Atlas of Nerve Conduction Studies

(NCS) 2
Nestor Galvez-Jimenez, John A. Morren,
Alexandra Soriano, Karin Armstrong,
Melissa Goldberg, Lourdes Gonzalez,
and Dana Higginbotham

Introduction General Concepts

There may be some acceptable variability in cer- The performance of NCS is deceptively simple but
tain aspects of NCS, depending on the laboratory the importance of standardization in key aspects
performing the testing. What is described in this across laboratories cannot be overemphasized.
chapter follows the methodology utilized in our Accordingly, being consistent and attentive to
laboratory, which conforms to what is generally ensure that the studies are always performed in the
considered standard practice in the field of elec- same fashion is crucial for reliable NCS results.
trodiagnostic medicine. Most errors during NCS are caused by incorrect
or inconsistent technical components. Otherwise,
an anatomical variation may produce apparently
spurious NCS results as well, so knowledge of these
N. Galvez-Jimenez (*) ∙ A. Soriano
is also essential. Additionally, it is imperative to
Braathen Neurological Center, Cleveland Clinic
Florida, Weston, FL, USA maintain the tested limb/region at the recommended
temperature (above 32 °C for the upper extremities
Cleveland Clinic Lerner College of Medicine of Case
Western Reserve University, Cleveland, OH, USA and above 30 °C for the lower extremities, mea-
e-mail: [email protected]; [email protected] sured at the dorsum of the hands and feet).
J. A. Morren Filter settings are also important, though typi-
Neuromuscular Center, Neurological Institute, cally preset in modern machines (e.g. 1 Hz–5 kHz
Cleveland Clinic, and Cleveland Clinic Lerner for compound muscle action potentials,
College of Medicine of Case Western Reserve
10 Hz–5 kHz for sensory nerve action potentials,
University, Cleveland, OH, USA
e-mail: [email protected] 2 Hz–10 kHz for needle EMG, and 500 Hz–10 kHz
for single fiber EMG).
K. Armstrong · M. Goldberg · L. Gonzalez
Neurophysiology Lab, Cleveland Clinic Florida, E1: recording/active electrode. For motor
Weston, FL, USA NCS, this is on the motor point of the muscle (the
e-mail: [email protected]; [email protected]; end plate region). Note: E1 used to be referred to
[email protected]
D. Higginbotham
Neurophysiology Lab, Neuromuscular Center,
Neurological Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2021 25

N. Galvez-Jimenez et al. (eds.), Electrodiagnostic Medicine,
https://doi.org/10.1007/978-3-030-74997-2_2
26 N. Galvez-Jimenez et al.

as G1, but use of this term is now discouraged. Position: Patient is supine with the forearm
The “G” designation referred to “grid” derived and hand supinated, resting completely on the
from the classic electroencephalography litera- bed.
ture, but now obsolete. Recording electrode location:
E2: reference/inactive electrode. For motor
NCS, this is usually on the tendon of the muscle. E1: Second metacarpo-phalangeal joint.
Note: Similarly, E2 used to be referred to as E2: Second Distal interphalangeal joint, 3–4 cm
G2, but this term is now discouraged. distally to E1.
Recorded responses are those obtained from
E1 while E2 is silent. However, in some instances, Ground: Between stimulation and recording
E2 may be active due to inadvertent volume sites, at the dorsum of the hand.
conduction. Stimulation: At the wrist between the tendons
The ground electrode should always be of the flexor carpi radialis (FCR) and palmaris
between the stimulation site and recording sites. longus (PL), 13 cm proximal from E1.
As previously discussed in Chap. 1, the Caveats/Notes: make measurements with fin-
expected response is that of a negative (upward) gers extended and abducted.
potential. For motor NCS, if there is a positive
(downward) deflection preceding the negative  edian Sensory Recording
M
deflection, is often because the E1 electrode is at the Thumb (See Fig. 2.2)
not adequately over the motor point/end plate Anatomy: brachial plexus (lateral cord ← upper
region and its position must be adjusted until a trunk) ← (mostly) C6 dorsal root ganglion
negative first potential response is obtained. (DRG).
Position: Patient is supine with the forearm
and hand supinated resting completely on the
Upper Extremities bed.
Recording electrode location:
Sensory NCS
E1: first metacarpo-phalangeal joint.
 edian Sensory Recording at Index
M E2: first interphalangeal joint.
Finger (See Fig. 2.1)
Anatomy: brachial plexus (lateral cord ← upper Ground: Between stimulation and recording
and middle trunk) ← (mostly) C6–7 dorsal root sites, at the dorsum of the hand.
ganglia (DRG).

E2
E1
E2
E1
C
C G
G

Fig. 2.1 Median sensory response—stimulating at wrist, Fig. 2.2 Median sensory response—stimulating at wrist,
recording index. C = Cathode; G = Ground recording thumb. C = Cathode; G = Ground
2 Atlas of Nerve Conduction Studies (NCS) 27

C
E1 E2
C
G
E1
E2

Fig. 2.3 Median sensory response—stimulating at wrist, Fig. 2.4 Ulnar sensory response—stimulating at wrist,
recording middle finger. C = Cathode; G = Ground recording little finger (D5). C = Cathode; G = Ground

Stimulation: At the wrist between the tendons Position: Patient is supine with the forearm
of the flexor carpi radialis (FCR) and palmaris and hand supinated resting completely on the
longus (PL), 13 cm proximal from E1. bed.
Caveats/Notes: make measurements with fin- Recording electrode location:
gers extended and abducted.
E1: Fifth metacarpo-phalangeal joint.
 edian Sensory Recording at Middle
M E2: Fifth Distal interphalangeal joint, 3–4 cm dis-
Finger (See Fig. 2.3) tally to E1.
Anatomy: brachial plexus (lateral cord ← middle
trunk) ← (mostly) C7 dorsal root ganglion Ground: Between stimulation and recording
(DRG). sites, at the dorsum of the hand.
Position: Patient is supine with the forearm Stimulation: At the medial wrist between ten-
and hand supinated resting completely on the dons of the flexor carpi ulnaris (FCU) and flexor
bed. digitorum profundus (FDP), 11 cm proximal to
Recording electrode location: E1.
Caveats/Notes: make measurements with fin-
E1: Third metacarpo-phalangeal joint. gers extended and abducted.
E2: Third Distal interphalangeal joint, 3–4 cm dis-
tally to E1.  orsal Ulnar Cutaneous Sensory
D
Recording at Dorsum of the Hand (See
Ground: Between stimulation and recording Fig. 2.5)
sites, at the dorsum of the hand. Anatomy: brachial plexus (medial cord ← lower
Stimulation: At the wrist between the tendons trunk) ← (mostly) C8 dorsal root ganglion
of the flexor carpi radialis (FCR) and palmaris (DRG).
longus (PL), 13 cm proximal from E1. Position: Patient is supine with the forearm
Caveats/Notes: make measurements with fin- and hand pronated, resting completely on the
gers extended and abducted. bed.
Recording electrode location.
 lnar Sensory Recording at Fifth Finger
U
(See Fig. 2.4) E1: dorsum of hand between the fourth and fifth
Anatomy: brachial plexus (medial cord ← lower finger web space.
trunk) ← (mostly) C8 dorsal root ganglion E2: 3–4 cm distal to E1, at the base of the fifth
(DRG). finger.
28 N. Galvez-Jimenez et al.

Recording electrode location:

G
E1: At the anatomic “V” or web space formed
C E1 between the index finger and thumb
E2 metacarpals.
E2: First digit interphalangeal joint, 3–4 cm dis-
tal to E1.

Ground: Between stimulation and recording

sites, at the dorsum of the hand.
Stimulation: over the radius 10 cm proximal
Fig. 2.5 Ulnar sensory response—stimulating at wrist,
recording dorsum of hand (dorsal ulnar cutaneous sensory
to E1.
response). C = Cathode; G = Ground
 edian Palmar Mixed Nerve (See
M
Fig. 2.7)
Anatomy: brachial plexus (lateral cord ← upper
and middle trunk) ← (mostly) C6–7 dorsal root
ganglia (DRG).
G
Patient position: Patient supine with arm rest-
C E1 ing comfortably completely on the bed. Palm fac-
E2
ing up and fingers abducted.
Important: This is an orthodromic nerve stim-
ulation study.
Recording electrode location:

Fig. 2.6 Radial sensory response—stimulating at distal

E1: at the wrist crease between the flexor carpi radi-
forearm, recording at first web space. C = Cathode; alis and flexor pollicis longus.
G = Ground E2: 3 cm proximal to E1, in a straight line.

Ground: Between stimulation and recording Ground: dorsum of the hand.

sites, at the dorsum of the hand. Stimulation: in the palm, 8 cm distal to the
Stimulation: At the wrist, 10 cm proximal E1 in the space between the second and third dig-
from E1 recording electrode, stimulating between its (second metacarpal interspace).
the ulna and flexor carpi ulnaris (FCU) tendon,
proximal to the ulna styloid.
Caveats/Notes: Helpful in determining ulnar
neuropathy at the elbow, or most other lesions
proximal to the wrist, as it is typically spared in
an ulnar lesion at the wrist (Guyon’s canal).
C

 adial Sensory Recording at Base

R E2 E1

of the Thumb (See Fig. 2.6) G

Anatomy: brachial plexus (posterior cord ←

upper and middle trunk) ← (mostly) C6–7 dorsal
root ganglia (DRG).
Position: Patient supine with forearm midway Fig. 2.7 Median palmar mixed nerve study—stimulating
between pronation and supination and resting the median nerve at the palm, recording at the wrist.
completely on the bed. C = Cathode; G = Ground
2 Atlas of Nerve Conduction Studies (NCS) 29

G
C
E2 E1

E2 E1
G

Fig. 2.9 Medial Antebrachial Cutaneous sensory

response—stimulating anteromedial elbow, recording
Fig. 2.8 Ulnar palmar mixed nerve study—stimulating medial forearm. C = Cathode; G = Ground
the ulnar nerve at the palm, recording at the wrist.
C = Cathode; G = Ground
ing up/forearm supinated and mildly flexed at the
Caveats/Notes: some laboratories use a stan- elbow.
dardized bar electrode (shown in picture). Recording electrode location:

 lnar Palmar Mixed Nerve (See Fig. 2.8)

U E1: anteromedial forearm 12 cm distal to the
Anatomy: brachial plexus (medial cord ← lower stimulation site/cathode (that is, point between
trunk) ← (mostly) C8 dorsal root ganglion the biceps tendon and the medial epicondyle).
(DRG). E2: 3 cm distal to E1, in a straight line.
Patient position: Patient supine with arm rest-
ing comfortably completely on the bed. Palm fac- Ground: between the stimulation and record-
ing up and fingers abducted. ing sites.
Important: This is an orthodromic nerve stim- Stimulation: find the midpoint between the
ulation study. biceps tendon and medial epicondyle, 12 cm
Recording electrode location: proximal to E1.
Caveats/Notes: some laboratories use a stan-
E1: at the wrist crease between the flexor carpi dardized recording bar electrode (shown in
ulnaris and flexor digitorum profundus. picture).
E2: 3 cm proximal to E1, in a straight line.
 ateral Antebrachial Cutaneous
L
Ground: dorsum of the hand. Sensory Recording Lateral Forearm
Stimulation: at the palm, 8 cm distal to the (See Fig. 2.10)
E1 in the space between the fourth and fifth digits Anatomy: musculocutaneous nerve ← brachial
(fourth metacarpal interspace). plexus (lateral cord ← upper trunk) ← (mostly)
Caveats/Notes: some laboratories use a stan- C6 dorsal root ganglion (DRG).
dardized bar electrode (shown in picture). Patient position: Patient supine with arm rest-
ing comfortably completely on the bed. Palm fac-
 edial Antebrachial Cutaneous
M ing up/forearm supinated and mildly flexed at the
Sensory Recording Medial Forearm elbow.
(See Fig. 2.9) Recording electrode location:
Anatomy: brachial plexus (medial cord ← lower
trunk) ← (mostly) T1 dorsal root ganglion E1: anterolateral forearm 12 cm distal to the stim-
(DRG). ulation site, which is a point lateral to the biceps
Patient position: Patient supine with arm rest- tendon at the antecubital fossa.
ing comfortably completely on the bed. Palm fac- E2: 3 cm distal to E1, in a straight line.
30 N. Galvez-Jimenez et al.

E1

E1
E2
E2
C

Fig. 2.11 Median motor response recording the abductor

pollicis brevis, distal stimulation at the wrist. C = Cathode;
G = Ground

Fig. 2.10 Lateral Antebrachial Cutaneous sensory C

response—stimulating anterolateral elbow, recording lat-

eral forearm. C = Cathode; G = Ground E1
E2

Ground: between the stimulation and record-

ing sites.
Fig. 2.12 Median motor response recording the abductor
Stimulation: lateral to the biceps tendon at the pollicis brevis, proximal stimulation at the elbow.
antecubital fossa, 12 cm proximal to E1. C = Cathode; G = Ground
Caveats/Notes: some laboratories use a stan-
dardized recording bar electrode (shown in Ground: Between stimulation and recording
picture). sites—usually proximal dorsum of hand.
Proximal palm may be used instead.
Stimulation:
Motor NCS
Distal site: At the wrist between the tendons of
 edian Motor Recording at Abductor
M the flexor carpi radialis (FCR) and palmaris
Pollicis Brevis (APB) longus (PL), 5 cm proximal from E1 (See
Anatomy/Innervation: Median nerve ← medial Fig. 2.11).
cord ← lower trunk ← C8-T1 spinal nerve roots. Proximal site: Antecubital fossa over pulse of
Position: Patient supine with forearm supi- brachial artery, just medial to the biceps ten-
nated, extended at the elbow and resting com- don (See Fig. 2.12).
pletely on the bed.
Recording electrode location: Caveats/Notes: If the recorded response when
stimulating at the antecubital fossa is larger in
E1: Motor point, belly of the ABP. amplitude than that recorded when stimulating at
E2: first metacarpophalangeal joint. the wrist, an anatomical variant/anomalous inner-
vation such as a Martin-Gruber anastomosis
2 Atlas of Nerve Conduction Studies (NCS) 31

(MGA) must be considered (this type of MGA

would involve cross-over median fibers innervat-
ing nearby thenar muscles which would typically
be ulnar-innervated, like the deep head of flexor C
pollicis brevis and the adductor pollicis). E1

E2
G

 lnar Motor Recording at Abductor

U
Digiti Minimi (ADM)
Anatomy/Innervation: ulnar nerve ← medial cord
← lower trunk ← C8–T1 spinal nerve roots.
Fig. 2.13 Ulnar motor recording abductor digiti minimi,
Position: Patient supine with forearm supi-
with distal stimulation at wrist. C = Cathode; G = Ground
nated extended at the elbow and resting com-
pletely on the bed.
Recording electrode location:

E1: Motor point, belly of the ADM.

E2: Mid-portion proximal phalanx fifth finger.
E2
Ground: Between stimulation and recording
sites—usually proximal dorsum of hand.
E1
Proximal palm may be used instead.
G
Stimulation:

Distal site: At the wrist medial to the tendon of

the flexor carpi ulnaris (FCU), 5 cm proximal
from E1 (See Fig. 2.13).
Proximal sites:
Below elbow: 4 cm distal to the ulnar groove/
medial epicondyle on the medial forearm C

(See Fig. 2.14).

Above elbow: 6 cm proximal to the ulnar
groove/medial epicondyle, at the medial
arm between biceps and triceps muscles
Fig. 2.14 Ulnar motor recording abductor digiti minimi,
(See Fig. 2.15). with proximal stimulation at below-elbow. C = Cathode;
G = Ground
Accordingly, the total distance is 10 cm across
the elbow between these two proximal stimula-
tion sites. This measurement must be done fol- block between the elbow and the wrist, an ana-
lowing the contour of the medial aspect of the tomical variant/anomalous innervation such as a
forearm and arm, and the elbow must be in a 90 Martin-Gruber anastomosis must be considered
degrees flexed position. This is done to avoid (in this scenario, the crossover median-to-ulnar
“bunching up” or redundancy of the ulnar nerve fibers are stimulated at the wrist, but not at the
if the arm is extended, which could artifactually elbow sites).
produce a decreased distance measurement (since
this is done on the surface), resulting in spuri-  lnar Motor Recording at First Dorsal
U
ously reduced motor conduction velocity. Interosseous (FDI)
Caveats/Notes: If the recorded response when Anatony/Innervation: ulnar nerve ← medial cord
stimulating at the elbow suggest a conduction ← lower trunk ← C8-T1 spinal nerve roots.
32 N. Galvez-Jimenez et al.

E2

E1
G
E1 C

E2

Fig. 2.16 Ulnar motor recording first dorsal interosse-

ous, with distal stimulation at wrist. C = Cathode;
G = Ground
Fig. 2.15 Ulnar motor recording abductor digiti minimi,
with proximal stimulation at above-elbow. C = Cathode;
G = Ground
Accordingly, the total distance is 10 cm across
the elbow between these two proximal stimula-
Position: Patient supine with forearm supi- tion sites. This measurement must be done fol-
nated extended at the elbow and resting com- lowing the contour of the medial aspect of the
pletely on the bed. forearm and arm, and the elbow must be in a 90
Recording electrode location: degrees flexed position. This is done to avoid
“bunching up” or redundancy of the ulnar nerve
E1: Motor point, belly of the FDI. if the arm is extended, which could artifactually
E2: Midportion of the middle phalanx index produce a decreased distance measurement (since
finger. this is done on the surface), resulting in spuri-
ously reduced motor conduction velocity.
Ground: Between stimulation and recording Caveats/Notes: If the recorded response when
sites—usually proximal dorsum of hand. stimulating at the elbow suggest a conduction
Proximal palm may be used instead. block between the elbow and the wrist, an ana-
Stimulation: tomical variant/anomalous innervation such as a
Martin-Gruber anastomosis must be considered
Distal site: At the wrist slightly radial to the ten- (in this scenario, the crossover median-to-ulnar
don of the flexor carpi ulnaris (FCU), other- fibers are stimulated at the wrist, but not at the
wise site similar to that used when recording elbow sites).
the ADM (See Fig. 2.16).
Proximal sites:  adial Motor Recording at Extensor
R
Below elbow: 4 cm distal to the ulnar groove/ Digitorum (Communis) [ED/EDC]
medial epicondyle on the medial forearm Anatomy/Innervation: posterior interosseous
(See Fig. 2.14—i.e. same stimulation site nerve ← radial nerve, posterior cord ← middle
as when recording ADM). and lower trunks ← C7–C8 spinal nerve roots.
Above elbow: 6 cm proximal to the ulnar Position: Patient supine with forearm pronated
groove/medial epicondyle, at the medial and elbow flexed and arm resting completely on
arm between biceps and triceps muscles the bed.
(See Fig. 2.15—i.e. same stimulation site Recording electrode location:
as when recording ADM).
2 Atlas of Nerve Conduction Studies (NCS) 33

E1: Motor point, belly of the EDC.

E2: posterior forearm about 5 cm proximal to
C
dorsum of wrist or ulnar styloid.

Ground: on the forearm between the recording

and stimulating sites. G
E1
Stimulation: E2

Distal site: At the elbow, at the groove between

biceps and brachioradialis muscles (See
Fig. 2.17). Fig. 2.19 Radial motor recording extensor digitorum,
Proximal sites: proximal stimulation at above-spiral groove. C = Cathode;
Below the spiral groove: between the biceps G = Ground
and triceps muscles, usually performed
only if there is a significant drop in ampli- Caveats/Notes: Do above spiral groove stimu-
tude when stimulating above the spiral lation site first, and then do the below spiral
groove recording EDC (See Fig. 2.18). groove stimulation site, only if there is a signifi-
Above the spiral groove, between the medial cant drop in amplitude (suggesting conduction
and lateral heads of the triceps (See block).
Fig. 2.19).
 usculocutaneous Recording at Biceps
M
Brachii
Anatomy/Innervation: musculocutaneous nerve
← lateral cord ← upper trunk ← C5–C6 spinal
nerve roots.
Position: Patient supine with forearm supi-
nated and extended at the elbow and resting com-
C
E2 pletely on the bed.
E1
Recording electrode location:
G

E1: Motor point, belly of the biceps.

E2: distal upper arm over the biceps tendon and
Fig. 2.17 Radial motor recording extensor digitorum, antecubital fossa.
distal stimulation at elbow. C = Cathode; G = Ground
Ground: Between stimulation and recording
sites.
Stimulation:
C

Distal: At the axilla beneath the tendon of the

G
short head of the biceps (See Fig. 2.20).
E1
Proximal: At Erbs point, in the supraclavicular
E2
fossa posterior to the sternocleidomastoid
muscle (See Fig. 2.21).

Caveat: Supramaximal stimulations may be

challenging at the Erb’s point due to patient dis-
Fig. 2.18 Radial motor recording extensor digitorum,
proximal stimulation at below-spiral groove. C = Cathode; comfort/pain intolerance. Important to compare
G = Ground
34 N. Galvez-Jimenez et al.

C
G E1

E2
G

E1

Fig. 2.20 Musculocutaneous motor recording biceps

brachii, distal stimulation at axilla. C = Cathode;
G = Ground

E2

C
E1 E2
G

Fig. 2.22 Axillary motor recording deltoid, stimulation

at Erb’s point. C = Cathode; G = Ground

Stimulation: At Erbs point, in the supracla-

Fig. 2.21 Musculocutaneous motor recording biceps
brachii, proximal stimulation at Erb’s point. C = Cathode; vicular fossa posterior to the sternocleidomastoid
G = Ground muscle (See Fig. 2.22).
Caveat: Supramaximal stimulations may be
challenging at the Erb’s point due to patient dis-
amplitude and latency of response to the contra- comfort/pain intolerance. Important to compare
lateral side. amplitude and latency of response to the contra-
lateral side.
 xillary Recording at Deltoid Muscle
A
Anatomy/Innervation: Axillary nerve ← poste-
rior cord ← upper trunk ← C5-C6 spinal nerve Lower Extremity
roots.
Position: Patient is supine with forearm supi- Sensory NCS
nated, resting completely on the bed.
Recording electrode location:  ural (Sensory) Recording Posterior
S
Distal Leg/Lateral Ankle (See Fig. 2.23)
E1: Motor point, belly of the deltoid (lateral Anatomy: the medial cutaneous branch from the
head). tibial nerve, and the lateral cutaneous branch from
E2: distal upper arm, above elbow. the common fibular nerve ← sciatic nerve ← lum-
bosacral plexus ← S1–2 dorsal root ganglia (DRG).
Ground: Between stimulation and recording Patient position: Patient in a lateral decubitus
sites, usually at the shoulder joint. position (contralateral limb down), with the knee
2 Atlas of Nerve Conduction Studies (NCS) 35

C
G
E2 E1
E1
E2 G
C

Fig. 2.23 Sural (sensory) recording at ankle/lateral mal-

leolus, stimulating at distal calf. C = Cathode; G = Ground Fig. 2.24 Superficial peroneal (fibular) sensory record-
ing dorsolateral aspect of ankle/proximal foot, stimulating
slightly flexed and leg resting comfortably, com- lateral distal leg. C = Cathode; G = Ground
pletely on the bed.
Recording electrode location:

E1: postero-inferior to the lateral malleolus.

E2: placed on the side of the foot 3 cm distal to
E1 E2
E1. C G

Ground: Lateral lower leg, between stimula-

tion and recording sites.
Stimulation: Posterior aspect of distal leg,
with stimulation electrode 14 cm proximal to the Fig. 2.25 Saphenous (sensory) nerve recording medial
distal leg, stimulation at medial calf. C = Cathode;
E1.
G = Ground
Caveats/Notes: some laboratories use a stan-
dardized recording bar electrode (shown in
picture). Stimulation: Placing stimulating electrode
(cathode) in a straight line 10 cm (but may be up
 uperficial Peroneal (Fibular) Sensory
S to 14 cm) proximal to E1.
Recording Dorsolateral Aspect Caveats/Notes: Some laboratories use a stan-
of Ankle/Proximal Foot (See Fig. 2.24) dardized recording bar electrode (shown in
Anatomy: peroneal (fibular) nerve ← sciatic picture).
nerve ← lumbosacral plexus, L5 (>S1) dorsal
root ganglion (DRG).  aphenous Nerve Recording Medial
S
Patient position: Patient in supine with the leg Distal Leg (See Fig. 2.25)
resting comfortably, completely on the bed. Anatomy: femoral nerve ← lumbar plexus ←
Recording electrode location: L3–L4 dorsal root ganglia (DRG).
Patient position: patient supine with the leg
E1: lower lateral leg, dorsum of ankle with E1 resting comfortably, completely on the bed.
located halfway between lateral malleolus and Recording electrode location.
extensor digitorum longus tendon.
E2: placed 3 cm distal to E1. E1: medial leg/lower calf at ankle medial to the
tibialis anterior tendon.
Ground: Distal lower leg, between stimulation E2: 3 cm distal to E1, in the space between the
and recording sites. medial malleolus and the tibialis anterior mus-
cle tendon.
36 N. Galvez-Jimenez et al.

Ground: medial lower leg/lower calf, between picture). The lateral femoral cutaneous nerve
stimulation and recording sites. response is also often difficult to obtain with
Stimulation: cathode 10 cm (but may be up to consistency (especially in overweight/obese
­
14 cm) proximal to E1 between the medial gas- individuals). Therefore, one should be careful to
trocnemius and the tibia. interpret an unelicitable response as a pathologi-
Caveats/Notes: Some laboratories use a stan- cal finding, unless the contralateral response (in
dardized recording bar electrode (shown in pic- an unaffected limb) is obtained.
ture). The saphenous response is often difficult to
obtain with consistency. Therefore, one should be  edial and Lateral Plantar Mixed Nerve
M
careful to interpret an unelicitable response as a Response Recording the Medial Ankle
pathological finding, unless the contralateral (See Figs. 2.27 and 2.28)
response (in an unaffected limb) is obtained. Anatomy: tibial nerve ← sciatic nerve ← lumbo-
sacral plexus, S1 (>S2, L4–5) dorsal root ganglia
 ateral Femoral Cutaneous Nerve
L (DRG).
Recording Lateral Thigh (See Fig. 2.26) Patient position: Patient supine with the leg
Anatomy: lumbar plexus, L2–3 dorsal root gan- resting comfortably, completely on the bed.
glia (DRG). Orthodromic stimulation.
Patient position: patient supine with the leg Recording electrode location:
resting comfortably, completely on the bed.
Recording electrode location: E1: recording electrode is placed on the postero-
medial aspect of the distal leg/medial malleo-
E1: recording electrode is placed on the antero- lus in the hollow between the Achilles tendon
lateral aspect of the thigh 12 cm distal to the and medial malleolus.
stimulation site. E2: 3 cm proximal to E1.
E2: 3 cm distal to E1.
Ground: dorsum of foot, between stimulation
Ground: lateral thigh, between stimulation and recording sites.
and recording sites. Stimulation:
Stimulation: cathode is placed superior to the
inguinal ligament about 1 cm medial to the ante- Medial Plantar: cathode is placed 11–14 cm dis-
rior superior iliac spine (ASIS). tal to E1 on the medial aspect of the sole of the
Caveats/Notes: Some laboratories use a foot.
standardized recording bar electrode (shown in

E1
E2 E2
G E1
C

Fig. 2.26 Lateral femoral cutaneous nerve recording lat- Fig. 2.27 Medial plantar mixed nerve response record-
eral thigh, with stimulation above inguinal ligament. ing the medial ankle, stimulation at the medial sole.
C = Cathode; G = Ground C = Cathode; G = Ground
2 Atlas of Nerve Conduction Studies (NCS) 37

division of the Sacral Plexus ← L5-S1 spinal

nerve roots.
Patient position: Patient supine with the leg
G
resting comfortably, completely on the bed.
Recording electrode location:
E2
E1 C
E1: recording electrode is placed on the motor
point, belly of the extensor digitorum brevis.
E2: distal to E1, at the fifth metatarsophalangeal
joint.

Fig. 2.28 Lateral plantar mixed nerve response record- Ground: dorsum of foot, between stimulation
ing the medial ankle, stimulation at the lateral sole. and recording sites.
C = Cathode; G = Ground
Stimulation:

Lateral Plantar: cathode is placed 13–14 cm dis- Distal Site: cathode is place on a straight line up
tal to E1 on the lateral aspect of the sole of the 6–8 cm (usually 7 cm) proximal to E1, stimu-
foot. lating at the distal ankle crease over the pero-
neal (fibular) nerve (See Fig. 2.29).
Caveats/Notes: Some laboratories use a stan- Proximal stimulation is performed at two sites:
dardized recording bar electrode (shown in Below the fibular head: 2–4 cm below the fib-
picture). Commonly, the plantar mixed nerve ular head in the lateral calf (See Fig. 2.30).
responses (especially the lateral response) may be Above the fibular head: in the lateral popliteal
unobtainable secondary to technical factors, espe- fossa adjacent to the biceps femoris ten-
cially if the patient is older than 50 years and/or don, about 10–12 cm proximal to the
has evidence of thickened skin of the sole of the below-fibular head stimulation site (See
foot. Therefore, one should be careful to interpret Fig. 2.31).
an unelicitable response as a pathological finding,
unless the contralateral response (in an unaffected Caveats/Notes: Some laboratories only per-
limb) is obtained. When these technical factors are form a below-fibular head site stimulation when
less likely (especially in those less than 50 years there is evidence of a conduction block between
old), absent plantar mixed nerve responses may the ankle and above-fibular head stimulation sites.
be the earliest electrodiagnostic manifestation
of a length-dependent large fiber polyneuropa-
thy. However, the complete set of routine lower
extremity studies should be performed and plantar
mixed nerve responses i­nterpreted in the context
of other electrodiagnostic findings obtained and
the clinical presentation.
G
E2

Motor NCS E1 C

 eroneal (Fibular) Motor Recording

P
at Extensor Digitorum Brevis (EDB)
Anatomy/Innervation: Deep Peroneal (fibular) Fig. 2.29 Fibular motor recording at extensor digitorum
nerve ← Common Peroneal (fibular) nerve ← brevis, distal stimulation at ankle. C = Cathode;
Sciatic nerve ← Lumbosacral trunk and Posterior G = Ground
38 N. Galvez-Jimenez et al.

G
E2
G E2
E1 E1

C
C

Fig. 2.32 Fibular motor recording at tibialis anterior, dis-

Fig. 2.30 Fibular motor recording at extensor digitorum tal stimulation at below-fibular head. C = Cathode;
brevis, proximal stimulation at below-fibular head. G = Ground
C = Cathode; G = Ground

G
E2 E1

C
E2
E1 G
C

Fig. 2.33 Fibular motor recording at tibialis anterior,

proximal stimulation at popliteal fossa/above-fibular
Fig. 2.31 Fibular motor recording at extensor digitorum head. C = Cathode; G = Ground
brevis, proximal stimulation at above-fibular head.
C = Cathode; G = Ground
Ground: between stimulation and recording
sites.
If the amplitude of the CMAP is reproducibly Stimulation:
higher at the below and above-fibular head stimu- Stimulation is performed at two sites:
lation sites (compared to that at the distal ankle
stimulation site), then an accessory peroneal (fib- Distal stimulation: 2–4 cm below the fibular head
ular) nerve variant must be considered. This is in the lateral calf (See Fig. 2.32).
typically confirmed by eliciting a significant Proximal stimulation: in the lateral popliteal
response with stimulation at the posterior aspect fossa adjacent to the biceps femoris tendon,
of the lateral malleolus, while recording the EDB. about 10–12 cm proximal to the below-fibular
head stimulation site (See Fig. 2.33).
 eroneal (Fibular) Motor Recording
P
at Tibialis Anterior (TA) Caveats/Notes: Amplitude and configuration
Anatomy/Innervation: Deep Peroneal (fibular) of the motor response may vary considerably
nerve ← Common Peroneal (fibular) nerve ← depending on location of E1. Unless there is evi-
Sciatic nerve ← Lumbosacral trunk and Posterior dence of conduction block between the standard
division of the Sacral Plexus ← L4, L5 spinal nerve distal and proximal stimulation sites outlined,
roots. there is usually no need to stimulate further
Patient position: Patient supine with the leg between these sites in the popliteal fossa.
resting comfortably, completely on the bed.
Recording electrode location:  ibial Motor Recording at Abductor
T
Hallucis (AH)
E1: recording electrode is placed on the muscle Anatomy/Innervation: Medial Plantar nerve ←
belly of the tibialis anterior muscle. Tibial nerve ← Sciatic nerve ← Anterior division
E2: placed anterior/top of ankle. of the Sacral Plexus, S1 > S2 spinal nerve roots.
2 Atlas of Nerve Conduction Studies (NCS) 39

Patient position: patient supine with the leg

resting comfortably, completely on the bed. E2
Recording electrode location: G
C E1

E1: recording electrode is placed on AH muscle

belly on the medial aspect of the plantar arch,
1 cm distal to the prominence of the navicular
bone.
E2: base of great toe, at the first metatarsophalan- Fig. 2.35 Tibial motor recording abductor hallucis, prox-
geal joint. imal stimulation at popliteal fossa. C = Cathode;
G = Ground
Ground: dorsum of foot, between stimulation
and recording sites. abundant popliteal fat pad, hence firm pressure
Stimulation: and higher stimulation intensity may be needed
(sometimes associated with marked discomfort).
Distal site: 8 cm proximal to E1 at the hollow Commonly, a significant drop in amplitude from
space between the medial malleolus and the proximal stimulation site (compared to that
Achilles tendon (See Fig. 2.34). obtained at the distal/ankle stimulation site) is
Proximal site: lateral aspect of the popliteal fossa, noted. Accordingly, caution must be applied to
at the level that corresponds to the lower bor- not overcall a partial/incomplete conduction
der of the kneecap (See Fig. 2.35). block in this scenario (typically, an amplitude
drop of up to 50% may be dismissed).
Caveats/Notes: Proximal stimulation may be
difficult to perform in some individuals with an  ibial Motor Recording at Abductor
T
Digiti Quinti Pedis (ADQP)
Anatomy/Innervation: Lateral Plantar nerve ←
Tibial nerve ← Sciatic nerve ← Anterior division
of the Sacral Plexus, S1 > S2 spinal nerve roots.
Patient position: Patient supine with the leg
E2
resting comfortably, completely on the bed.
Recording electrode location:

G E1: recording electrode is placed on ADQP mus-

cle belly—about mid-distance between the
E1
lower edge of the lateral malleolus and the lat-
eral border of the foot.
E2: little toe, at the fifth metatarsophalangeal
joint.
C

Ground: dorsum of foot, between stimulation

and recording sites.
Stimulation:

Distal site: 8 cm proximal to E1 at the hollow

space between the medial malleolus and
Achilles tendon (See Fig. 2.36).
Fig. 2.34 Tibial motor recording abductor hallucis, distal Proximal site: lateral aspect of the popliteal fossa,
stimulation at medial ankle. C = Cathode; G = Ground at the level that corresponds to the lower bor-
40 N. Galvez-Jimenez et al.

G E1
C
E2

E2

E1

Fig. 2.37 Femoral motor recording at rectus femoris,

G stimulation at just below inguinal ligament. C = Cathode;
G = Ground

approximately at mid-point between the hip

C
and knee joints.
E2: tendinous portion just above the knee.

Ground: proximal thigh, between stimulation

and recording sites.
Stimulation: cathode is place below the ingui-
nal ligament at the inguinal crease, just lateral to
Fig. 2.36 Tibial motor recording abductor digiti quinti the femoral pulse point (See Fig. 2.37).
pedis, distal stimulation at medial ankle (proximal stimu-
lation at popliteal fossa is identical to that for abductor Caveat: Effective stimulation may be difficult
hallucis). C = Cathode; G = Ground to perform in some larger individuals due to tis-
sue impediment (including difficulty palpating
the femoral pulse). Hence firm pressure may be
der of the kneecap (See Fig. 2.35—i.e. same required. Observing the contraction of the rectus
proximal stimulation site when recording femoris is more important in this scenario. If no
AH). observable rectus femoris contraction is noted, or
other muscles (e.g. vastus medialis) respond to
Caveats/Notes: Proximal stimulation may be stimulation instead, the cathode must be
difficult to perform in some individuals with an repositioned.
abundant popliteal fat pad, hence firm pressure
and higher stimulation intensity may be needed  ibial H-Reflex Recording at Soleus
T
(sometimes associated with marked Anatomy/Innervation: Tibial nerve ← Sciatic
discomfort). nerve ← Anterior division of the Sacral Plexus,
S1 > S2 spinal nerve roots.
 emoral Motor Recording at Rectus
F Patient position: The patient should be prone
Femoris on the bed, using a pillow or similar item to help
Anatomy/Innervation: Femoral nerve ← Posterior keep the limb comfortable during the study.
division of the Lumbar Plexus ← (L2)L3-L4 spi- Recording electrode location:
nal nerve roots.
Patient position: Patient supine with the leg Recording: E1 is placed at soleus muscle, just
resting comfortably, completely on the bed. over the point in between the medial and lat-
Recording electrode location: eral heads of the gastrocnemius muscle. It is
helpful to have the patient plantar flex the foot
E1: recording electrode is placed over the belly to help with delineating space just below the
of the rectus femoris in the anterior thigh, separation of the two heads of the gastrocne-
2 Atlas of Nerve Conduction Studies (NCS) 41

mius muscle. The E1 electrode must be placed Although a bilaterally absent tibial H-reflex
over this space. response may confer less diagnostic yield in the
Reference: E2 is placed in distal leg, typically work-up of a focal lesion/process, reduction or
above or at the Achilles tendon (usually absence of the response with preservation on the
10–15 cm distal to E1). contralateral/unaffected side is diagnostically
valuable.
Ground: Proximal to E1 on the leg below the The lack of proper positioning and patient
knee, between stimulation and recording sites. relaxation commonly results in an absent/subop-
Stimulating: mid-popliteal fossa (over the timal response.
popliteal pulse), with the cathode positioning
reversed/polarity of the stimulator reversed, so  pinal Accessory Motor Recording at
S
that the cathode is effectively proximal to the Trapezius
anode in the popliteal fossa (See Fig. 2.38). Anatomy/Innervation: spinal accessory nerve ←
Caveats/Notes: The tibial H-reflex response C3&C4 spinal nerves.
usually has a latency between 25 and 35 ms. Patient position: Patient supine with arm rest-
The H-response/reflex begins to be observed ing comfortably, completely on the bed.
before the “M” or muscle response. Recording electrode location:
As the intensity of the H-reflex stimulation
increases, the M response increases and the E1: Belly of the (upper) trapezius muscle.
H-response decreases until the H-response is no E2: placed on top of the shoulder (over glenohu-
longer obtainable. meral joint).
The tibial H-reflex is commonly absent after
age 60, after lumbosacral spine surgeries, proxi- Ground: upper back, between stimulation and
mal (e.g. root-level) demyelination injury, axon-­ recording sites.
loss radiculopathies, and large fiber Stimulation: lateral to the sternocleidomastoid
polyneuropathies [loss of the sensory (afferent) muscle.
and/or motor (efferent) volley]. Therefore, this This setup can be used during the repetitive
response provides a very sensitive evaluation of nerve stimulation protocol, in the work-up of a
those S1 > S2/tibial sensory fibers that pass neuromuscular junction transmission disorder
through the popliteal fossa. (See Fig. 2.39).
The tibial H-reflex is affected by both axon Caveats/Notes: Some laboratories may use a
loss and demyelination processes along the standardized bar electrode connected to the hand-
S1 > S2/tibial nerve fiber pathway from the pop- held stimulator prongs via an adapter (shown in
liteal fossa to the spinal cord, including the pre- picture).
ganglionic sensory root segment.
 acial Motor Recording at Nasalis
F
Anatomy/Innervation: Facial nerve (cranial
nerve VII) originates from the union of the
axons coming from the facial motor nucleus
E2 (primarily motor fibers for facial expression
E1
G
muscles) and the nervus intermedius (giving
C parasympathetic, taste, and non-taste sensory
fibers). The zygomatic branch innervates the
nasalis muscle.
Patient position: Patient supine,
Fig. 2.38 Tibial H-Reflex recording at Soleus. C = Cathode; semi-recumbent.
G = Ground
42 N. Galvez-Jimenez et al.

Ground: under the chin (shown in picture), or

forehead.
Stimulation: cathode is place just below the
ear and anterior to the mastoid process (See
C Fig. 2.40).
Caveat: Disposable electrodes may be used
G
for facial nerve conduction studies. In a similar
E1
manner, other facial muscles may be used for
recording purposes. However, each laboratory
E2
must ensure technique consistency for results
reliability, reproducibility, and comparison
purposes.
The nasalis (shown), frontalis, zygomaticus,
orbicularis oris, orbicularis oculi, buccinators or
quadratus labii superioris (levator labii superi-
oris), and mentalis muscles may all be target
Fig. 2.39 Spinal accessory motor recording at trapezius, muscles from which the facial CMAP response
stimulation lateral to the sternocleidomastoid muscle. may be recorded.
C = Cathode; G = Ground The chosen muscle will depend on the clinical
context and indication, determined on a case-by-­
case basis.
Suboptimal placement of the stimulating elec-
trode may result in an initial positive deflection in
the motor response. The appropriate motor
E2 E1
response consists of an initial negative
deflection.

C
G
Suggested Reading
1. Kubhare D, Robinson L, Buschbacher R, editors.
Buschbacher’s manual of nerve conduction studies.
3rd ed. New York: Demos Medical; 2016.
2. Neal PJ, Katirji B. Nerve conduction studies. Practical
guide and diagnostic protocols. AANEM. 2011.
3. Ferrante M. Comprehensive electromyography
with clinical correlations. Cambridge: Cambridge
Fig. 2.40 Facial motor recording at nasalis, stimulation University Press; 2018.
at anterior mastoid process. C = Cathode; G = Ground 4. Training Programs in Electromyography Manual.
Rochester, MN: Mayo Clinic; 1980.
Recording electrode location: 5. Wilbourn AJ. Training program in electromography
special nerve conduction studies. Manual. Cleveland,
OH: Cleveland Clinic; 1992.
E1: recording electrode is placed on the nasalis 6. Hammer K. Nerve conduction studies. Springfield:
muscle (immediately lateral to mid-nose) Charles C. Thomas Pub; 1981.
bilaterally. 7. Lee HJ, DeLisa JA. Manual of nerve conduction study
and surface anatomy of needle electromyography. 4th
E2: placed at the same location contralaterally. ed. New York: Lippincott Williams & Wilkins; 2005.