Title: Johnson's Practical Electromyography, 4th Edition Copyright 2007 Lippincott Williams & Wilkins
> Table of Contents > II - Technical Aspects of EMG > Chapter 9 - Pictorial Guide to Nerve Conduction Techniques
E2
Cathode
Anode
Cranial Nerves
Table 9-1 Cranial Nerve VII to Nasalis (Fig. 9-1)
Electrode placement
E1
E2
Postauricular stimulationbehind the lower ear, below the mastoid process and behind the neck of the mandible
Normal values
Mean SD
Normal limit
3.5 0.4 ms
4.2 ms
1 mV
Note: Alternate recording sites from other facial muscles as needed to evaluate specific branches of CN VII.
Electrode placement
E1
E2
Chin
Cathode
Anode
Superiorly
R1 latency
Ipsilateral R2 latency
Electrode placement
E1
Over the upper trapezius, midway between C7 spinous process and acromion.
E2
On acromion
Medial clavicle
Cathode
Anode
Superiorly
Normal values (4,5) (n = 30) Figure 9-3 Cranial nerve XI Mean SD Normal limit
Onset latency
2.2 0.4 ms
3.0 ms
Peak amplitude
3.9 1.6 mV
1.0 mV
image
Electrode placement
E1
E2
Medial sternum
Cathode
3 cm above the clavicle, along the posterior border of the sternocleidomastoid muscle
Anode
Superiorly
Mean SD
Normal limit
Onset latency
6.3 0.8 ms
8.6 ms
Amplitude
597 139 V
400 V
E1
Self-adhesive, 8.0 0.5-cm, ring-type electrodecranial end at nipple level (5 cm distal to the bipolar stimulator) in line with the bipolar stimulator contact points and the anterior superior iliac spine
E2
Self-adhesive surface electrode over the seventh rib distal to the pectoralis muscle
Side
Mean SD
Normal limit
Onset latency
Right
2.3 0.5 ms
3.5 ms
Left
2.3 0.4 ms
3.2 ms
Side-to-side difference
0.3 0.2 ms
0.6 ms
Right
3.8 1.9 mV
1.6 mV
Left
3.9 1.9 mV
1.2 mV
Side-to-side difference
0.6 0.6 mV
2 mV
Electrode placement
E1
A needle electrode is placed into the digitation of the serratus anterior muscle over the fifth rib, along the midaxillary line.
E2
Two cm distal to the E1 (no need if a concentric needle electrode is used for E1)
Cathode
Slightly above the upper margin of the clavicle lateral to the clavicular head of the sternocleidomastoid muscle
Anode
Superomedially
Age (years)
Normal limit
2035
3.6 0.3 ms
4.2 ms
3650
3.8 0.4 ms
4.4 ms
5165
4.0 0.4 ms
4.8 ms
Electrode placement
E1
E2
At deltoid tubercle
Cathode
Supraclavicular fossa
Anode
Superomedially
Mean SD
Normal limit
Onset latency
3.9 0.5 ms
5.0 ms
Electrode placement
E1
E2
Cathode
Supraclavicular fossa
Anode
Superomedially
Normal values (9) (n = 62) Figure 9-7 Musculocutaneous nerve Mean SD Normal limit
Onset latency
4.5 0.6 ms
5.7 ms
Electrode placement
E1
A concentric recording needle (E2 = reference/outer cannular of needle) Supraspinatus: Insert the needle just above the scapular spine at the midpoint. Advance the needle in a downward and forward direction until the needle touches the scapula, then withdraw it 23 mm. Infraspinatus: Insert the needle 3 cm below the scapular spine and 3 cm lateral to the medial border of the scapula.
Cathode
Supraclavicular fossa
Anode
Superomedially
Mean SD
Normal limit
2.7 0.5 ms
3.7 ms
Infraspinatus recording
3.3 0.5 ms
4.2 ms
E1
Supine position with the arm abducted to 90 degrees. E1 is on the posterior axillary line at the intersection of the line horizontally drawn from the inferior angle of the scapula.
E2
S1
Cathode
Anode
Superior
S2
Cathode
Erb's point
Anode
Superior
Mean SD
Range
Onset latency
1.9 0.4 ms
2.7 ms
Amplitude, right
4.1 1.8 mV
1.4 mV
Onset latency
3.6 0.4 ms
4.5 ms
Amplitude
6.0 2.0 mV
2.0 mV
Table 9-10 Median Nerve to the Abductor Pollicis Brevis (Fig. 9-10)
Electrode placement
E1
Midline between the first metacarpophalangeal joint and the first carpometacarpal joint
E2
Cathode
S1: 8 cm proximal to the E1, measured first to the midpoint of the distal wrist crease and then on the line between the
tendons of the flexor carpi radialis and the palmaris longus S2: On the antecubital crease, at the medial border of the biceps brachii tendon
Anode
Proximal
Mean SD
Normal limit
Onset latency
3.7 0.3 ms
4.3 ms
Amplitude
13.2 5.0 mV
5.0 mV
50 m/s
Mean SD
Normal limit
Onset latency
3.7 0.5 ms
4.7 ms
Amplitude
10.2 3.6 mV
3.0 mV
57 5 m/s
47 m/s
Table 9-11 Median Nerve (Anterior Interosseous Branch) to the Pronator Quadratus (Fig. 9-11)
Electrode placement
E1
Centrally over the dorsum of the forearm, 3 cm proximal to the ulnar styloid
Figure 9-11 Median nerve (anterior interosseous branch) to the pronator quadratus
E2
On the medial dorsum of the wrist over the ulnar styloid process
Cathode
On the antecubital crease, at the medial border of the biceps brachii tendon
Anode
Proximally
Right
Left
Onset latency
3.6 0.4 ms
3.5 0.4 ms
3.1 0.8 mV
3.1 0.8 mV
Electrode placement
E1
Proximal third from the antecubital crease (S1), over the belly of the extensor digitorum
On the medial dorsum of the wrist over the ulnar styloid process
Cathode
S1: In the antecubital fossa just lateral to the biceps tendon as the tendon crosses the flexor crease S2: In the axilla between the coracobrachialis and the long head of the triceps
Anode
Proximally
Mean SD
Normal limit
Onset latency
2.6 0.4 ms
3.5 ms
Amplitude
11.2 3.5 mV
4.3 mV
Conduction velocity
68 7.0 m/s
54 m/s
Table 9-13 Radial Nerve to the Extensor Indicis Proprius (Fig. 9-13)
E1
Concentric needle electrode into the extensor indicis proprius, at the distal third of the dorsal forearm and on the dorsum of the ulna (E2 = outer cannula of needle)
Cathode
S1: In pronation of the forearm; 4 cm proximal to the needle insertion site, radial border of the extensor carpi ulnaris muscle S2: In pronation of the forearm; 5 cm proximal to the lateral epicondyle, lateral border of the triceps brachii muscle S3: Erb Point
Anode
Proximally
Mean SD
Normal limit
2.4 0.5 ms
2.9 ms
S1-S2
50 m/s
S2-S3
60 m/s
Table 9-14 Ulnar Nerve to the Abductor Digiti Minimi (ADM) (Fig. 9-14)
Electrode placement
E1
On the border of the palm and dorsum of the hand, halfway between the wrist crease and the base of the little finger
E2
On the dorsum of the hand or between the stimulating and recording electrodes
Cathode
The arm is in a 45 degrees abducted and externally rotated position with the elbow moderately flexed to 90135 degrees (18). S1: 2 cm proximal to the E1, along the radial border of the tendon of the flexor carpi ulnaris S2: 2 cm distal to the ulnar groove at the elbow S3: 10 cm proximal to the S2, measured in a curve along the ulnar groove to a point between triceps and brachialis S4: 10 cm proximal to S3 in the axilla
Anode
Proximally
Mean SD
Normal limit
3.2 0.5 ms
4.2 ms
Amplitude
6.14 1.90 mV
2.3 mV
S1-S2
53 m/s
S2-S3
52 m/s
S3-S4
51 m/s
Normal values (21) (n = 248) Figure 9-14 Ulnar nerveto the abductor digiti minimi Mean SD Normal limit
3.0 0.3 ms
3.6 ms
11.6 2.1 mV
7.4 mV
S1-S2
61 5 m/s
51 m/s
S2-S3
61 9 m/s
43 m/s
S3-S4
61 7 m/s
47 m/s
Table 9-15 Ulnar Nerve to the First Dorsal Interosseous (Fig. 9-15)
Electrode placement
E1
On the dorsum of the hand, the first web space, 1 cm radial to the midpoint of the second metacarpal bone
E2
Between E1 and S1
Cathode
At the ulnar wrist crease, along the radial border of the tendon of the flexor carpi ulnaris
Anode
Proximally
Onset latency
Amplitude
Age (years)
Mean
Limit
Mean
Limit
<20
3.3 ms
4.2 ms
15 mV
8 mV
2029
3.4 ms
4.1 ms
14 mV
8 mV
3039
3.3 ms
4.4 ms
15 mV
6 mV
4049
3.2 ms
4.2 ms
13 mV
6 mV
5059
3.4 ms
4.4 ms
13 mV
6 mV
6069
3.6 ms
4.5 ms
12 mV
7 mV
3.6 ms
4.2 ms
12 mV
8 mV
Note: No summarized values are available (22). Mean side-to-side difference, FDI = 0.2 ms (0.01.3); ipsilateral difference, FDI - ADM = 0.9 ms (0.22.0) (22).
Electrode placement
E1
Median nerve: over the abductor pollicis brevis (see Fig. 9-10) Ulnar nerve: over the abductor digiti minimi (see Fig. 9-14)
E2
Median nerve: slightly distal to the first metacarpophalangeal joint Ulnar nerve: distal to the fifth metacarpophalangeal joint
Cathode
Positioned as for standard wrist stimulation (see Figs. 9-10 and 9-14)
Anode
Nerve
Range
Side-to-side differences
Median/APB
2231 ms
2.3 ms
Ulnar/ADM
2132 ms
2.5 ms
Note: Ulnar F wave latency (25) = [arm length (cm) 0.31] [ulnar nerve forearm velocity (m/s) 0.123] + 11.05. A prolongation of >2.5 ms is considered abnormal.
E1
On volar aspect of the forearm, over the radius bone, 10 cm distal to the stimulating cathode
E2
3 cm distal to E1
Cathode
Anode
Proximally
Mean SD
Normal limit
Peak latency
2.2 0.2 ms
2.6 ms
18 10 V
3 V
Mean SD
Normal limit
Peak latency
2.8 0.2 ms
3.3 ms
18.9 9.9 V
8 V
E1
On volar aspect of the forearm, over the ulna bone, 14 cm distal to the stimulating point
E2
3 cm distal to E1
Cathode
Along the medial border of the biceps brachii muscle, 5 cm proximal to the medial epicondyle
Anode
Proximally
Mean SD
Normal limit
Peak latency
2.7 0.2 ms
3.3 ms
11.4 5.2 V
5 V
Table 9-19 Median Sensory Nerve to the Second and Third Digits (Fig. 9-19)
Electrode placement
E1
A ring electrode is placed distal to the base of the second or third digit.
E2
Cathode
S1: 14 cm proximal to E1 on the line between the tendons of the flexor carpi radialis and the palmaris longus S2: The midpoint of the line from E1 to S1
Anode
Proximal
Mean SD
Normal limit
Figure 9-19 Median sensory nerve to the second and third digits
Peak latency
S1 S2 S2/S1
Peak amplitude
S1 S2 S2/S1
52 13 V 67 20 V 128 29%
26 V 37 V 186 %
Mean SD
Normal limit
Onset latency
S1 S2
3.3 ms 1.8 ms
Peak latency
S1 S2
4.1 ms 2.8 ms
S1 S2
41 20 V 43 28 V
10 V 4 V
S1 S2
63 33 V 66 43 V
12 V 5 V
Mean SD
Normal limit
Onset latency
S1 S2
3.2 ms 1.7 ms
Peak latency
S1 S2
4.1 ms 2.4 ms
S1 S2
37 19 V 38 24 V
8 V 4 V
S1 S2
56 31 V 53 36 V
9 V 4 V
Table 9-20 Median and Radial Sensory Nerves to the Thumb (Fig. 9-20)
E1
E2
Cathode
Sm: Median nerve, 10 cm proximal to E1, in a line measured first to the midpoint of the distal wrist crease and then on the line between the tendons of the flexor carpi radialis and the palmaris longus Sr: Radial nerve, over the lateral radius, 10 cm proximal to the active electrode
Anode
Proximal
Figure 9-20 Median and radial sensory nerves to the thumb Peak latency
Mean SD
Normal limit
Median Radial
2.9 ms 2.8 ms
Median Radial
30 2 V 12 1 V
Note: The upper limit of normal differences between the median and radial nerve is latency difference 0.3 ms, and amplitude of median nerve 200% amplitude of radial nerve.
Table 9-21 Median and Ulnar Sensory Nerves to the Fourth Digit (Fig. 9-21)
Electrode placement
E1
E2
Cathode
Sm: Median nerve, 14 cm proximal to E1, in a line measured first to the midpoint of the distal wrist crease and then to a point on the line between the tendons of the flexor carpi radialis and the palmaris longus Su: Ulnar nerve, 14 cm proximal to E1, along the radial border of the flexor carpi ulnaris tendon
Anode
Proximally
Distal Latency
Side
Mean SD
Normal limit
Dominant hand
Median Ulnar
3.6 ms 3.5 ms
Nondominant hand
Median Ulnar
3.7 ms 3.6 ms
Note: The upper limit of normal increase in latency for the median versus ulnar nerve is 0.5 ms. No information on amplitude is available (32).
Figure 9-21 Median and ulnar sensory nerves to the fourth digit
Table 9-22 Radial Sensory Nerve to the Base of the Thumb (Fig. 9-22)
E1
Cathode
Anode
Proximally
E1
Over the tendon of the extensor pollicis longus tendon at the apex of the first web space (near the wrist)
E2
On the skin between the heads of the first and second metacarpal bones
Cathode
Anode
Proximally
Thumb recording
E1
E2
Cathode
Anode
Proximally
Mean SD
Normal limit
Onset latency
1.8 0.3 ms
2.4 ms
Peak latency
2.3 0.4 ms
3.1 ms
31 20 V
Mean SD
Normal limit
Onset latency
1.6 0.1 ms
1.9 ms
42.2 14.9 V
16.0 V
Mean SD
Normal limit
Onset latency
2.8 0.2 ms
3.3 ms
12.3 4.9 V
5.0 V
Table 9-23 Ulnar Sensory Nerve to the Fifth Digit (Fig. 9-23)
Electrode placement
E1
E2
Cathode
S1: 14 cm proximal to E1, along the radial border of the flexor carpi ulnaris tendon S2: At the midpoint of the line from E1 to S1
Anode
Proximally
Mean SD
Normal limit
Onset latency
S1 S2
3.0 ms 1.8 ms
Peak latency
S1 S2
4.1 ms 2.5 ms
Figure 9-23 Ulnar sensory nerve to the fifth digit Onset to peak amplitude S1 S2 32 20 V 33 17 V 6 V 3 V
S1 S2
50 32 V 55 36 V
4 V 4 V
Electrode placement
E1
Over the proximal point of the V formed by the fourth and the fifth metacarpal bones
E2
Cathode
810 cm proximal to E1 between the ulna and the flexor carpi ulnaris tendon
Anode
Proximally
Mean SD
Normal limit
1.84 0.20 ms
2.3 ms
10-cm study: peak Figure 9-24 Ulnar dorsal cutaneous sensory nerve latency
2.09 0.21 ms
2.7 ms
23.5 8.8 V
5.9 V
E1
About 6 cm above from the superior and medial border of the patella
E2
Cathode
S1: Above the inguinal ligament S2: Below the inguinal ligament The distance between stimulation points across the inguinal ligament is 5.5 1.6 cm.
Anode
Proximally
Mean SD
Normal limit
7.1 0.7 ms
8.5 ms
6.0 0.7 ms
7.4 ms
1.1 0.4 ms
1.9 ms
50 m/s
Mean SD
Normal limit
4.6 0.5 ms
5.5 ms
Amplitude
12.1 1.1 mV
2.5 mV
Note: The bipolar surface stimulation electrodes were placed lateral to the point of pulsation over the inguinal ligament while a concentric needle electrode was inserted into the belly of the rectus femoris.
E1
On the extensor digitorum brevis (Fig. 9-27, peroneal portion), abductor hallucis (Fig. 9-28A, tibial portion), or abductor digiti minimi (Fig. 9-28B, tibial portion)
E2
Cathode
S1: Surface stimulation in the popliteal fossa S2: A long needle electrode in the midway below the gluteal fold
Anode
Proximally
Mean SD
Normal limit
Nerve conduction velocity to abductor digiti minimi Figure 9-26 Sciatic nerve
42 ms
E1
On the extensor digitorum brevis muscle, which is 1 cm distal to the tubercle that is its origin. This is 23 cm distal to the lateral malleolus.
E2
Cathode
S1: 8 cm proximal to E1, lateral to the tibialis anterior tendon S2: Posterior and inferior to the fibular head S3: Approximately 10 cm proximal to the S2, and medial to the tendon of the biceps femoris
Anode
Proximally
Mean SD
Normal limit
Onset latency
4.5 0.8 ms
6.0 ms
Amplitude
4.4 1.2 mV
2.0 mV
Conduction Velocity
S1-S2
40 m/s
S2-S3
40 m/s
Mean SD
Normal limit
Onset latency
4.8 0.8 ms
6.4 ms
Amplitude
5.9 2.6 mV
0.7 mV
Conduction Velocity
S1-S2
47 4 m/s
39 m/s
S2-S3
57 9 m/s
39 m/s
Electrode placement
E1
1 cm posterior and 1 cm inferior to the navicular tubercle, at the junction of plantar skin and dorsal foot skin
E2
Cathode
S1: 8 cm proximal to E1, right behind the medial malleolus S2: At the popliteal fossa
Anode
Proximally
Mean SD
Normal limit
4.8 0.8 ms
6.4 ms
Amplitude (43)
11.6 4.3 mV
3.0 mV
38 m/s
Table 9-28 Lateral Plantar Motor to Abductor Digiti Minimi (Fig. 9-28B)
Electrode placement
E1
Half distance from the sole of the foot to the tip of the lateral malleolus
E2
Cathode
Anode
Proximally
Normal values (44) (n = 10) Figure 9-28 B. Tibial nerve (lateral plantar) Mean SD Normal limit
Onset latency
4.4 0.5 ms
5.4 ms
Amplitude (43)
11.0 3.9 mV
3.2 mV
Electrode placement
E1
For peroneal nerve: over the extensor digitorum brevis (see Fig. 9-27) For tibial nerve: over the abductor hallucis (see Fig. 9-28A)
E2
For peroneal nerve: at the fifth metatarsophalangeal joint For tibial nerve: at the first metatarsophalangeal joint
Cathode
For peroneal nerve: 8 cm proximal to E1, lateral to the tibialis anterior tendon For tibial nerve: 8 cm proximal to E1, and just behind the medial malleolus
Anode
Distally
Normal values (45) Peroneal nerve F wave latency in ms (shortest of 10 stimuli, n = 180)
Age
Height (cm)
Mean SD
Normal limit
<160
43.6 2.5
48.6
19 39
160169
47.1 3.7
54.5
>170
51.5 4.1
59.7
<160
45.4 4.8
55.0
40 79
160169
49.6 4.6
58.8
>170
54.6 4.5
63.6
(Reprinted from Buschbacher RM. Peroneal nerve F-wave recorded from extensor digitorum brevis. Am J Phys Med Rehabil 1999;78:S48S52, with permission.)
Height (cm)
Mean SD
Normal limit
<160
43.2 2.2
47.6
160169 19 39 170179
47.2 3.0
53.2
52.0 4.0
60.0
>180
53.1 4.4
61.9
<160
45.4 4.0
53.4
160169 40 59 170179
49.3 2.2
53.7
53.6 3.7
61.0
>180
58.3 5.3
68.9
<160
49.0 4.8
58.6
160169 60 79 170179
52.8 4.4
61.6
54.7 3.2
61.1
>180
57.3 5.8
68.9
(Modified from Buschbacher RM: Tibial nerve F-wave recorded from abductor hallucis. Am J Phys Med Rehabil 1999;78;S43S47, with permission.)
Electrode placement
E1
Halfway between the popliteal crease and the medial malleolus, with subject in prone position
E2
Cathode
Anode
Distal
Age
Height (cm)
Mean SD
Normal limit
1939
<160
27.1 1.8
30.7
160169
28.6 1.9
32.4
170179
30.3 1.8
33.9
>180
32.0 2.1
36.2
4049
<160
27.8 1.1
30.0
160169
30.2 1.4
33.0
170179
31.0 1.6
34.2
>180
32.7 2.1
36.9
5079
<160
29.3 1.9
33.1
160169
31.7 1.6
34.9
170179
31.9 1.7
35.3
>180
33.2 2.5
38.2
Note: The upper limit of increase in latency from one side to the other is 2.0 ms (47). Equation to calculate: H Lat at 9.1 + (0.1 Age) + (0.46 Length) (48) (Reprinted from Buschbacher RM. Normal range for H-reflex recorded from the calf muscles. Am J Phys Med Rehabil 1999;78:S75S79, with permission.)
Electrode placement
E1
1720 cm distal to the anterior superior iliac spine, on the line between the anterior superior iliac spine and the lateral border of the patella
E2
3 cm distal to E1
Cathode
S1: below the inguinal ligament, 1 cm medial to the line between the anterior superior iliac spine and the lateral border of the
patella S2: above the inguinal ligament, 1 cm medial to the anterior superior iliac spine
Anode
Proximally
Mean SD
Normal limit
2.5 0.2 ms
2.8 ms
S2 (1720 cm)
2.8 0.4 ms
3.6 ms
S1
7.0 1.8 V
3.4 V
S2
6.0 1.5 V
3.0 V
Electrode placement
E1
E2
3 cm distally
3 cm distally
Cathode
Anode
Proximally
Mean SD
Normal limit
Peak latency
2.8 0.2 ms
3.2 ms
6.5 1.5 V
3.5 V
Electrode placement
E1
Slightly anterior to the highest prominence of the medial malleolus, between the malleolus and the tendon of the tibialis anterior
E2
Cathode
Anode
Proximally
Mean SD
Normal limit
Onset latency
3.2 0.3 ms
3.8 ms
Peak latency
3.8 0.3 ms
4.4 ms
6.5 3 V
3.5 V
Table 9-34 Superficial Peroneal* Nerve: Medial and Intermediate Dorsal Cutaneous Branches (Fig. 9-34)
Electrode placement
E1
At the level of the ankle Medial branch: just lateral to the tendon of the extensor hallucis longus Intermediate branch: 12 cm medial to the lateral malleolus
E2
Cathode
Anode
Proximally
Figure 9-34 Superficial peroneal nerve: medial and intermediate dorsal cutaneous branches
Branch
Mean SD
Normal limit
Peak latency
Medial Intermediate
2.74.7 ms 2.84.6 ms
Medial Intermediate
2.3 V 4 V*
Intermediate
20.5 6.1 V
8.3 V
Medial Intermediate
Table 9-35 Tibial Nerve (Mixed Nerve Responses): Medial and Lateral Plantar Nerves (Fig. 9-35)
Electrode placement
E1
E2
Proximally
Cathode
1. Medial branch: 10 cm distal to E1 to the first web space, and then 4 cm more distal along the first web space (total 14 cm distal to E1) 2. Lateral branch: 14 cm distal to E1, on the sole between the fourth and fifth metatarsals
Anode
Distally
Branch
Mean SD
Normal limit
Peak
Medial
3.16 0.26 ms
3.7 ms
Latency
Lateral
3.15 0.25 ms
3.7ms
Amplitude
Medial Lateral
>10 V >8 V
Electrode placement
E1
E2
3 cm distally
Cathode
14 cm proximal to E1 in the midline or slightly lateral to the midline of the posterior lower leg, between the two heads of gastrocnemius
Anode
Proximally
Mean SD
Normal limit
3.5 0.25
4.0 ms
23.7 3.8 V
10 V
34.7 m/s
Mean SD
Normal limit
Onset latency
3.1 0.3 ms
3.6 ms
Peak latency
3.8 0.3 ms
4.5 ms
17 10 V
4 V
Electrode placement
E1
At the midpoint of the fifth metatarsal and just lateral to the extensor digitorum brevis tendon to the fifth toe
E2
Distally
Cathode
Anode
Proximally
Normal values (57) (n = 40) Figure 9-37 Sural nerve lateral dorsal cutaneous branch Mean SD Normal limit
Onset latency
3.2 0.4 ms
4.0 ms
Peak latency
3.9 0.5 ms
4.9 ms
5.8 2.1 V
3 V
28.0 m/s
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