American Journal of EEG Technology

ISSN: 0002-9238 (Print) 2375-8600 (Online) Journal homepage: http://www.tandfonline.com/loi/utnj18

Basic Introduction to Nerve Conduction Studies:

Technical Aspects and Pitfalls

Jennifer Bowers

To cite this article: Jennifer Bowers (1993) Basic Introduction to Nerve Conduction Studies:
Technical Aspects and Pitfalls, American Journal of EEG Technology, 33:1, 35-48

To link to this article: http://dx.doi.org/10.1080/00029238.1993.11080429

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Am. J. EEG Techno/.
33:35-48, 1993
«:> ASET, Iowa

Basic Introduction to Nerve Conduction Studies:

Technical Aspects and Pitfalls
Jennifer Bowers, R. EDT.

Atlanta Neurological Clinic PC

105 Collier Road NW
Atlanta, Georgia 30309

ABSTRACT. Nerve conduction studies are utilized to evaluate

damage sustained by the peripheral nervous system. There are nu-
merous technical considerations that must be addressed properly for
the physician to diagnose correctly where and how severe the damage
is, what method of treatment is called for, and the predicted clinical
outcome. This paper will address what a nerve conduction study does,
generally how to perform one, common difficulties encountered, gen-
eral guidelines for setting up a laboratory, and a short reading list.

KEY WORDS. Axonal, demyelinating, electromyography (EMG),

entrapment, muscles, nerve conduction study (NCS), nerves, peripheral
nervous system (PNS), technical aspects.

INTRODUCTION
Many neurodiagnostic technologists are asked to learn laboratory tasks that
cover multiple disciplines. One of the most difficult aspects of any new procedure
is translating the new terminology into a familiar language. In this discussion of
nerve conduction studies (NCS), a correlation, where possible, between periph-
eral nervous system (PNS) terminology and central nervous system (CNS) ter-
minology will be drawn. The PNS works essentially in the same way physiolog-
ically as the CNS. The neurophysiology and overall anatomy will not be covered
here in an attempt to compress this topic to a manageable length, but excellent
resource materials are Grey's Anatomy of the Human Body, Peripheral Nerve
Injuries, and Electrodiagnosis in Diseases of the Nerve and Muscle. All these
resources are listed in the Bibliography of this paper. Good working knowledge
of the peripheral anatomy must accompany all topics in nerve conduction studies.

Received for publication: September 26, 1992.

35
36 INTRODUCTION TO NCS

Without knowing the physiology and the anatomy, one cannot successfully test
the system.

WHAT IS A NERVE CONDUCTION STUDY?

Nerve conduction studies evaluate the peripheral nervous system by testing
the function of the individual nerves. Nerves, like any other part of the body,
may be damaged, bruised, stretched, cut, or affected by disease. Unlike utilizing
an imaging technique such as magnetic resonance imaging (MRI) or computed
tomography (CT), electrical testing gives us information about how the system
is functioning. The best method of testing the function of the PNS is to perform
nerve conduction studies and EMG. These two tests in conjunction can suc-
cessfully gauge damage to the system.
The nerve conduction study is performed to measure the nerve response to
electrical stimulation across a given segment of the pathway. The method used
for calculating a normal versus abnormal NCS is a function of time and ampli-
tude. To perform a NCS, a recording electrode is placed on the belly of a muscle
innervated by the nerve you are about to test and a reference electrode is placed
somewhere off the muscle, three to four centimeters distal (away from the body).
An electrical depolarization (shock) building up to a supramaximallevel is given
to the nerve with a surface stimulator, and a compound muscle action potential
is recorded on the instrument screen. By repeating this procedure along the course
of a nerve, we can identify areas of disease or trauma that are interrupting the
flow of signals along the pathway. A simple analogy would have you visualize
a train that leaves Washington, DC traveling to Atlanta, GA with stops in
Roanoke, VA and Charlotte, NC. If the tracks are clear, there are no delays and
the train gets to Atlanta on time. However, if there are cows on the track between
Roanoke and Charlotte, the train is delayed past this obstruction (Figure I). This
obstruction might occur in one localized area or on many different parts of the
track. The train can become derailed or just delayed. This is a very simplified
example, but one that clearly describes the nerve conduction study as well as
the somatosensory evoked potential test. In Figure 2 you see a normal nerve
conduction study ofthe ulnar nerve with the wrist site representing Atlanta and
the above elbow site representing Washington. In Figure 3 you can see the
difference in the waveform response and the slowing across the elbow segment

----+
FIG. 1. The top train schedule is an example of a normal, nondelayed schedule. The
bottom schedule is an example of a delay due to blockage between Roanoke, VA and
Charlotte, NC. (Reprinted with permission from Technical Synapse, Inc.)
 INTRODUCTION TO NCS 37

Train Schedule

8:00AM. 0
Washington, DC

12:00 Noon

5:00P.M.
Charlotte, NC

8:00P.M.

Slow Train Schedule

12:00Noon
8:00A.M.

J.-oc
8:00P.M.

11:00 P.M. 0
Atlanta, GA
38 INTRODUCTION TO NCS

ATLANTA NEUROLOGICAL CLINIC, PIEDMONT OFFICE, EMG LAB

I-
FILE ID: V2.1.4 13 FEB 92 11:12

HNC RECORD I 2 Ulnar Nerue.R 11: 12:3~

I I
AVERAGE: ON I 1!11 STEP: 2 I LEVEL: 0 vI SWITCH: STIH

Recording Site : IDI

A1r-----1"J. .~ ,..--,S'""T~IKJ::-::L"""Us:;:--:,sr=-=TE=--,.L:-:::;!,....'r:ru==••
=-R -r:::':"=v--.-::::=-=~~~
· · · A1: Above Elbow 7.5 8.0 11.67~9.77
A2: Below Elbow 6.0 7.9 11.~6~9.38
A2 l. · · · · ~ov
5 a\
A3: Wrist 2.9 7.512.10u8.~6
11
1

AS: Erb's Point

A

DIST DIFF C:V

o o 0 0

NORMAL ULNAR NERVE STUDY

0 I o I
SEGMENT • rns •Is

·
5
·~ Above Elbow-Below Elbow 100 1.5 67
Below Elbow-Wrist 180 3.1 58
Wrist-Axi I\ a
"5 ~ Axi 1\a-Erb's Point

FIG. 2. This is a normal ulnar nerve study with the schedule from wrist (Atlanta) to
above the elbow (Washington) intact. The velocity is normal from wrist to below elbow
and from below elbow to above elbow. (Reprinted with permission from Technical Syn-
apse, Inc.)

caused by an ulnar entrapment neuropathy. Note the difference in velocity (speed)

of the two examples (shown in the box labeled "CV rnls").
The electromyogram (EMG) studies the PNS by evaluating the passive and
active electrical discharges of the muscles. EMG, like EEG, is a dynamic study
and is in most cases interpreted during the study. EMGs are done by a physician
usually specializing in neurology or physical medicine. Each muscle of the body
 INTRODUCTION TO NCS 39

ATLANTA NEUROLOGICAL CLINIC , PIEDMONT OFFICE, EMG LAB

FILE ID: V2.1.4 13 FEB 92 11 : 14

HNC RECORD 12 Ulnar Nerve.R II: 1~:30

IAVERAr:f: ON /IIJ ISTEP: 2 T LEVEL: 0 VI SWITCH: STIH / -
2 ms ~~~~~tffiY; oJ ~! I19MIII/ NONREC

Record ing Site :ADM

· · ·~ '+OOU
AI ~~- shington STIHULUS SITE ...
LRT1 CUR
115
RI1P
.v
AREA
.Ums
BIG COVV ' · · · AI: Above Elbow 10.8 7.2 2.161 ~.m

A2 ·A/~
0 E
'+OOV
2 •
A2: Below Elbow
A3: Wrist
7.7 7.0 6.068 120.00
3.8 7.2 7.227 18.76
A'l: Axi II a
AS: Erb's Point
35'+U
A ff

flL
Atlanta

ABNORMAL ULNAR NERVE. STUDY 2 ~ Above Elbow-Below Elbow

SEGMENT
-
DIST DIFF
115

110 3.1 35
cv
m/s

. Below Elbow-Wrist 200 3.9 51

Wrist-Axi II a
~ .2 .u Axi lla-Erb's Point

FIG. 3 . This is an abnormal ulnar nerve study revealing a delay in conduction and an
amplitude drop across the elbow segment. Note the slowing of velocity above the el-
bow, 35m/sec, and the drop in amplitude to 2 . 1 mV as compared to FIG. 2. (Reprinted
with permission from Technical Synapse, Inc.)

is innervated by a specific nerve and nerve root. By testing muscles of each nerve
root of interest, the physician may isolate the area of the spine, plexus, and/ or
distal nerve that has been damaged. EMG testing is performed by inserting a
needle electrode into the muscle and recording motor unit action potentials
during contraction and normal quiet baseline or abnormal positive sharp waves,
fibrillations, and occasionally fasciculations during rest. The EMG combined
40 INTRODUCTION TO NCS

with the nerve conduction study will give a clear picture of the amount and
location of PNS damage.

HOW DO YOU PERFORM A NERVE CONDUCTION STUDY?

Any readily accessible nerve can be successfully tested by depolarizing the
nerve with stimulation and recording either a motor (efferent) or a sensory
(afferent) response. Commonly tested nerves in the upper extremity are the
median, ulnar, radial, and spinal accessory. In the lower extremity, common
nerves are the posterior tibial, peroneal, and sural nerves. Some nerves, consid-
ered uncommon nerves, that should be tested routinely are the musculocuta-
neous, axillary, supraclavicular, anterior interosseous, dorsal ulnar sensory, pe-
roneal dorsal sensory, medial and lateral plantar sensory, femoral and medial
antebrachial nerves. These uncommon nerves are just as susceptible to injury,
entrapment, disease, and dysfunction as are the common nerves and the ability
to test them is just as crucial to the diagnosis, prognosis, and treatment of the
patient. Usually, uncommon nerves are tested in a side to side comparison,
utilizing precise measurements from one limb to the other. The common nerves
should be compared to your laboratory's normative data for distal latency, ve-
locity, and amplitude measurements. Age and gender should be considered in
these normals.
Using a differential amplifier (just as in EEG or EP) you may record on the
oscilloscope action potentials that can be measured for speed (myelination) and
amplitude (axonal response). By stimulating the nerve at different points along
its course, precisely measuring the distance of the segments in millimeters, and
dividing the distance by the difference in time in milliseconds, you may calculate
a velocity or speed in meters per second (Figure 2). A nerve impulse should
travel at a speed of about 130 miles per hour. In nerve conduction studies we
are looking for a relatively discrete change to about 70 miles per hour.

WHAT CLINICAL CONDITIONS WOULD REQUIRE NCS/EMG?

Traumatic Nerve Injuries
Any nerve may be injured by trauma. Trauma can be specific as in the case
of a gunshot wound, a laceration, a crush, or any other specific traumatic insult
to a localized area of the body. Trauma may also occur from repetition such as
is found in carpal tunnel syndrome, often seen in computer operators or chicken
packers, and with cubital tunnel syndrome, often seen in sales representatives
and postal workers. Any nerve that can be stimulated can be tested following a
 INTRODUCTION TO NCS 41

nerve injury. In traumatic cases, always test the opposite side for comparison
regardless of whether the nerve is a commonly tested one.

Entrapment Neuropathies
Entrapment neuropathy simply means that a nerve is being impinged or
smashed at a certain anatomical point along its course. Entrapment neuropathies
include carpal tunnel syndrome (CTS) involving the median nerve at the wrist;
cubital tunnel entrapment involving the ulnar nerve at the elbow; peroneal palsy
or foot drop involving the peroneal nerve, usually at the knee; Saturday night
palsy or wrist drop involving the radial nerve above the elbow; tarsal tunnel
syndrome involving the tibial nerve at the ankle; and multiple pressure point
entrapments seen in weight lifters. Entrapment neuropathies can be superim-
posed on generalized peripheral neuropathies or they may stand alone. The
crucial factor in evaluating the patient presenting with a possible entrapment
neuropathy is to test nerves that should not be involved as part of the routine
investigation. For instance, if a patient presents with complaints of index finger
and thumb numbness worse at night, relieved by shaking the hands, and is a
full time data entry operator you will expect an entrapment of the median nerve
at the wrist (carpal tunnel syndrome). If the patient is an unknown diabetic,
however, you could be dealing with a more generalized peripheral neuropathy.
If you test only the median nerve you could miss a more generalized peripheral
neuropathy, send the patient to surgery for a mild carpal tunnel syndrome, and
have the patient back in the lab four months later with the same complaints.

Peripheral Neuropathies
Nonspecific peripheral neuropathies are generalized neuropathies affecting
more than one nerve and usually associated with some chronic problem such as
diabetes mellitus, alcohol abuse, toxic substances including medications, hered-
itary diseases, infectious processes, or in some cases just plain old age. These
neuropathies can manifest themselves in myriad ways and can indeed have
entrapment neuropathies superimposed on them. For example, femoral entrap-
ment neuropathy is a frequent harbinger of a full diabetic neuropathy; a diabetic
radiculopathy can present with the same features as a herniated disc; often
alcoholics will present with a wrist drop when the entire system is involved. As
in EEG, the technologist's role is extremely helpful not only in the investigation
of the physical complaint, but in the history we are able to obtain. Patients often
reveal to us information they will not admit to the physician. If the technologist
sees a decreased amplitude, slowing of conduction velocities, or multiple en-
42 INTRODUCTION TO NCS

trapment neuropathies, it is critical to continue the investigation to the other

side and include both an arm and leg to assure that a generalized neuropathy is
not present. (Unless a generalized neuropathy is the suspected diagnosis, keep
looking for a normal nerve.)

Infectious Neuropathies
The most prevalent infectious nervous system disorder seen recently is the
peripheral neuropathy associated with acquired immunodeficiency syndrome
(AIDS). Other common infectious neuropathies include Guillain-Barre syn-
drome (GBS), diphtheria, post-polio syndrome, and chronic inflammatory pe-
ripheral disease (CIPD). These may present in the electrodiagnostic lab with
slowed velocities and diminished amplitude just as any other peripheral neu-
ropathy but are more often seen in the acute state. The most unusual aspect of
GBS is the extremely prolonged latencies of the late responses, F-waves and
H-reflexes. See Nerve Conduction Studies and Electrodiagnosis in Diseases ofthe
Nerve and Muscle, listed in the Bibliography, for a thorough discussion ofH-re-
flexes (monosynaptic reflex arcs) and F-responses (antidromic motor neuron
discharges). These responses will be severely delayed or absent. The latency of
an F-wave in the lower extremity of a patient with GBS might be 80 msec as
opposed to 50 msec in a normal subject. The technologists must adjust the sweep
speed accordingly for a patient with sudden onset "creeping" weakness and
numbness. Often the late responses are the only abnormality on the electrical
exam. The neuropathy caused by human immunodeficiency virus (HIV) is cur-
rently classified as an infectious viral neuropathy. It does differ somewhat from
the others in its electrical presentation. In HIV-positive patients, all distal la-
tencies will be prolonged and often will have very slowed conduction velocities
with relatively normal amplitudes. Acute AIDS patients may present in the
electrophysiologicallaboratory to rule out GBS. A finding of note in these patients
is that their nerve conduction studies are normal with no prolonged late re-
sponses. In this clinical setting, with normal nerve conduction study results, the
spinal fluid has been found to be the only reactive HIV test.

Neuromuscular Junction
There are diseases which affect the chemical conversation between the ter-
minal branch of the nerve and the muscle fiber. These diseases are specific to
the neuromuscular junction. The two syndromes of neuromuscular junction
dysfunction tested with nerve conduction studies are myasthenia gravis (post-
synaptic) and myasthenic syndrome (presynaptic). These are investigated with
repetitive stimulation techniques fraught with technical difficulties and pitfalls
and should be covered as a separate topic. There are several excellent references
 INTRODUCTION TO NCS 43

MNC RECORD I 2 Ulnar Nerue.R 11: 13:1f5

IAIJERAGE: ON,. !STEP: 2 I LEUEL: lffiO uI SWITCH: STIH /Ill
2 ... ~~~¥~: o.l ~! llltllml/ MlNREC
0 0 0 0 I 0

0 • • • •
Recording Site : fllH
.1. • • • •
AI :'0011
STIIIILUS SITE L:!1 DUR AREA
5 •\
•• '= .v••
AI: Above Elbow 7.5 8.0 11.67 ~9.77
A2: Below Elbow 6.0 7.9 11.~6 ~9.38
II' ~ ~011
A3: Wrist 2.9 7.5 12.10 ~8.~6
~: Axilla

LtN0 . AS: Erb's Point

II
A
.
SE!i£NT
-
DIST DIFF
•• .,.
1:11

fll .5 II\
Above Elbow-Below Elbow 100 1.5 67
Below Elbow-Wrist 180 3.1 58
Wrist-Axilla
~ .5 1111 Axilla-Erb's Point

FIG. 4. This is a normal ulnar nerve study, with distances and latencies measured
accurately. (Reprinted with permission from Technical Synapse, Inc.)

listed in the Bibliography. This subject is too complex to be covered in this brief
article, a task akin to covering epilepsy techniques with a four page article.

COMMON ERRORS AND PITFALLS DURING NERVE

CONDUCTION STUDY TESTING
Measurement Errors
There is nothing in life like consistency. Incorrect measurement is the biggest
single error made in NCS. Just as in EEG in which electrode placement on the
scalp is crucial to the study, correct measurement of the stimulation sites in NCS
can substantially affect the outcome. In entrapment neuropathies quite often a
surgical procedure awaits the patient so BE ACCURATE! Figure 4 shows a
44 INTRODUCTION TO NCS

PIEI»«)NT HOSPITAL NEUROPHYSIOLOGY IABORA'lURY

FILE ID: V2.1.4 23 APR 92 11:14

Ulnar Nerve.R 11:1~:37

lEVEL: 1!00 U SWITCH: STIH I Ill
2 ... ~~~~~; o.l ~! tiiiGW I NONlEC

Recording Site :fllH

LRTI IIIR Ill' RRER

STifiJ!.US SITE •• liS fiN .V••
t: Above Elbow 7.5
: Below Elbow 5.8
3: Wrist 2.9
: Rxi II a
: Erb's Point

SED DIST DIFF CV

- as •Is:

Above Elbow-BeiO\I Elbow 80 t. 7 ~7

Below Elbow-Wrist 180 2. g 62
rist-Axilla
Rxi lla-Erb's Point

FIG. 5. The same normal ulnar nerve study as in FIG. 4. The study has now been
made abnormal by measurement errors. The below elbow latency has been changed by
.2 msec from 6 msec to 5 .8 msec and the below elbow to above elbow limb measure-
ment changed by 2 em from 10 em to 8 em. This results in a 20m/sec slowing across
the elbow and could result in a normal study being interpreted as abnormal. (Reprinted
with permission from Technical Synapse, Inc.)

normal nerve conduction study of the ulnar nerve with the correct measurements.
Figure 5 is the same study but the below elbow to above elbow segment distance
has been changed by 2 em and the latency measurement of the below elbow site
has been changed by .2 msec. Note the apparent chance in conduction velocity
from 67 m/sec to 47 m/sec. This results in a change from normal to severely
abnormal and could send the patient to surgery.
 INTRODUCTION TO NCS 45

Neurophysiology Laboratory
FILE ID: V2.1.4 11 MAR 92 13:01

HNC RECORD •I 13:01:5&

I AVERAGE: ON,. !STEP: 3 I LEVEL:
FREQUENCY: 1 Hz
I
128 u SWITCH: STIH /Jill
2 •• DURATION I 0.1 •s liWWtt«JNlEC

Recording Site .
.l, 392V
AI
~r STIIIILUS SITE LAT1
I
•• ':3'
IIJR AREA
•s llll•s
Rl: ULNAR ELBOW 7.~ 5.8 1~.51 ~3.23

J 109U
:1 ...
A2: MEDIAN WRIS'I 3.5
A3: MEDIAN ELBm 7.0
R'/: MEDIAN WRIS~ 3.5
5.8 9. 792 32.16
6.0 10.25 33.23
5.8 9.883 32.93
RS:
A

flll . . . . . . 160U
SEGIENT
-
DIST DIFF
•• .
.,cv

J.. . . . . . . . . :J . .
RI-A2 MEDIAN TO
A2·R VELOCITY.
3
R3-R'I MEDIAN TO
ULNAR
VOLUM:

MEDIAl
220 3.9 56
3.5
220 3.5 63
fPt·frfELOCITY
·~ 1111

FIG. 6. Volume conduction of the stimulus can result in these findings. Traces A4
and A3 are from normal, correct median nerve stimulation at the wrist and elbow. Traces
A2 and A 1 demonstrate volume conduction at the elbow site from median to ulnar
nerve. Note the change in waveform morphology and the difference in velocity. This error
was produced by moving the cathode 2 em medially. (Reprinted with permission from
Technical Synapse, Inc.)

Stimulating the Wrong Nerve and Volume Conduction

At both the elbow and popliteal fossa, errors are often made by directly
stimulating an adjacent nerve or indirectly stimulating it through volume con-
duction. Figure 6 demonstrates volume conduction from the median to ulnar
46 INTRODUCTION TO NCS

nerves at the elbow site. Note in the upper traces that the waveform morphology
changes and the elbow waveform no longer looks like the wrist waveform.

Anatomical Variants
There are two major anatomical variants which cause difficulties in the
study of the PNS. One, called Martin Gruber anastomosis, consists of some of
the median nerve fibers crossing over to the ulnar nerve in the forearm. This
causes amplitude changes in the workup of the upper extremity; the ability to
assess this anomaly must be part of your lab criteria. There are three major
presentations of Martin Gruber which are very well described in most of the
publications listed in the Bibliography. In the lower extremity, an accessory
peroneal nerve may also be present and again will give you amplitude differences.
The accessory peroneal nerve amplitude changes are less likely to cause inter-
pretation difficulties than the Martin Gruber anastomosis.

Temperature
Limb temperature is crucial to accurate NCS. A diminished temperature
will slow velocities and latencies and increase amplitudes. If we are evaluating
the speed and amplitude of responses, obviously we should pay attention to
factors affecting these two parameters. If the patient's arms and legs are cold,
warm them up. A limb temperature of34-37° C. is optimal. Surface temperature
may affect sensory latencies up to 1 msec although 0.5 msec is more common.
This can radically affect interpretations of palmar latencies, in which some lab-
oratories consider a 0.2 msec difference between ulnar and median palmars as
abnormal.

Other Sources of Error

Movement of electrodes and stimulators in repetitive stimulation techniques
cause 90 percent of the problems in evaluating myasthenia gravis with electrical
studies. In a two technologist lab, immobilization is easy. When a single tech-
nologist is trying to accomplish repetitive stimulation, the only method I have
found successful is to tape the stimulator and the recording electrodes down with
five or six inch surgical tape (the foamy-stretchy kind). When using this technique
and stimulating the spinal accessory nerve, please do not compress the carotid
artery with your tape. One other source of error in the EMG lab arises from not
utilizing both the EMG and NCS in conjunction. Each test evaluates the system
a different way and gives additional information about what is and is not in-
 INTRODUCTION TO NCS 47

valved. A patient presenting with thumb and index finger numbness and pain
may have a carpal tunnel syndrome and/or a CS-6 herniated disc.

SETTING UP A LABORATORY
Setting up an EMG laboratory is very similar to setting up an evoked
potential laboratory. Normal values for the instrument, patient population, and
technique must be gathered in both instances. Published data will vary widely,
just as in evoked potential testing. Different instruments, often from the same
manufacturer, will have different recording characteristics; interinstrument dif-
ferences also need to be documented. The following are general environmental
and instrument needs: an instrument on rollers; disposable items; a sink; incan-
descent lighting; a wide, wooden bed; and necessary storage. There are numerous
instruments available to perform EMG and NCS. As with any other instrument
purchase, you should choose the company and instrument based on the needs
of your laboratory. Do you expect to do single fiber, quantitative motor unit
analysis, facial nerve monitoring in the operating theater, evoked potential test-
ing, or any combination of these tests in addition to routine studies? These are
questions you need to answer and then specify to the vendor. One word of
caution: there are many instruments designed for dual purposes, i.e., evoked
potential testing and EMG testing. Be cautious in trying to equip your EMG and
EP needs with one instrument. Scheduling problems abound as the EMG must
be done when the physician is present and the EP series can take much longer
than predicted. Just the image of a neurologist waiting to perform an EMG while
you finish an EP series on a patient with multiple sclerosis should give you the
picture. Having an instrument with the ability to perform both EP and EMG is
theoretically a good idea. While it requires learning only one instrument, provides
backup for both procedures, and allows your facility to deal with only one
manufacturer, do not expect to get all your EMGs and EPs done on one unit.
Buy two unless you do only a few procedures! As with any instrument purchase,
there will be aspects you like and dislike about all of them.
Disposables in the lab consist primarily of surface electrodes (reusable),
disposable needle electrodes, measuring tapes, conductivity gel (do not use EEG
paste), and alcohol preps. Most instrument manufacturers carry disposables as
do other companies dedicated to accessories only. Instrument manufacturers
usually supply some startup disposables with the instrument, but rarely enough
to work for a week. When purchasing disposable needle electrodes for the first
time, you should make certain testing has been done by the manufacturer to
assure acquisition integrity between the older types of needles and the newer
disposables. Technologists are often asked to purchase and maintain an inventory
48 INTRODUCTION TO NCS

of needle electrodes, and since we do not use them, the manufacturer must be
our source for intemeedle integrity.
A wide wooden bed is almost a necessity in the EMG laboratory. We must
position the patient comfortably, but in a position which allows accurate mea-
surement oflong legs and arms. A stretcher is suboptimal and a recliner is out
of the question. Wood prevents many problems, e.g., interference from metal
touching electrodes, and it increases patient safety. Wood tables, however, are
difficult to find and often must be custom made. Do not use carpet in the room;
the instrument will need to be moved from head to toe along the bed during the
study.
The following items are helpful in the EMG lab and should be present prior
to your needing them. An emesis basin, washcloths, cold water, and Gatorade
all assist with those patients who get a little green around the edges during the
EMG. Vasovagal responses have occurred and you should be prepared to deal
with these problems quickly. A professional attitude and explanation ofthe test
you are about to perform will always assist both you and your patient through
this and all other diagnostic procedures.
As new avenues of professional opportunity open to the technologists of the
1990s we must continue our historical attention to good technique, professional
testing protocol, and reliable results. Nerve conduction study testing is no dif-
ferent from other modalities you face daily and are a dynamic change of pace
for the professionals performing them.

Address reprint requests to: Jennifer Bowers, R.ED T., Atlanta Neurological
Clinic PC, 105 Collier Road NW, Atlanta, GA. 30309

BIBLIOGRAPHY
Aminoff, M.J. (1986): Electrodiagnosis in Clinical Neurology. 2nd ed. Churchill-Livingstone,
New York, 755 pp.
Dawson, D.M., Hallett, M., and Millender, L. ( 1990): Entrapment Neuropathies. 2nd ed. Little,
Brown and Co, Boston-Toronto.
Delagi, E.F. and Perotto, A. ( 1980): Anatomic Guide for the Electromyographer. 2nd ed. Charles
C Thomas, Springfield, IL.
Dong, M.M. and Levison, J .A. ( 1983): Nerve Conduction Handbook. F. A. Davis, Philadelphia.
Goodgold, J. (1974): Anatomical Correlates of Clinical Electromyography. Williams and Wil-
kins, Baltimore-London.
Gross, C. (&l.Xl959): Grey's Anatomy ofthe Human Body. 27th ed. Lea and Febiger, Phila-
delphia.
Hammer, K. (1982): Nerve Conduction Studies. Charles C. Thomas, Springfield, IL.
Haymaker, W. and Woodall, B. (1953): Peripheral Nerve Injuries. 2nd ed. Saunders, Phila-
delphia.
Kimura, J. Electrodiagnosis in Diseases ofNerve and Muscle. 2nd ed. F. A. Davis, Philadelphia.
Wellborn, A. (1991): Brachial Plexus Lesions. Lecture in the AAET Symposium, Vancouver,
BC.