2 (elbow) to obtain maximal responses. Use the takeoff for latency and measure distances from cathode to recording active.
SEG-0 NCU (ns) (n/d 1-R 5.8 1.03 40.5 2-R 14.0 2 . 7 2 5 1 . 5 3-R 30.8 6.53 50.2
DIST
(CHI
6. Calculate NCV using the following equation:
7. Perform palmar stimulation and record latency.
Notes
5. Stimulate at sites I (wrist), 2 (distal elbow), and 3 (proximal elbow) to obtain maximal
responses. Use the take-off for latency and measure distances from cathode t o recording active.
SEG-0 NCV
(nr) ( W s ) 2.13 65.7 5.28 70.1

6.88 65.4
, . . .
"-,A
, . -
".L.-""hu
At:
...-.... .. ,'.. -'" :
. " ,.
6. Record latencies and compare to norms. Calculate the velocities in the arm
segments. Distal conduction velocity is based on d = 140 millimeters.
5. Stimulate the forearm to obtain maximal response. Measure the distal latency.
DXST
1-R 16.8
(cn)
NCU Ws)
61.8
Notes
Tibia1 Nerve Motor NCV Using Abductor Hallucis

Gain
5,000 pV/div 10 kHz 10 Hz 5 ms/div 100 to 200 p
Electrode Placement
Motor point of abductor hallucis Medial big toe Below medial malleolus or tip of foot
Peroneal Nerve Motor NCV Using Extensor Digitorurn Brevis (EDB)

Gain High-cut filter Low-cut filter Sweep speed Pulse width 5,000W d i v 10 kHz 10 Hz 5 ms/div 100 to 200 ps
Electrode Placement
Motor point o f EDB Lateral small toe Top of foot
COPLITEAL CREASE
STIMULATION I
Tibia1 Nerve F Wave Using Abductor Hallucis

Gain
200 to 500 pV/div

10 kHz 10 Hz 5 msldiv 100 to 200 ps
Electrode Placement
Active
Reference Ground
Motor point o f abductor hallucis Medial big toe Below medial malleolus or tip of foot
Cathode
Anode
snuuvm z
Peroneal Nerve F Wave Using Extensor Digitorurn Brevis (EDB)

Gain High-cut filter Low-cut filter Sweep speed Pulse wldth 200 to 500 Wdiv 10 kHz 10 Hz
5 msldiv
100 to 200 ms
Electrode Placement
Motor point of EDB Lateral small toe Top of foot
Peroneal Nerve F Wave Response
Notes
Lower Extremity ~offrnatnn Reflex

What is an H Reflex?
The H reflex is an eledrophysiological analog of thc 'lonosynaptic ankle jerk reflex. It is present in all muscle at birth but is restricted to tht astroc-soleous after the first year. Afferent access is made through the posterior tibial ewe. The posterior tibial nerve consists of afferent la fibers and efferent alpha mot fibers of the S I root. The H reflex is elicited by a low intensity stimulus a 1 produces a response larger than the M response. Care must be exercised in distinguish !between the H reflex an4 the F wave.
Tibia1 Nerve H Reflex

The H reflex should be viewed as a motor study that uses the tibia1 nerve and the gastrocsoleous. The recording consists of M wave and H reflex from muscle tissue. A t certain stimulus levels an F wave can also be noted.
Gain Htghtut filter Low-cut filter Sweep speed Pulse width 500 to 1,000p.V/div 10 kHz 10 Hz 1 0 ms/div 200 to 500 p
Electrode Placement
Active
Reference Ground
Gastroc-soleous Achilles tendon Between stimulation site and active
Tibia1 Nerve Motor NC and F Wave Using Abductor Halluci

I . Conned recording and ground eledrodbs to the subject for a tibia1 nerve motor NCV protocol.
-snYUID*
uno
Motor point o f abductor ha1 lcis Medial big toe Below medial malleolus or 1 3 of foot
2. Set the appropriate instrument parameters and onnect the subject to the preamplifier.
Gain High-cut filter Low-cut filter Sweep speed Pulse width 5,000 pV/div 10 kHz 10 Hz 5 ms/div I00 to 200 ps
3. Obtain compound muscle action potentials by stimulating at sites I (ankle)and 2
(popliteal fossa). Use low stimulator current to start and gradually increase intensity to produce a maximal amplitude response. Pay attention to the shape of the waveform. Reconnect the active If necessary.
' ! TIBIAL
MOTORNCV
4.
Calculate the motor NCV for the lower leg.
5 . Using the same setup, perform the
iave tesf F-M
em ember to reverse the stimulator
polarity and increase the gain setting (200 to 5 1 D pV/div).
Peroneal Motor NCV and F Wave Using Extensor Digitorurn Brevis

I . Connect the recording and ground electrodes to the subject using the peroneal motor
NCV protocol.
Motor point o f EDB Lateral small toe Top of foot
2. Set the appropriate instrument parameters and connect the subject to the preamplifier.
Gain High-cut filter Low-cut filter Sweep speed Pulse width 5,000 pV/div 10 kHz 10 Hz 5 msldiv 100 to 200 p
6. Reverse the stimulus polarity, increase the gain (200 to 500 pvldiv), and obtain F-wave responses with supramaximal stimuli. Using the TI 2 distance measurement and F and M latencies, calculate the F-wave velocity and F ratio.
3. Stimulate the tibia1 nerve at the popliteal fossa while watching for an abductor hallicus
contraction to verify the stimulation site. Also look for the M response from the gastroc-soleous.
4. When sure of the stimulation site, start stimulation at low subthreshold levels and
slowly increase the stimulus. Watch for an H reflex before the M response appears. At higher levels the H reflex will disappear and then an F wave will appear. Remember to place cathode proximal! The H reflex is remarkably stable in repeated trlals. Measure its latency.
H REFLEX OF LOWER EXTREMITY
Stimulation
Tibia1 nerve at ankle and popliteal fossa Obtain ten responses from each location
Measurements
Measure the distance between the cathode and active in millimeters.
Calculations
Calculate the nerve conduction velocity using the following Formula: ,
Notes
Sural Nerve Sensory NCV (Antidromic)

20 pV/div 2 kHz 30 Hz 5 ms/div I00 to 200 ps
Electrode Placement
ref. act.
Active
Reference Ground
Over the sural newe posterior and inferior to the medial malleolus 3 cm distal
Above ankle
3. Stimulate the tibia1 nerve at the ankle and popliteal fossa. Obtain responses from - -
both locations.
Drsr
1 2-R 3-R 4-R 5-R
(cn) 9.5' 40.0 0.0 0.8 0.0
NCVT
(nI9)
11.5 29.1
0.0 0.0 0.0
TlBlAL SENSORY NCV i
2 3 4 5
P-T
202 2 0 0 0
4. Measure the distance from cathode to active and between cathodes.
5. Calculate the NCV for both segments using the following formula:
2. Set the appropriate instrument parameters and connect the subject to the preamplifier.
Gain High-cut filter Low-cut f i l t e r Sweep s p e e d Pulse width
20 pV/div
2
kHz
30 Hz 5 ms/div 100 t o 200 J.IS
3. Stimulate the sural nerve below the gastroc. Measure the latency.
r
SURAL SENSORY NCV
SHEEP
2
NCUT
l7,7
0.0 0.8 0.8 0.8
(n/d
4:
Use 10, 14, 17, or 20 centimeters as the measured distance from cathode to active. This allows you to compare your data to normative data.
Minimal Workup for Specific Conditions

Peripheral Neuropathy
Motor, sensory, and mixed NCV in one ulnar and one median nerve Sensory study of bilateral sural nerves Bilateral motor study o f tibial and peroneal nerves F waves in median, ulnar, tibial, and peroneal nerves
Carpal Tunnel Syndrome
Motor, sensory, and mixed NCV in median and ulnar of the symptomatic arm When confirmed in the symptomatic arm, the opposite side should be studied
Tardy Ulnar Nerve Palsy

Motor, sensory, and mixed NCV in median and ulnar newesdn involved arm Ulnar tests should emphasize conduction across the elbow-the distance of which should be about 10 centimeters If one limb tests positive, the opposite should be studied
Peroneal Nerve Palsy

Motor NCV in peroneal and tibial nerves with attention to the peroneal velocity across the fibular head
Impact of Noise
All electricity at any point on the body from separate sources sums linearly. The,evoked potential is superimposed on all other background noise. Muscle evoked potentials, such as those recorded in nerve conduction studies, are often substantially larger than the background electrical noise upon which they are superimposed. It is therefore unnecessary to use anything but straightforward recording techniques to reveal them. Nerve, spinal cord, and brain evoked potentials of microvolt and submicrovolt amplitude are virtually always "buried"under the background noise. These evoked potentials are invisible to simple biorecording techniques.
Signal Averaging
The technique of signal averaging is used to unmask the tiny evoked potential from the background noise that obscures it. i
Comparison of EP to EKG
EKC immediate Result EP
Delayed Results Continuous Data Sampled Data
Comparison of EP to Blood Chemistry

Blood Chem. Sampled Delayed Results Instant
I EP Sampled
Delayed Result
Averaged
Stimuli vs. Sweeps

Every sweep of the averager starts with the presentation of a stimulus. However, when artifact reject is being employed, every sweep may not be included in the actual average. The artifact reject function detects when input to the AID convertor is larger than its allow* able range. Under these circumstances, the input is peak clipped and therefore distorted. When the artifact reject function detects the input "over-scale condition" it does not allow the sweep to be included in the average. Therefore, when the average is completed more stimuli may have been delivered than total sweeps in the average.
Display Scale
The input sensitivity, which expresses the gain of the instrument when data is being collected, is specified prior to commencing an average. This sensitivity also, tells the operator the vertical scale of the input as displayed on the screen when set to view the input signal during acquisition. In evoked potential work, this is usually 10 microvolts per vertical division. The evoked potentials themselves, however. are commonly in the range of one microvolt or less. If the averaged EP were to be displayed at the same scale factor as the input, its morphology would be barely appreciated. Thus it becqmes necessary to define a scale factorseparately from that of the input to be used for the displayed average. For this definition, the input waveform scale is defined as a unit, and the averaged waveform is expressed as a multiple of it. Note that this scale factor has nothing to do with the gain of the preamplifier while data is being collected. Rather, it is calculated by the computer and factors can be altered at will even after the subject is disconnected from the input. Operators must exercise care in using the display scale as it can confuse interpretation.
Notes
The key assumption is that the noise is a Gaussian-distributed random variable so that the average o f the noise is zero. Under this circumstance,at the end o f averaging, the display screen shows the average o f the input signal which should be the average o f the evoked signals. Actually, the noise does not average to zero. This would require an infinite number of samples. What does happen is the noise averages to a residual amount still superimposed on the evoked signal average but reduced significantly in size so as to unmask the tiny evoked potential component. The following figure illustrates this theory.
Notes
There are, however, two assumptions underlying this theory: random noise and invariant signal. These assumptions are never strictly met in clinical applications. The following departures should be noted: Noise Transience Periodic interference Signal Amplitude variability Latency variability Departures of the noise from the assumed randomness can make EPs difficult to interpret. This is because the residual noise after averaging, still superimposed upbn the averaged EP, may be much larger than theory would predict and also unstable from trial to trial. When the average obtained appears difficult to deal with, It is advisablk to test the validity of the random noise assumption. This can be accomplished in two ways. The first is to obtain averages with the stimulus absent. This, in effect. renders the EP component equal to zero so that the averaged waveform displayed Is simply the average of the background noise. The second is to perform multiple trials and superimpose them on the screen to t enable a determination of their similarity.
Notes
Assessing t h e Adequacy
Mechanical
t h e Preparation
Electrodes must be securely attached to minimize relative movement of electrode and skin.
Impedance
lmpedance should be measured using an electrode impedance meter and kept as low as possible. This usually means about 2,000 ohms or less for the best work. When low impedances are not achieved for any reason, it is desirable to Have the impedances matched to within a few thousand ohms in any given channel. Be advised that the impedance of the ground electrode must be as low as all others for optimal performance of the preamplifiers.
\
Quality of Input
Both the visual appearance and sound of the incoming signal should be noted for possible problems before commencing averaging. The input should be &ell behaved as well as not showing evidence of periodic interference. Any periodic interference component can be detected by the presence of a perceived pitch when listening to the input.
Notes
For details on how an electric field in a tissue can initiate action potentials in axons, a basic physiology text can be consulted. For the present purpose, it should be sufficient to recall f the cathode and that the resulting action that the depolarlzation occurs in the region o potential propagates in both directions away from the site of stimulation. Only those action potentials that are conducted orthodromically with respect to the relevant pathway are of interest because they alone produce the evoked potential. It is the Group I1 fibers that are responsible for the SEP. Group I fibers generally do not go to the cortex, and Group Ill and IV fibers are difficult to stimulate-necessary currents would be too painful and would damage tissue. The following figure shows the expected response when one records from a mixed nerve that has received an electrical stimulus. Since only mild stimuli are used, only the first peak is actually seen in EP recordings o f peripheral nerves.
1
Stimulus
Stim
Time
Segmental and Dermatomal SEPs

Overview of Root and Spinal Nerve Anatomy Overview of Radiculopathy Pathophysiology Evaluation Clinical Eledrophyslological SEP technique adapted for root study The cortical recording Root-specific stimulation Dermatomal system Sensory nerve system Norms Interpretation
Notes
Using Existing Normal Values

If it were necessary to determine every clinical norm needed for all applications, the process would be prohibitive indeed both in cost and time. Fortunately, it is possible to simplify the process but not avoid it entirely.
Absolute latencies must be determined for each instrument and parameter. Measurements based on differences are not instrument dependent and if care is used the following can be used from the literature: Interpeak latencies Side differences Gender differences Standard deviations
I
(Theseare essentially in the definition of abnormality.) The following pages show how to incorporate literature norms in the values used at a local lab.
Notes
#
Example SEP Norms ( ~ e d i a Nerve n at Wrist)

Measurements
Subject
I
I
I
I
I DIF I
I
I
I
L ( DIF
I
To obtain the mean latency, use:
To obtain the sample standard deviation (s.d.),use:
The critical value for each peak is obtained using:
where CV is critical value x is the mean latency s.d. Is the standard deviation from the norms z is the normal deviate selected to establish the desired false positive role. (See table.)
b
False positive rate

1 in 100
2.33
Absolute Latencies
Montage
2 Channel
Channel
1
Active C3' or C4' Spine
Reference lpsilateral Erb's FPz or
Channel I
Active C3' o r C4' plus lpsi Erb's Spine
Reference Fpz
FPz
3 Channel
Channel
1
Active
Reference Forehead
. I
C3' or C4' Spine (psi Erb's
4 Channel Channel Active Reference
C3' or C4' Spine
Contralateral Erb's FPz
lpsi Erb's
( Contralateral Erbs
I I
C h2
Ch 3
C h4
Ground Corn R e f
<
Contralateral
Cortex
I
I
Contralateral Erb's
J
Ipsilateral
Stimulated limb pmxlmai to cathode
(hand area)
Forehead
Median N e r v e SEP Normal R e s p o n s e
Normal V a l u e s
1 wave
Erb's
Cervical Spine Cortical
Side Diff
Erb's Spine
Spine - Cortex Erb's - Cortex
Montage
2 Channel
I Channel
p p
- -
Active
Reference lpsilateral Erb's Fp
C3'or C4'
Spine
I
I
I Channel
or
Active
C3' or C4'
Reference
plus lpsi Erb's Spine
3 Channel
1 Channel
Active
Reference Forehead
I
C3'or C4'
Spine lpsi E r b ' s
Channel
Channel
1
Active C3' or C4' C3' o r C4' Spine lpsi Erb's
Reference FP~ Contralateral Erb's FPz Contralateral Erb's
3
4
ChI
Contralateral cortex (hand area)
Spine Forehead
I
I
Stimulated limb proximal to cathode lpsilateral M1
Contralateral Erb's
Ulnar Nerve SEP Normal Response

RINISCRLE 10 5.0
RR 2.70
RUE(
258) :
258
REJECT
62
SWEEP
5
SSEP
Normal Values
Wave
Ulnar Nerve
CV
S i d e Diff
CV
Erb's
Cervical Spine
Cortical
Erb's Spine
Splne - Cortex
Erb's Cortex
Montage
Active
C3' or C4'
Reference
Ground
FPz Proximal arm
Stimulation
C6,C7, and C8 nerve roots
Notes
preamplifier.
Gain Highlcut filter Low-cut filter Sweep speed Pulse width Repetition rate Scale
10 pV/div 500 kHz 10 Hz 5 msldiv 200 ps 2.71s 2 to 4
3. Obtain responses from both the median and ulnar nerves. To save time, only conned
for unilateral testing. Remember that in actual testing both sides are always studied.
RI NISCRLE 10 2.0
RR 2.70
RUE(
258):
149
REJECT
1z
SWEEP
5
SSEP
Median nerve SEP response.
Montage
Channel Active
Reference Forehead
Cz'
T12S
L4S
TlOS
L2S
PF
PF
- B
A
EpF
L 2 ! 3
u s
Normal Values
Wave
Lat.
CV
Dif.
Tl2S
L4S (Cauda equina) PF (Peripheral nerve)
21.6 1 8 . 0
25.6 20.0
0.8 0.7
8.4
ll.O
OA
Posterior Tibial Nerve at the Ankle

Latency vs. Height
0 0 / 00 ~ ~ / /
-mean lat. --- eit. val
Legend
ISM
1.OM
1.7M
1.OM
1. O M
Height (Meters)
Montage
I Channel (
Active
Reference Forehead
Cz'
Tl2S
L4S
TlOS
L2S
Normal Values
Wave Lat.
CV
Dif
CV
Cz'
L4S (Cauda equina)
Cd-T12S
Montage
Cz'
FP~
Proximal leg
Stimulation
L4,L5,and S1 nerve roots
Notes
11NISCCILE
10
3.4
RR 2.70
AWE(
258):
258
REJECT 0x
SWEEP
10
Posterior tibia1 nerve S E P response.
~RIN/SCRLE
10 6.0
RR 2.70 Y ' A V E ( 250):
250
REJECT Sx
SWEEP
10
Common peroneal nerve S E P response.

Nerve Conduction Studies

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Nerve Conduction Studies and Somatosensory Evoked Potentials

Cadwell Educational Programs

(509) 735-6481 or (800) 245-3001 (509) 783-6503

Nerve Conduction Studies and Somatosensory ~voked Potentials

Neuromuscular Electricity and Instrument Basics

Cellular Basis of Bioelectricity

lohnson EW: Practical Electromyography, e d 2. Williams a n d Wilkins.

11. Liveson I: Peripheral Neurology, ed 2. F.A. Davis. 1990.

Posterior tibia! nerve SEP resporrse.

GRIN/SCALE : RR 2.78 18 6.0 ,.'FIVE( 250):

Common peroneal nerve SEP response.

Lower Extremity SEPs

Set the appropriate instrument parameters.

Low-cut filter Scale Sweep speed Pulse width Repetition rate

5 msldiv 200 ps 2.71s

Collecting Lower Extremity SEP Responses

Knee Ankle Above ankle Ankle

Lower Extremity Dermatomal SEPs (L4, L5, and SI)

Ground the leg proximal to the stimulation site

0.59 0.99 0.6

Common Peroneal Nerve SEP Normal Response

Stimulated limb proximal to cathode

Common Peroneal Nerve SEP

Posterior Tibia1 ~ e r v e at / the Ankle

Latency vs. ~elght

Posterior Tibia1 Nerve SEP Normal Response

Posterior Tibia1 Nerve SEP

Lower Extremity SEP Protocols

Ulnar nerve SEP response.

responses from C6, C7, and C8.

10 pvldiv 500 kHz 10 Hz 5 msldiv 200 ps 2.71s 2 to4

Median nerve SEP response.

Median and Ulnar Nerve SEPs

Erb's point (ipsilateral)

Active C3' or C4' Spine lpsi Erb's

Active C3' or C4' C3' or C4' Spine lpsi Erb's

Reference FP~ Contralateral Erb's FP~ Contralateral Erb's

Collecting Upper Extremity SEP Responses

Forearm Thumb Fingers 2 G 3 Finger 5

Upper Extremity Dermatomal SEPs (C6, C7, a n d C8)

C3' C4' Fpz

Ground the arm proximal to the stimulation site

Ulnar N e r v e SEP Normal desponse

Ground Corn Ref

Stimulated limb proximal to cathode

(C2. ' 3 . or C7)

Ulnar Nerve SEP

Cervical Spine C2, C5, or C7

Erb's point (ipsilateral)

Median Nerve SEP Notmal esponse

Erbs CY o r ~ 4 ' lpsi~ated~ Spine

Spine lpsi Erb's

Spine lpsi Erb's

Stimulated limb proximal to cathode

Median Nerve SEP

c e r v i c a l Spine C2, C5, o r C7 Erb's point (ipsilateral)

Upper Extremity SEP Protocols

To obtain the mean latency, use:

To obtain the sample standard deviatibn (s.d. use:

The critical value for each peak is obtained I ing:

False positive rate

Calculation: Interpeak Latencies

Example SEP ~ d r m s (Median Nerve at WI

Rate of false positives '