pictorial guide to nerve conduction techniques

Editors: Pease, William S.; Lew, Henry L.; Johnson, Ernest W.

Title: Johnson's Practical Electromyography, 4th Edition

Copyright ©2007 Lippincott Williams & Wilkins

> Table of Contents > II - Technical Aspects of EMG > Chapter 9 - Pictorial Guide to Nerve Conduction Techniques

Chapter 9

Pictorial Guide to Nerve Conduction Techniques

Henry L. Lew

Su-Ju Tsai

Abbreviations for the electrode placement are as follows:

E1 Placement of the active electrode

E2 Placement of the reference electrode

G Placement of the ground electrode

S • Cathode Placement of the cathode for stimulation

• Anode Relation of stimulator anode to the cathode

Cranial Nerves

Table 9-1 Cranial Nerve VII to Nasalis (Fig. 9-1)

Figure 9-1 • Cranial nerve VII

Electrode placement

E1 Over nasalis (lateral side of midnose)

E2 Over contralateral nasalis

G On the cheek or chin

S Postauricular stimulation—behind the lower ear, below the mastoid

process and behind the neck of the mandible

Normal values

Mean ± SD Normal limit

Onset latency

(1)

3.5 ± 0.4 ms ≤4.2 ms

Amplitude (2) ≥1 mV

Note: Alternate recording sites from other facial muscles as needed to evaluate specific

branches of CN VII.

Table 9-2 Blink Reflex (Fig. 9-2)

Electrode placement

E1 Over bilateral orbicularis oculi muscle, lower lateral

portion

E2 Medial inferior orbit

Figure 9-2 • Blink reflex

G Chin

S Cathode At the supraorbital notch

Anode Superiorly

Normal values (3) (n = 83)

Mean ± SD (Normal

limit)

Side-to-side difference

(Normal limit)

R1 latency 10.5 ± 0.8 ms (≤13.0

ms)

0.3 ± 0.9 ms (≤1.2 ms)

Ipsilateral R2 latency 30.5 ± 3.4 ms (≤41.0

ms)

1.0 ± 3.4 ms (≤4.4 ms)

Contralateral R2

latency

30.5 ± 4.4 ms (≤44.0

ms)

Note: Amplitudes are variable.

Table 9-3 Cranial Nerve XI to Trapezius (Fig. 9-3)

Figure 9-3 • Cranial nerve XI

Electrode placement

E1 Over the upper trapezius, midway between C7 spinous process

and acromion.

E2 On acromion

G Medial clavicle

S Cathode At the posterior edge of the

sternocleidomastoid muscle

Anode Superiorly

Normal values (4,5) (n = 30)


Onset latency 2.2 ± 0.4

ms

≤ 3.0 ms

Peak

amplitude

3.9 ± 1.6

mV

≥ 1.0 mV

Upper Body

Upper Body: Motor Nerves

Table 9-4 Phrenic Nerve (Fig. 9-4)

image

Figure 9-4 • Phrenic nerve

Electrode placement

E1 On the xiphoid process

E2 On the costal margin, at anterior axillary line

G Medial sternum

S Cathode 3 cm above the clavicle, along the posterior border

of the sternocleidomastoid muscle

Anode Superiorly


Mean ±

SD

Normal limit

Onset

latency

6.3 ± 0.8

ms

≤8.6 ms

Amplitude 597 ± 139

µV

≥400 µV

Table 9-5A Long Thoracic Nerve-1 to Serratus Anterior (Fig. 9-5A)

Figure 9-5 • A. Long thoracic nerve

Electrode placement (7) (Fig. 9-5A)

E1 Self-adhesive, 8.0 × 0.5-cm, ring-type electrode—cranial end at nipple level (5 cm

distal to the bipolar stimulator) in line with the bipolar stimulator contact points and

the anterior superior iliac spine

E2 Self-adhesive surface electrode over the seventh rib distal to the pectoralis muscle

G Over the ipsilateral latissimus dorsi

S In the axilla just anterior to the midaxillary line

Normal values (7) (n = 15, self-adhesive ring-type electrode recording)

Side Mean ± SD Normal limit

Onset

latency

Right 2.3 ± 0.5 ms ≤3.5 ms

Left 2.3 ± 0.4 ms ≤3.2 ms

Side-to-side difference 0.3 ± 0.2 ms ≤0.6 ms

Amplitude Right 3.8 ± 1.9 mV ≥1.6 mV

Left 3.9 ± 1.9 mV ≥1.2 mV

Side-to-side difference 0.6 ± 0.6 mV ≤2 mV

Table 9-5B Long Thoracic Nerve-2 to Serratus Anterior (Fig. 9-5B)

Figure 9-5 • B. Long thoracic nerve

Electrode placement

E1 A needle electrode is placed into the digitation of the serratus anterior muscle

over the fifth rib, along the midaxillary line.

E2 Two cm distal to the E1 (no need if a concentric needle electrode is used for

E1)

G Over the 12th rib level at the anterior axillary line

S Cathode Slightly above the upper margin of the clavicle lateral to

the clavicular head of the sternocleidomastoid muscle

Anode Superomedially

Normal values (8) (n = 16, concentric needle recording)

Age

(years)

Onset latency

Mean ± SD

Normal limit

20–35 3.6 ± 0.3 ms ≤4.2 ms

36–50 3.8 ± 0.4 ms ≤4.4 ms

51–65 4.0 ± 0.4 ms ≤4.8 ms

Table 9-6 Axillary Nerve to Deltoid (Fig. 9-6)

Figure 9-6 • Axillary nerve

Electrode placement

E1 Midway between acromion and deltoid tubercle

E2 At deltoid tubercle

G Between the stimulating point and active electrode

S Cathode Supraclavicular fossa




Onset latency 3.9 ± 0.5 ms ≤5.0 ms

Note: No information on amplitude is available (9).

Table 9-7 Musculocutaneous Nerve to Biceps (Fig. 9-7)

Figure 9-7 • Musculocutaneous nerve

Electrode placement

E1 Midpoint of the biceps brachii muscle belly

E2 Distal biceps tendon

G Over the acromion







Table 9-8 Suprascapular Nerve (Fig. 9-8)

Figure 9-8 • Suprascapular nerve

Electrode placement

E1 A concentric recording needle (E2 = reference/outer cannular of needle)

Supraspinatus: Insert the needle just above the scapular spine at the

midpoint. Advance the needle in a downward and forward direction until

the needle touches the scapula, then withdraw it 2–3 mm. Infraspinatus:

Insert the needle 3 cm below the scapular spine and 3 cm lateral to the

medial border of the scapula.

G Over the posterolateral shoulder




Onset latency Mean ± SD Normal limit

Supraspinatus

recording

2.7 ± 0.5 ms ≤3.7 ms

Infraspinatus

recording

3.3 ± 0.5 ms ≤4.2 ms


Table 9-9 Thoracodorsal Nerve to Latissimus Dorsi (Fig. 9-9)

Figure 9-9 • Thoracodorsal nerve

Electrode placement (10)

E1 Supine position with the arm abducted to 90 degrees. E1 is on the posterior

axillary line at the intersection of the line horizontally drawn from the inferior

angle of the scapula.

E2 On the posterior axillary line distal to E1

G On the chest wall, between E1 and S1

S1 Cathode In the axilla toward the lateral margin of the

scapula

Anode Superior

S2 Cathode Erb's point

Anode Superior


Mean ± SD Range

Axilla

(S1)


Amplitude, right 4.1 ± 1.8 mV ≥1.4 mV

Erb's

point

(S2)


Amplitude 6.0 ± 2.0 mV ≥2.0 mV

Table 9-10 Median Nerve to the Abductor Pollicis Brevis (Fig. 9-10)

Figure 9-10 • Median nerve to the abductor pollicis brevis

Electrode placement

E1 Midline between the first

metacarpophalangeal

joint and the first

carpometacarpal joint

E2 Distal to E1 on the first

metacarpophalangeal

joint

G On the dorsum of the

hand

S Cathode S1: 8 cm

proximal

to the E1,

measured

first to the

midpoint

of the

distal wrist

crease and

then on

the line

between

the

tendons of

the flexor

carpi

radialis

and the

palmaris

longus

S2: On the

antecubital

crease, at

the medial

border of

the biceps

brachii

tendon

Anode Proximal


Mean ±

SD

Normal

limit

Onset

latency

3.7 ±

0.3 ms

≤4.3 ms

Amplitude 13.2 ±

5.0 mV

≥5.0 mV

Nerve

conduction

velocity

56.7 ±

3.8 m/s

≥50 m/s


Mean ±

SD

Normal

limit

Onset

latency

3.7 ±

0.5 ms

≤4.7 ms

Amplitude 10.2 ±

3.6 mV

≥3.0 mV

Nerve

conduction

velocity

57 ± 5

m/s

≥47 m/s

Table 9-11 Median Nerve (Anterior Interosseous Branch) to the Pronator Quadratus (Fig. 9-11)

Figure 9-11 • Median nerve (anterior interosseous branch) to the pronator quadratus

Electrode placement

E1 Centrally over the dorsum of the

forearm, 3 cm proximal to the ulnar

styloid

E2 On the medial dorsum of the wrist

over the ulnar styloid process

G On the dorsal forearm, between the E1

and stimulating electrodes

S Cathode On the antecubital

crease, at the medial

border of the biceps

brachii tendon

Anode Proximally


Right Left

Onset

latency

3.6 ± 0.4

ms

3.5 ± 0.4 ms

Onset to

peak

amplitude

3.1 ± 0.8

mV

3.1 ± 0.8 mV

Table 9-12 Radial Nerve to the Extensor Digitorum (Fig. 9-12)

Figure 9-12 • Radial nerve to the extensor digitorum

Electrode placement

E1 Proximal third from the antecubital

crease (S1), over the belly of the

extensor digitorum

E2 On the medial dorsum of the wrist over

the ulnar styloid process

G Between the E1 and the S1

S Cathode S1: In the antecubital

fossa just lateral to the

biceps tendon as the

tendon crosses the flexor

crease

S2: In the axilla between

the coracobrachialis and

the long head of the

triceps

Anode Proximally


Mean ±

SD

Normal limit

Onset

latency

2.6 ± 0.4

ms

≤3.5 ms

Amplitude 11.2 ±

3.5 mV

≥4.3 mV

Conduction

velocity

68 ± 7.0

m/s

≥54 m/s

Table 9-13 Radial Nerve to the Extensor Indicis Proprius (Fig. 9-13)

Figure 9-13 • Radial nerve—to the extensor indicis proprius


E1 Concentric needle electrode into the extensor indicis proprius,

at the distal third of the dorsal forearm and on the dorsum of

the ulna (E2 = outer cannula of needle)

G Between E1 and S1, on the dorsum of the forearm

S Cathode S1: In pronation of the forearm; 4 cm proximal

to the needle insertion site, radial border of the

extensor carpi ulnaris muscle

S2: In pronation of the forearm; 5 cm proximal

to the lateral epicondyle, lateral border of the

triceps brachii muscle

S3: Erb Point

Anode Proximally

Normal values (n = 49)


Distal latency

(17)

2.4 ± 0.5

ms

≤2.9 ms

Conduction

velocity (16)

S1-S2 61.6 ± 5.9

m/s

≥50 m/s

S2-S3 72.0 ± 6.3

m/s

≥60 m/s

Table 9-14 Ulnar Nerve to the Abductor Digiti Minimi (ADM) (Fig. 9-14)

Electrode placement

E1 On the border of the palm and dorsum of the hand, halfway

between the wrist crease and the base of the little finger

E2 Distal to the fifth metacarpophalangeal joint

G On the dorsum of the hand or between the stimulating and

recording electrodes

S Cathode The arm is in a 45 degrees abducted and externally

rotated position with the elbow moderately flexed

to 90–135 degrees (18).

S1: 2 cm proximal to the E1, along the radial border

of the tendon of the flexor carpi ulnaris

S2: 2 cm distal to the ulnar groove at the elbow

S3: 10 cm proximal to the S2, measured in a curve

along the ulnar groove to a point between triceps

and brachialis

S4: 10 cm proximal to S3 in the axilla

Anode Proximally

Figure 9-14 • Ulnar nerve—to the abductor digiti minimi

Normal values (n = 31)

Mean ±

SD

Normal limit

Onset latency (18) 3.2 ± 0.5

ms

≤4.2 ms

Amplitude 6.14 ±

1.90 mV

≥2.3 mV

Nerve conduction

velocity (18,19,20)

S1-S2 61.8 ± 5.0

m/s

≥53 m/s

S2-S3 62.7 ± 5.5

m/s

≥52 m/s

S3-S4 62.8 ± 6.0

m/s

≥51 m/s


Mean ±

SD

Normal limit

Distal latency (21) 3.0 ± 0.3

ms

≤3.6 ms

Amplitude, peak to

peak (21)

11.6 ± 2.1

mV

≥7.4 mV

Conduction velocity

(21)

S1-S2 61 ± 5 m/s ≥51 m/s

S2-S3 61 ± 9 m/s ≥43 m/s

S3-S4 61 ± 7 m/s ≥47 m/s

Table 9-15 Ulnar Nerve to the First Dorsal Interosseous (Fig. 9-15)

Electrode placement

E1 On the dorsum of the hand, the first web space, 1 cm radial to the midpoint of the second

metacarpal bone

E2 Over the first metacarpophalangeal joint

G Between E1 and S1

S Cathode At the ulnar wrist crease, along the radial border of the tendon of the flexor

carpi ulnaris

Figure 9-15 • Ulnar nerve—to the first dorsal

interosseous

Anode Proximally


Onset latency Amplitude

Age (years) Mean Limit Mean Limit

<20 3.3 ms ≤4.2 ms 15 mV ≥8 mV

20–29 3.4 ms ≤4.1 ms 14 mV ≥8 mV

30–39 3.3 ms ≤4.4 ms 15 mV ≥6 mV

40–49 3.2 ms ≤4.2 ms 13 mV ≥6 mV

50–59 3.4 ms ≤4.4 ms 13 mV ≥6 mV

60–69 3.6 ms ≤4.5 ms 12 mV ≥7 mV

>70 3.6 ms ≤4.2 ms 12 mV ≥8 mV

Note: No summarized values are available (22).

Mean side-to-side difference, FDI = 0.2 ms (0.0–1.3); ipsilateral difference, FDI - ADM = 0.9 ms

(0.2–2.0) (22).

Table 9-16 F Wave in the Upper Extremity (Fig. 9-16)

Figure 9-16 • F wave in the upper extremity

Electrode placement

E1 Median nerve: over the abductor pollicis brevis (see Fig. 9-10)

Ulnar nerve: over the abductor digiti minimi (see Fig. 9-14)

E2 Median nerve: slightly distal to the first metacarpophalangeal joint

Ulnar nerve: distal to the fifth metacarpophalangeal joint

G On the dorsum of the hand

S Cathode Positioned as for standard wrist stimulation (see Figs.

9-10 and 9-14)

Anode Distally with supramaximal stimulation (see Figs. 9-10

and 9-14)

Normal values (23,24) (shortest of 10 stimuli, minimal latency)

Nerve Range Side-to-side differences

Median/APB 22–31 ms ≤2.3 ms

Ulnar/ADM 21–32 ms ≤2.5 ms

Note: Ulnar F wave latency (25) = [arm length (cm) × 0.31] – [ulnar nerve forearm velocity

(m/s) × 0.123] + 11.05. A prolongation of >2.5 ms is considered abnormal.

Upper Body—Sensory Nerves

Table 9-17 Lateral Antebrachial Cutaneous Sensory Nerve (Fig. 9-17)

Figure 9-17 • Lateral antebrachial cutaneous sensory nerve


E1 On volar aspect of the

forearm, over the radius

bone, 10 cm distal to the

stimulating cathode

E2 3 cm distal to E1

G Between the stimulating

and recording electrodes

S Cathode Just lateral

to the

biceps

tendon on

the

antecubital

crease

Anode Proximally

Normal values (26) (10-cm distance) (n

= 213)

Mean ±

SD

Normal

limit

Peak

latency

2.2 ±

0.2 ms

≤2.6 ms

Onset to

peak

amplitude

18 ± 10

µV

≥3 µV

Normal values (27) (10-cm distance) (n

= 157)

Mean ±

SD

Normal

limit

Peak

latency

2.8 ±

0.2 ms

≤3.3 ms

Onset to

peak

amplitude

18.9 ±

9.9 µV

≥8 µV

Table 9-18 Medial Antebrachial Cutaneous Sensory Nerve (Fig. 9-18)

Figure 9-18 • Medial antebrachial cutaneous sensory nerve


E1 On volar aspect of the forearm,

over the ulna bone, 14 cm

distal to the stimulating point


G Between the stimulating and

recording electrodes

S Cathode Along the medial

border of the

biceps brachii

muscle, 5 cm

proximal to the

medial

epicondyle

Anode Proximally


Mean ±

SD

Normal limit

Peak

latency

2.7 ±

0.2 ms

≤3.3 ms

Onset to

peak

amplitude

11.4 ±

5.2 µV

≥5 µV

Table 9-19 Median Sensory Nerve to the Second and Third Digits (Fig. 9-19)

Figure 9-19 • Median sensory nerve to the second and third

digits

Electrode placement

E1 A ring electrode is placed distal to the base of the second or third

digit.

E2 4 cm distal to the active electrode


S Cathode S1: 14 cm proximal to E1 on the line between the

tendons of the flexor carpi radialis and the palmaris

longus

S2: The midpoint of the line from E1 to S1

Anode Proximal

Digit 3: Normal values (28) (n = 50)


Peak latency S1

S2

S2/S1

3.07 ± 0.2 ms

1.58 ± 0.15 ms

52 ± 4%

≤3.5 ms

≤1.88 ms

≥44%

Peak amplitude S1

S2

S2/S1

52 ± 13 µV

67 ± 20 µV

128 ± 29%

≥26 µV

≥37 µV

≤186 %



Onset latency S1

S2

2.7 ± 0.3 ms

1.4 ± 0.2 ms

≤3.3 ms

≤1.8 ms

Peak latency S1

S2

3.4 ± 0.3 ms

2.0 ± 0.4 ms

≤4.1 ms

≤2.8 ms

Onset to peak

amplitude

S1

S2

41 ± 20 µV

43 ± 28 µV

≥10 µV

≥4 µV

Peak to peak

amplitude

S1

S2

63 ± 33 µV

66 ± 43 µV

≥12 µV

≥5 µV



Onset latency S1

S2

2.6 ± 0.3 ms

1.3 ± 0.2

≤3.2 ms

≤1.7 ms

Peak latency S1

S2

3.4 ± 0.3 ms

1.9 ± 0.2 ms

≤4.1 ms

≤2.4 ms

Onset to peak

amplitude

S1

S2

37 ± 19 µV

38 ± 24 µV

≥8 µV

≥4 µV

Peak to peak

amplitude

S1

S2

56 ± 31 µV

53 ± 36 µV

≥9 µV

≥4 µV

Table 9-20 Median and Radial Sensory Nerves to the Thumb (Fig. 9-20)

Figure 9-20 • Median and radial sensory nerves to the thumb

Electrode placement (30,31)

E1 Ring electrode, on the proximal phalanx

E2 Ring electrode, on the distal phalanx

G Dorsum of the hand

S Cathode Sm: Median nerve, 10 cm proximal to E1, in a line

measured first to the midpoint of the distal wrist crease

and then on the line between the tendons of the flexor

carpi radialis and the palmaris longus

Sr: Radial nerve, over the lateral radius, 10 cm proximal to

the active electrode

Anode Proximal



Peak latency Median

Radial

2.5 ± 0.2 ms

2.4 ± 0.2 ms

≤2.9 ms

≤2.8 ms

Baseline to

peak

amplitude

Median

Radial

30 ± 2 µV

12 ± 1 µV

Note: The upper limit of normal differences between the median and radial nerve is latency

difference ≤0.3 ms, and amplitude of median nerve ≥200% amplitude of radial nerve.

Table 9-21 Median and Ulnar Sensory Nerves to the Fourth Digit (Fig. 9-21)

Electrode placement

E1 Ring electrode, on the first metacarpophalangeal joint of the fourth digit

E2 Ring electrode, on the distal interphalangeal joint of the fourth digit

G Dorsum of the hand

S Cathode Sm: Median nerve, 14 cm proximal to E1, in a line measured

first to the midpoint of the distal wrist crease and then to a

point on the line between the tendons of the flexor carpi

radialis and the palmaris longus

Su: Ulnar nerve, 14 cm proximal to E1, along the radial

border of the flexor carpi ulnaris tendon

Anode Proximally


Distal

Latency

Side Mean ± SD Normal limit

Figure 9-21 • Median and ulnar sensory nerves to the fourth

digit

Dominant

hand

Median

Ulnar

3.14 ± 0.24 ms

3.03 ± 0.21 ms

≤3.6 ms

≤3.5 ms

Non-

dominant

hand

Median

Ulnar

3.11 ± 0.32 ms

3.01 ± 0.32 ms

≤3.7 ms

≤3.6 ms

Note: The upper limit of normal increase in latency for the median versus ulnar nerve is ≤0.5

ms. No information on amplitude is available (32).

Table 9-22 Radial Sensory Nerve to the Base of the Thumb (Fig. 9-22)

Figure 9-22 • Radial sensory nerve to the base of the thumb


E1 Over the extensor pollicis longus tendon at the wrist

level

E2 4 cm distal to E1, on the radial side of the second

metacarpal bone

G Between E1 and the stimulating cathode

S Cathode Over the radius, 10 cm proximal to E1

Anode Proximally


First web space recording

E1 Over the tendon of the extensor pollicis longus tendon

at the apex of the first web space (near the wrist)

E2 On the skin between the heads of the first and second

metacarpal bones

G Dorsal aspect of the hand

S Cathode On the radial side of the forearm, 10

cm proximal to the active electrode

Anode Proximally

Thumb recording

E1 Proximal phalanx of the thumb

E2 Distal phalanx of the thumb

G Dorsal aspect of the hand

S Cathode On the radial side of the forearm, 15–

17 cm proximal to the active

electrode

Anode Proximally




ms

≤2.4 ms

Peak latency 2.3 ± 0.4

ms

≤3.1 ms

Peak to peak

amplitude

31 ± 20 µV ≥µV


First web space recording (10 cm)



ms

≤1.9 ms

Peak to peak

amplitude

42.2 ± 14.9

µV

≥16.0 µV

Thumb recording (15–17 cm)



ms

≤3.3 ms

Peak to peak

amplitude

12.3 ± 4.9

µV

≥5.0 µV

Table 9-23 Ulnar Sensory Nerve to the Fifth Digit (Fig. 9-23)

Electrode placement

E1 Ring electrode, middle of proximal phalanx of the fifth digit

E2 Ring electrode, on the distal phalanx of the fifth digit, 4 cm distal to E1

Figure 9-23 • Ulnar sensory nerve to the fifth digit


S Cathode S1: 14 cm proximal to E1, along the radial border of the flexor

carpi ulnaris tendon

S2: At the midpoint of the line from E1 to S1

Anode Proximally



Onset latency S1

S2

2.6 ± 0.2 ms

1.4 ± 0.2 ms

≤3.0 ms

≤1.8 ms

Peak latency S1

S2

3.4 ± 0.3 ms

2.0 ± 0.2 ms

≤4.1 ms

≤2.5 ms

Onset to peak

amplitude

S1

S2

32 ± 20 µV

33 ± 17 µV

≥6 µV

≥3 µV

Peak to peak

amplitude

S1

S2

50 ± 32 µV

55 ± 36 µV

≥4 µV

≥4 µV

Table 9-24 Ulnar Dorsal Cutaneous Sensory Nerve (Fig. 9-24)

Figure 9-24 • Ulnar dorsal cutaneous sensory nerve

Electrode placement

E1 Over the proximal point of the “V” formed by the fourth and the fifth

metacarpal bones

E2 Over the fifth metacarpophalangeal joint


S Cathode 8–10 cm proximal to E1 between the ulna and the flexor

carpi ulnaris tendon

Anode Proximally



8-cm study: peak

latency

1.84 ± 0.20

ms

≤2.3 ms

10-cm study: peak

latency

2.09 ± 0.21

ms

≥2.7 ms

Baseline to peak

amplitude

23.5 ± 8.8

µV

≥5.9 µV

Lower Body

Lower Body—Motor Nerves

Table 9-25 Femoral Motor Nerve (Fig. 9-25)

Figure 9-25 • Femoral motor nerve

Electrode placement for surface recording (37)

E1 About 6 cm above from the superior and medial border of the

patella

E2 Over the quadriceps tendon just proximal to the patella

G Between E1 and stimulating cathode

S Cathode S1: Above the inguinal ligament S2: Below the

inguinal ligament The distance between

stimulation points across the inguinal ligament is

5.5 ± 1.6 cm.

Anode Proximally


Mean ±

SD

Normal limit

Above the inguinal

ligament latency

7.1 ± 0.7

ms

≤8.5 ms

Below the inguinal

ligament latency

6.0 ± 0.7

ms

≤7.4 ms

Delay across the

inguinal ligament

1.1 ± 0.4

ms

≤1.9 ms

Nerve conduction

velocity above the

inguinal ligament

66.7 ± 7.4

m/s

≥50 m/s

Note: No amplitude data available (37).

Normal values with needle recording (38) (n = 16)

Stimulation at the

inguinal ligament

Mean ±

SD

Normal limit

Latency ligament

latency

4.6 ± 0.5

ms

≤5.5 ms

Amplitude 12.1 ± 1.1

mV

≥2.5 mV

Note: The bipolar surface stimulation electrodes were placed lateral to the point of pulsation

over the inguinal ligament while a concentric needle electrode was inserted into the belly of

the rectus femoris.

Table 9-26 Sciatic Nerve (Fig. 9-26)


Figure 9-26 • Sciatic nerve

E1 On the extensor digitorum brevis (Fig. 9-27, peroneal portion),

abductor hallucis (Fig. 9-28A, tibial portion), or abductor digiti

minimi (Fig. 9-28B, tibial portion)

E2 See Figures 9-27 and 9-28.

G Between E1 and stimulating cathode

S Cathode S1: Surface stimulation in the popliteal fossa S2:

A long needle electrode in the midway below

the gluteal fold

Anode Proximally



Nerve conduction

velocity to abductor

digiti minimi

51.3 ± 4.4

m/s

≥42 ms

Table 9-27 Peroneal* Motor Nerve to EDB (Fig. 9-27)

Figure 9-27 • Tibial nerve


E1 On the extensor digitorum brevis muscle, which is 1 cm

distal to the tubercle that is its origin. This is 2–3 cm distal

to the lateral malleolus.

E2 At the fifth metatarsophalangeal joint

G On the dorsum of the foot

S Cathode S1: 8 cm proximal to E1, lateral to the

tibialis anterior tendon S2: Posterior and

inferior to the fibular head S3:

Approximately 10 cm proximal to the S2,

and medial to the tendon of the biceps

femoris

Anode Proximally


Mean ±

SD

Normal limit

Onset

latency

4.5 ± 0.8

ms

≤6.0 ms


mV

≥2.0 mV

Conduction Velocity

S1-S2 49.9 ±

5.9 m/s

≥40 m/s

S2-S3 51.1 ±

6.3 m/s

≥40 m/s


Mean ±

SD

Normal limit

Onset

latency

4.8 ± 0.8

ms

≤6.4 ms


mV

≥0.7 mV

Conduction Velocity

S1-S2 47 ± 4

m/s

≥39 m/s

S2-S3 57 ± 9

m/s

≥39 m/s

*Note: No amplitude data available37.

*Peroneal nerve also known as fibular.

Table 9-28 Medial Plantar Motor to Abductor Hallucis (Fig. 9-28A)

Figure 9-28 • A. Tibial nerve (medial plantar)

Electrode placement

E1 1 cm posterior and 1 cm inferior to the navicular tubercle, at

the junction of plantar skin and dorsal foot skin

E2 On the first metatarsophalangeal joint

G Over the dorsum of the foot

S Cathode S1: 8 cm proximal to E1, right behind the

medial malleolus S2: At the popliteal fossa

Anode Proximally



Onset latency

(42)

4.8 ± 0.8

ms

≤6.4 ms

Amplitude (43) 11.6 ± 4.3

mV

≥3.0 mV

Conduction

velocity (42)

49.8 ± 6.0

m/s

≥38 m/s

Table 9-28 Lateral Plantar Motor to Abductor Digiti Minimi (Fig. 9-28B)

Figure 9-28 • B. Tibial nerve (lateral plantar)

Electrode placement

E1 Half distance from the sole of the foot to the tip of the lateral

malleolus

E2 On the fifth toe


S Cathode 8 cm proximal to a site 1 cm posterior and 1 cm

inferior to the navicular tubercle

Anode Proximally



Onset

latency

4.4 ± 0.5

ms

≤5.4 ms

Amplitude

(43)

11.0 ± 3.9

mV

≥3.2 mV

Table 9-29 F Wave in the Lower Extremity (Fig. 9-29)

Electrode placement

E1 For peroneal nerve: over the extensor digitorum brevis (see Fig. 9-27) For tibial

nerve: over the abductor hallucis (see Fig. 9-28A)

E2 For peroneal nerve: at the fifth metatarsophalangeal joint For tibial nerve: at the

first metatarsophalangeal joint

G Dorsum of the foot

S Cathode For peroneal nerve: 8 cm proximal to E1, lateral to the tibialis

anterior tendon

For tibial nerve: 8 cm proximal to E1, and just behind the medial

malleolus

Anode Distally

Normal values (45) Peroneal nerve F wave latency in ms (shortest of 10 stimuli, n = 180)

Age Height (cm) Mean ± SD Normal limit

Figure 9-29 • F wave in the lower extremity

19–

39

<160 ≤43.6 ± 2.5 48.6

160–169 ≤47.1 ± 3.7 54.5

>170 ≤51.5 ± 4.1 59.7

40–

79

<160 ≤45.4 ± 4.8 55.0

160–169 ≤49.6 ± 4.6 58.8

>170 ≤54.6 ± 4.5 63.6

(Reprinted from Buschbacher RM. Peroneal nerve F-wave recorded from extensor digitorum

brevis. Am J Phys Med Rehabil 1999;78:S48–S52, with permission.)

Tibial nerve F wave latency to AH in ms (shortest of 10 stimuli, n = 180) (46)


19–

39

<160 43.2 ± 2.2 ≤47.6

160–169 47.2 ± 3.0 ≤53.2

170–179 52.0 ± 4.0 ≤60.0

>180 53.1 ± 4.4 ≤61.9

40–

59

<160 45.4 ± 4.0 ≤53.4

160–169 49.3 ± 2.2 ≤53.7

170–179 53.6 ± 3.7 ≤61.0

>180 58.3 ± 5.3 ≤68.9

60–

79

<160 49.0 ± 4.8 ≤58.6

160–169 52.8 ± 4.4 ≤61.6

170–179 54.7 ± 3.2 ≤61.1

>180 57.3 ± 5.8 ≤68.9

(Modified from Buschbacher RM: Tibial nerve F-wave recorded from abductor hallucis. Am J

Phys Med Rehabil 1999;78;S43–S47, with permission.)

Table 9-30 H Reflex to the Calf (Soleus) (Fig. 9-30)

Electrode placement

E1 Halfway between the popliteal crease and the medial malleolus, with subject in prone position

E2 Over the Achilles tendon

Figure 9-30 • H reflex to the calf

G Between the stimulating and recording electrodes

S Cathode At the midpopliteal crease

Anode Distal

Stimulation duration = 1.0 ms

Normal values: onset latency (ms) (47) (n = 251)


19–39 <160 27.1 ± 1.8 ≤30.7

160–169 28.6 ± 1.9 ≤32.4

170–179 30.3 ± 1.8 ≤33.9

>180 32.0 ± 2.1 ≤36.2

40–49 <160 27.8 ± 1.1 ≤30.0

160–169 30.2 ± 1.4 ≤33.0

170–179 31.0 ± 1.6 ≤34.2

>180 32.7 ± 2.1 ≤36.9

50–79 <160 29.3 ± 1.9 ≤33.1

160–169 31.7 ± 1.6 ≤34.9

170–179 31.9 ± 1.7 ≤35.3

>180 33.2 ± 2.5 ≤38.2

Note: The upper limit of increase in latency from one side to the other is 2.0 ms (47).

Equation to calculate: HLat at 9.1 + (0.1 × Age) + (0.46 × Length) (48)

(Reprinted from Buschbacher RM. Normal range for H-reflex recorded from the calf muscles. Am J Phys Med Rehabil

1999;78:S75–S79, with permission.)

Lower Body—Sensory Nerves

Table 9-31 Lateral Femoral Cutaneous Sensory Nerve (Fig. 9-31)

Electrode placement

E1 17–20 cm distal to the anterior superior iliac spine, on the line between the

anterior superior iliac spine and the lateral border of the patella



S Cathode S1: below the inguinal ligament, 1 cm medial to the line between

the anterior superior iliac spine and the lateral border of the

Figure 9-31 • Lateral femoral cutaneous sensory

nerve

patella

S2: above the inguinal ligament, 1 cm medial to the anterior

superior iliac spine

Anode Proximally



Onset

S1 (14–18

cm)

2.5 ± 0.2 ms ≤2.8 ms

S2 (17–20

cm)

2.8 ± 0.4 ms ≤3.6 ms

Peak to peak

amplitude

S1 7.0 ± 1.8 µV ≥3.4 µV

S2 6.0 ± 1.5 µV ≥3.0 µV

Note: No data on onset to peak amplitude available.

Table 9-32 Posterior Femoral Cutaneous Nerve (Fig. 9-32)

Figure 9-32 • Posterior femoral cutaneous nerve

Electrode placement

E1 6 cm proximal to the midpopliteal fossa

E2 3 cm distally

G 3 cm distally

S Cathode 12 cm proximal to E1 on a line between E1 and the ischia

tuberosity

Anode Proximally




ms

≤3.2 ms

Onset to peak

amplitude

6.5 ± 1.5

µV

≥3.5 µV

Table 9-33 Saphenous Sensory Nerve (Fig. 9-33)

Figure 9-33 • Saphenous sensory nerve—distal technique

Electrode placement

E1 Slightly anterior to the highest prominence of the medial

malleolus, between the malleolus and the tendon of the tibialis

anterior

E2 3 cm distal to E1, at the level of the malleolus


S Cathode 14 cm proximal to E1 deep to the medial

border of the tibia

Anode Proximally




Peak latency 3.8 ± 0.3 ms ≤4.4 ms

Onset to peak

amplitude

6.5 ± 3 µV ≥3.5 µV

Table 9-34 Superficial Peroneal* Nerve: Medial and Intermediate Dorsal Cutaneous Branches (Fig. 9-34)

Figure 9-34 • Superficial peroneal nerve: medial and intermediate dorsal

cutaneous branches

Electrode placement

E1 At the level of the ankle Medial branch: just lateral to the

tendon of the extensor hallucis longus Intermediate branch:

1–2 cm medial to the lateral malleolus

E2 3–4 cm distal to the E1s


S Cathode 14 cm proximal to E1 on the

anterolateral aspect of the lower leg

Anode Proximally


Branch Mean ± SD Normal limit

Peak latency Medial

Intermediate

3.4 ± 0.4 ms

3.4 ± 0.4 ms

≤2.7–4.7 ms

≤2.8–4.6 ms

Peak to peak

amplitude

Medial

Intermediate

18.3 ± 8.0 µV

15.1 ± 8.2 µV

≥2.3 µV

≥4 µV*

Onset to peak

amplitude

(53)

Intermediate 20.5 ± 6.1 µV ≥8.3 µV

Nerve

conduction

velocity

Medial

Intermediate

51.2 ± 5.7 m/s

51.3 ± 5.4 m/s

≥39.8 m/s

≥40.5 m/s

Note: The value is the smallest value of the range.

*Peroneal nerve also known as fibular.

Table 9-35 Tibial Nerve (Mixed Nerve Responses): Medial and Lateral Plantar Nerves (Fig. 9-35)

Figure 9-35 • Tibial nerve: medial and lateral plantar nerves

Electrode placement

E1 Behind the medial malleolus at the level of the ankle

E2 Proximally


S Cathode Medial branch: 10 cm distal to E1 to the first web

space, and then 4 cm more distal along the first

web space (total 14 cm distal to E1)

1.

Lateral branch: 14 cm distal to E1, on the sole

between the fourth and fifth metatarsals

2.

Anode Distally


Branch Mean ± SD Normal limit

Peak Medial 3.16 ± 0.26 ms ≤3.7 ms

Latency Lateral 3.15 ± 0.25 ms ≤3.7ms

Amplitude Medial

Lateral

>10 µV

>8 µV

Table 9-36 Sural Sensory Nerve (Fig. 9-36)

Figure 9-36 • Sural sensory nerve

Electrode placement

E1 Posterior and inferior to the lateral malleolus

E2 3 cm distally


S Cathode 14 cm proximal to E1 in the midline or slightly

lateral to the midline of the posterior lower

leg, between the two heads of gastrocnemius

Anode Proximally


Mean ±

SD

Normal limit

Peak latency

(55)

3.5 ±

0.25

≤4.0 ms

Baseline to peak

amplitude (53)

23.7 ±

3.8 µV

≥10 µV

Nerve

conduction

velocity (54)

43.3 ±

4.3 m/s

≥34.7 m/s


Mean ±

SD

Normal limit


ms

≤3.6 ms


ms

≤4.5 ms

Onset to peak

amplitude

17 ± 10

µV

≥4 µV

Table 9-37 Sural Nerve—Lateral Dorsal Cutaneous Branch (Fig. 9-37)

Figure 9-37 • Sural nerve— lateral dorsal cutaneous branch

Electrode placement

E1 At the midpoint of the fifth metatarsal and just lateral to

the extensor digitorum brevis tendon to the fifth toe

E2 Distally

G On the dorsum of the foot

S Cathode 12 cm proximal to E1 behind the

lateral malleolus

Anode Proximally




Peak latency 3.9 ± 0.5 ms ≤4.9 ms

Baseline to peak

amplitude (57)

5.8 ± 2.1 µV ≥3 µV

Nerve conduction

velocity (onset)

37.6 ± 4.8 m/s ≥28.0 m/s

Nerve conduction

velocity (peak)

37.6 ± 4.8 m/s

30.7 ± 3.7 m/s

≥28.0 m/s

≥23.3 m/s

References

1. Miller DW, Nelson JA, Bender LF. Measurement of latency in facial nerve in normal and uremic persons. Arch Phys Med Rehabil 1970;51: 413.

2. Olsen PZ. Prediction of recovery in Bell's palsy. Acta Neurol Scand 1975;52:1.

3. Kimura J, Powers JM, Van Allen MW. Reflex response of orbicularis oculi muscle to supraorbital nerve stimulation. Study in normal subjects and in peripheral fascial

paresis. Arch Neurol 1969;21:193–199.

4. Redmond MD, Dibenedetto M. Electrodiagnostic evaluation of the hypoglossal nerve. Arch Phys Med Rehabil 1984;65:633.

5. Redmond MD, Dibenedetto M. Hypoglossal nerve conduction in normal subjects. Muscle Nerve 1988;11:447–452.

6. Bolton CF. AAEM mini-monograph #40. Clinical neurophysiology of the respiratory system. Muscle Nerve 1993;16:809–818.

7. DePalma MJ, Pease WS, Johnson EW. A novel recording technique of the serratus anterior compound muscle action potential and establishment of normal values. Arch

Phys Med Rehabil 2005;86:17–20.

8. Alfonsi E, Moglia A, Sandrini G, et al. Electrophysiological study of the long thoracic nerve conduction in normal subjects. Electromyogr Clin Neurophysiol 1986;26:63–67.

9. Kraft GH. Axillary, musculocutaneous and suprascapular nerve latency studies. Arch Phys Med Rehabil 1972;53:383–387.

pictorial guide to nerve conduction techniques

Documents