"Practical tips for trainees" teaching course at 16th European Congress of Clinical Neurophysiology on 30th August 2017 in Budapest, Hungary

1. Practical tips for trainees II.
NCS and near nerve
Edina Timea Varga MD, PhD
Department of Neurology, University of Szeged
30 August 2017
www.varganeuro.com

2. www.varganeuro.com

3. I. Nerve conduction study (NCS) – general
aspects
II. Motor nerve conduction studies
I. inchig
II. (F-waves, H-reflex)
III. Sensory nerve conduction studies
IV. Near nerve measurements

4. motor NCS
sensory NCS
http://bcs.whfreeman.com/thelifewire9e
Purves et al. Life The Science of Biology IVth Edition 1995.
http://chadwaterbury.com
http://emedicine.medscape.com/article/1846028-overview
http://jdr.sagepub.com
http://www.erikstalberg.com/www.varganeuro.com

5. axonmembrane
www.varganeuro.com

6. I. General aspects

7. NCS environment
www.varganeuro.com

8. NCS environment
www.varganeuro.com

9. Accessories
www.varganeuro.com

10. Accessories
1. Skin prep pads / disinfectant
2. Ground electrode
3. Stimulator
4. Registering electrodes (superficial / needle)
5. Electrode cables
6. Ring electrodes
7. (Electrode gel)
8. Thermometer (built in / external)
9. Distilled water (prevents fur formation)
10. Marker
11. Gloves
12. Tape-measure
13. Medical tape /cotton wool
14. Heating lamp / warm water bath / heating pads
www.varganeuro.com

11. Patient information
Contraindications
Inconvenience
www.varganeuro.com

12. II-III. Motor and sensory NCS

13. Nerve conduction study (NCS)
=electroneurography (ENG)
www.varganeuro.com
orthodromic - antidromic

14. Nerve conduction study (NCS)
=electroneurography (ENG)
www.varganeuro.com
orthodromic - antidromic

15. Nerve conduction study (NCS)
=electroneurography (ENG)
www.varganeuro.com
orthodromic - antidromic
temperature
position of ground electrode
supramaximal stimulation
repeatable curves
averaging (sensory NCS)

16. Nerve conduction study (NCS)
www.varganeuro.com

17. Nerve conduction study (NCS)
www.varganeuro.com

18. Nerve conduction study (NCS)
www.varganeuro.com

19. Nerve conduction studies (NCS)
motor NCS
sensory NCS
http://bcs.whfreeman.com/thelifewire9e
Purves et al. Life The Science of Biology IVth Edition 1995.
http://chadwaterbury.com
http://emedicine.medscape.com/article/1846028-overview
http://jdr.sagepub.com
http://www.erikstalberg.com/www.varganeuro.com

20. Nerve conduction studies (NCS)
motor NCS
sensory NCS
www.varganeuro.com

21. onset/distalis latency (DL)
Nerve conduction studies (NCS)
www.varganeuro.com

22. onset/distalis latency (DL)
Nerve conduction studies (NCS)
∆T
www.varganeuro.com

23. amplitude
amplitude
Nerve conduction studies (NCS)
www.varganeuro.com

24. ∆T
conduction velocity=distance / ΔT
Nerve conduction studies (NCS)
www.varganeuro.com

25. Nerve conduction studies (NCS)
duration
area under the curve
morphology
temporal dispersion
www.varganeuro.com
conduction block
https://mmcneuro.files.wordpress.com/2012/12/mmn-cb.jpg?w=271&h=322

26. needle electrode
superficial registration
www.varganeuro.com
Nerve conduction studies (NCS)

27.  stimulation with superficial electrode
 registration with needle
www.varganeuro.com
Nerve conduction studies (NCS)
Radial nerve motor NCS

28. ∆T
www.varganeuro.com
Motor NCS of median nerve
1.
2.

29. www.varganeuro.com
Motor NCS of ulnar nerve

30. Motor NCS of ulnar nerve
Registration simultaneously from two muscles (AMD – FDI)

31. www.varganeuro.com
Motor NCS of ulnar nerve
INCHING
1 inch= 2.54 cm

32. Inching
possible about any
nerve segments
localisation
1 inch= 2.54 cm

33. Sensory NCSs of median nerve
www.varganeuro.com

34. www.varganeuro.com
Sensory NCSs of median nerve
Orthodromic stimulation over 2 different segments

35. www.varganeuro.com
Sensory NCS of radial nerve
antidromic stimulation

36.  superficial electrodes
 sensory nerve conduction
Sensory NCS of medial and
lateral plantar nerve
www.varganeuro.com

37. Carpal tunnel syndrome (CTS)
www.varganeuro.com

38. Carpal tunnel syndrome (CTS)
www.varganeuro.com
MODERATE

39. Carpal tunnel syndrome
www.varganeuro.com
MILD
MODERATE
SEVERE
Muscle Nerve. 2011 Oct;44(4):597-607

40. Compression neuropathies
Affected nerve Site of compression
suprascapular nerve lig. transversum scapulae superius
brachial plexus / medial fasciculus TOS – thoracic outlet syndrome
median nerve
wrist
elbow
CTS
pronator teres sy
interosseus anterior sy
ulnar nerve
wrist
elbow
UTS
cubitalis tunnel sy/Guyon’s tunnel
dorsal interosseal nerve radialis tunnel sy
(where the nerve enters supinator
muscle)
lateral femoral cutaneous nerve
(meralgia paraesthetica)
ligamentum inguinale
obturator nerve obturator channel
piriformis nerve hiatus piriformis
posterior tibial nerve tarsal tunnel syndrome
(malleolus medialis-flexor retinaculum)
peroneal nerve / plantar branches Morton’s metatarsalgia www.varganeuro.com

41. Indication of NCS
………….
……………………….
………………………………………
…………………………………………………..
www.varganeuro.com

42. www.varganeuro.com

43. ?
www.varganeuro.com

44. Near nerve technique
closer to the nerve
higher detectable answer
more precise information
www.varganeuro.com

45. Indication
If the nerve could not be investigated by non/invasive
technique (superficial NCS, US, MRI…)
If the nerve is
 diameter<7 um (n. calcaneus med.)
 running deeply (ulnar, alveolaris inf. nerve)
 hard to differentiate the distal branches(plantar/palmar
interdigital branches): tarsal tunnel/Morton’s metatarsalgia
n. cut. fem. lat.
Became more and more limited due to high
resolution ultrasound…
www.varganeuro.com

46. Contraindications
 local infection, decubitus
 anticoagulant treatment (?) – rel.
 external pacemaker – abs.
 implanted PM, ICD, (VNS, DBS) – rel.
Al-Sheekle, Preston, Shapiro Muscle&Nerve 2003; 27:517-26. www.varganeuro.com

47. Possible complications
 bleeding
 infection (SINGLE USE!!! Needles are acceptable
HIV, CJD, hepatitis – HBV!), needle top!
 nerve lesion
 pain
 electric damage
Al-Sheekle, Preston, Shapiro Muscle&Nerve 2003; 27:517-26. www.varganeuro.com

48. www.varganeuro.com

49.  n. cutaneus femoris lateralis
 n. tibialis / rami plantares mediales et laterales
 n. ulnaris
www.varganeuro.com

50. N. cutaneus femoris lateralis
http://www.neurofys.uu.se/v2/docs/metod/index_eng.php
Preston&Shapiro 2. Edition www.varganeuro.com

51.  superficial electrodes
 sensory nerve conduction
Sensory NCS of medial and
lateral plantar nerve
www.varganeuro.com

52. Near nerve technique
tarsal tunnel syndrome Morton’s metatarsalgia
www.varganeuro.com

53. http://www.neurofys.uu.se/v2/docs/metod/index_eng.php
http://www.aafp.org/afp/2003/1001/p1356.html
Morton’s metatarsalgia
www.varganeuro.com

54. Morton’s metatarsalgia
www.varganeuro.com

55. Ulnar nerve neuropathy
www.varganeuro.com

56. Cubital tunnel syndrome – near nerve
www.varganeuro.com

57. NORMAL VALUES
age
gender
height
own lab
intraindividual
(side comparison)

58. Reporting
Description
Conclusion
Clinical comment
www.varganeuro.com

59. Special thanks to
Professor S. Beniczky
Professor A. Antal
Professor E. Stålberg
Rudsel Schoobaar, Cadwell Industries, Inc.
www.varganeuro.com

60. Thank you for your attention
www.varganeuro.com