NERVE CONDUCTION VELOCITY

By: Niyati Patel

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Introduction
 The Nerve Conduction Study (NCS) is a
electrodiagnostic test commonly used to evaluate the
function, especially the ability of electrical conduction
of the sensory and motor nerves of the human body.
 These studies assess the ability of peripheral nerve to
conduct electrical impulses by recording the evoked
potential generated by electrical stimulation of a
peripheral nerve.

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 Uses of NCS
 To assess the amount of denervation in the muscle.
 To detect which fiber is affected.[Sensory/Motor)
 To find out the location of peripheral lesion and how many
peripheral nerves are affected.
 To assess the progression of lesion whether degenerating
or recovering.
 To find out localized nerve block/ axonal degeneration/
segment demyelination.

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INSTRUMENTATION
 Recording NCV/EMG requires a system that includes
three phases:
1. Input phase
2. Processor phase
3. Output phase

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Input Phase

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ELECTRODES

 Active recording electrode

 Reference electrode
 Ground electrode
 Stimulating electrode – has cathode (active) directed
towards the recording muscle and anode (inactive)
 Concentric needle electrodes
 Single fiber needle electrodes

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SURFACE ELECTRODES

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GROUND ELECTRODES

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RING ELECTRODES

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STIMULATING ELECTRODES

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CONCENTRIC NEEDLE ELECTRODE

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PROCESSOR PHASE- AMPLIFIER

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PROCESSOR PHASE
 DIFFERENTIAL AMPLIFIER

 Small myoelectric signals amplified to be large enough

to be displayed
 Noise is cancelled out

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PROCESSOR PHASE
 FILTERS

 Nerves and muscles respond physiologically at

particular frequency ranges
 “noise” can be removed electronically from excitable
tissue signal by an electronic device called FILTER

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PROCESSOR PHASE
 Notch filter – eliminates DC and 60Hz AC line noise. It
passes a band of frequencies less than and greater
than 60Hz

 High-pass filter – keeps the high frequency signals and

filters out low frequency signals

 Low-pass filter – keeps the low frequency signals and

rejects the higher frequencies

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PROCESSOR PHASE
 SIGNAL AVERAGERS

 If single response to electrical stimulus is very small,

and the “noise” is large with respect to it, multiple
signals are averaged
 Frequently used to record SNAP

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PROCESSOR PHASE
 INTEGRATORS

 Calculation of an area under a signal waveform

 Unit – volt-seconds
 Applies to full wave rectified signals, rectified value is
always positive
 Used in quantitative analysis

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OUTPUT PHASE
 Amplified signals displayed on a monitor, heard on a
speaker
 Sample and data can be stored and analyzed

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VARIABLES AFFECTING THE NERVE
CONDUCTION STUDY

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 1) Age: The nerve conduction velocity in a full term
infant is nearly half of the adult value. As the
myelination progresses, the nerve conduction velocity
attains the adult value by 3-5 years of age.
 2) upper versus lower limb :-The median and ulnar
nerve conduction is higher compared to tibial and
peroneal. An inverse relationship between height and
nerve conduction velocity suggests that the longer
nerves conduct slower than the shorter nerves
(Campbell 1980).

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 3) Temprature:Low temperature results in slowing of
nerve conduction velocity and increases the
amplitude. The laboratory temperature, therefore,
should be maintained between 21-23ºC. If skin
temperature is below 34ºC, the limb should be
warmed by infrared lamp, by warm water immersion
or making appropriate correction of the results.

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 Nerve Conduction Study consist of:
1. Motor NCS
2. Sensory NCS
3. F- wave study
4. H- reflex study

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1) Motor NCS
 Motor NCS are performed by electrical stimulation of
a peripheral nerve & recording from a muscle supplied
by the nerve.
 Principles:
 Motor NCS are performed by stimulating a peripheral
nerve at two or more points & recording muscle
action potentials with a pair of surface electrodes:
active placed on the belly of the muscle and inactive
lead placed on the tendon.

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 The time it takes for electrical impulses to travel from
the stimulation to the recording site is measured.
 This value is called latency which is measured in
milliseconds (ms)
 The size of the response called amplitude is also
measured in millivolts (mV)
 By stimulating two or more different location along
the same nerve, the NCV across different segments
can be determined

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Recording settings:
 Filter setting= 5Hz-10KHz
 Sweep speed= 2-5 ms/devision
 Wave form= square wave
 Pulse duration= 0.1ms
 intensity= 5-40 mA

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Procedure
 Explanation about procedure in brief to the patient.
 Position the patient comfortably and the part to be
tested to be firmly supported.
 Lower the skin resistance.
 Surface electrode are placed with gel which also
provide an interface between patient and equipment.
 The surface recording electrode is placed in muscle
belly.

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 The reference electrode is placed over the tendon distal
to active electrode[4cm]
 The ground electrode is placed between the stimulating
and recording electrode.
 Stimulating electrode:
 Cathode [Black] is directed towards the recording
electrode to stimulate the depolarization towards the
muscle.
 Anode [Red] is an inactive electrode.

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 Stimulate the nerve at least two points along its
course.
 It is important to ensure supramaximal stimulation
keeping the cathode close to active recording
electrode, to stimulate depolarization towards the
muscle. This prevent hyperpolarization effect of anode
and anodal conduction block.
 Stimulus intensity starts low, and is slowly increased
until the action potential is clearly observed.
 A biphasic action potential with initial negativity is
thus recorded.


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Parameter of MNCS
1) Onset latency: this is the time require for an electrical
stimulus to initiate an action potential
 It is the time from the stimulus to the first negative
deflection of CMAP.
 It measure of conduction in the fastest conducting
nerve fibers.
 It also include neuromuscular transmision time and
propagation time

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2) Amplitude: it is measured from baseline to negative peak
[base to peak] or between negative and positive
peek[peak to peak]
 It correlates with the number of nerve fibers activated
and their synchronicity of firing.
 Nerve pathology decrease the amplitude

3) Duration: it is measured from the onset to negative or

positive peak or final return to baseline
 It correlate with density of small fiber.
 Nerve pathology increase the duration of CMAP

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Nerve conduction velocity: this is the speed an impulse
travel along a nerve and is primarily dependent on
the integrity of the myeline sheath
 It is calculated measuring the distance between two
points of stimulation in mm which is divided by the
latency difference in ms. The never conduction
velocity is expressed as m/sec.
 The distance between the two stimulation points
should be measured from cathode to cathode not
from cathode to anode

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CALCULATION

NERVE CONDUCTION VELOCITY 33

 Conduction velocity = D m/sec
PL-DL

 PL =proximal latency in ms
 DL=distal latency in ms
 D= distance between proximal and distal
stimulation in mm

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ELECTRODE PLACEMENT

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1) MEDIAN NERVE

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NORMAL VALUE

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2) ULNAR NERVE

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3) RADIAL NERVE

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4) POSTERIOR TIBIAL NERVE

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 The normal conduction velocity of tibial nerve is 48.3 ±
4.5 m/s. (ma and Liveson 1983).
 The latency (mean ±SD ) across 10cm distance is3.8±
0.5 ms

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5) COMMON PERONEAL NERVE

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 The latency (mean ±SD ) across 10cm distance 3.9 ±
0.5ms
 The normal conduction velocity of common peroneal
nerve nerve is 48.3 ± 4.5 m/s. (ma and Liveson 1983).

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2) Sensory NCS
 Sensory conduction can be measured orthodromically
or antidromically
 Orthodromic – distal portion of nerve is stimulated
and SNAP is recorded at a proximal point along the
nerve
 Antidromic – nerve is stimulated proximally and SNAP
recorded distally.
 For orthodromic conduction, ring electrodes are
preferred to stimulate the digital nerve, whereas
surface stimulating electrodes are commonly used for
antidromic stimulation.

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 SNCS recording settings:
 Filter settings: 10 Hz - 2 KHz,
 Sweep speed 1-2 ms /divison and
 Gain 1-5 μv/division.

 Parameter:
 Latency
 Amplitude
 Duration
 Conduction velocity
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1) MEDIAN NERVE

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2) ULNAR NERVE

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3) RADIAL NERVE

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4) SURAL NERVE

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 Sural nerve conduction velocity in healthy volunteers
(n=30) 50.9 ±5.4 m/s and amplitude of SNAP 18.0
±10.5 μV.

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Abnormality findings in NCV study
 In peripheral nerve injury:
 3 type of nerve injury: if NCV study is
performed within 3-7 days of injury, normal
values will be obtained, as degeneration is
not started.

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Neuropraxia Axonotmesis Neurotmesis
[Type-1] [Type-2] [Type-3]

1) Conduction block: 1) Partial denervation No action potential is

Latency: Prolonged
Amplitude: decreased across
the site of injury.
Velocity: decreased
2) Demyelination:
Latency: Prolonged 2) Complete denervation:
Amplitude: Normal
Velocity: Reduced
Reduced amplitude elicited
with the stimulation
above the level of
lesion and normal
Velocity and latency
Absence of CMAP in the
distribution of the
nerve

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