Nerve conduction study

A nerve conduction study (NCS) is a test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body.

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.

Purposes

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 which can be diagnosed by nerve conduction studies are:

• Peripheral neuropathy
• Carpal tunnel syndrome
• Ulnar neuropathy
• Guillain-Barré syndrome
• Facioscapulohumeral muscular dystrophy
• Spinal disc herniation

Description

The nerve conduction study consists of the following components:

• Motor NCS
• Sensory NCS
• F-wave study
• H-reflex study

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.The recording electrode is the more proximal of the two. 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 electrode.

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 anterior horn cell 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 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 $\frac{2 D}{F-M-1}$.

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 towards 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.

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-shaped 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. A new version, uses a potentiometer to objectively measure the amplitude of the action potential at a distant site along the nerve being tested. The previous version relied on the patient reporting a sensation when the nerve fired. The spf-NCS does not require myelin loss to detect function change, so velocity is not measured.

Interpretation of nerve conductions

The interpretation of nerve conduction studies is complex, but 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 a little painful due to the electrical shocks. The shocks are associated with a low amount of electrical 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.

The nerve conduction study is sometimes combined with electromyography.

Other special nerve conduction studies that are occasionally performed include double stimuli and repetitive stimulation.

See also

• Bioelectronics
• Cable theory
• Biological neuron models

External links

• Association of EMG technologists of Canada
• American Association of Neuromuscular & Electrodiagnostic Medicine
• American Board of Electrodiagnostic Medicine
• Information about measuring the NCV
• EMG and Nerve Conduction education, training, and expert analysis of NCV reports
• Details of NCV from National Institutes of Health
• WebMD summary of EMG and NCS