BASICS OF ELECTRODIAGNOSTIC STUDIES

 Peripheral nerves are stimulated with an controlled electrical stimulus

 Responses recorded
 1. Compound motor action potential (CMAP)
 2. Sensory nerve action potential (SNAP)
 3. F wave
 4. H- reflex
MOTOR NCS

 CMAP- biphasic potential with an initial negativity (upward deflection).

 Also called M response
 For each stimulation site: latency, amplitude, duration, and area of the CMAP are
measured.
 A motor conduction velocity can be calculated after two sites of stimulation, one
distal and one proximal.
If an initial positive deflection exists, it may be due to:

 1. Inappropriate placement of the active electrode from the motor point

 2.Volume conduction from other muscles or nerves
 3. Anomalous innervations
MOTOR LATENCY

 It is the time from the stimulus to the initial negative deflection from baseline
 In milliseconds (ms).

In CMAP latency represents three separate processes:

 (1) the nerve conduction time .
 (2) the time delay across the NMJ
 (3) the depolarization time across the muscle.
MOTOR CONDUCTION VELOCITY

 Calculated by dividing the change in distance (between proximal stimulation site &
distal stimulation site in mm) by the change in time

 Normal values are > 50 meters/sec in the upper limbs And > 40 meters/sec in the
lower limbs
CMAP AMPLITUDE

 Most commonly measured from baseline to the negative peak (baseline-to-peak)

 Less commonly from the first negative peak to the next positive peak (peak-to-peak).

 Reflects the number of muscle fibers that depolarize.

 Low CMAP amplitudes most often result from loss of axons (as in a typical axonal
neuropathy), conduction block
CMAP DURATION

 Measured from the initial deflection from baseline to the final return
 Also measured from the initial deflection from baseline to the first baseline crossing
 2nd is preferred as the terminal CMAP returns to baseline very slowly and can be
difficult to mark precisely
CMAP AREA

 This is a function of both the amplitude and duration of the waveform.

 CMAP area is measured between the baseline and the negative peak.
 Differences in CMAP area between distal and proximal stimulation sites for
determination of conduction block from a demyelinating lesion(>50%)
SENSORY NCS

 Onset latency: the time required for an electrical stimulus to initiate an evoked
potential.
 Onset latencies reflect conduction along the fastest nerve fibers
 Peak latency : represents the latency along the majority of the axons and is
measured at the peak of the waveform amplitude (first negative peak).
 Both latencies are primarily dependent on the myelination of a nerve.
 It may be difficult to determine the precise point of deflection from baseline

 Peak latency can be ascertained in a straightforward manner.

 Peak latency cannot be used to calculate a conduction velocity

 SNAP amplitude -sum of all the individual sensory fibers that depolarize.

 Conduction velocity - Only one stimulation site is required to calculate a sensory

conduction velocity.
PRE-GANGLIONIC LESION

 Lesions proximal to DRG (pre-ganglionic lesion) preserve the SNAP waveform

despite clinical sensory abnormalities.

 Eg: Radiculopathies, spinal cord pathologies

ANTIDROMIC VS ORTHODROMIC

 Antidromic studies are performed by recording potentials directed toward the

sensory receptors

 Orthodromic studies are obtained by recording potentials directed away from these
receptors.
ANTIDROMIC SENSORY STUDIES

 Antidromic studies are easier to record a response than orthodromic studies.

 May be more comfortable than orthodromic studies due to less stimulation required.
 May have larger amplitudes due to the nerve being more superficial at the distal
recording sites.
 More chances of volume conducted motor potential.
TEMPORAL DISPERSION OF WAVE FORM

 (SNAPs) and(CMAPs) both are compound potentials

 They represent summation of individual sensory and muscle fiber action potentials,
respectively.
 With distal stimulation, fast and slow fiber potentials arrive at the recording site at
approximately the same time
 With proximal stimulation, the slower fibers lag behind the faster fibers.
 Temporal dispersion is more prominent with SNAP than CMAP

 Amplitude drop of 50% is considered normal when recording a proximal SNAP

 Drop of 15% is considered normal when recording a proximal CMAP

CONDUCTION BLOCK

DEFINITE

 > 50% drop in CMAP amplitude with <15% prolongation of CMAP duration, or
 > 50% drop in CMAP amplitude and area, or
 > 20% drop in CMAP amplitude and area over a short nerve segment (10 cm)
CONDUCTION BLOCK

PROBABLE

 20‐50% drop in CMAP amplitude with < 15% prolongation of CMAP duration, or
 20‐50% drop in CMAP amplitude and area
EFFECT OF TEMPERATURE

 Cooler temperature prolong time of depolarization

 Conduction velocity slows between 1.5-2.5m/s, distal latency prolong by 0.2 ms for
every degree drop in temperature

 Higher amplitude and longer duration

 Temperature to be maintained between 32-34 degree