Nerve conduction

study

Nerve conduction velocity

A nerve conduction study (NCS) is a

medical diagnostic test commonly used to
evaluate the function, especially the ability
of electrical conduction, of the motor and
sensory nerves of the human body. These
tests may be performed by medical
specialists such as clinical
neurophysiologists, chiropractors,
physiatrists (physical medicine and
rehabilitation physicians), and neurologists
who subspecialize in electrodiagnostic
medicine. In the United States,
neurologists and physiatrists receive
training in electrodiagnostic medicine
(performing needle electromyography and
NCSs) as part of residency training and in
some cases acquire additional expertise
during a fellowship in clinical
neurophysiology, electrodiagnostic
medicine, or neuromuscular
medicine.[1][2][3] Outside the US, clinical
neurophysiologists learn needle EMG and
NCS testing.

Nerve conduction velocity (NCV) is a

common measurement made during this
test. The term NCV often is used to mean
the actual test, but this may be misleading,
since velocity is only one measurement in
the test suite.

Medical uses
Nerve conduction studies along with
needle electromyography measure nerve
and muscle function, and may be indicated
when there is pain in the limbs, weakness
from spinal nerve compression, or concern
about some other neurologic injury or
disorder.[4] Spinal nerve injury does not
cause neck, mid back pain or low back
pain, and for this reason, evidence has not
shown EMG or NCS to be helpful in
diagnosing causes of axial lumbar pain,
thoracic pain, or cervical spine pain.[4]

Nerve conduction studies are used mainly

for evaluation of paresthesias (numbness,
tingling, burning) and/or weakness of the
arms and legs. The type of study required
is dependent in part by the symptoms
presented. A physical exam and thorough
history also help to direct the
investigation. Some of the common
disorders that can be diagnosed by nerve
conduction studies are:

Carpal tunnel syndrome

Cubital Tunnel Syndrome
Guillain–Barré syndrome
Guyon's canal syndrome
Peripheral neuropathy
Peroneal neuropathy
Spinal disc herniation
Tarsal Tunnel Syndrome
Ulnar neuropathy
Technique
The nerve conduction study consists of
the following components

Motor NCS
Sensory NCS
F wave study
H-reflex study

The nerve conduction study is often

combined with needle electromyography.

Other

The Department of Health and Human

Services Inspector General recently
identified the use of NCSs without a
needle electromyography at the same time
a sign of questionable billing.[5]

Motor NCS

Motor NCS are performed by electrical

stimulation of a peripheral nerve and
recording from a muscle supplied by this
nerve. The time it takes for the electrical
impulse to travel from the stimulation to
the recording site is measured. This value
is called the latency and is measured in
milliseconds (ms). The size of the
response – called the amplitude – is also
measured. Motor amplitudes are
measured in millivolts (mV). By
stimulating in two or more different
locations along the same nerve, the NCV
across different segments can be
determined. Calculations are performed
using the distance between the different
stimulating electrodes and the difference
in latencies.

Sensory NCS

Sensory NCS are performed by electrical

stimulation of a peripheral nerve and
recording from a purely sensory portion of
the nerve, such as on a finger. Like the
motor studies, sensory latencies are on
the scale of milliseconds. Sensory
amplitudes are much smaller than the
motor amplitudes, usually in the microvolt
(μV) range. The sensory NCV is calculated
based upon the latency and the distance
between the stimulating and recording
electrodes.

Sensory NCS: An example screenshot showing the

results of a sensory nerve conduction velocity study of
the right median nerve.
F-wave study

F-wave study uses supramaximal

stimulation of a motor nerve and recording
of action potentials from a muscle
supplied by the nerve. This is not a reflex,
per se, in that the action potential travels
from the site of the stimulating electrode
in the limb to the spinal cord's ventral horn
and back to the limb in the same nerve
that was stimulated. The F-wave latency
can be used to derive the conduction
velocity of nerve between the limb and
spine, whereas the motor and sensory
nerve conduction studies evaluate
conduction in the segment of the limb. F
waves vary in latency and an abnormal
variance is called "chrono dispersion".
Conduction velocity is derived by
measuring the limb length, D, in
millimeters from the stimulation site to the
corresponding spinal segment (C7
spinous process to wrist crease for
median nerve). This is multiplied by 2 as it
goes to the cord and returns to the muscle
(2D). 2D is divided by the latency
difference between mean F and M and 1
millisecond subtracted (F-M-1). The

formula is .
H-reflex study

H-reflex study uses stimulation of a nerve

and recording the reflex electrical
discharge from a muscle in the limb. This
also evaluates conduction between the
limb and the spinal cord, but in this case,
the afferent impulses (those going toward
the spinal cord) are in sensory nerves
while the efferent impulses (those coming
from the spinal cord) are in motor nerves.
This process cannot be changed.

Specialized testing

Repetitive nerve stimulation

Small-pain-fibers method

In 1998, a small-pain-fibers (spf-NCS)

method was cleared by the FDA. This
method uses an electrical stimulus with a
neuroselective frequency to determine the
minimum voltage causing conduction.
Rather than comparing the data with
population averages on a bell-shape curve,
which at best has about 65% sensitivity,
the patient is his own control. In a three-
year LSU Pain Center study, it was found
that the nerve requiring the greatest
voltage to cause conduction of the A-delta
(Fast Pain) fibers identified nerve root
pathology with 95% sensitivity. Besides
being painless, the test is fast. This test
can determine nerve
impingement/pathology (pain causing)
within the spine (nerve root level) where
EMG and Velocity Tests fail. The test uses
a potentiometer to objectively measure the
amplitude of the action potential at a
distant site along the nerve being tested.
The patient confirms a sensation when the
nerve fires. Objectivity of the patient's
response is confirmed by the
measurement of nerve recruitment for
surrounding nerves and is displayed on the
instrument. The impinged nerve (pain
fibers) can only report (peak) momentarily
while recruiting other nerves to assist and
sustain the reporting of the stimulus. Non
impinged nerves (pain fibers) do not
recruit surrounding nerves and this is
readily seen on the display.

The spf-NCS does not require myelin loss

to detect function change, so velocity is
not measured. The Small-Pain-Fibers NCS
(pf-NCS) is the preferred test with over
95% accuracy for determining the spine
level(s) and side(s) for Small Pain Fiber
impingement/pathology allowing for the
most accurate diagnosis and treatment
procedures for patients experiencing back
pain. Patients diagnosed with the
EMG/NCV studies alone (while
experiencing pain but having no significant
myelin loss) were misdiagnosed in over
50% of cases including the diagnosis and
treatment of incorrect nerve root levels
and sides in patients.

Interpretation of nerve
conductions
The interpretation of nerve conduction
studies is complex and requires the
expertise of medical practitioners such as
clinical neurophysiologists, neurologists or
physiatrists. In general, different
pathological processes result in changes
in latencies, motor, and/or sensory
amplitudes, or slowing of the conduction
velocities to differing degrees. For
example, slowing of the NCV usually
indicates there is damage to the myelin.
Another example, slowing across the wrist
for the motor and sensory latencies of the
median nerve indicates focal compression
of the median nerve at the wrist, called
carpal tunnel syndrome. On the other
hand, slowing of all nerve conductions in
more than one limb indicates generalized
diseased nerves, or generalized peripheral
neuropathy. People with diabetes mellitus
often develop generalized peripheral
neuropathy.
Patient risk
Nerve conduction studies are very helpful
to diagnose certain diseases of the nerves
of the body. The test is not invasive, but
can be painful due to the electrical shocks.
The shocks are associated with a low
amount of electric current so they are not
dangerous to anyone. Patients with a
permanent pacemaker or other such
implanted stimulators such as deep brain
stimulators or spinal cord stimulators
must tell the examiner prior to the study.
This does not prevent the study, but
special precautions are taken.
Cardiac pacemakers and implanted
cardiac defibrillators (ICDs) are used
increasingly in clinical practice, and no
evidence exists indicating that performing
routine electrodiagnostic studies on
patients with these devices pose a safety
hazard. However, there are theoretical
concerns that electrical impulses of nerve
conduction studies (NCS) could be
erroneously sensed by devices and result
in unintended inhibition or triggering of
output or reprogramming of the device. In
general, the closer the stimulation site is
to the pacemaker and pacing leads, the
greater the chance for inducing a voltage
of sufficient amplitude to inhibit the
pacemaker. Despite such concerns, no
immediate or delayed adverse effects
have been reported with routine NCS.[6]

No known contraindications exist from

performing needle EMG or NCS on
pregnant patients. In addition, no
complications from these procedures have
been reported in the literature. Evoked
potential testing, likewise, has not been
reported to cause any problems when it is
performed during pregnancy.[6]

See also
Bioelectronics
Cable theory
 Biological neuron models

References
1. "Archived copy" (PDF). Archived from the
original (PDF) on 2014-04-18. Retrieved
2015-01-19.
2. "Archived copy" (PDF). Archived from the
original (PDF) on 2014-12-26. Retrieved
2014-12-26.
3. "Archived copy" (PDF). Archived from the
original (PDF) on 2014-12-26. Retrieved
2015-01-19.
4. North American Spine Society (February
2013), "Five Things Physicians and Patients
Should Question" , Choosing Wisely: an
initiative of the ABIM Foundation, North
American Spine Society, retrieved 25 March
2013, which cites
Sandoval, AE (Nov 2010).
"Electrodiagnostics for low back pain".
Physical Medicine and Rehabilitation
Clinics of North America. 21 (4): 767–
76. doi:10.1016/j.pmr.2010.06.007 .
PMID 20977959 .
North American Spine Society (2011).
"Diagnosis and treatment of
degenerative lumbar spinal stenosis" .
Burr Ridge, Illinois: Agency for
Healthcare Research and Quality: 104.
5. http://oig.hhs.gov/oei/reports/oei-04-12-
00420.pdf
6. "Archived copy" . Archived from the
original on 2014-12-26. Retrieved
2014-12-26..

External links
EMG & Nerve Conduction Education &
Resources
Association of EMG technologists of
Canada
American Association of Neuromuscular
& Electrodiagnostic Medicine
American Board of Electrodiagnostic
Medicine
 Details of NCV from National Institutes
of Health
WebMD summary of EMG and NCS
American Association of Sensory
Electrodiagnostic Medicine

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