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    NCS FINAL

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    elsayed.ayman

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    © All Rights Reserved
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    NCS FINAL

    Uploaded by

    elsayed.ayman
    1 views48 pages

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    1 views48 pages

    NCS FINAL

    Uploaded by

    elsayed.ayman

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 48

    NCS AND EMG

    BY

    Dena M. Elghazzawy
    Assistant lecturer of neurology
    INTRODUCTION

    MOTOR NCS

    SENSORY NERVE CONDUCTION

    LATE RESPONSE (F WAVE , H REFLEX)

    TECHNIQUE FOR NCS


    Agenda
    EXAMPLES

    MEASURING PARAMETERS

    FACTORS AFFECTING NCS

    EMG

    EXAMPLES
    NCS are very imp to understand peripheral nerve function in
    healthy and diseased states.
    Moreover, they differentiate () axonal & demyelinating nature of
    INTRODUCTION the underlying disorder and their extent.
    Also, often provide further valuable information about the fiber
    types involved and the underlying nerve pathophysiology and
    narrow the differential diagnosis.
    NCS play a great role in detecting the distribution ( localization) of the
    lesion either

    Primary motor neurons (anterior horn cells),


    Sensory neurons (dorsal root ganglia),
    Nerve roots,
    Brachial and lumbosacral plexuses,
    Peripheral nerves,
    Neuromuscular junctions, and
    Muscles.
    Nerve structure
    Types of axon
    Orthodromic

    Motor neurons

    Antidromic

    Axon
    Sensory neurons

    Orthodromic

    Antidromic
    Motor neuron sensory neuron
    AHCs present in ventral horn of Primary sensory neuro outside spinal
    spinal cord cord
    Has dendrities &one long axon No dendrite , 2 long axonal
    projection
    Efferent pathway Afferent pathway
    No receptors, axonal terminal relay Has receptors
    on NMJ
    Median
    nerve
    Motor conduction study
    More stable Orthodromic 
    Large in amplitude
    Easily producible

     We have to stimulate 2 sites or more.


     Recording G1 is placed on the ms belly ,
    ref G2 is placed distally over the tendon
    of the muscles
     Ground electrode: () the stimulating &
    recording electrode
     Stimulator : anode 2-3 cm px to
    cathode
     Intensity of stimulus: () 20:50 mA
    Motor conduction study:
    Median nerve
    Latency: time impulse take through 
    fastest nerve fibers from site of
    stimulation

    Amp: from base to top of negative 


    wave, it depends on No of fibers
    activated

    Cv measures the speed of fastest 


    conducting fibers
    Need two sites
    = distance/time
    Distance () 2 stimulated site
    Time(latency difference ) = px latency-dx
    latency
    Nerve conduction velocity

    Latency (s) L1

    L2
    Main cause of
    Main cause of
    prolonged in
    decrease in amp
    latency >> loss of
    >> loss of axons
    myelin
    ex

    Normal values of median n 


    Tl in median till 4.2 ms
    Amp above 4mV
    CV ABOVE 45 m/s
    MOTOR SENSORY
    Tibial Sural
    Fibular Median
    (peroneal) Ulnar
    Routinely Median
    Ulnar
    evaluated
    nerves
    Normal values
    Nerve Terminal latency Amp (m V) Cv m/s
    (ms)
    Median Till 4.2 ms More than 4 More than 45
    Ulnar Till 3.8 More than 6 More than 45
    Tibial Till 6.1 More than 4 More than 35
    Peroneal Till 6.5 More than 1.5 More than 35
    Sensory median Peak tl till 3.5 More 20 microvolt More than 45
    Sensory ulnar Peak tl till 4 More than 15 More than 45
    microvolt
    Ncs was done on rt tibial nerve ,, It revealed
    Normal tl, cv and amp of rt tibial motor study
    Concllusion: Normal motor ncs of rt tibial n
    Ncs was done on lt peroneal nerve ,, It revealed
    Prolonged tl, with severe decrease in amp of lt peroneal motor study with normal cv
    Conclusion: axonal and demylinating neuropathy of lt peroneal nerve
    Ncs was done on lt peroneal nerve ,, It revealed
    normal tl, with severe decrease in amp of lt peroneal motor study with normal cv
    Conclusion: axonal neuropathic affection of lt peroneal nerve
    Ncs was done on rt tibial nerve ,, It revealed
    normal tl, with decrease in amp of rt tibial motor study with normal cv
    Conclusion: axonal neuropathic affection of rt tibial nerve for clinical correlation
    Ncs was done on rt ulnar nerve ,, It revealed
    normal tl, with decrease in amp of rt ulnar motor study with normal cv
    Conclusion: axonal neuropathic affection of rt ulnar nerve for clinical correlation
    Ncs was done on rt median nerve ,, It revealed
    Prolonged tl, with normal amp and cv of rt median motor study
    Conclusion: rt demylinating neuropathy at wrist ( CTS)
    Ncs was done on rt median nerve . It revealed
    ===============
    Normal tl (3.93 ) with normal amp 5.9 and normal cv
    88.9
    Conclusion
    ==============
    Normal ncs of rt median nerve
    Sensory
    NCS
    SENSORY NCS

    Latency (ms) 
    Onset Peak: more commonly used
    Amplitude (μV) Baseline to peak Peak to peak 
    Duration 
    Conduction velocity 
    Can calculate a distal velocity
    Use onset latency for CV
    Fastest fibers
    Carpal tunnel syndrome
    Reflexes: NCS are basically performed to study the distal segment involvement. The late responses are
    preformed to study the more proximal segment involvement(plexus and roots).

    F Wave is a long latency muscle action potential seen after supramaximal stimulation to a nerve. •
    It results from anti-dromic stimulation of motor neurons involving conduction to and from spinal
    cord and occurs at the interface between peripheral and central nervous system.
    not a true reflex
    needs supramaximal stimulus
    Its amplitude is 10 % of the M wave amplitude.
    Afferent motor-efferent motor.
    from any nerve in the body.
    Screen proximal conduction
    F WAVE
    Motor neuron

    Neuromuscular
    junction
    Neuromuscular
    junction
    Factors affecting NCS

    Physiological Non physiological


    Age : NCV ↓↓ with age in older ptn above 60
    Technical factors
    Temp: ↓ temp , the prolonged the latency, ↑
    duration, ↓ CV Artifact
    TEMP MUST BE MONITORED FOR 32-34 C Anomalous innervation
    Height: ↑ IN HEIGHT, ↑↑ DL
    EMG examination
    Electrodes in EMG and NCSs

    1) Surface
    2) Needle
    EMG
    examination  1- Insertional activity: activity related to the movement of the needle.

     2- At rest: silent normally


    Spontaneous activity: abnormal and usually seen with denervation

     3- Mild Contraction: Motor unit potentials


    Amplitude, duration and morphology
    The amplitude and duration are directly proportional to the number of
    muscle fibres within the motor unit.

     4- Maximum contraction: full or reduced IPs.


    The IPs is directly proportional to the number of motor units
    Spontaneous activity

    SIGNS OF DENERVATION
     A- Fibrillation potentials: small amplitude 50-
    200 uvolt amplitude and biphasic potentials
     b- positive sharp waves: monophasic positive
    waves: 200-300 uvolt amplitude.
    >> Both denotes denervation especially in
    peripheral lesions.
     C- Fasciculations: large potentials that
    favors proximal neurogenic lesion
    especially AHCs lesion.
    Mild Contraction
    motor unit potentials
    amplitude: .5-3 mvolt
    duration: 5-15 msec.
    no of phases: more than 4 phases is
    termed polyphasic
    it is accepted in normal mups to
    have 10-15 % polyphasic mups
    Interference pattern

     Full: normal and in muscle disorders.


     Reduced: Neurogenic or UMNL
    1- Insertional : normal
    2- At rest: silent
    3- Mild Contraction: small amplitude
    EMG in short duration
    myopathy
    spiky and polyphasic
    4- Max. Contraction: Full IPs.
    Conduction studies: normal
    Myopathy

    Emg was done on rt Quadriceps ms


    It revealed no resting activity
    Low amp MUAP with short duration
    With complete interferrance pattern of low amp
    Conclusion >> coping with myopathic pattern
    Neuropathy

    Emg was done on rt biceps ms


    It revealed no resting activity
    High amp MUAP with long duration and polyphasicity
    With incomplete interferrance pattern
    Conclusion >> coping with neurogenic pattern
    Peripheral Neuropathy

    - Axonal Neuropathy: 
    1- Insertional activity: prolonged
    2- At rest: signs of denervation.
    3- Mild Contraction: normal or ↑ ↑ amplitude. Broad and polyphasic
    MUPs
    4- Max. Contraction: moderate reduction in IPs
    Conduction studies: mild reduction in C.V. and normal distal latency
    with remarkable amplitude suppression.
    1- Insertional activity: prolonged 
    2- At rest: fasciculation, fibs and positive sharp 
    waves.
    Proximal Mild Contraction: giant broad and polyphasic 
    lesion (AHC) MUPs.
    Max. Contraction: marked reduction in IPs. 
    Conduction studies: normal 
    THANK YOU

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