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Electromyography and Nerve Conduction Studies

  • Author: Stephen Kishner, MD, MHA; Chief Editor: Jonathan P Miller, MD  more...
 
Updated: Oct 09, 2015
 

Background

Electrodiagnostic testing encompasses a range of specialized tests, including nerve conduction studies (NCS) and needle electromyography (EMG), that are used to evaluate the conduction of electrical impulses down peripheral nerves. These tests should be considered and performed only after a careful history and physical examination, which are sometimes sufficient to establish a diagnosis of neuromuscular dysfunction without further testing. However, in some cases, the subtlety of sensory or motor deficits necessitates further workup for a conclusive diagnosis.[1]

Nerve conduction studies and needle EMG are commonly performed by physical medicine and rehabilitation or neurology specialists to assess the ability of the nervous system to conduct electrical impulses and to evaluate nerve/muscle function to determine if neuromuscular disease is present.

Nerve conduction studies

For this test, a series of surface electrodes are placed at different locations along specific peripheral nerves. The nerve is stimulated at one site and recorded at a different site to determine if the nerve is conducting appropriately.

Each electrical stimulation is recorded as a waveform on a computer and analyzed by the electromyographer performing the test.[2]

Standard nerve conduction studies typically include motor nerve conduction, sensory nerve conduction, F waves, and H reflexes.

Sensory and motor nerve conduction studies involve analysis of specific parameters, including latency, conduction velocity, and amplitude. Onset latency is the time it takes for the stimulus to initiate an evoked potential and reflects the conduction along the fastest fibers. Peak latency is the latency along the majority of axons and is measured at the peak amplitude.[3] Both are affected by the state of the myelination of the nerve.

The conduction velocity along the nerve also depends on the state of myelination and is often decreased in disorders or trauma that affects nerve myelination, although it may be normal if a few myelinated axons remain intact. Reduction of amplitudes of recorded responses generally indicates a loss of axons.[4]

These studies, in conjunction with the physical examination and correlation to a set of normative values, assist the electromyographer in diagnosing a multitude of nerve disorders, including entrapment neuropathies, brachial plexopathies, and polyneuropathies.

It is often important to distinguish between sensory and motor nerves, as certain disease processes can affect one or both. Radiculopathy produces motor deficits but does not affect sensory nerves since the anatomic location of the damage is proximal to the dorsal root ganglion. When a lesion is distal to the dorsal root ganglion, such as in brachial plexopathies, both motor and sensory nerves are affected.

Sensory nerve conduction studies

Sensory nerve conduction studies are performed via stimulation of a nerve (ie, sufficient to produce an action potential) at one point and measurement of the action potential at another point along the course of the nerve.[5] Peripheral sensory nerves can be used to localize a lesion in relation to the dorsal root ganglion that contains the cell body of the nerve, allowing differentiation of preganglionic disorders (eg, radiculopathies, cauda equina lesions, posterior column disease) from postganglionic disorders (eg, neuropathies, plexopathies). With a preganglionic lesion, the sensory nerve action potential is normal (although clinically abnormal) because axonal transport from the cell body to the peripheral axon remains intact.[6]

Motor nerve conduction studies

In motor nerve conduction studies, motor nerves are stimulated and the compound muscle action potential from the muscle is recorded. This corresponds to the integrity of the motor unit. Results of this study can be affected by any process that damages the anterior horn cell body or axon, Schwann cells, the neuromuscular junction, or the muscle cell itself.[7] Also analyzed are the size, shape, and morphology of the compound muscle action potential to determine the state of myelination, the number of functioning muscle fibers, and the function of the neuromuscular junction. Since the cell body of motor nerves is located in the anterior horn of the spinal cord, the motor nerve conduction is abnormal in both preganglionic and postganglionic injuries.

Late responses

Distal nerve segments are relatively easy to analyze since they can be studied directly. To study proximal nerve segments, late responses based on conduction along the proximal nerve are used. Late responses include F waves and H reflexes.

F waves

The F wave is a late response involving the motor axons that can be elicited in most upper and lower extremity muscles. A stimulus is applied to a distal motor nerve that travels antidromically to the anterior horn cell, and a response fires back down the motor neuron and is recorded as a muscle response that occurs after the compound muscle action potential. F waves tend to have lower sensitivity for radiculopathy but can be useful in the assessment of polyneuropathy.

H reflexes

The H reflex is basically an electrophysiologically recorded Achilles muscle stretch reflex. It is performed by stimulating the tibial nerve in the popliteal fossa. From there, the stimulus goes proximally through the reflex arc at that spinal segment, then distally from the anterior horn cell and the motor nerve. It can be recorded over the soleus or gastrocnemius muscles. The H reflex is most commonly used to evaluate for an S1 radiculopathy or to distinguish from an L5 radiculopathy.

Needle EMG is used to assess both nerve and muscle function. A small-diameter monopolar pin or coaxial needle is placed into a muscle to evaluate insertional activity, resting activity, voluntary recruitment, morphology, and size of motor units, as well as motor unit recruitment. The needle electrode examination provides valuable information about the electrical characteristics of individual muscle fibers and motor units, as well as the integrity and innervation of muscle fibers. This test can be uncomfortable for the patient.

Insertional activity

Insertional activity is the electrical activity present as the electrode is passed through muscle cells. These are discharge potentials provoked by the disruption of the cell membrane itself. Careful attention is given to the duration and amount of electrical noise after each movement of the needle. This activity is decreased in atrophied muscle or fatty tissue. Conversely, it is also increased in many abnormal conditions that cause membrane instability, such as neuropathies, radiculopathies, and inflammatory myopathies.

Spontaneous activity at rest

Resting or spontaneous activity is the electrical activity present when the muscle is at rest and the electrode is not being moved. This includes both normal and abnormal spontaneous activity.

Normal muscle should be silent after the needle is inserted; however, if the needle happens to be near the neuromuscular junction, miniature endplate potentials or endplate potentials may be heard or seen. The most common abnormal spontaneous activity is reported as a gradation of either positive sharp waves (PSWs) or fibrillation potentials on a scale of 1+ (transient but reproducible discharges) to 4+ (abundant spontaneous potentials).

Fibrillations result from motor axonal loss that is not balanced by reinnervation. Conditions that cause this include any nerve disorder that affects the motor axon, inflammatory myopathies, and direct muscle injury. Depending on the amplitude of the PSWs and/or fibrillation potentials, the electromyographer can determine how recently the injury to the nerve occurred. Low-amplitude fibrillation potentials suggest that denervation occurred in the remote past, whereas high-amplitude fibrillation potentials suggest an ongoing active denervation process.

Voluntary muscle recruitment

Recording of voluntary recruitment of motor unit action potentials can provide additional information. Reduced recruitment signifies motor axonal loss or functional dropout due to focal demyelination or conduction block. By contrast, increased recruitment with a small voluntary force can be seen with myopathy.

Interpretation

The information gathered from needle EMG is combined with that provided by nerve conduction studies to determine the overall interpretation. The results of the analysis of the collective studies often permits delineation of the type of underlying pathologic process, such as a polyneuropathy, mononeuropathy or entrapment neuropathy, radiculopathy, plexopathy, disordered neuromuscular transmission, or myopathic process. In many cases, one diagnosis explains the abnormalities found on the study, but, occasionally, more than one diagnosis is necessary to complete the interpretation of the electrodiagnostic findings.

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Indications

EMG and nerve conduction studies are an extension of the physical examination. They can be useful in aiding in the diagnosis of peripheral nerve and muscle problems. This can include peripheral neuropathies[8] , entrapment neuropathies[10] , radiculopathies[9] , and muscle disorders.

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Contraindications

Contraindications to EMG and nerve conduction studies include significant coagulopathies or blood dyscrasia or an implanted cardiac defibrillator. Extra care must be taken if a patient is on any anticoagulation.

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Common Nerve Conduction Study/Electromyography Findings

Radiculopathy

Radiculopathy is a pathologic process that affects nerves at the root level, often presenting as pure sensory complaints since the sensory fibers are much larger and more easily injured, but sensorimotor or pure motor complaints are also possible.[6] A pure sensory lesion will have negative EMG and sensory NCS results, even though the patient is experiencing a clinical sensory deficit. Other possible findings include normal sensory nerve action potential (SNAP) and a compound motor action potential (CMAP) that is normal to reduced.

An H reflex could be abnormal with an S1 radiculopathy, but F waves are neither sensitive nor specific for a radiculopathy. EMGs show PSWs and fibrillation potentials in at least two different muscles innervated by two separate peripheral nerves with the same root.

Chronology of radiculopathy findings

Upon injury to a nerve root, the patient may begin to report clinical symptoms immediately, but abnormalities in EMG/nerve conduction studies do not appear right away.[3] Thus, although a physician may be tempted to obtain an EMG/nerve conduction study, the electrodiagnostic evidence may be insufficient to confirm or exclude the diagnosis.

A few days after the injury, there may be decreased recruitment and prolonged late responses. After one week, there may be decreased CMAP and some abnormal spontaneous activity in the paraspinals. At 2-3 weeks, abnormal spontaneous activity may be seen in the limbs and paraspinals, and this is when an EMG/nerve conduction study is appropriate. Around 5-6 weeks, reinnervation begins, demonstrated by increased amplitude from the reinnervated motor unit.

Table 1. Findings of Nerve Conduction Studies and EMG in Carpal Tunnel Syndrome[1] (Open Table in a new window)

Severity of Carpal Tunnel Sensory Nerve Action Potential Compound Motor Action Potential Needle EMG Activity
Mild Prolonged latency Normal Normal
Moderate Prolonged latency and decreased amplitude Prolonged latency Normal
Severe Absent Prolonged latency and decreased amplitude Abnormal activity

Table 2. Common Disorders[2] (Open Table in a new window)

Disorder Distal Motor Latency Distal Sensory Latency Conduction Velocity Amplitude of the Evoked Response
Motor neuron disease Normal Normal Normal Reduced
Axonal polyneuropathy Normal Normal Slight decrease Reduced
Demyelinating polyneuropathy Prolonged Prolonged Decreased Normal
Entrapment neuropathy Normal (may be prolonged if this is a distal entrapment such as carpal tunnel syndrome) Normal (May be prolonged if this is a distal entrapment such as carpal tunnel syndrome) Decreased at the entrapment region May be decreased when stimulating proximal to the site of entrapment
Radiculopathy Normal Normal Normal Motor response may be decreased
Myopathies Normal Normal Normal Decreased motor amplitudes
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Contributor Information and Disclosures
Author

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Lindsay Elliott, DO Resident Physician, Department of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine in New Orleans

Lindsay Elliott, DO is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery Center, Associate Professor of Neurological Surgery, George R and Constance P Lincoln Endowed Chair, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic Neuromodulation.

References
  1. DeLisa JA, Gans BM. Physical Medicine and Rehabilitation: principles and practice. 4th ed. Lippincott Williams & Wilkins: Philadelphia; 2005.

  2. Braddom RL, Chan L, Harrast MA. Physical medicine and rehabilitation. Saunders/Elsevier. 4th ed. Philadelphia; 2011.

  3. Kimura J. Electrodiagnosis in diseases of nerve and muscle : principles and practice. Ed. 3. New York: Oxford University Press; 2001.

  4. Oh SJ. Clinical electromyography : nerve conduction studies. 3rd ed. Lippincott Williams & Wilkins: Philadelphia; 2003.

  5. Weiss LD, Silver JK, Weiss J. Easy EMG : a guide to performing nerve conduction studies and electromyography. Butterworth-Heinemann, Edinburgh. New York: 2004.

  6. Aminoff MJ. Aminoff's electrodiagnosis in clinical neurology. 6th ed. Saunders: Philadelphia; 2012.

  7. Daube JR, Rubin DI. Clinical neurophysiology. 3. ed. New York: Oxford University Press; 2009.

  8. de Souza RJ, de Souza A, Nagvekar MD. Nerve conduction studies in diabetics presymptomatic and symptomatic for diabetic polyneuropathy. J Diabetes Complications. 2015 Aug. 29 (6):811-7. [Medline].

  9. Pawar S, Kashikar A, Shende V, Waghmare S. The study of diagnostic efficacy of nerve conduction study parameters in cervical radiculopathy. J Clin Diagn Res. 2013 Dec. 7 (12):2680-2. [Medline].

  10. Galamb AM, Minea ID, Rogozea L. Electrodiagnostic approach in entrapment neuropathies of the median and ulnar nerves. Pak J Med Sci. 2015. 31 (3):688-93. [Medline].

 
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Median sensory nerve conduction set up
Median sensory nerve response
Distal median motor nerve conduction set up
Proximal median motor nerve conduction set up
Median motor nerve responses.
Table 1. Findings of Nerve Conduction Studies and EMG in Carpal Tunnel Syndrome [1]
Severity of Carpal Tunnel Sensory Nerve Action Potential Compound Motor Action Potential Needle EMG Activity
Mild Prolonged latency Normal Normal
Moderate Prolonged latency and decreased amplitude Prolonged latency Normal
Severe Absent Prolonged latency and decreased amplitude Abnormal activity
Table 2. Common Disorders [2]
Disorder Distal Motor Latency Distal Sensory Latency Conduction Velocity Amplitude of the Evoked Response
Motor neuron disease Normal Normal Normal Reduced
Axonal polyneuropathy Normal Normal Slight decrease Reduced
Demyelinating polyneuropathy Prolonged Prolonged Decreased Normal
Entrapment neuropathy Normal (may be prolonged if this is a distal entrapment such as carpal tunnel syndrome) Normal (May be prolonged if this is a distal entrapment such as carpal tunnel syndrome) Decreased at the entrapment region May be decreased when stimulating proximal to the site of entrapment
Radiculopathy Normal Normal Normal Motor response may be decreased
Myopathies Normal Normal Normal Decreased motor amplitudes
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