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
Placement of the ground electrode
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)
Electrode placement
E1
Over nasalis (lateral side of midnose)
E2
Over contralateral nasalis
On the cheek or chin
Postauricular stimulationbehind 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) Figure 9-1 Cranial nerve VII
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
Chin
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 Figure 9-2 Blink reflex latency
30.5 4.4 ms (44.0 ms)
Note: Amplitudes are variable.
Table 9-3 Cranial Nerve XI to Trapezius (Fig. 9-3)
Electrode placement
E1
Over the upper trapezius, midway between C7 spinous process and acromion.
E2
On acromion
Medial clavicle
Cathode
At the posterior edge of the sternocleidomastoid muscle
Anode
Superiorly
Normal values (4,5) (n = 30) Figure 9-3 Cranial nerve XI Mean SD Normal limit
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
Electrode placement
E1
On the xiphoid process
E2
On the costal margin, at anterior axillary line
Medial sternum
Cathode
3 cm above the clavicle, along the posterior border of the sternocleidomastoid muscle
Anode
Superiorly
Figure 9-4 Phrenic nerve
Mean SD
Normal limit
Onset latency
6.3 0.8 ms
8.6 ms
Amplitude
597 139 V
400 V
Table 9-5A Long Thoracic Nerve-1 to Serratus Anterior (Fig. 9-5A)
Electrode placement (7) (Fig. 9-5A)
E1
Self-adhesive, 8.0 0.5-cm, ring-type electrodecranial 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
Over the ipsilateral latissimus dorsi
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 Figure 9-5 A. Long thoracic nerve
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)
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)
Over the 12th rib level at the anterior axillary line
Cathode
Slightly above the upper margin of the clavicle lateral to the clavicular head of the sternocleidomastoid muscle
Anode
Superomedially
Figure 9-5 B. Long thoracic nerve
Normal values (8) (n = 16, concentric needle recording)
Age (years)
Onset latency Mean SD
Normal limit
2035
3.6 0.3 ms
4.2 ms
3650
3.8 0.4 ms
4.4 ms
5165
4.0 0.4 ms
4.8 ms
Table 9-6 Axillary Nerve to Deltoid (Fig. 9-6)
Electrode placement
E1
Midway between acromion and deltoid tubercle
E2
At deltoid tubercle
Between the stimulating point and active electrode
Cathode
Supraclavicular fossa
Anode
Superomedially
Mean SD
Normal limit
Onset latency
3.9 0.5 ms
5.0 ms
Figure 9-6 Axillary nerve
Note: No information on amplitude is available (9).
Table 9-7 Musculocutaneous Nerve to Biceps (Fig. 9-7)
Electrode placement
E1
Midpoint of the biceps brachii muscle belly
E2
Distal biceps tendon
Over the acromion
Cathode
Anode
Superomedially
Normal values (9) (n = 62) Figure 9-7 Musculocutaneous nerve Mean SD Normal limit
Onset latency
4.5 0.6 ms
5.7 ms
Table 9-8 Suprascapular Nerve (Fig. 9-8)
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 23 mm. Infraspinatus: Insert the needle 3 cm below the scapular spine and 3 cm lateral to the medial border of the scapula.
Over the posterolateral shoulder
Cathode
Anode
Superomedially
Onset latency Figure 9-8 Suprascapular nerve Supraspinatus recording
Mean SD
Normal limit
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)
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
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
Figure 9-9 Thoracodorsal nerve Axilla (S1)
Mean SD
Range
Onset latency
1.9 0.4 ms
2.7 ms
Amplitude, right
4.1 1.8 mV
1.4 mV
Erb's point (S2)
Onset latency
3.6 0.4 ms
4.5 ms
Amplitude
6.0 2.0 mV
2.0 mV
Table 9-10 Median Nerve to the Abductor Pollicis Brevis (Fig. 9-10)
Electrode placement
E1
Midline between the first metacarpophalangeal joint and the first carpometacarpal joint
Figure 9-10 Median nerve to the abductor pollicis brevis
E2
Distal to E1 on the first metacarpophalangeal joint
On the dorsum of the hand
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
Normal values (11,12) (n = 47)
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
57 5 m/s
47 m/s
Table 9-11 Median Nerve (Anterior Interosseous Branch) to the Pronator Quadratus (Fig. 9-11)
Electrode placement
E1
Centrally over the dorsum of the forearm, 3 cm proximal to the ulnar styloid
Figure 9-11 Median nerve (anterior interosseous branch) to the pronator quadratus
E2
On the medial dorsum of the wrist over the ulnar styloid process
On the dorsal forearm, between the E1 and stimulating electrodes
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)
Electrode placement
E1
Proximal third from the antecubital crease (S1), over the belly of the extensor digitorum
E2 Figure 9-12 Radial nerve to the extensor digitorum
On the medial dorsum of the wrist over the ulnar styloid process
Between the E1 and the S1
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)
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)
Between E1 and S1, on the dorsum of the forearm
Figure 9-13 Radial nerveto the extensor indicis proprius
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)
Mean SD
Normal limit
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
On the dorsum of the hand or between the stimulating and recording electrodes
Cathode
The arm is in a 45 degrees abducted and externally rotated position with the elbow moderately flexed to 90135 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
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
Normal values (21) (n = 248) Figure 9-14 Ulnar nerveto the abductor digiti minimi 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
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
Between E1 and S1
Cathode
At the ulnar wrist crease, along the radial border of the tendon of the flexor carpi ulnaris
Anode
Proximally
Onset latency
Amplitude
Age (years)
Mean
Limit
Mean
Limit
<20
3.3 ms
4.2 ms
15 mV
8 mV
2029
3.4 ms
4.1 ms
14 mV
8 mV
3039
3.3 ms
4.4 ms
15 mV
6 mV
4049
3.2 ms
4.2 ms
13 mV
6 mV
5059
3.4 ms
4.4 ms
13 mV
6 mV
6069
3.6 ms
4.5 ms
12 mV
7 mV
>70 Figure 9-15 Ulnar nerveto the first dorsal interosseous
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 (0.01.3); ipsilateral difference, FDI - ADM = 0.9 ms (0.22.0) (22).
Table 9-16 F Wave in the Upper Extremity (Fig. 9-16)
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
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
Figure 9-16 F wave in the upper extremity
Median/APB
2231 ms
2.3 ms
Ulnar/ADM
2132 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 BodySensory Nerves

Table 9-17 Lateral Antebrachial Cutaneous Sensory Nerve (Fig. 9-17)
E1
On volar aspect of the forearm, over the radius bone, 10 cm distal to the stimulating cathode
Figure 9-17 Lateral antebrachial cutaneous sensory nerve
E2
3 cm distal to E1
Between the stimulating and recording electrodes
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
18 10 V
3 V
Normal values (27) (10-cm distance) (n = 157)
Mean SD
Normal limit
Peak latency
2.8 0.2 ms
3.3 ms
18.9 9.9 V
8 V
Table 9-18 Medial Antebrachial Cutaneous Sensory Nerve (Fig. 9-18)
E1
On volar aspect of the forearm, over the ulna bone, 14 cm distal to the stimulating point
Figure 9-18 Medial antebrachial cutaneous sensory nerve
E2
3 cm distal to E1
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
11.4 5.2 V
5 V
Table 9-19 Median Sensory Nerve to the Second and Third Digits (Fig. 9-19)
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
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)
Mean SD
Normal limit
Figure 9-19 Median sensory nerve to the second and third digits
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 V 67 20 V 128 29%
26 V 37 V 186 %
Mean SD
Normal limit
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
S1 S2
41 20 V 43 28 V
10 V 4 V
Peak to peak amplitude
S1 S2
63 33 V 66 43 V
12 V 5 V
Mean SD
Normal limit
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
S1 S2
37 19 V 38 24 V
8 V 4 V
S1 S2
56 31 V 53 36 V
9 V 4 V
Table 9-20 Median and Radial Sensory Nerves to the Thumb (Fig. 9-20)
Electrode placement (30,31)
E1
Ring electrode, on the proximal phalanx
E2
Ring electrode, on the distal phalanx
Dorsum of the hand
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
Figure 9-20 Median and radial sensory nerves to the thumb Peak latency
Mean SD
Normal limit
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 V 12 1 V
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
Dorsum of the hand
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
Dominant hand
Median Ulnar
3.14 0.24 ms 3.03 0.21 ms
3.6 ms 3.5 ms
Nondominant 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).
Figure 9-21 Median and ulnar sensory nerves to the fourth digit
Table 9-22 Radial Sensory Nerve to the Base of the Thumb (Fig. 9-22)
E1
Over the extensor pollicis longus tendon at the wrist level
E2 Figure 9-22 Radial sensory nerve to the base of the thumb G
4 cm distal to E1, on the radial side of the second metacarpal bone
Between E1 and the stimulating cathode
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
Dorsal aspect of the hand
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
Dorsal aspect of the hand
Cathode
On the radial side of the forearm, 15 17 cm proximal to the active electrode
Anode
Proximally
Mean SD
Normal limit
Onset latency
1.8 0.3 ms
2.4 ms
Peak latency
2.3 0.4 ms
3.1 ms
31 20 V
First web space recording (10 cm)
Mean SD
Normal limit
Onset latency
1.6 0.1 ms
1.9 ms
42.2 14.9 V
16.0 V
Thumb recording (1517 cm)
Mean SD
Normal limit
Onset latency
2.8 0.2 ms
3.3 ms
12.3 4.9 V
5.0 V
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
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
Mean SD
Normal limit
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
Figure 9-23 Ulnar sensory nerve to the fifth digit Onset to peak amplitude S1 S2 32 20 V 33 17 V 6 V 3 V
S1 S2
50 32 V 55 36 V
4 V 4 V
Table 9-24 Ulnar Dorsal Cutaneous Sensory Nerve (Fig. 9-24)
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
Cathode
810 cm proximal to E1 between the ulna and the flexor carpi ulnaris tendon
Anode
Proximally
Mean SD
Normal limit
8-cm study: peak latency
1.84 0.20 ms
2.3 ms
10-cm study: peak Figure 9-24 Ulnar dorsal cutaneous sensory nerve latency
2.09 0.21 ms
2.7 ms
Baseline to peak amplitude
23.5 8.8 V
5.9 V
Lower Body Lower BodyMotor Nerves
Table 9-25 Femoral Motor Nerve (Fig. 9-25)
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
Between E1 and stimulating cathode
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
Figure 9-25 Femoral motor nerve
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)
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.
Between E1 and stimulating cathode
Cathode
S1: Surface stimulation in the popliteal fossa S2: A long needle electrode in the midway below the gluteal fold
Anode
Proximally
Mean SD
Normal limit
Nerve conduction velocity to abductor digiti minimi Figure 9-26 Sciatic nerve
51.3 4.4 m/s
42 ms
Table 9-27 Peroneal* Motor Nerve to EDB (Fig. 9-27)
E1
On the extensor digitorum brevis muscle, which is 1 cm distal to the tubercle that is its origin. This is 23 cm distal to the lateral malleolus.
E2
At the fifth metatarsophalangeal joint
Figure 9-27 Tibial nerve
On the dorsum of the foot
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
Amplitude
4.4 1.2 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
Amplitude
5.9 2.6 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)
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
Over the dorsum of the foot
S Figure 9-28 A. Tibial nerve (medial plantar)
Cathode
S1: 8 cm proximal to E1, right behind the medial malleolus S2: At the popliteal fossa
Anode
Proximally
Normal values (42,43) (n = 37)
Mean SD
Normal limit
Onset latency (42)
4.8 0.8 ms
6.4 ms
Amplitude (43)
11.6 4.3 mV
3.0 mV
49.8 6.0 m/s
38 m/s
Table 9-28 Lateral Plantar Motor to Abductor Digiti Minimi (Fig. 9-28B)
Electrode placement
E1
Half distance from the sole of the foot to the tip of the lateral malleolus
E2
On the fifth toe
Cathode
8 cm proximal to a site 1 cm posterior and 1 cm inferior to the navicular tubercle
Anode
Proximally
Normal values (44) (n = 10) Figure 9-28 B. Tibial nerve (lateral plantar) Mean SD Normal limit
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
Dorsum of the foot
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
<160
43.6 2.5
48.6
19 39
160169
47.1 3.7
54.5
>170
51.5 4.1
59.7
<160
45.4 4.8
55.0
40 79
160169
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:S48S52, with permission.)
Tibial nerve F wave latency to AH in ms (shortest of 10 stimuli, n = 180) (46)
Age Figure 9-29 F wave in the lower extremity
Height (cm)
Mean SD
Normal limit
<160
43.2 2.2
47.6
160169 19 39 170179
47.2 3.0
53.2
52.0 4.0
60.0
>180
53.1 4.4
61.9
<160
45.4 4.0
53.4
160169 40 59 170179
49.3 2.2
53.7
53.6 3.7
61.0
>180
58.3 5.3
68.9
<160
49.0 4.8
58.6
160169 60 79 170179
52.8 4.4
61.6
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;S43S47, 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
Cathode
At the midpopliteal crease
Anode
Distal
Stimulation duration = 1.0 ms
Normal values: onset latency (ms) (47) (n = 251)
Age
Height (cm)
Mean SD
Normal limit
1939
<160
27.1 1.8
30.7
160169
28.6 1.9
32.4
170179
30.3 1.8
33.9
>180
32.0 2.1
36.2
4049
<160
27.8 1.1
30.0
160169
30.2 1.4
33.0
170179
31.0 1.6
34.2
>180
32.7 2.1
36.9
Figure 9-30 H reflex to the calf
5079
<160
29.3 1.9
33.1
160169
31.7 1.6
34.9
170179
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: H Lat 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:S75S79, with permission.)
Lower BodySensory Nerves

Table 9-31 Lateral Femoral Cutaneous Sensory Nerve (Fig. 9-31)
Electrode placement
E1
1720 cm distal to the anterior superior iliac spine, on the line between the anterior superior iliac spine and the lateral border of the patella
E2
3 cm distal to E1
Cathode
S1: below the inguinal ligament, 1 cm medial to the line between the anterior superior iliac spine and the lateral border of the
patella S2: above the inguinal ligament, 1 cm medial to the anterior superior iliac spine
Anode
Proximally
Mean SD
Normal limit
S1 (1418 cm) Onset
2.5 0.2 ms
2.8 ms
S2 (1720 cm)
2.8 0.4 ms
3.6 ms
S1
7.0 1.8 V
3.4 V
Figure 9-31 Lateral femoral cutaneous sensory nerve
S2
6.0 1.5 V
3.0 V
Note: No data on onset to peak amplitude available.
Table 9-32 Posterior Femoral Cutaneous Nerve (Fig. 9-32)
Electrode placement
E1
6 cm proximal to the midpopliteal fossa
E2
3 cm distally
3 cm distally
Cathode
12 cm proximal to E1 on a line between E1 and the ischia tuberosity
Anode
Proximally
Mean SD
Normal limit
Peak latency
2.8 0.2 ms
3.2 ms
Onset to peak Figure 9-32 Posterior femoral cutaneous nerve amplitude
6.5 1.5 V
3.5 V
Table 9-33 Saphenous Sensory Nerve (Fig. 9-33)
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
Cathode
14 cm proximal to E1 deep to the medial border of the tibia
Anode
Proximally
Figure 9-33 Saphenous sensory nervedistal technique
Mean SD
Normal limit
Onset latency
3.2 0.3 ms
3.8 ms
Peak latency
3.8 0.3 ms
4.4 ms
6.5 3 V
3.5 V
Table 9-34 Superficial Peroneal* Nerve: Medial and Intermediate Dorsal Cutaneous Branches (Fig. 9-34)
Electrode placement
E1
At the level of the ankle Medial branch: just lateral to the tendon of the extensor hallucis longus Intermediate branch: 12 cm medial to the lateral malleolus
E2
34 cm distal to the E1s
Cathode
14 cm proximal to E1 on the anterolateral aspect of the lower leg
Anode
Proximally
Figure 9-34 Superficial peroneal nerve: medial and intermediate dorsal cutaneous branches
Branch
Mean SD
Normal limit
Peak latency
Medial Intermediate
3.4 0.4 ms 3.4 0.4 ms
2.74.7 ms 2.84.6 ms
Medial Intermediate
18.3 8.0 V 15.1 8.2 V
2.3 V 4 V*
Onset to peak amplitude (53)
Intermediate
20.5 6.1 V
8.3 V
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)
Electrode placement
E1
Behind the medial malleolus at the level of the ankle
E2
Proximally
Cathode
1. 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) 2. Lateral branch: 14 cm distal to E1, on the sole between the fourth and fifth metatarsals
Figure 9-35 Tibial nerve: medial and lateral plantar nerves
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 V >8 V
Table 9-36 Sural Sensory Nerve (Fig. 9-36)
Electrode placement
E1
Posterior and inferior to the lateral malleolus
E2
3 cm distally
G Figure 9-36 Sural sensory nerve 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 V
10 V
Nerve conduction velocity (54)
43.3 4.3 m/s
34.7 m/s
Mean SD
Normal limit
Onset latency
3.1 0.3 ms
3.6 ms
Peak latency
3.8 0.3 ms
4.5 ms
17 10 V
4 V
Table 9-37 Sural NerveLateral Dorsal Cutaneous Branch (Fig. 9-37)
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
On the dorsum of the foot
Cathode
12 cm proximal to E1 behind the lateral malleolus
Anode
Proximally
Normal values (57) (n = 40) Figure 9-37 Sural nerve lateral dorsal cutaneous branch Mean SD Normal limit
Onset latency
3.2 0.4 ms
4.0 ms
Peak latency
3.9 0.5 ms
4.9 ms
Baseline to peak amplitude (57)
5.8 2.1 V
3 V
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;21:193199.
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;11:447452.
6. Bolton CF. AAEM mini-monograph #40. Clinical neurophysiology of the respiratory system. Muscle Nerve 1993;16:809818.
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;86:1720.
8. Alfonsi E, Moglia A, Sandrini G, et al. Electrophysiological study of the long thoracic nerve conduction in normal subjects. Electromyogr Clin Neurophysiol 1986;26:6367.
9. Kraft GH. Axillary, musculocutaneous and suprascapular nerve latency studies. Arch Phys Med Rehabil 1972;53:383387.

Pictorial Guide To Nerve Conduction Techniques

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Pictorial Guide To Nerve Conduction Techniques

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

Chapter 9 Pictorial Guide to Nerve Conduction Techniques

Placement of the reference electrode

Placement of the ground electrode

Placement of the cathode for stimulation

Relation of stimulator anode to the cathode

Over nasalis (lateral side of midnose)

Over contralateral nasalis

On the cheek or chin

Onset latency (1)

Amplitude (2) Figure 9-1 Cranial nerve VII

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

Over bilateral orbicularis oculi muscle, lower lateral portion

Medial inferior orbit

At the supraorbital notch

Normal values (3) (n = 83)

Mean SD (Normal limit)

Side-to-side difference (Normal limit)

10.5 0.8 ms (13.0 ms)

0.3 0.9 ms (1.2 ms)

30.5 3.4 ms (41.0 ms)

1.0 3.4 ms (4.4 ms)

Contralateral R2 Figure 9-2 Blink reflex latency

30.5 4.4 ms (44.0 ms)

Note: Amplitudes are variable.

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

At the posterior edge of the sternocleidomastoid muscle

Upper Body Upper Body: Motor Nerves

On the xiphoid process

On the costal margin, at anterior axillary line

Figure 9-4 Phrenic nerve

Normal values (6) (n = 50)

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

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

Over the ipsilateral latissimus dorsi

In the axilla just anterior to the midaxillary line

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

Amplitude Figure 9-5 A. Long thoracic nerve

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

Over the 12th rib level at the anterior axillary line

Figure 9-5 B. Long thoracic nerve

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

Onset latency Mean SD

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

Midway between acromion and deltoid tubercle

Between the stimulating point and active electrode

Normal values (9) (n = 62)

Figure 9-6 Axillary nerve

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

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

Midpoint of the biceps brachii muscle belly

Distal biceps tendon

Over the acromion

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

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

Over the posterolateral shoulder

Normal values (9) (n = 62)

Onset latency Figure 9-8 Suprascapular nerve Supraspinatus recording

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

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

Electrode placement (10)

On the posterior axillary line distal to E1