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Principles of Nerve Conduction Studies and Needle EMG Principles of Nerve Conduction Studies and Needle EMG Mark A. Ferrante, MD Teresa Spiegelberg BS, CNCT, R.NCS.T, R.EEG.T Bryan E. Tsao, MD AANEM 61st Annual Meeting Savannah, Georgia Copyright © October 2014 American Association of Neuromuscular & Electrodiagnostic Medicine 2621 Superior Drive NW Rochester, MN 55901 Printed by Johnson Printing Company, Inc. 1 Please be aware that some of the medical devices or pharmaceuticals discussed in this handout may not be cleared by the FDA or cleared by the FDA for the specific use described by the authors and are “off-label” (i.e. use not described on the product’s label). “Off-label” devices or pharmaceuticals may be used if, in the judgment of the treating physician, such use is medically indicated to treat a patient’s condition. Information regarding the FDA clearance status of a particular device or pharmaceutical may be obtained by reading the product’s package labeling, by contacting a sales representative or legal counsel of the manufacturer of the device or pharmaceutical, or by contacting the FDA at 1-800-638-2041. 2 Principles of Nerve Conduction Studies and Needle EMG Table of Contents Program Committee & Course Objectives 4 Faculty 5 Nerve Conduction Studies: What Gets Measured and What It Means 7 Mark A. Ferrante, MD Troubleshooting Nerve Conduction Studies 19 Teresa Spiegelberg, BS, CNCT, R.NCS.T, R.EEG.T The Needle Electrode Examination 25 Bryan E. Tsao, MD CME Questions 33 No one involved in the planning of this CME activity had any relevant financial relationships to disclose. Chair: Mark A. Ferrante, MD The ideas and opinions expressed in this publication are solely those of the specific authors and do not necessarily represent those of the AANEM. 3 Objectives Objectives - Participants will acquire skills to (1) Demonstrate what measurements are made during the NCS and needle EMG, (2) discuss what the measurements reflect, (3) discuss how various NMDs affect the measurements, and (4) explain NCS pitfalls and their resolution. Target Audience: • Neurologists, physical medicine and rehabilitation and other physicians interested in neuromuscular and electrodiagnostic medicine • Health care professionals involved in the diagnosis and management of patients with neuromuscular diseases • Researchers who are actively involved in the neuromuscular and/or electrodiagnostic research Accreditation Statement - The AANEM is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for physicians. CME Credit - The AANEM designates this live activity for a maximum of put in 3.0 AMA PRA Category 1 Credits™. If purchased, the AANEM designates this enduring material for a maximum of 5.75 AMA PRA Category 1 Credits™. This educational event is approved as an Accredited Group Learning Activity under Section 1 of the Framework of Continuing Professional Development (CPD) options for the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Physicians should claim on the credit commensurate with the extent of their participation in the activity. CME for this course is available 10/2014 – 10/2017. CEUs Credit - The AANEM has designated this live activity for a maximum of 3.0 AANEM CEUs. If purchased, the AANEM designates this enduring material for a maximum of 5.75 CEUs. 2013-2014 Program Committee Zachary Simmons, MD, Co-Chair Elizabeth A. Giles, CNCT Vern C. Juel, MD Hershey, PA Medina, TN Durham, NC Holli A. Horak, MD, Co-Chair Taylor B. Harrison, MD A. Arturo Leis, MD Tucson, AZ Atlanta, GA Jackson, MS Amanda Casey, CNCT Robert W. Irwin, MD Samuel D. Nortman, MD Jackson, TN Miami, FL Denver, CO Jasvinder P. Chawla, MBBS, MD, MBA Shawn Jorgensen, MD Katalin Scherer, MD Darien, IL Queensbury, NW Tucson, AZ Urvi G. Desai, MD Charlotte, NC 2013-2014 AANEM President Francis O. Walker, MD Winston Salem, NC 4 Principles of Nerve Conduction Studies and Needle EMG Faculty Mark A. Ferrante, MD Bryan E. Tsao, MD EMG Laboratory Department of Neurology University of Tennessee Health Science Center Loma Linda University School of Medicine Neuromuscular Division of the VA Medical Center Loma Linda, CA Memphis, TN Dr. Tsao completed his medical degree and neurology residency at Loma Dr. Ferrante received his medical degree at the University of South Florida Linda University (LLU) and his fellowship in clinical neurophysiology – Tampa. He completed an electromyography (EMG) fellowship at the with an emphasis in EMG and neuromuscular disorders at the Cleveland Cleveland Clinic Foundation, and a fellowship in clinical neuromuscular Clinic. He was full staff at the Cleveland Clinic prior to becoming the medicine at The Ohio State University. He was formerly the chief of Chair of Neurology at LLU School of Medicine where he also serves as neurology and director of the EMG laboratory at Keesler Medical Center the LLU Neurology EDX Medicine Laboratory Director. Dr. Tsao is an (Keesler Air Force Base, Biloxi, MS), where he received the United ABPN Diplomate with added qualifications in clinical neurophysiology States Air Force Meritorious Service Award. Dr. Ferrante currently serves and neuromuscular medicine and a Diplomate of the American Board of as the director of the EMG laboratory at the University of Tennessee Electrodiagnostic Medicine. His clinical interests include peripheral nerve Health Science Center, as well as director of the Neuromuscular Division injury, brachial plexopathy, and the Parsonage-Turner syndrome. Dr. Tsao Vern C. Juel, MD and the co-director of the Neurophysiology Fellowship at the VA Medical serves on various AANEM committees and is also a member of American Durham, NC Center. He is a member of the American Association of Neuromuscular Academy of Neurology and the American Neurological Association. & Electrodiagnostic Medicine (AANEM) and the American Academy A. Arturo Leis, MD of Neurology (AAN), and has served on various AANEM committees. Jackson, MS His current research interests include brachial plexopathies, neuralgic amyotrophy, and the risk factors associated with carpal tunnel syndrome, Samuel D. Nortman, MD as well as its optimal management. Denver, CO Teresa Spiegelberg, BS, CNCT, R.NCS.T, Katalin Scherer, MD R.EEG.T Tucson, AZ University of Michigan Hospital and Health Systems Ann Arbor, MI Ms. Spiegelberg earned her bachelor’s degree in biology from Adrian College. She currently works at the University of Michigan Hospital and Health Systems in the electromyography (EMG) laboratory, and the physical medicine and rehabilitation and neurology laboratory. She also serves as a teacher for new residents, fellows, and technologists. Ms. Spiegelberg received the rehabilitation resident teaching award in 2013. Her research focus is diabetes and carpal tunnel syndrome, among other topics. 5 6 PRINCIPLES OF NERVE CONDUCTION STUDIES AND NEEDLE EMG Nerve Conduction Studies: What Gets Measured and What It Means Mark A. Ferrante, MD Clinical Professor, Department of Neurology Co-Director, Neurophysiology Fellowship University of Tennessee Health Science Center and Director, EMG Laboratory, VAMC Memphis, TN INTRODUCTION The electrodiagnostic (EDX) examination is an extension of serve to redirect the referring clinician. EDX assessment of the the clinical neurologic examination that provides important PNS elicits a number of different types of responses. Multiple information about the peripheral nervous system (PNS) that measurements are made from each response, each of which often cannot be obtained in any other manner. It is an objective provides specific information about the neuromuscular elements study with a low false–positive rate. EDX testing of the PNS under study. Consequently, EDX medicine providers (i.e., includes nerve conduction studies (NCSs), the needle electrode physicians and technicians) must possess an understanding of the examination (NEE), and a variety of special studies (e.g., F significance of these measurements. This understanding requires waves, H responses, and repetitive nerve stimulation). The a knowledge of certain anatomic, physiologic, pathologic, and motor NCS and NEE assess the motor nerve fibers of the PNS pathophysiologic principles pertinent to the PNS and to EDX from the lower motor neurons in the brainstem and spinal cord to testing. In addition, an understanding of basic electronics and the muscle fibers that they innervate, whereas the sensory NCS instrumentation is required (the latter two topics are outside assesses the sensory nerve fibers of the PNS from the dorsal the scope of this discussion). With this foundation, the EDX root ganglia (DRG) to the stimulating or recording electrodes manifestations associated with the various pathologic states are (whichever set is more distal). Although there is some overlap easily understood and recognized by the EDX provider. between the information gleaned from the NCS and NEE, in almost every situation both components must be performed. The two major goals of the EDX examination include lesion In addition, the conclusions drawn from each element must localization and lesion characterization. Lesions should be be in agreement with each other. Consequently, whenever localized to the PNS level involved (e.g., neuron, root, plexus, two measurements yield discordant interpretations, one of the nerve, neuromuscular junction [NMJ], muscle) and, when measurements (or its interpretation) is incorrect. Similarly, possible, to the specific element (e.g., C7 root, lateral cord the EDX impression
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