Laboratory Reference for Clinical NeurophysiologyLaboratory Reference for Clinical Neurophysiology Jay A. Liveson, M.D. Visiting Associate Professor in Neurology Sackler Faculty of Medicine Tel Aviv University Tel Aviv, Israel Clinical Associate Professor Department of Neurology New York University School of Medicine New York, New York Dong M. Ma, M.D. Clinical Associate Professor Department of Rehabilitation Medicine New York University Medical Center New York, New York 3 F.A. DAVIS COMPANY » PhiladelphiaCopyright © 1992 by F. A. Davis Company Al rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopy- ing, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 1098765432 ‘acquisitions editor: Robert H. Craven ‘developmental editor: Bernice M. Wissler production editor: Gail Shapiro over design by: Steven Ross Morrone ‘As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done every- thing possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication, The authors, editors, and publisher are not responsible (or errors or omissions. ‘or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circum- stances that may apply in each situation. The reader is advised always to check product informa- tion (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new oF infrequently ordered rugs. Library of Congress Cataloging-in-Publication Data Liveson, Jay Allan, 1937 - Laboratory reference for clinical neurophysiology / Jay A. Liveson, Dong M. Ma. and update of: Nerve conduction handbook / Dong M. Ma, Jay A. Liveson, ¢1983. Includes bibliographical references and index. ISBN 0-8036-5651-3 (hardbound = alk. paper) : $60.00 (approx.) 1. Neural conduction—Measurement. 2. Evoked potentials (Electrophysiology) 3, Electrodiagnosis. 1. Ma, Dong M., 1941~ HL. Ma, Dong M., 1941- Nerve conduction handbook. Ill Title. [ONLM: 1. Electrodiagnosis—handbooks. 2. Evoked Potentials—handbooks. 3. Neural Conduction—handbooks. 4. Peripheral Nerves — physiopathology —handbooks, WL 39 [795L] RC349,N4BLS7 1992 616,8'07547—de20 DNLM/DLC for Library of Congress sag998 Authorization to photocopy items for internal or personal use, oF the internal or personal use of specific clients, is granted by F.A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is pai directly to CCC, 27 Congress St. Salem, MA 01970. For those organizations that have been granted photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036:5651/92 0 + $.10.Preface This book is divided for convenience into three Parts. Part One consists of procedures to study the function of peripheral nerves. These can be accomplished with the use of basic electrodiagnostic equipment (although many will be facilitated with the addition of an averager). Part Two is restricted to methods that require the additional use of an averager. Part Three is more eclectic. Some sections appear here by exclusion from the previous Parts. Others describe procedures requiring additional equipment, and specialized training and practice. Obviously this Part reflects personal taste. It is unlikely that many individuals would agree on the list to include in such a Part. Notable omissions include elec- troencephalography, electrocochleography, tremor studies, quantitative motor stud- ies, intraneural autonomic nerve studies, polysomnographic studies of sleep dis. orders, evaluation of brain death, and electromyographic waveform recognition. Within the first two Parts, the organization of the sections is anatomical, extend- ing from cranial to sacral studies. Within each section, a summary is presented of the available methods to study a specific region or nerve. Of these, one method is presented in greater detail to help the reader to master an unfamiliar procedure. Optimally, normal values should be collected in one’s own laboratory. To help, sample blank worksheets (lor copying) are presented in Appendix V (page 470). Ideally, normal subjects should include both genders and extend over the age range seen clinically. These groups can be tested for any significant difference, and normal mean values and limits can also be calculated using the tables in Appendix IV (page 468), and the formulas on page 471. If you decide that a study should become part of your armamentarium, it is best learned by apprenticeship, followed by a collection of normal values in one’s own laboratory. Obviously, no individual can avoid the inevitable occasion when an unfamiliar study will seem appropriate. Proper use of this book should help in these situations. Although it is risky to rely solely on any such new study as the basis for a diagnosis, it is valid to collect the information and to compare an asymptomatic side with a symptomatic side. If the response is easily obtained on the asymptomatic side and is within normal published values, this normal side can serve as an internal control for the involved side, although the data should be interpreted cautiously. This book is primarily for the experienced clinical neurophysiologist, which is vwhy wave identification in electromyography is omitted from this reference text. Its in object is to place at this person's fingertips as exhaustive a collection of available techniques as possible. The novice in this field will probably find the plethora of available tests overwhelming. Entry into the field of clinical neurophysi- ology should entail a period of apprenticeship (and electromyographic wave recog- nition should be mastered at that time). During this, attention should be concen- trated on mastering a modest number of basic procedures. Although individual tastes will vary, this should include motor, sensory, and F and H studies of the main nerves in the upper and lower extremity, some cranial nerve and proximal plexus studies, and some repetitive nerve stimulation studies. In addition, an approach to frequently seen syndromes should be learned (including carpal tunnel syndrome and possibly ulnar and peroneal nerve lesions). Subsequently, other techniques can be added with broadening experience. It is difficult and beyond the scope of this book to suggest which other methods should be added. To help, however, each section is preceded by a short introduction outlining the anatomy and pathology of each nerve. These decisions, however, require further experience and consultation with other books (such as Liveson, JA: Peripheral Neurology, ed. 2, F.A. Davis, Philadelphia, 1991). Each reader will find sections in this book which are useful, and others that have no immediate personal relevance. Although this is especially true of Part Three, each reader will find unfamiliar ground in each Part. The chapters in Part Three are presented to give the reader a flavor of procedures and potential applications out- side one’s own experience. Those that look relevant can be mastered with the appropriate investment of training efforts and acquisition of additional equipment ‘This book is related to its precursor Ma & Liveson: Nerve Conduction Handbook which was published in 1983. Part One contains all the material published in that Handbook, but this has been substantially expanded and revised. Not only has each yn been updated with relevant articles published since 1983, but twelve new sections have been added to this Part alone. In addition, separate sections have been added collecting methods to study some of the most frequently encountered entrap- ments (carpal tunnel syndrome, ulnar neuropathy at the elbow, peroneal entrapment at the fibular head). Part Two is entirely new and was next added because of the ‘emergence of the ubiquitous use of averagers. And finally, Part Three was added as a catch for all other techniques that were thought potentially relevant for our own personal use. ‘Thanks are due to the publishers for being a constant reminder that the out-of- print Nerve Conduction Handbook was constantly being requested. James Gibfried contributed many procedures to the Handbook and deserves much gratitude. Thanks are also due to Dr. Brodie and Dr. Gizzi, experts in electroretinography and electro- nystagmography, for the time they devoted to these sections. ‘The original objective of this book was to have at hand, for personal reference, a source of data for any and all procedures that could possibly be needed. This gradually evolved and expanded. The new objective was soon collecting and seeking complete sets of published procedures and especially of esoteric techniques. Al- though personal interests determined what was included, we hope there will be sufficient overlap with your needs so that this Reference serves a useful function in your own laboratory. Jay A. Liveson vi Dong M. MaContents PART I CONDUCTION STUDIES.............. Chapter 1 Introduction. Pathophysiology . ‘The Response . Biologic Variables Age. Temperature .- Gender ....... Handedness. Diurnal Variation. Technical Variables. Electrodes. Stimulation Ground . 3 Distance Measurement Machine Settings. Error. Statistics... 6 Format of the Book . Chapter 2 Cranial Nerves ‘Trigeminal Nerve... Facial Nerve “ Sykinesis Studies. . Blink Reflex ...... Spinal Accessory Nerve Chapter 3. Cervical Plexus Greater Auricular Nerve Phrenic Nerve t Breer Chapter 4 Brachial Plexus. Cervical Root . . Brachial PlexusChapter 5 Thoracic Dermatomes . .. Chapter 6 Lumbar Plexus Chapter 7 Lumbosacral Plexus... viii Long Thoracic Nerve. Dorsal Scapular Nerve. Suprascapular Nerve..... ‘Thoracodorsal Nerve. Musculocutaneous Nerve . Lateral Antebrachial Cutaneous Nerve . Axillary Nerve ...... Radial Nerve Posterior Antebrachial Cutaneous Nerve . Superficial Radial Nerve 3 Median Nerve (Motor) . ‘Anomalous Hand Innervation Median Nerve (Sensory). . Carpal Tunnel Syndrome Studies ge 1 Screening Test Using Ring Finger Stimulation =... .- i“ WU Palraar Stimulation. <0 -<-..70y.0. 3.1 (2.8-3.6) Total 27 £037 ‘Surface stimulation at angle of jaw; temperature measured on skin of cheeks. Johnson and Waylonis (1964) 3° $=39 (13-72 y.o) Latency (msec) 34208" ‘Surface stimulation below ear, anterior to mastoid; needle recording from orbicularis oris (superior to corner); ground on contralateral forehead; latency to first negative deflection; age not significant, Waylonis and Johnson (1964)? s=78 Newbom-1 mo. 1 mo.-Ty.0. 1-2 y.0. 2-30, 3-4y.0, 45 yo. 5-7 y.0. 7-16 y.0. ‘Mean of 3-16 y.0. Latency (msec) 10.1 (6.4-12.0) 7.0 (5.0-10.0) 5.1.8.6-63) 3.93.8-4.5) 3.7 G.4-400) 4.1. 3.5-5.0) 3.9 (3.2-5.0) 4.03.0-5.0) 39 Technique described in Johnson and Waylonis (1964). Including patients with unrelated lesions‘CRANIAL NERVES * Taverner (1965) n=254 110 Latency (msec) 2.7 £0.36 Stimulation at angle of jaw; skin temperature measured. Ghelarducci and Perfetti (1967)? s=19 Cond. Velocity (M/sec) Superior branch 46,26 2 6.75 (32.30-61.00) Inferior branch 39.45 + 10.54 (23.40-63.00) Proximal stimulation near stylomastoid foramen, distal stimulation 5 cm along the nerve course; needle recording from orbicularis oculi and ori Ronchi and Riccardi (1967)°* S=6 (16-58 y.o.) Latency (msec) 3.89 (3,754.10) Surface stimulation near stylomastoid foramen; needle recording from orbicularis oris. Miller, Nelson, and Bender (1970)*? s=55 (19-59 y.0.) Latency (ensec) From nasalis. 3.45 +£0.38 [8.8-13.1 cm) Surface electrodes; stimulation below ear; optimal recording from nasali temperature approximately 72°F. Taylor, Jebsen, and Tenckhoff (1970) n=55 s=40 (18-64 y.0.,m=41) Latency (msec) 40405 Technique similar to Waylonis and Johnson (1964)"" with stimulating cathode over the stylomastoid foramen; needle recording from the orbicularis oris; temperature not measured, but subjects allowed 30 minutes to adjust to room temperature; gender and age not significant.24 +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Halar, Taylor, and Kao (1972)5* $=38 (23-85 y.o., m= 52+ 17.2) Latency (mseo) 333 £038 ‘Technique similar to Miller, Nelson, and Bender (1970); surface recording over nasalis muscle (active) and base of nose (reference); ground over forehea latency. Olsen (1975)"5 62. (nonparetic side in patients with Bell's or traumatic facial lesions) Latency (msec) Bell's 3.8204 Traumatic 38403 Needle electrodes; stimulation at exit of nerve near stylomastoid foramen; recording electrodes from frontalis (temporal branch), orbicularis oris (zygomatic branch), or triangularis (mandibular branch); distance correction; onset latency; skin tempera- ture 33.7 to 35.4°C, subjects allowed to adjust to room temperature of 20°C to 25°C for 30 minutes. Halar et al. (1978)?" 6.1 + 15.3 y.0.) 30 (m= Latency (mse) 35 £0.40 ‘Technique similar to Miller, Nelson, and Bender (1970). Joachims, Bialik, and Eliachar (1980)?"* 100 s= 100 healthy side of patients with Bell's palsy Latency (msec) 3.6 (24-60) DeMeirsman, Claes, and Geerdens (1980) 7 s=40 (15-65 y.0.) Latency (msec) Amplitude (mV) Duration (msee) 1.92 £0.35 25-10) 3.704 (15-24) Needle electrodes; stimulation below ear and anterior to mastoid foramen; ground ‘on contralateral forehead; recording electrodes in posterior auricular muscle (mid- position at posterior aspect of pinna); latency to first negative deflection; skin temperature 34 to 35°C; slight age difference (less than I SD) in subjects over 30 y.o. only (lower amplitude, higher latency and duration); gender not sigCRANIAL NERVES *** 25, Synkinesis Stu ielsen (1984)*” (Fig. 11) Surface stimulation and concentric needle recording of two separate branches. Mandibular branch stimulation at the lower edge of the mandible (Sm), 5 to 7 cm from the recording electrodes on the mental muscle (Rm). Zygomatic branch stimu- lation at the lower edge of the zygomatic bone (So), 4 to 6 cm from the recording electrodes in the inferior orbicularis oculi (Ro) muscle. The stimulating cathodes are placed proximal to the anodes and a minimal stimulus can be used. ‘To examine for synkinesis, ephaptic and ectopic excitation, responses are sought in the inappropriate muscle: in the mentalis on zygomatic stimulation or in the orbicularis oculi on mandibular stimulation". Nielsen (1984)4°747° ‘This is an extension of the blink reflex based on the fact that normally no response is elicited in the lower facial muscles. Surface stimulation of the supraorbi- tal nerve with the cathode over the supraorbital notch and anode on forehead. Concentric needle recording electrodes, in addition to the regular blink reflex re- cording from the inferior orbicularis oculi, is performed from the mentalis muscle. ‘To examine for synkinesis, ephaptic and ectopic excitation, responses are sought in the inappropriate muscle, which is the mentalis. Figure 11. Studies for aberrant innervation (“synkinesis"). Zy- gomatic stimulation (S,) should produce no mentalis response (R,); mandibular stimulation (S.) should produce no orbicu- laris oculi response (R.).26 +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY BLINK REFLEX ‘The blink reflex is the electrical analog of the corneal reflex, Like the latter, the afferent limb is the ophthalmic division of the trigeminal nerve, and the efferent limb is the facial nerve. Electrical stimulation is applied to the supraorbital nerve, which innervates the upper lid and forehead. This is the largest branch of the ophthalmic (or first) division of the trigeminal nerve. Its course is in the cavernous sinus while in the it then becomes intracranial by passing through the superior orbital fissure, Its cell bodies lie within the trigeminal ganglion and fibers enter the ventrolateral pons. ‘The efferent loop is the facial nerve, which leaves the pons to enter the facial canal via the internal acoustic meatus. It exits at the stylomastoid foramen. The fibers of the blink reflex pass through the temporofacial division to innervate the orbicularis oculi. Within the pons, the course is less clear. An early response (R1) is present ipsilateral to the stimulus, suggesting an oligosynaptic reflex pathway. There is a delayed bilateral response (R2) which corresponds to the consensual blink. This probably has a polysynaptic pathway with eventual bilateral facial nucleus innervation. The reflex does not normally result in a response in the lower facial muscles (see Gandiglio and Fra (1967) on p. 29). Stimulation Procedure (Figs. 12, 13) Setup Stimulation Surface stimulation is performed with the cathode over the supraorbital nerve, at the supraorbital notch. Ground This is placed under the chin. Recording Surface electrodes are used. The active electrode is placed on the lower (orbicularis oculi) bilaterally, and the reference electrode on the side of the nasal bone. Ipsilateral and contralateral responses are recorded. Values Kimura (1975) s=83 (7-86 y.o.,m=37) Latency (msec) Difference between Sides (msec) {04s tesa" 03:09 (1.r 2, Ipsilateral 305 + 3.4 (81) 101.2 6)Figure 12, Blink reflex. BLINK RESPONSES mv ‘Stimulation on tight side Stimulation on let side TOms Figure 13. Blink reflex. Surface recording trom orbicularis oculi muscles; upper recordings from right side, lower from left side. Calibration: 1 mV, 10 msec/em.28 +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY srence between Sides (msec) Continued Latency (msec) R2, Contralateral 305 + 4.4 (44) e+ me Limits of normal defined as 3 SDs from the mean. + Dilference between direct and consensual + Differences between responses to R- and Lsided stimulus, Technical Comments For convenience, recording electrodes are placed over the orbicularis oculi bilaterally. If two channels are available for recording, stimulation is performed on one side with the responses from both sides recorded. If only one channel is available, the recording electrodes from one side can be connected and stimulation performed first ipsilaterally then contralaterally. The procedure is then repeated while recording from the opposite side. The availability of two recording channels is not a requirement for this test. Stimulation is performed at the supraorbital notch. This can be palpated and the cathode placed below the orbital ridge at the foramen. The anode is directed above the ridge and somewhat laterally. Stimulation is most comfortable at a slower rate (eg. every 2 to 3 seconds). The subject should be instructed to keep eyes open to minimize muscle artifacts. ‘The R2 responses may vary and have an unclear onset. Several responses should be superimposed and the earliest latency measured. Attempts should be made to avoid prolonging the study as the R2 response tends to habituate on repeated stimulation, ‘The blink responses are present in the upper but not the lower facial muscles. If aberrant innervation is suspected (e.g., in synkinesis and in Moebius’s syndrome) the response may be sought in the lower facial muscles. Studies Rushworth (1962) 5 =70 patients with unrelated lesions (9-80 y.o.) RI: Ra: Latency (msec) Latency (msec) (9-14) (23-40) Supraorbital surface stimulation; needle recording in the orbicularis oculi. Gandiglio and Fra (1967)? n<20 s=10 (16-65 y.0.) Ri: Ipsilateral Duration Contralateral Duration *— Katency (msec) (msec) Bt Latency (msec) (msec) Supraorbital stim To orb oculi 2 107 (9-14) (4-9) =a = = To orb oris 4 43(1-1) 6-13) = = 2 To mentalis 4 148 (13-16 (5-7) (15-16) 6-6)® Ipsilateral Duration #* Latency (msec) (msec) o Continued Inieaorbital sti To orb oculi 17 1079-13) a9) = To orb oris 17 1600-1 (3-8) ~ To mentalis 8 127011-16 (5-10) 2 Mental stim. To otb ocull 7 1079-12) a7) - To orb ovis 13 13.701-16) (4-13) = To mentalis 10 © 122(10-14) 8-7) 2 R; Ipsilateral Duration Ww Latency (msec) (msec) a Supraorbital stim. To orb oculi 20 326(26-38) (12-40) 20 To orb oris = = a To mentalis 5 38.6(29-48) (20-50) 5 Infraorbital stim. To otb oculi 20 31,4(25-35) (5-35) 20 To otb or 11 39,327-80) (4-30) 9 To mentalis 14 382(30-45) (11-52) B Mental stim. To orb ocull 18 32.6 (25-44) 16 To orb onis 3 34.2027-39) 4 To mentalis 732.0 (28-40) 5 CRANIAL NERVES Contralateral Latency (msec) (04-15) Contralateral Latency (msec) 33.9 (23-40) 39.8 (31-50) 32.7 (28-36) 35.7 (0-45) 38,7 (31-43) 33.0 (26-45) 35.7 (25-43) 34.0 (27-40) 29 Duration (seo) Duration (rnsee) (8-39) 2-40) (7-35) (10-40) (8-40) (7-25) (4-22) (12-38) *# = number of responses elicited in 20 stimuli. Surface stimulation of supraorbital, infraorbital, and mental nerves; needle recording electrodes in orbicularis oculi, orbicularis oris, and mentalis, Shahani and Young (1968) 8 (4-68 y.0.) Ri: Ri Latency (msec) Latency (msec) (10-18) (23-50) Surface electrodes; recording electrodes over inferior portion of orbicularis oculi. Shahani (1970) 8 (16-64 y.0.) Ri Latency (msec) Duration (msec) 108 3.2 (8-20) 9.3 2.3 (8-12)30 +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Ra: Latency (msec) 34.4449(28-40) — 34.6-+4.9 (30-42) ‘Technique similar to Shahani and Young (1968); room temperature 24°C to 27°C. Shahani and Young (1972)* s=22 (4-68 y.o) Ri 2: Latency (msec) Latency (msec) (10-16) 3-44) Stimulation can be performed anywhere in the distribution of V1 (eg., midline of nose, glabella, hairline); recording over inferior orbicularis oculi Bender, Maynard, and Hastings (1969)*" $<67 (20-65 y.0.) RE Ra: Latency (msec) Latency (msec) eft 12.28 1.14 (10-15) 33.18 + 3.70 (27-50) Right 12461.27 (10-16) 34.05 + 4.91 (25-60) Surface electrodes; bilateral simultaneous supraorbital stimulation; recording from lower lid of orbicularis oculi; no temperature regulation. Kimura, Powers, and Van Allen (1969)*5* n=60 s=30 (7-67 y.o.) Ri Ipsilateral Contralateral Latency (msec) Amplitude (mV) Latency (msec) 106 +0.82 0.38 £0.23 No response: 38D #25 Normals <13.1 Contralateral Latency (msec) Amplitude (mV) Latency (msec) Amplitude (mV) 3133.33 053 £0.24 31.6 £3.78 0.49 0.24 38D £10 an Normals 12.5 3375 Contralateral Variation (msec) Abnormal —->0.85 355 Supraorbital surface stimulation; monopolar needle recording in center of lower orbicularis oculi with reference over malar eminence; ground between stimulator and recording electrode; no temperature regulation. Dehen et al (1976)'*" 20 (22-72 y.0.) Rt 2: Latency (msec)__Latency (msec) 2 2845 Rate at which the response habituates: >5 stim/sec D1=2 stim/sec concentric needle recording in orbicularis oculi, or and root of nose. Supraorbital surface stimulation surface recording on lower32 +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Kaplan and Kaplan (1980) s=20 normal side of hemiplegic patients Rr R2: Latency (msec) Latency (msec) 10.2 £0.9 30.1 43.9 Surface electrodes; supraorbital stimulation; recording from lower lateral orbicularis cul SPINAL ACCESSORY NERVE ‘The spinal accessory nerve is a cranial nerve whose anterior horn cells originate ly from the CI through C5 spinal segments (and rarely as low as C3 to C7). It is a motor nerve innervating the sternocleidomastoid and the trapezius muscles. The latter is accomplished after a plexus is formed with branches passing directly from the C2, C3, and C4 roots. The fibers of this nerve originate extracranially, and travel through the foramen magnum to lie intracranially on the occipital bone. After crossing this, the nerve exits through the jugular foramen and turns dorsally. At this point its surface course can be traced by connecting a line between two points. The upper point lies midway between the mastoid process tip and the mandibular angle. The lower point lies slightly above the midpoint of the posterior border of the sternocleidomastoid. The nerve’s course continues along an extension of this line to the anterior border of the upper trapezius, 5 cm above the clavicle. As the nerve passes under the sternocleidomastoid it pierces it (although rarely remains under it), supplies it, and emerges behind it. It becomes superficial as it emerges from behind the sternocleidomastoid muscle slightly above the middle of its posterior border. Its course in the posterior of the neck remains superficial, being covered only by deep fascia and subcutaneous tissue, until it passes under the trapezius. Stimulat n Procedure (Fig. 14) Setup Stimulation Surface stimulation is performed in the posterior triangle of the neck. The stimulation point is posterior to the sternocleidomastoid muscle slightly above its midpoint. Ground This is placed between the stimulating and recording electrodes, or over the acromion process. Recording Surface recording is used with the active electrode over the upper trapezius, about 9 cm lateral to the seventh spinous process. Placement of the reference electrode is 3 cm more laterally.Figure 14, Spinal accessory nerve.34 =** LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Values Ma and Gibfried (1983)** n=52 s=28 (23-56 y.0., m=38) Latency (msec)” Amplitude (mv) 23404(17-30) _>3-4 * Onset latency + Peak-to-peak amplitude Subjects were allowed to adjust to a room temperature of 23 to 26°C. Significance of gender and age not tested. Technical Comments ‘Stimulation should be performed halfway between the mastoid process and the suprasternal notch (approximately at the level of the upper portion of the thyroid cartilage) and behind the sternocleidomastoid muscle (not over the muscle). At this point there is no problem of stimulating the brachial plexus and errone- ously recording a response from the supraspinatus which lies under the upper trapezius. The stimulator should be posterior to the border of the sternocleidomas- toid to avoid stimulation of the phrenic nerve and, theoretically, of the cervical plexus, Branches of the latter are mostly sensory, but a branch to the levator scapulae muscle could theoretically interfere. Itis important to monitor the clinical response. Spinal accessory nerve stimula- tion should result in shrugging of the shoulder because of upper trapezius function. In contrast, phrenic nerve stimulation will result in hiccough (which the subject can describe). This is a convenient proximal nerve for Repetitive Nerve Stimulation studies for myasthenia gravis (see Chap. 18). Also see facial nerve (p. 20). Studies Cherington (1968)'* s=25 (10-60 y.0.) Latency (msec) (1.8-3.0) (5-8.5 em} Surface electrodes; stimulation in posterior triangle of neck; recording over upper trapezius, 5 cm lateral to C7. Eisen and Bertrand (1972) 75 Latency (msec) 2.8 (<3.2) Technique similar to Cherington (1968).(CRANIAL NERVES * Krogness (1974)?* s=21 (23-72 y.0, m=47) Latency (msee) Amplitude (mV) Tosternomastoid 2.3 0.5 [9.6 + 1.4 cm] 87 446 To trapezius 35205 (125¢14em] 107 £56 Surface stimulation in front of mastoid; concentric needle recording from the sterno- cleidomastoid and upper trapezius muscles; onset latency. Fabrer et al (1974)? s=10 males (24-61 y.0.) Latency (msec) (1.2-60) [1-36 em] ‘Technique similar to Cherington (1968).!%* Green and Brien (1985)? s=21 (18-65 y.0.) Latency (msec) To upper trapezius 2.1402 (15-29) To middle wapezivs 3.00.2 (2.2-3.8) To lower trapezius 46 £03 3.9-5.6) Surface stimulation of 0.1 msec duration. Stimulation site in the posterior cervical triangle at a point 1 to 2 cm posterior to the midpoint of the posterior edge of the sternocleidomastoid muscle. Ground electrode over the acromion process. Surface recording using bipolar block electrodes (Fig. 15): upper trapezius —active elec- trode 5 cm lateral to seventh cervical spinous process (R,); middle trapezius —36 +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Figure 15. Spinal accessory nerve. Evaluation of upper, middle, and lower portions. active electrode halfway between the scapular spine and adjacent spinous process (R,.); lower trapezius — active electrode two finger breadths lateral to spine at lever of the inferior scapular angle (R,). Room temperature was 21°C to 22°C.Cervical Plexus Chapter 3 GREATER AURICULAR NERVE The greater auricular nerve is composed of fibers from C2 and C3. It is the largest ascending branch of the cervical plexus. It originates from the base of the neck, passes deep to the sternocleidomastoid, then winds around its posterior border. It then ascends over this muscle, its most superficial course being at its midpoint. Its function is purely sensory, supplying the skin over the posterior lower auricle and the mastoid Stimulation Procedures (| Setup Stimulation Antidromic, bipolar surface stimulation is performed at the lateral border of the sternocleidomastoi is 8cm. Ground ‘This is placed at the back of the neck. Recording Surface recording electrodes are placed 2 cm apart on the back of the earlobe. 37LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Figure 16. Greater auricular nerve. Values Palliyath (1984)5 n=35 s=20 (21-66y.0.) Lateney (msec) Amplitude (uV) 17 £02 a7 £44 Cond. Velocity (M/sec) Duration (msec) 46.8 + 6.6 08 40.2 Latency measurement to peak. Amplitude measurement of negative peak. Skin tem- perature maintained between 33°C and 35°C. Gender and age not distinguished. Technical Comments It may be necessary to “tune” the electrodes by rotating the stimulating anode with the cathode in place, or to move the ground in order to minimize the shock artifact. Studies Kimura et al..(1987)° n=64 s=32 (14-88 yo, m=45,7) Latency—onset (msec) Amplitude (aV) 1.34 £0.15 (1.0-1.7) 22.4 +9.0 (8-46) Latency—peak (msec) Duration (msec) 1.86 £0.21 (1.4-2.4) 1.10 0.18 (0.8-1.4)CERVICAL PLEXUS +++ 39) Antidromic, bipolar surface stimulation at lateral border of sternocleidomastoid. Surface recording electrodes 2 cm apart on back of earlobe. Ground electrode at back of neck. Latency measurement to onset and peak. Amplitude measurement peak to peak. Distance between stimulating and recording electrodes of 8 cm. Skin tempera- ture maintained at or above 33°C. Amplitude decreases slightly with age. PHRENIC NERVE The phrenic nerve is a branch of the cervical plexus arising from the anterior primary rami of C3, C4, and C5 (especially C4) with occasional contributions from C2 or C6. It is primarily a motor nerve, supplying the diaphragm (along with branches from lower thoracic nerves), but it does supply some sensory fibers to the pericar- dium and peritoneum. Its higher course is across the scalenus anterior muscle in a medial direction. Its subsequent course under the sternocleidomastoid muscle can be traced on the surface by connecting two points. The upper point is midway between the anterior and posterior borders of the sternocleidomastoid muscle at the level of the superior horn of the thyroid cartilage. The lower point is a little to the lateral side of the sternoclavicular joint. Its later course is intrathoracic where it lies between the mediastinal pleura and the pericardium, reaching and piercing the diaphragm. The left phrenic nerve is longer and more superficially placed than the right. Stimulation Procedure (Fig. 17) Setup Stimulation Surface stimulation is performed above the clavicle, just lateral to the sternal portion of the sternocleidomastoid muscle, medial to the clavicular insertion of the muscle (see Figs. 17, 20). Ground ‘This is placed on the ipsilateral shoulder (Gd 1), or on the sternum (Gd 2). Recording Surface recording is used with the active electrode fixed on the eighth intercos- tal space at the anterior axillary line. The reference electrode is placed caudal to thi: on the ninth intercostal space. Values Ma and Gibfried (1983) n=15 s=8 (28-43 y.o, m=34) Latency (msec)* Amplitude (mv)t 0.8)AQ +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Figure 17. Phrenic nerve. Subjects were allowed to adjust to room temperature of 23 to 26°C. No significant difference was found between values on the right or left sides.CERVICAL PLEXUS *** 41 Technical Comments An approximate method of placing the recording electrodes is by using the xiphoid process as an estimate of the level of the sixth rib, and adding two inter- spaces (see Fig. 17). Placement of the recording electrodes should be parallel to the anterior axillary line, in contrast to the long thoracic nerve study where they are parallel to the rib (see Figs. 20, 21). Surface electrodes are used; plastic-embedded electrodes are convenient. Care should be taken to stimulate medial to the clavicular insertion of the sternocleidomastoid muscle (see Fig. 21). This will prevent stimulation of the brach- ial plexus at Erb’s point, which is lateral to the clavicular insertion. If the plexus is, stimulated by mistake, a response may be erroneously recorded from the serratus anterior. To guard against this, the clinical response should be checked. Phrenic nerve stimulation elicits an abdominal pulsation with the subject reporting a hic- cough. In contrast, stimulation of the brachial plexus elicits gross movement of the entire arm. Studies Davis (1967) 3" n=22 s=18 (20-61 y.0.) Latency (msec) Amplitude (V) 7.7 £08(61-9.2) (160-500) mulation at the posterior border of the sternocleidomastoid; th intercostal Surface electrodes; diaphragmatic recording—surface electrodes over the eighth or space (anterior axillary line). Shaw, Glenn, and Holcomb (1975) n=12 s Latency (msec) 8,66 + 0.36 (lef) 8,60 * 0.71 (right) Surface electrodes; thimble stimulator; recording electrodes over the eighth inter- costal space (see Sarnoff, Sarnoff, and Whittenberger, 19515), Delhez (1965, 1975)" $=30 (21-27 y.0,) Latency (msec) Amplitude (uV) 8.2 £0.71 (left) (100-300) 0.53 (right” (300 1000)¢ * Significant p < 0.001 + Using diaphragmatic needle42 +++ LABORATORY REFERENCE FOR CLINICAL NEUROPHYSIOLOGY Surface stimulation using esophageal electrodes, or concentric needle electrodes in the diaphragm; recording electrodes 44 to 49 cm distal to the stimulator. Shaw et al. (1979) n=32 Latency (msec) Amplitude (mV) 8400.78 (70-100) 0.65 0.24 (0.4-1.3) Surface electrodes; stimulator, anterior to scalenus anticus, 2 to 4 cm above clavicle; ground behind neck; onset latency; amplitude from baseline to peak. Wolf, Gonen, and Shochina (1980)72° n=44 s=22 (22-58y.0) Latency (msec) Amplitude (mV)__—_Duration (msee) 664097 0.49 +039 32.9 £103 Surface electrodes; stimulation at posterior border of the sternocleidomastoid at the upper level of the thyroid cartilage; recording electrodes over the eighth intercostal space (anterior axillary line); no significant difference between right and left sides. Maclean and Mattioni (1981)*" n=60 s=30 (18-74 y.o,, m= 32) Latency (msec) Duration (msec) 7.44 £0.59 (6.0-9,5) 845 405 (200-2000) 48,1 + 12.2 (9.0-69) Needle cathode stimulation at the posterior border of the sternocleidomastoid mus- cle (at the level of the cricoid cartilage) with a surface anode over the manubrium; surface recording electrode over the xiphoid with reference electrode over the hth intercostal space at the costochondral junction; gender not significant; la- tency increased with age (no figures given).