2 Coursebook Neuroanatomy For Ncs CNCT Study Material2

Neuroanatomy for Nerve Conduction Studies
Kimberley Butler, R.NCS.T, CNIM, R. EP T.

Jerry Morris, BS, MS, R.NCS.T.
Kevin R. Scott, MD, MA
Zach Simmons, MD
AANEM 57th Annual Meeting

Québec City, Québec, Canada
Copyright © October 2010

American Association of Neuromuscular
& Electrodiagnostic Medicine
2621 Superior Drive NW
Rochester, MN 55901
Printed by Johnson Printing Company, Inc.

AANEM Course
Neuroanatomy for Nerve Conduction Studies iii
Contents
CME Information iv
Faculty v
The Spinal Accessory Nerve and the Less Commonly Studied Nerves of the Limbs 1
Zachary Simmons, MD
Ulnar and Radial Nerves 13

Kevin R. Scott, MD
The Tibial and the Common Peroneal Nerves 21

Kimberley B. Butler, R.NCS.T., R. EP T., CNIM
Median Nerves and Nerves of the Face 27

Jerry Morris, MS, R.NCS.T.
iv
Course Description
This course is designed to provide an introduction to anatomy of the major nerves used for nerve conduction studies, with emphasis on the surface land-
marks used for the performance of such studies. Location and pathophysiology of common lesions of these nerves are reviewed, and electrodiagnostic
methods for localization are discussed. This course is designed to be useful for technologists, but also useful and informative for physicians who perform
their own nerve conduction studies, or who supervise technologists in the performance of such studies and who perform needle EMG examinations..
Intended Audience
This course is intended for Neurologists, Physiatrists, and others who practice neuromuscular, musculoskeletal, and electrodiagnostic medicine with the
intent to improve the quality of medical care to patients with muscle and nerve disorders.
Learning Objectives
Upon conclusion of this program, participants should be able to:
(1) describe anatomy as it pertains to common sites of entrapment.
(2) improve their ability to perform nerve conduction studies.
Activity Profile
This enduring material activity is a reproduction of the printed materials from a course at the AANEM Annual Meeting (October 6-9, 2010). Physician
participation in this activity consists of reading the manuscript(s) in the book and completing the clinical and CME questions.
Release Date: January 10, 2011

Expiration Date: January 10, 2014. Your request to receive AMA PRA Category 1 Credits™ must be submitted on or before the credit expiration date.
Duration/Completion Time: 2 hours
Accreditation and Designation Statements

The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.
The AANEM designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit com-
mensurate with the extent of their participation in the activity.
AANEM Course Neuroanatomy for Nerve Conduction Studies vv
Faculty
Kimberley B. Butler, R.NCS.T, R. EP T., CNIM Jerry Morris, MS, R.NCS.T.

Electroneurodiagnostic Technologist Electrodiagnostic Technologist
Hartford Health Care Neurodiagnostic Laboratory
Willimantic, Connecticut Willis-Knighton Medical Center
Ms. Butler has 30 years experience working in medicine. Originally a Shreveport, Louisiana
cardiac technologist and cardiac monitor technician, she has gone on to Mr. Morris has more than 25 years of experience teaching at various
perform electroencephalograms (EEGs), long-term monitoring (LTM), electrodiagnosis seminars and as a guest speaker for engagements across
intraoperative monitoring (IOM), evoked potentials (EPs), and now the United States and Canada. Topics have included neuromuscular
nerve conduction studies (NCSs). She has served on many boards and junction disease, entrapment and generalized neuropathies, late responses
at one time was chair of the American Association of Electrodiagnostic (F waves and H reflexes), blink reflexes, myopathies, basic to advanced
Technologists (AAET) Examination Committee. She speaks and teaches nerve conduction study (NCS) electrode placement, and anatomy and
regularly on board review courses, as well as a host of other topics. She physiology of the nervous system. He is currently a member of the
has been published many times, including articles in Muscle & Nerve. American Association of Neuromuscular & Electrodiagnostic Medine
Currently, she is branching into a new area, video urodynamics and pelvic (AANEM), the American Society of Electroneurodiagnostic Technologists
floor neurophysiology. (ASET), and the American Association of Electrodiagnostic Technologists
(AAET). His past positions in these organizations include: AAET—past
president, past member of the Board of Directors, and past member
of the Examination Committee; ASET—past member of the Board of
Directors, Program Chair of the 2009 Annual Meeting, and member of
the Membership Committee. He is currently developing online an NCS
course for ASET to be published in 2010. He was the ASET Theda Sannit
Educational Award recipient for 2008.
Dr. Simmons is a consultant for Neuralstem, Inc. Any conflict

of interest was resolved according to ACCME Standards.
All other authors/faculty have nothing to disclose.
Course Chair: Zachary Simmons, 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.
vi
Kevin R. Scott, MD, MA Zachary Simmons, MD

Associate Professor of Neurology Professor of Neurology
Department of Neurology Department of Neurology
Pennsylvania State College of Medicine Pennsylvania State College of Medicine
Milton S. Hershey Medical Center Milton S. Hershey Medical Center
Hershey, Pennsylvania Hershey, Pennsylvania
Dr. Scott received his medical degree from Wake Forest University School Dr. Simmons received his medical degree from the University of Florida,
of Medicine. He completed a neurology residency and a neurophysiology and then trained in neurology at the University of Iowa and in neuro-
fellowship training at Pennsylvania State College of Medicine. He is cur- muscular diseases and electromyography at the University of Michigan.
rently an associate professor of neurology specializing in neuromuscular He now serves as professor of neurology at Pennsylvania State Hershey
medicine and clinical neurophysiology. He is the program director of the Medical Center, where he is the director of the Neuromuscular Program
Clinical Neurophysiology and Clinical Neuromuscular Fellowship pro- and the Clinical Neurophysiology Laboratory. He founded and directs the
grams at Pennsylvania State College of Medicine. Dr. Scott in an American Hershey Medical Center ALS Clinic. Active research programs under his
Board of Electrodiagnostic Medicine Diplomate. supervision include studies of quality of life, cognitive function, and the
development of evidence-based practice protocols for patients with amyo-
trophic lateral sclerosis. Dr. Simmons has served on the AANEM Training
Program, Workshop, and Program Committees, has been chair of the
ABEM Maintenance of Certification Committee, and currently is chair of
the ABEM Examination Committee. Dr. Simmons is an American Board
of Electrodiagnostic Medicine Diplomate.
AANEM Course Neuroanatomy for Nerve Conduction Studies viivii
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., a use not described on the product’s
label). “Off-label” devices or pharmaceuticals may be used if, in the judgement of the treating physician, such use is medically indi-
cated 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.
AANEM Course
Neuroanatomy for Nerve Conduction Studies 1
The Spinal Accessory Nerve and

the Less Commonly Studied
Nerves of the Limbs
Zachary Simmons, MD
Professor of Neurology
Department of Neurology
Pennsylvania State College of Medicine
Milton S. Hershey Medical Center
Hershey, Pennsylvania
INTRODUCTION the SCM muscle, the nerve is superficial just posterior to the pos-
terior border of the SCM muscle at the midpoint of that muscle,
In addition to the major nerves of the upper extremity, lower ex- making it easily accessible to surface stimulation at this level. It then
tremity, and face, there are a number of less commonly studied continues distally to innervate the trapezius muscle.
nerves which are useful for localizing lesions within the brachial or
lumbosacral plexus or for helping to distinguish plexopathies from In the neck the spinal accessory nerve is joined by additional nerve
radiculopathies, particularly when used in conjunction with the fibers from C1-C4 through communication with the cervical plexus.
needle electromyography (EMG) examination. Electrodiagnostic These fibers preferentially innervate the trapezius muscle. These
(EDX) technologists and physicians should develop a basic under- direct innervations from C1-C4 is the reason that there may be vari-
standing of the anatomy and EDX assessment of these nerves, with able weakness of the trapezius muscle involving lesions of the spinal
particular knowledge of causes and sites of injury, and the utility of accessory nerve.
EDX testing in the assessment of lesions of these nerves. The spinal
accessory nerve, though not a “limb’ nerve like the others presented
in this course, is a nerve that is subject to injury, and for which EDX Lesions: Etiology
assessment can play an important role.
The lesion etiology usually is iatrogenic, due to surgical procedures in the
posterior cervical triangle, most commonly lymph node biopsy. Tumor
SPINAL ACCESSORY NERVE excision is the next most common cause, but there are many other pos-
sible etiologies, as listed in Table 1.1,2 Some cases are idiopathic.3
Anatomy
The spinal accessory nerve is composed of cranial and spinal por- Lesions: Clinical Presentation
tions. The spinal portion originates from motor neurons at the
C1-C5 levels. Rootlets from these levels proceed superiorly and fuse Most commonly the lesion is distal, resulting in atrophy and weak-
and then enter the skull through the foramen magnum. They join ness of the trapezius muscle, with resulting shoulder drop. On
with the cranial portion of the nerve (fibers from cranial nerve X), examination, the patient demonstrates mild scapular winging (dis-
and then exit the skull through the jugular foramen, splitting into the placement of scapula laterally and slightly upward), especially when
cranial and spinal divisions. The cranial portion joins the vagus nerve the arm is abducted. There is apparent weakness of shoulder abduc-
to innervate laryngeal and pharyngeal muscles. The spinal division tion and external rotation as a result of poor shoulder fixation. Pain
descends into the posterior triangle of the neck (an area bounded by may occur due to traction on the brachial plexus as a result of the
the posterior border of the sternocleidomastoid [SCM] muscle, the dropped shoulder. Less commonly, there is a more proximal lesion,
upper trapezius muscle, and the clavicle), passing deep to the superior resulting in weakness of the SCM muscle, leading to weakness of
portion of the SCM and innervating this muscle. After innervating neck flexion and contralateral turning of the head and neck.
2 The Spinal Accessory Nerve and the Less Commonly Studied Nerves of the Limbs AANEM Course
Table 1 Causes of spinal accessory neuropathy
Surgery
Lymph node biopsy
Tumor excision
Carotid endarterectomy
Face lift surgery
Radiation
Trauma
Stretch or contusion
Penetrating wounds such as lacerations
Bullet wounds Figure 1 Nerve conduction study of the accessory nerve. Stimulation is
Compression just posterior to the sternocleidomastoid muscle.
Shoulder strap
External tumors 2. To distinguish a spinal accessory neuropathy from a more wide-
Intrinsic nerve tumors spread process affecting other nerves and muscles of the shoulder
girdle. Because weakness of the trapezius muscle may destabilize
Weight lifting
the scapula and produce shoulder girdle weakness, a needle exami-
Peripheral neuropathy nation should be performed on the supraspinatus, infraspinatus,
Leprosy deltoid, rhomboid, and cervical paraspinal muscles.
Mononeuritis multiplex
Idiopathic brachial plexopathy (neuralgic amyotrophy, Parsonage- THE BRACHIAL PLEXUS: THE KEY TO UNDERSTANDING
Turner syndrome) UPPER EXTREMITY NEUROPATHIES
Idiopathic
The upper extremity receives its entire motor and sensory innerva-
Electrodiagnostic Testing4 ( see Fig. 1) tion from the brachial plexus. The brachial plexus runs behind the
clavicle and pectoral muscles as it courses from the neck into the arm.
Recording electrodes It is divided into:
• Active electrode (E1): over the belly of the trapezius muscle. • Roots (C5-T1)
That is, on the trapezius muscle approximately 5 cm lateral to • Trunks (upper, middle, and lower)
the C7 spinous process on a line between this structure and the • Divisions (anterior and posterior from each trunk)
acromion. • Cords (medial, lateral, and posterior)
• Reference electrode (E2): over the acromion process at the • Branches (nerves)
shoulder joint.
Stimulator Brachial plexopathies have many etiologies. Trauma is the most
• Just posterior to the middle of the SCM muscle, midway common cause, but there are a wide range of nontraumatic causes
between the mastoid process and the clavicle. The anode is po- of partial or complete brachial plexopathies (Table 2). A few
sitioned superior to the cathode. deserve special mention. Radiation-induced brachial plexopathies
Normal values are dose-related, often are painless, appear years after radiation,
• Onset latency: 1.8-3.0 ms for a distance of 5.0-8.2 cm. progress indolently, and are associated with myokymic discharges
• Amplitude: compare to contralateral side. on needle EMG examination. Idiopathic brachial plexopathy
(neuralgic amyotrophy, or Parsonage-Turner syndrome) is be-
lieved to have an autoimmune pathogenesis and often is preceded
Utility of Electrodiagnostic Testing by a viral illness or immunization. The onset usually is intensely
painful, followed by resolution of the pain in conjunction with
Nerve conduction studies (NCSs) of the spinal accessory nerve are used in the appearance of weakness that usually affects the plexus in
conjunction with the needle EMG examination for two main purposes: a patchy distribution, often not following a clearly localizable
pattern of trunk, division, or cord involvement. For example,
1. To distinguish a spinal accessory neuropathy from a mechanical the long thoracic nerve and anterior interosseous nerve are par-
injury to the shoulder joint. In a spinal accessory neuropathy, ticularly likely to be affected.5,6 True neurogenic thoracic outlet
NCSs of the spinal accessory nerve will be abnormal. On needle syndrome is rare, and usually is caused by a fibrous band running
examination, the trapezius muscle will demonstrate denervation, from a rudimentary cervical rib to the first thoracic rib, entrap-
and the SCM muscle may demonstrate denervation, depending ping the lower trunk of the brachial plexus.7
on the location of the lesion.
AANEM Course Neuroanatomy for Nerve Conduction Studies 3
Table 2 Causes of Brachial Plexopathy

inability to fully flex the fingers and thumb. There is sparing of
the finger and wrist extensors, which are C8-innervated radial
Trauma nerve muscles, because these arise from the posterior cord.
Motor vehicle accidents Sensory loss occurs in the distribution of the medial arm (median
brachial cutaneous nerve), medial forearm (medial antebrachial
Bicycle accidents
cutaneous nerve), and the medial hand and digits 4-5 (ulnar
Penetrating trauma—knife or gunshot injuries sensory nerve). The MAC nerve also is damaged in lesions of the
Birth—traction of newborns during delivery lower trunk of the brachial plexus, which produces the deficits
Invasion/compression by neoplasms noted above, plus weakness of C8-innervated radial nerve muscles
(extensor indicis proprius, extensor pollicis brevis, extensor
Pancoast tumor at the lung apex invading lower plexus
carpi ulnaris), leading to partial weakness of thumb, finger, and
Metastatic tumor to lymph nodes wrist extension.
Direct nerve infiltration by lymphoma and leukemia
Tumors of the nerve sheath—schwannomas, neurofibromas
Electrodiagnostic Testing8,9 (see Fig. 2)
Compression by nonneoplastic structures
Hematoma Recording electrodes
Aneurysm • Active electrode (E1): on the medial forearm, 12 cm distal to the
Arteriovenous malformation stimulation site, on a line between the stimulation site and the
ulnar aspect of the wrist.
Radiation-induced plexopathy
• Reference electrode (E2): 3-4 cm distal to E1.
Perioperative traction, particularly to lower plexus Stimulator
Thoracic outlet syndrome producing lower plexopathy • In the medial portion of the antecubital fossa, midway between
Idiopathic the tendon of the biceps brachii muscle and medial epicondyle.
Normal values (Preston)9
MEDIAL ANTEBRACHIAL CUTANEOUS NERVE • Amplitude ≥ 5 µV
• Conduction velocity ≥ 50 m/s
• Distal peak latency ≤ 3.2 ms
Anatomy
Normal values (Pribyl)8
• Amplitude ≥ 10 µV
The medial antebrachial cutaneous (MAC) nerve arises from the • Conduction velocity ≥ 41.7 m/s
medial cord of the brachial plexus, just proximal to the takeoff of • Distal peak latency mean 2.1 ms
the ulnar nerve. It is also called the medial cutaneous nerve of the Notes
forearm. It is strictly a sensory nerve, supplying sensation to the • The nerve is superficial, and maximal responses usually can be
medial portion of the forearm. obtained at low levels of stimulation.
• Side-to-side comparisons of the symptomatic and asymptomatic
side are more useful than absolute values.
Lesions: Etiology
MAC neuropathies generally arise from lesions that affect the

lower trunk or medial cord of the brachial plexus. Although there
are many causes of brachial plexopathy (Table 2), several are par-
ticularly likely to affect the lower trunk or medial cord: 1) trauma
in which the arm and shoulder are pulled up; 2) invasion of the
plexus by a Pancoast tumor at the lung apex; 3) stretch injuries
of the lower plexus during chest surgery such as coronary artery
bypass surgery; and 4) thoracic outlet syndrome entrapping the
lower trunk of the plexus.
Lesions: Clinical Presentation
MAC neuropathy occurs in lesions of the medial cord or lower

trunk of the brachial plexus. Medial cord lesions produce weak-
ness of all ulnar nerve-innervated muscles and of C8- to T1- Figure 2 Nerve conduction study of the medial antebrachial cutaneous
innervated muscles supplied by the median nerve. Clinically this nerve. Stimulation is in the medial portion of the antecubital fossa.
leads to weakness of grip due to weakness of hand muscles and
Utility of Electrodiagnostic Testing

physical exercise,11,12 as well as surgery, pressure during sleep, and
1. To distinguish a radiculopathy from a plexopathy: Radiculopathy, malpositioning during anesthesia.13,14 Rare cases of musculocutane-
a lesion at the nerve root level, produces pain and numbness in a ous nerve compression have included repeated carrying of items on
manner similar to that of brachial plexopathy, but the EDX find- the shoulder with the arm curled around the item, or osteochon-
ings are different. The MAC nerve can be used to distinguish a droma of the humerus compressing the musculocutaneous nerve.9
C8-T1 root lesion from a lesion of the medial cord or lower trunk The musculocutaneous nerve may also be involved in idiopathic
of the brachial plexus. In radiculopathy, because the lesion occurs brachial plexopathy.
proximal to the dorsal root ganglion, sensory NCSs are normal,
even in the distribution of the numbness. That is because the nerve Isolated injury of the LAC sensory nerve can occur. It may be en-
is intact from the level of its cell body to the level of the skin. In trapped, usually at the elbow, where it is compressed by the biceps
plexopathies (or in peripheral nerve lesions), the lesion occurs at aponeurosis and tendon against the brachialis muscle.13,15 Other
or distal to the dorsal root ganglion, so that the sensory NCSs are causes of isolated LAC injury include hyperextension injury of the
abnormal, because of axon loss from the level of the cell body to elbow, such as during sports, and antecubital phlebotomy.16
the skin. A needle examination of the paraspinal muscles can also
help distinguish radiculopathy from plexopathy, because these are
denervated in radiculopathy but not plexopathy. Lesions: Clinical Presentation
2. To distinguish lower trunk plexopathy from medial cord brachial Patients with musculocutaneous neuropathies present with weakness
plexopathy: The MAC sensory response will be abnormal in a of elbow flexion, an absent biceps reflex, and sensory alteration in the
lower trunk or medial cord brachial plexus lesion. It cannot be distribution of the LAC nerve (lateral forearm), whereas those with
used to distinguish one from the other. A needle examination is an isolated LAC neuropathy demonstrate the sensory alteration, but
needed. In a lower trunk lesion, radial C8-innervated muscles with normal muscle strength and reflexes. Patients in whom the LAC
(extensor indicis proprius, extensor pollicis brevis, extensor carpi nerve is entrapped at the elbow present with pain in the anterolateral
ulnaris) will be involved. aspect of the elbow region which is worsened by pronation of the arm
and extension at the elbow.13,15,17
3. To distinguish ulnar neuropathy from lower trunk or medial cord
brachial plexopathy: The MAC nerve will be involved in the plex- Musculocutaneous neuropathy occurs in lesions of the lateral cord
opathies, but spared in an isolated ulnar neuropathy. or upper trunk of the brachial plexus. Lateral cord lesions produce
weakness of all muscles innervated by the musculocutaneous nerve
(see above) and of C6-C7 innervated median nerve muscles, produc-
MUSCULOCUTANEUS AND LATERAL ANTEBRACHIAL ing weakness of forearm pronation (pronator teres) and wrist flexion
CUTANEUS NERVES (flexor carpi radialis). Sensory loss occurs in the LAC distribution and
in the palmar aspect of the lateral hand and in digits 1-3 (median
Anatomy sensory nerve). Lesions of the upper trunk, which is formed from roots
C5-C6, result in the deficits above, plus weakness of muscles not inner-
Once again, consider the brachial plexus. The musculocutaneous vated by the lateral cord, including the deltoid muscle (innervated by
nerve arises from the lateral cord of the brachial plexus. It pierces the axillary nerve), the supraspinatus and infraspinatus muscles (inner-
the coracobrachialis muscle to run between the biceps and brachialis vated by the suprascapular nerve), and the brachioradialis muscle (in-
muscles. It innervates three muscles—the coracobrachialis, biceps nervated by the radial nerve). Sensory loss is found in the lateral upper
brachii, and brachialis muscles—before continuing as a pure sensory arm (axillary nerve) and in the lateral hand and digits 1-3 (median and
nerve, the lateral antebrachial cutaneous (LAC) nerve, which supplies radial sensory branches) as well as the LAC sensory distribution. Biceps
sensation to the lateral forearm. and brachioradialis reflexes are depressed or absent.
Lesions: Etiology Electrodiagnostic Testing
Musculocutaneous nerve lesions most commonly are caused by Musculocutaneous nerve9,18 (see Fig. 3)
trauma to the shoulder and upper arm, especially factures of the
proximal humerus from falls or sports injuries. In such cases, other Recording electrodes
nerves usually are damaged as well. For example, primary shoulder • Active electrode (E1): over the biceps, just distal to the midpoint
dislocations or fractures of the humeral neck may result in injuries to of the muscle.
several nerves, including the axillary, suprascapular, radial, and mus- • Reference electrode (E2): distally to E1 in the antecubital fossa,
culocutaneous nerves.10 Other forms of trauma, including gunshot over the biceps tendon.
wounds and lacerations, also may produce musculocutaneous nerve Stimulator
lesions. Isolated nontraumatic lesions of the musculocutaneous • Erb’s point.
nerve are rare, usually occurring as it passes through the coraco- Normal values (Preston)9
brachialis muscle. Causes include weightlifting or other vigorous • Latency ≤ 5.7 ms at distance 23-29 cm, using calipers.
Normal values (Preston)9

• Amplitude ≥ 10 μV
• Conduction velocity ≥ 55 m/s
• Peak latency ≤ 3.0 ms
Normal values (Spindler and Felsenthal)20
• Amplitude ≥ 12 μV
• Conduction velocity ≥ 57.8 m/s
• Distal peak latency ≤ 2.5 ms
Notes
• The nerve is superficial, and maximal responses usually can be
obtained at low levels of stimulation.
• Side-to-side comparisons of the symptomatic and asymptomatic
side are more useful than absolute values.
Figure 3 Nerve conduction study of the musculocutaneous nerve.
Stimulation is at Erb’s point.
1. To distinguish a radiculopathy from a plexopathy: As with the

MAC nerve, studies of the LAC nerve can be used in this manner.
Specifically, they can be used to distinguish a C5-C6 root lesion
from a lesion of the lateral cord or upper trunk of the brachial
plexus. In root lesions, the LAC sensory response will be normal,
whereas in lesions of the lateral cord or upper trunk the LAC
sensory responses will be of low amplitude or absent. A needle
examination of the paraspinal muscles can also help determine this
because these are denervated in radiculopathy but not plexopathy.
2. To distinguish isolated musculocutaneous nerve involvement from

upper trunk or lateral cord brachial plexopathy. The lateral ante-
brachial cutaneous sensory response and the musculocutaneous
nerve study will be abnormal in all three of these types of lesions.
Other NCSs and the needle examination are needed to make
Figure 4 Nerve conduction study of the lateral antebrachial cutaneous further distinction. Lateral cord lesions will result in an abnormal
nerve. Stimulation is in the lateral portion of the antecubital fossa. median sensory response. Denervation will be present on needle
examination of all muscles innervated by the musculocutaneous
nerve and of C6-C7 innervated median nerve muscles, such as the
Normal values (Kraft)18 pronator teres and flexor carpi radialis. In an upper trunk lesion,
• Latency ≤ 5.7 ms at distance of 23.5-29.0 cm (calipers), 28.0- the abnormalities noted above will be present, plus the radial
41.5 cm (tape, arm at side), or 26.0-35.5 cm (tape, arm ab- sensory response will be of low amplitude or absent, and the needle
ducted 90 degrees) examination will demonstrate denervation of muscles not inner-
Normal values (Oh)19 vated by the lateral cord, including the deltoid muscle (innervated
• Latency 5.5-6.7 ms at distance of 25-33 cm, using calipers. by the axillary nerve), the supraspinatus and infraspinatus muscles
Note (innervated by the suprascapular nerve), and the brachioradialis
• Supramaximal stimulation is difficult to achieve. Best to muscle (innervated by the radial nerve).
compare symptomatic to asymptomatic side.
Lateral antebrachial cutaneous nerve9 (see Fig. 4) AXILLARY NERVE
Recording electrodes Anatomy

• Active electrode (E1): on the lateral forearm, 12 cm distal to the
stimulation site, on a line between the stimulation site and the The axillary nerve arises from C5-C6 fibers that course through the
radial pulse. upper trunk to the posterior cord of the brachial plexus and leaves the
• Reference electrode (E2): 3-4 cm distal to E1. axilla through the quadrilateral space formed by the humerus, teres
Stimulator minor muscle, teres major muscle, and the long head of the triceps
• Lateral portion of the antecubital fossa, just lateral to the tendon muscle. It innervates the deltoid and teres minor muscles and has a
of the biceps brachii muscle. branch that supplies sensation to the lateral shoulder as the superior
lateral cutaneous nerve of the arm.
Lesions: Etiology Utility of Electrodiagnostic Testing

The most common cause of this type of lesion is trauma, including 1. To distinguish a radiculopathy from a plexopathy: Sensory NCSs
shoulder dislocations, fractures of the humeral neck,10 blunt trauma are not performed on the axillary nerve. But, because it arises from
to the shoulder in contact sports,21 gunshot wounds, and injections. the upper trunk and the posterior cord of the brachial plexus,
Compression may produce an axillary neuropathy during general an- sensory studies of nerves that arise from these structures should be
esthesia or by sleeping with the arms above the head. The nerve may performed: median sensory nerve from the thumb (upper trunk,
be entrapped within the quadrilateral space by muscular hypertrophy lateral cord), LAC nerve (upper trunk, lateral cord), and radial
and repetitive trauma in athletes such as tennis players and baseball sensory nerve (upper trunk, posterior cord). Abnormalities in these
pitchers.22,23,24 As for other upper extremity neuropathies, idiopathic indicate plexopathy, while sparing of these is indicative of C5-C6
brachial plexopathy may be a cause. radiculopathy. Needle examination of the cervical paraspinal
muscles is also helpful. Denervation of these muscles is indicative
of radiculopathy.
2. To distinguish an isolated axillary neuropathy from an upper trunk
Patients with an axillary neuropathy present with partial weak- or posterior cord brachial plexopathy: As with assessment for ra-
ness of shoulder abduction and external rotation, motions which diculopathy above, because the axillary nerve is derived from the
are partially maintained by the supraspinatus and infraspinatus upper trunk and posterior cord, sensory nerves that originate in
muscles, respectively. Atrophy of the deltoid region of the upper these portions of the brachial plexus should be studied. Lesions in
arm may result. There is sensory loss over the lateral aspect of the the posterior cord will produce abnormal findings in the axillary
upper arm. nerve and the radial sensory nerve, but will spare the median and
LAC nerves (lateral cord). On needle examination, denervation
will be present in muscles innervated by the axillary nerve (deltoid
Electrodiagnostic Testing18,25 (see Fig. 5) and teres minor) and by radial-innervated muscles such as the
triceps, brachioradialis, extensor carpi radialis, extensor digitorum
Recording electrodes communis, extensor digiti minimi, extensor carpi ulnaris, extensor
• Active electrode (E1): middle deltoid pollicis longus and brevis, and extensor indicis muscles. Upper
• Reference electrode (E2): distally to E1, over the deltoid trunk lesions will result in abnormal findings not only in the axil-
tendon. lary nerve and the radial sensory nerve, but also in the median
Stimulator sensory and LAC nerves, which derive from the posterior cord.
• Erb’s point. Needle examination will demonstrate denervation in muscles sup-
Normal values18 plied by the axillary nerve (deltoid and teres minor) and in other
• Latency ≤ 5.0 ms at a distance of 14.8-21.0 cm (calipers), muscles which derive all or part of their innervations at the C5-C6
20.0-26.5 cm (tape, arm at side), or 17.5-25.3 cm (tape, arm levels, such as the supraspinatus, infraspinatus, biceps, some radial-
abducted 90 degrees). innervated muscles (brachioradialis, extensor carpi radialis, and
Notes triceps) and some median-innervated muscles (pronator teres and
• Compare symptomatic to asymptomatic side. flexor carpi radialis).
• May be technically difficult to obtain supramaximal
stimulation.
SUPRASCAPULAR NERVE
Anatomy
The suprascapular nerve arises from the upper trunk of the brachial
plexus, supplied by the C5 and C6 nerve roots. It passes through the
suprascapular notch of the scapula, an area covered by the transverse
scapular ligament, and supplies motor branches to the supraspina-
tus muscle. Then, it continues around the spinoglenoid notch of
the scapular spine (bounded by the scapula spine medially and the
spinoglenoid ligament [inferior transverse scapular ligament] later-
ally) to supply motor branches to the infraspinatus muscle. There are
no cutaneous sensory fibers.
Lesions: Etiology
Figure 5 Nerve conduction study of the axillary nerve. Stimulation is at
Erb’s point. The suprascapular nerve may be entrapped as it passes through the
suprascapular notch, or, less commonly, as it passes through the
spinoglenoid notch.26,27 Causes of suprascapular nerve entrapment

also include mass lesions such as ganglion cysts, sarcomas, and meta-
static carcimomas.9,28-31 Traumatic causes of suprascapular neuropathy
include shoulder dislocation or protraction or scapular fracture,32,33
as well as injuries that generally produce more widespread damage to
the brachial plexus such as stretch, gunshot, and penetrating injuries.
Weightlifters may suffer suprascapular neuropathies, probably due to
repetitive movement of the scapula. Other athletic activities involv-
ing overhand activities can predispose individuals to suprascapular
entrapment, particularly at the spinoglenoid notch. Such injuries are
particularly common in professional volleyball players,34,35 but also
are seen in baseball pitchers and dancers.36,37 As with many other
upper extremity neuropathies, the suprascapular nerve also may be
affected in idiopathic brachial plexopathy.
Figure 6 Nerve conduction study of the suprascapular nerve, recording
from the supraspinatus muscle. Usually a needle rather than surface
Lesions: Clinical Presentation recording electrode is used. Stimulation is at Erb’s point.
Entrapment at the suprascapular notch usually is accompanied by

pain, most prominently along the superior aspect of the scapula
and radiating to the posterior and lateral shoulder. The pain may be
referred to the arm, neck, or upper anterior chest wall9,27 and may be
exacerbated by shoulder movements. The suprascapular notch may
be tender to palpation. When suprascapular nerve is injured or when
it is entrapped at the suprascapular notch, the clinical manifestation
is primarily weakness of shoulder external rotation (infraspinatus
muscle weakness). Shoulder abduction (supraspinatus muscle) is
weakened only slightly, because of preservation of the deltoid muscle.
Atrophy may be noted, particularly of the infraspinatus muscle,
which is only partly covered by the overlying trapezius muscle. If
entrapment occurs at the spinoglenoid ligament, then only infraspi-
natus weakness occurs, resulting in weakness of shoulder external
rotation but no weakness of shoulder abduction. There is no cutane- Figure 7 Nerve conduction study of the suprascapular nerve, record-
ous sensory alteration. ing from the infraspinatus muscle. Usually a needle rather than surface
recording electrode is used. Stimulation is at Erb’s point.
Electrodiagnostic Testing18 (see Figs. 6 and 7)

Recording electrodes
• Active electrode (E1): A monopolar needle in the supraspinatus 1. To distinguish a radiculopathy from a plexopathy: Because the
or infraspinatus muscle. Do not use a surface electrode, as the suprascapular nerve arises from the upper trunk of the brachial
trapezius muscle is more superficial and covers the intended plexus, studies of sensory nerves that pass through the upper trunk
muscles. should be performed, including studies of the median sensory
• Reference electrode (E2): Distally over shoulder joint. nerve from the thumb (upper trunk, lateral cord), LAC sensory
Stimulator nerve (upper trunk, lateral cord), and radial sensory nerve (upper
• Erb’s point. trunk, posterior cord). Abnormalities in these indicate plexopathy,
Normal values while sparing of these is indicative of C5-C6 radiculopathy. Needle
• Recording from supraspinatus muscle: latency ≤ 3.7 ms at a dis- examination of the cervical paraspinal muscles is also helpful.
tance of 7.4-12 cm (calipers) or 9.0-13.8 cm (tape, arm at side Denervation of these muscles is indicative of radiculopathy.
or abducted 90 degrees).
• Recording from infraspinatus muscle: latency ≤ 4.2 ms at a dis- 2. To distinguish an isolated suprascapular neuropathy from an upper
tance of 10.0-15.0 cm (calipers) or 15.0-19.5 cm (tape, arm at trunk brachial plexopathy: As with assessment for radiculopathy
side or abducted 90 degrees). above, sensory nerves that originate in the upper trunk of the bra-
Notes chial plexus should be studied. Upper trunk lesions will produce
• Compare symptomatic to asymptomatic side. abnormal responses from the median sensory, radial sensory, and
• May be technically difficult to obtain supramaximal lateral antebrachial cutaneous sensory nerves. On needle examina-
stimulation. tion, denervation will be dependent on the location of the lesion
Table 3 Causes of lumbosacral plexopathy

in the plexus. In addition to checking the supraspinatus and
infraspinatus muscles, the examiner should also check the deltoid
and brachioradialis muscles (upper trunk, posterior cord), biceps Trauma—usually from traction
brachii muscle (upper trunk, lateral cord), and pronator teres and Pelvic fractures
flexor carpi radialis muscles (upper trunk, lateral cord). Paraspinal Hip fractures and dislocations
muscles will be spared.
Invasion/compression
3. To differentiate a lesion at the suprascapular notch from one at the Retroperitoneal hematoma
spinoglenoid notch: Damage by trauma or entrapment at the su- Tumor/neoplasm
prascapular notch generally produces a prolonged latency to both Endometriosis
the supraspinatus and infraspinatus muscles on the symptomatic
Surgery
side compared to the asymptomatic side.27 Entrapment at the
spinoglenoid notch produces selective prolongation of the latency Traction during total hip replacements and other pelvic/hip procedures
to the infraspinatus muscle only.26 Retraction injuries
Positioning during surgery
THE LUMBOSACRAL PLEXUS: THE KEY TO Radiation

UNDERSTANDING LOWER EXTREMITY NEUROPATHIES Postpartum
Diabetes
The lower extremity receives its entire motor and sensory innerva- Idiopathic
tions from the lumbosacral plexus, which has an upper and lower
part. The upper part, or lumbar plexus, is located in the retroperi- and intermediate cutaneous nerves of the thigh and to the branches
toneum, behind the psoas muscle, and is formed from L1-L4 nerve innervating the sartorius and pectineus muscles. The posterior divi-
roots. It gives rise to six major nerves: the iliohypogastric, ilioingui- sion supplies the quadriceps femoris muscles (vastus medialis, vastus
nal, genitofemoral, lateral femoral cutaneous, femoral, and obturator. lateralis, vastus intermedius, and rectus femoris muscles) and then
The lower part, which has been called lower lumbosacral plexus or continues as the saphenous nerve, a pure sensory nerve.
the sacral plexus, is formed from L5-S3 nerve roots, plus a compo-
nent from L4 (which also supplies the lumbar plexus). L4 and L5 The saphenous nerve passes through Hunter’s canal (subsartorial
combine to form the lumbosacral trunk. It gives rise to four major canal) in the distal third of the thigh. It is bounded by the vastus
nerves: the sciatic, superior gluteal, inferior gluteal, and posterior medialis muscle laterally, and by the adductor longus and magnus
cutaneous nerve of the thigh. muscles medially. The roof is formed by a connective tissue bridge
between these two muscle groups, over which lies the sartorius
The specific nerves discussed in this section may be affected as part muscle. It exits by piercing through this connective bridge to
of a more widespread lumbosacral plexopathy. As with brachial become subcutaneous about 10 cm proximally to the femur’s medial
plexopathy, lumbosacral plexopathy may result from trauma, an epicondyle. Once subcutaneous, the nerve gives off an infrapatellar
assortment of compressive and infiltrative causes, surgery, and radia- branch to supply cutaneous sensation to the infrapatellar region. The
tion. Retroperitoneal hemorrhage, usually characterized by bleeding remainder of the nerve continues on as the main trunk of the saphen-
into the psoas muscle, occurs in 4.3-6.6% of patients receiving ous nerve to supply sensation to the medial calf and foot.
heparin,38 and also is seen in hemophiliacs. Diabetic radiculoplexus
neuropathy (diabetic amyotrophy) usually begins with upper lumbar
pain, followed by rapidly progressive distribution in a lower thoracic Lesions: Etiology
and upper lumbar distribution as the pain resolves.39,40 Postpartum
lumbosacral plexopathy is thought to be due to compression of the The causes of femoral neuropathy are many and may occur in isolation
lumbosacral trunk by the head of the fetus.41 Radiculoplexus neu- or as part of a more widespread lumbosacral plexopathy (Table 4).9,43
ropathy may also be idiopathic (neuralgic amyotrophy), presumably As with many neuropathies, traumatic injuries are not uncommon.
autoimmune, similar to that seen in idiopathic brachial plexopathy.42 Perioperative damage may occur as a result of the surgery itself or of
Table 3 lists the major causes. positioning during surgery.44,45 When the hip is flexed and externally
rotated, such as occurs when patients are placed in the lithotomy
position during gynecological procedures, urological procedures, or
FEMORAL AND SAPHENOUS NERVES during labor and delivery, there is compression of the femoral nerve
by the inguinal ligament.46 Retroperitoneal hematomas and diabetic
Anatomy amyotrophy, discussed above as a cause of cause lumbosacral plexopa-
thy, may present with prominent femoral nerve involvement.9,43
The femoral nerve is derived from L2-L4 nerve roots that course
through the lumbar plexus. It gives off branches to the psoas and The saphenous nerve can be damaged selectively, without involve-
then the iliacus muscles, then runs deep to the inguinal ligament. ment of the motor branches of the femoral nerve, via entrapment
About 4 cm distal to the inguinal ligament, it divides into anterior where it pierces the connective tissue roof of Hunter’s canal.47 48,49
and posterior divisions. The anterior division gives rise to the medial Other causes of selective saphenous nerve damage include periopera-
Table 4 Causes of femoral neuropathy
Trauma
Gunshot
Knife
Stretch/traction
Injections
Perioperative damage
Traction with abdominal or pelvis retractors
Positioning, particularly lithotomy position
Inadvertent transection
Nerve ischemia during renal transplantation
Figure 8 Nerve conduction study of the femoral nerve. Stimulation is
Compression below the inguinal ligament, just lateral to the femoral artery.
Tumors or other masses
Hematoma formation after femoral artery catheterization
Retroperitoneal hemorrhage
Nerve infarction secondary to vasculitis
Diabetic amyotrophy
tive damage, either as a direct result of damage during varicose vein

surgery and arthroscopic procedures of the knee, or secondary to
stretch or compression from improper positioning. Proximal tibial
fractures have been implicated in selective saphenous nerve damage,
as have neurilemmomas.50 Some of these causes may selectively
damage the infrapatellar branch of the saphenous nerve.
Damage of the femoral nerve above the inguinal ligament causes Figure 9 Nerve conduction study of the saphenous nerve. Stimulation is
weakness of hip flexion, resulting in difficulty lifting the leg at the in the medial calf, between the medial gastrocnemius muscle and tibia.
hip, so that the patient drags the leg when walking. Lesions either
above or below the inguinal ligament cause weakness of knee exten-
sion. In such cases, the knee will buckle, causing falls, and patients
often experience difficulty climbing stairs, arising from a chair, or Normal values
arising from a squatting position unless they push with the arms. • Amplitude ≥ 3.7 mV (age < 40 years), ≥ 0.8 mV (age > 40 years)
When walking, patients may hyperextend the knee to lock it and (to vastus medialis muscle)
prevent the leg from buckling. Examination reveals a depressed or Notes
absent patellar reflex. Involvement of the saphenous nerve produces • Amplitudes vary a great deal between individuals. Compare
sensory disturbances over the medial calf and foot; a lesion isolated to side-to-side for each patient.
the infrapatellar branch of the saphenous nerve can produce sensory
disturbances restricted to the medial leg just below the knee. Saphenous nerve9,52 (see Fig. 9)
• Active electrode (E1): halfway between the tibialis anterior tendon
Electrodiagnostic Testing and the medial malleolus, 14 cm distal to the stimulator.
• Reference electrode (E2): 3-4 cm distal to E1.
Femoral nerve9,51 (see Fig. 8) Simulator
• On the medial calf, in the groove between the medial gastroc-
Recording electrodes nemius muscle and tibia, 14 cm proximal to the recording
• Active electrode (E1): over the quadriceps muscle, usually rectus electrodes.
femoris or vastus medialis. Normal values
• Reference electrode (E2): quadriceps tendon at the patella. • Amplitude ≥ 4 µV (Preston),9 9.0 ± 3.4 µV (Wainapel).52
Stimulator • Conduction velocity ≥ 40 m/s (Preston),9 ≥ 38.3 m/s
• Below the inguinal ligament, just lateral to the femoral artery. (Wainapel).52
• Distal peak latency ≤ 4.4 ms (Preston and Wainapel).9,52
Notes pants or underpants. Other less common causes of lateral femoral cu-
• Response may be very small or absent, particularly in those over taneous neuropathy include compression of the lumbosacral plexus
40 years of age. by tumors and other mass lesions, perioperative damage during
• Side-to-side comparison is important. Averaging may be helpful. pelvic osteotomies, such as those done for hip dysplasia, acetabular
insufficiency, and Perthes’ disease, and damage during removal of
bone for grafting from the ilium. Trauma may be a cause, usually in
Utility of Electrodiagnostic Testing association with a more widespread lumbosacral plexopathy or with
damage to other nerves arising from the plexus.53,54
When comparing amplitude side to side, a lower amplitude can indi-
cate axon loss or may indicate loss of muscle, as occurs in quadriceps
muscle atrophy in inclusion body myositis. A significantly prolonged Lesions: Clinical Presentation
latency on one side relative to the other may indicate focal demyeli-
nation between the points of stimulation and recording. Patients develop an area of sensory disturbance over the anterolateral
thigh, described variously as a numbness, burning, pain, or tingling.
Femoral and saphenous nerve studies can be used to distinguish a This is known as meralgia paresthetica. The discomfort may be wors-
femoral neuropathy from a lumbosacral plexopathy and from L2-L4 ened by rubbing or touching the skin over this area. There may be pain
radiculopathy. In femoral neuropathy, the saphenous nerve response will to palpation around the area of the inguinal ligament. No weakness, no
be of low amplitud, compared to the contralateral asymptomatic side, or muscle atrophy, no reflex changes are present on examination.
will be absent. This will be true also in a lumbar plexopathy if the lesion
involves the femoral nerve. In radiculopathy, the saphenous response will
be normal because the injury is proximal to the dorsal root ganglion. The Electrodiagnostic Testing9,55 (see Fig. 10)
needle examination in femoral neuropathy will reveal denervation of the
quadriceps femoris muscles (vastus medialis, lateralis, intermedius, and Recording electrodes
rectus femoris muscles). If the lesion in a femoral neuropathy is proximal • Active electrode (E1): anterolateral thigh, 12 cm distal to stimu-
to the inguinal ligament, then the iliopsoas muscle will reveal denerva- lator.
tion. In plexopathy, there will be denervation on needle examination in • Reference electrode (E2): 3-4 cm distal to E1.
L2-L4 innervated muscles not supplied by the femoral nerve, such as Stimulator
the adductors (L2-L4) and the tibialis anterior muscle (L4-L5). Other • 1 cm medial to the anterior superior iliac spine, above the in-
muscles outside the L2-L4 distribution should be explored to determine guinal ligament. A monopolar needle electrode may need to be
whether the area of denervation is more widespread, suggesting a broader used for stimulation if the patient is not thin.
plexopathy, including muscles supplied by the peroneal, tibial, sciatic, Normal values (Butler et al)55
superior gluteal, and inferior gluteal muscles. Needle examination of the • Latency ≤ 3.0 ms
paraspinal muscles is important to assess for radiculopathy, particularly if • Amplitude ≥ 10 µV
the saphenous response is normal. Notes
• May be difficult to obtain in many normal individuals, particu-
larly obese ones.
LATERAL FEMORAL CUTANEOUS NERVE • Side to side comparison is necessary.
• If no response can be obtained on the asymptomatic side, there
Anatomy is no value in testing the symptomatic side.
The lateral femoral cutaneous nerve is derived from the L2-L3 nerve
roots. It usually passes under the inguinal ligament but superficial to
the sartorius muscle, just medial and inferior to the anterior superior
iliac spine. However, there are several possible anatomic variants:
1) over the anterior iliac crest, 2) between two slips of the inguinal,
3) deep to the sartorius muscle, and 4) through the sartorius muscle.53
It supplies sensation to the skin over the anterolateral thigh. This is
strictly a cutaneous sensory nerve, without a motor component.
Lesions: Etiology
Entrapment of the lateral femoral cutaneous nerve may occur as it

passes under the inguinal ligament, or at any of the other four sites
described above. It may also be entrapped as it passes through the Figure 10 Nerve conduction study of the lateral femoral cutaneous nerve.
deep fascia distal to the region of the inguinal ligament and sartorius Stimulation is slightly medial to the anterior superior iliac spine, above the
muscle. Entrapment is most common in patients who are obese or inguinal ligament.
wear tight-fitting clothing, including tight or wide belts, or tight
Utility of Electrodiagnostic Testing 16. Sander HW, Conigliari M, Masdeu JC. Antecubital phlebotomy com-
plicated by lateral antebrachial cutaneous neuropathy. N Engl J Med
Generally this nerve is tested only when the patient demonstrates 1998;339:2024.
sensory disturbances over the relevant area of skin. In such cases, 17. Felsenthal G, Mondell DL, Reischer MA, Mack RH. Forearm pain
testing of this nerve plays a role in differentiation of an isolated secondary to compression syndrome of the lateral cutaneous nerve
lateral femoral cutaneous neuropathy from an L2-L3 radiculopathy of the forearm. Arch Phys Med Rehabil 1984;65:139-141.
18. Kraft GH. Axillary, musculocutaneous and suprascapular nerve
or a lumbar plexopathy. If the sensory response on the symptomatic
latency studies. Arch Phys Med Rehabil 1972;53:383-387.
side is significantly lower in amplitude than on the asymptomatic 19. Oh SJ. Clinical electromyography: nerve conduction studies, 3rd ed.
side, this helps to excludes a radiculopathy. Testing of the saphen- Philadelphia: Lippincott Williams & Wilkins; 2003.
ous response will help determine whether there is more widespread 20. Spindler HA, Felsenthal G. Sensory conduction in the musculocuta-
involvement of the lumbar plexus. If that is normal, then it is more neous nerve. Arch Phys Med Rehabil 1978;59:20-23.
likely that this is an isolated lesion of the lateral femoral cutaneous 21. Perlmutter GS, Leffert RD, Zarins B. Direct injury to the axil-
nerve or that involvement of the plexus has spared the femoral nerve. lary nerve in athletes playing contact sports. Am J Sports Med
However, because the lateral femoral cutaneous response may be 1997;25:65-68.
difficult to obtain accurately and reliably, a needle examination of 22. Cahill BR, Palmer RE. Quadrilateral space syndrome. J Hand Surg
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a throwing athlete. Am J Sports Med 1986;14:511-513.
of the lumbar paraspinal muscles should be done to assess for ra-
24. McKowen HC, Voorhies RM. Axillary nerve entrapment in the
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25. Currier DP. Motor conduction velocity of axillary nerve. Phys Ther
1971;51:503-509.
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Ulnar and Radial Nerves
Kevin R. Scott, MD, MA

Associate Professor of Neurology
Department of Neurology
Pennsylvania State College of Medicine
Milton S. Hershey Medical Center
Hershey, Pennsylvania
PART I: ULNAR NEUROPATHY

digiti minimi [ADM], and flexor digiti minimi), palmar and dorsal
interossei, 3rd and 4th lumbricals, adductor pollicis, and the deep
Anatomy head of the flexor pollicis brevis muscles.2
The ulnar nerve is derived from the C8-T1 nerve roots. Nearly all
ulnar nerve fibers travel through the lower trunk and medial cord of Clinical Features of Ulnar Nerve Dysfunction
the brachial plexus.1 During its descent through the medial arm, the
ulnar nerve does not give off any branches until it reaches the elbow. Ulnar Neuropathy at the Elbow
At the elbow, the ulnar nerve travels through the groove formed by
the medial epicondyle and olecranon process of the ulnar bone, and This neuropathy is the second most common entrapment neuropa-
passes deep to the humeroulnar aponeurotic arcade (HUA), better thy after carpal tunnel syndrome. Typical symptoms include numb-
known as the cubital tunnel. Here, muscular branches to the flexor ness and tingling in the distribution of the ulnar nerve. Some patients
carpi ulnaris (FCU) and flexor digitorum profundus (FDP)—ring report elbow pain that radiates into the ulnar aspect of the hand. In
and little finger—arise, while the main trunk of the ulnar nerve con- some cases, only sensory symptoms are present.1 Impaired sensation
tinues its descent to the wrist.2 in the fingertips is the most common sensory deficit. Sensory loss
in the ulnar palm is less frequent.3 An early sign may be inability
Approximately 5 cm proximal to the wrist, the main ulnar nerve gives to adduct the little finger (Wartenberg’s sign). In more severe cases,
rise to two sensory branches. The dorsal ulnar cutaneous sensory there will be weakness of handgrip and atrophy of the intrinsic hand
branch travels beneath the FCU to provide sensation over the dor- muscles. Weakness of the first dorsal interosseous muscle (hand)
somedial aspect of the hand. The palmar cutaneous sensory branch (FDIH) is more frequent (84%) than weakness of the ADM muscle
provides sensation over the hypothenar area of the hand and nails.2 (76%).4 Weakness of the FDP and FCU muscles occur in 56% and
20%, respectively.4 In severe cases, clawing of the ring and little finger
The ulnar nerve then enters Guyon’s canal at the wrist. Guyon’s canal, can develop. Deep tendon reflexes are usually preserved in this type
also known as the ulnar canal, is a small anatomical space formed by of neuropathy. Various provocative maneuvers have been described
the pisiform and hamate bones. The ulnar artery travels with the that may increase the diagnostic yield. These include sustained
ulnar nerve through this space on their way into the hand. Here, manual pressure over the cubital tunnel, sustained elbow flexion,
digital branches arise that provide sensation to the palmar aspect of and flexion combined with manual pressure. Combined flexion with
the medial ring and little finger. In addition, motor branches arise to manual pressure over the cubital tunnel has been reported to have the
innervate the hypothenar muscles (opponens digiti minimi, abductor highest sensitivity (91%).5 The differential diagnosis in a patient sus-
14 Ulnar and Radial Nerves AANEM Course
pected of an ulnar neuropathy at the elbow includes: a lower trunk or

medial cord brachial plexopathy, a C8–T1 radiculopathy, or an ulnar
neuropathy at some location other than the elbow. Some common
causes of ulnar neuropathy at the elbow are listed in Table 1.
Electrophysiology. As with other mononeuropathies, the electrodi-

agnostic (EDX) study should localize the abnormalities to the ulnar
nerve. Evaluation of the ulnar nerve requires recording ulnar sensory
and motor responses. As with all nerve conduction studies, limb tem-
peratures should be maintained within the reference range (> 32°) and
documented.
Ulnar sensory responses are obtained and are usually compared to

the median and radial sensory responses in order to exclude a diffuse
polyneuropathy. The antidromic ulnar sensory study (See Fig. 1) Figure 1 Ulnar sensory conduction study (antidromic). Antidromic conduc-
is performed using ring electrodes to record from the little finger. tion: The recording electrodes are placed 3-4 cm apart on the little finger on
Ring electrodes are placed with G1 over the proximal metacarpal– the proximal and distal phalanxes, the proximal electrode being the active
phalangeal (MCP) joint, and G2 placed 3-4 cm away over the distal recording electrode. A ground is placed over the wrist crease. The distal
MCP joint.1 The ulnar nerve is then stimulated proximal to the wrist stimulation site is over the ulnar nerve at the wrist 14 cm from the active
adjacent to the FCU tendon.1 The distance between the stimulation recording electrode, with the cathode distal to the anode. Proximal ulnar
site and the G1 electrode will be dependent on the normative values sensory nerve conduction velocity can be determined by stimulating proxi-
used in the practioner's laboratory. Typically, this distance ranges from mally either below or above the elbow, but this is rarely done in the author's.
Orthodromic conduction: The recording electrodes are placed 3-4 cm apart
11-14 cm.
over the ulnar nerve at the wrist toward the flexor carpi ulnaris tendon, 14
cm proximal to the stimulating electrode, with the active recording electrode
At times, a dorsal ulnar cutaneous sensory study may also be per- distal to the reference electrode. The stimulating electrodes are placed over
formed (See Fig. 2), particularly if there is the confounding possibil- the little finger in the same positions as for the recording electrodes with
ity of wrist pathology. This study is performed using standard disc antidromic stimulation, placing the cathode 3-4 cm proximal to the anode.
electrodes. G1 is placed over the web space between the ring and little The ground is again placed on the wrist crease.
fingers, while G2 is placed 3-4 cm distal over the little finger.1 This
nerve is stimulated 8-10 cm proximally. The stimulation site lies just
proximal to and slightly below the ulnar styloid.1 Because this nerve
arises proximal to the wrist, it may be involved in ulnar neuropathies
at the elbow but will be normal when the ulnar nerve is entrapped
at the wrist.
Table 1 Common causes of ulnar neuropathy at the elbow
1. Old fracture with joint deformity

2. Recent elbow trauma without fracture
3. Habitual leaning on elbow
4. Occupational repetitive flexion/extension
5. Congenital variations of HUA architecture
A. Absent HUA with nerve prolapse
B. Hypertrophy of retinaculum
Figure 2 Dorsal ulnar cutaneous sensory study. The active recording
C. Anconeus epitrochlearis muscle
electrode is placed over the web space between the little and ring fingers
6. Diabetes mellitus (you can feel the bones come together like a V). The reference electrode is
7. Hereditary neuropathy with liability to pressure palsies placed 3-4 cm distal over the little finger. The ground is placed between the
recording electrode and the stimulation site. The nerve is stimulated slightly
8. Rheumatoid arthritis
proximal and inferior to the ulnar styloid with the hand pronated, 8 cm proxi-
9. Iatrogenic mal to the active recording electrode, with the cathode distal to the anode.
A. Malpositioning during surgery
B. Nerve infarction during transposition
The ulnar motor study is next and its focus is to demonstrate or refute
HUA = humeroulnar aponeurotic arcade the presence of focal demyelination at the elbow. Demyelination
across the elbow segment is characterized by either focal slowing
(i.e., a motor nerve conduction velocity < 50 m/s, or a motor nerve

conduction velocity that is > 10 m/s slower than the below elbow to
wrist conduction velocity) or conduction block. When performing
the ulnar motor study, it is important to understand that elbow posi-
tion is crucial. The flexed (at 70-90 degrees) elbow position should be
utilized because it has been shown to be more sensitive than testing
with the elbow extended.6,7
The ulnar motor study can be recorded from either the ADM (See
Figs. 3-5) and/or FDIH (See Fig. 6) muscles. Recording over the
FDIH muscle may be more sensitive than the ADM muscle.7,8 Using
standard disc electrodes, G1 is placed over the belly of the muscle
being recorded while G2 is placed 3-4 cm distal over the MCP
Figure 3 Ulnar motor conduction study in the abductor digiti minimi muscle joint.1 The ulnar nerve is then stimulated at up to four sites: 1) wrist
stimulating at the wrist. The active recording electrode is placed over the (W): this site is just proximal to the wrist adjacent to the FCU tendon
hypothenar muscles approximately one-half way between the distal wrist (See Fig. 3); 2) below elbow (BE): this site lies 3-4 cm distal to the
crease across the ulnar border of the wrist and the distal transverse palmar medial epicondyle (See Fig. 4); 3) above elbow (AE): this site lies ap-
crease across the ulnar border of the hand, so as to be over the belly of the proximately 10-12 cm proximal to the below elbow site, in the space
muscle. The inactive electrode is placed over the hypothenar tendon at the between the biceps and triceps muscles (See Fig. 5); and less commonly,
level of the M–P joint on the little finger. The ulnar nerve is stimulated over 4) axilla (A): this site lies in the proximal axilla, medial to the biceps
the flexor carpi ulnaris tendon with the cathode distal to the anode, at a dis-
muscle, and over the axillary pulse.1 Remember that measurement
tance of 7 cm from the cathode stimulation site to the active recording elec-
across the elbow segment must follow the curved path of the ulnar
trode. The ground is placed over the wrist crease. The proximal stimulation
sites are over the ulnar nerve distal and proximal to the medial epicondyle, nerve—imprecise measurements are one of the most common causes
with a distance of approximately 10-12 cm between the distal and proximal of technical error. Also be aware that the AE and axilla stimulation
sites, and with the elbow flexed to 90 degrees. Conduction velocity can also sites may require higher current intensities to achieve supramaximal
be determined by stimulating the ulnar nerve in the upper arm and in the stimulation.
supraclavicular fossa (Erb’s point).
Figure 4 Ulnar motor conduction study in the abductor digiti minimi muscle Figure 5 Ulnar motor conduction study in the abductor digiti minimi muscle
stimulating below elbow. stimulating above elbow.
Table 2 Electrodiagnostic evaluation of ulnar neuropathy at the

elbow1
1. Nerve conduction studies (See Figs. 1-6)

A. Ulnar nerve studies
i. Ulnar motor study, stimulating at the wrist, below elbow, and above
elbow sites while recording from the abductor digiti minimi muscle.
ii. Ulnar F responses.
iii. Ulnar sensory study stimulating at the wrist while recording from
the little finger.
B. Median nerve studies
i. Median motor study stimulating at the wrist and elbow sites
while recording from the abductor pollicis brevis muscle.
ii. Median F responses.
Figure 6 Ulnar motor conduction study recording at the first dorsal in- iii. Median sensory study stimulating at the wrist while recording
terosseous muscle. from the thumb.
2. Needle electromyography
In certain cases, inching across the elbow can be performed to dem- A. Routine
onstrate focal demyelination.7,9 The setup is identical to ulnar motor i. At least one ulnar-innervated muscle distal to the wrist (e.g., first
studies recording from the ADM and FDIH muscles. Recording is dorsal interosseous or abductor digiti minimi)
performed at the W and BE sites as described above. The BE–AE ii. Two ulnar-innervated muscles of the forearm (e.g., flexor
section is then divided into 1-2 cm segments and individual motor digitorum profundus III/IV and flexor carpi ulnaris).
responses are obtained at each increment.1 The most convincing B. If testing of any of the routine muscles is abnormal, then
abnormality would be a change in latency and/or a change in com- additional needle examination should include:
pound muscle action potential (CMAP) amplitude (> 20%), mor-
i. At least two nonulnar, lower trunk, C8-T1 muscles (e.g., abductor
phology, or area across the BE–AE segment.7 pollicis brevis, flexor pollicis longus, extensor indicis proprius).
Evaluation of the ulnar nerve with nerve conduction studies should ii. C8 and T1 paraspinal muscles.
include the routine studies shown in Table 2. Should routine nerve
Table 3 Clinical syndromes produced by ulnar nerve compression
conduction studies not localize the lesion, additional techniques may
within the canal of Guyon1,9
be helpful to consider. These may include: 1) repeating the ulnar
motor study, while recording from the FDIH muscle; 2) ulnar motor
study using inching techniques across the elbow segment; 3) sensory 1. Combined motor and sensory syndrome (Type 1). A lesion at the
or mixed nerve studies across the elbow; 4) comparing the dorsal proximal portion of the canal may involve both motor and sensory
ulnar cutaneous sensory responses between the affected and asymp- divisions. Weakness of all ulnar innervated hand muscles and loss
tomatic limb; and 5) comparing the medial antebrachial cutaneous of sensation over the palmar little and medial ring fingers occurs.
Cutaneous sensation over the hypothenar and dorsomedial surfaces of
sensory response between affected and asymptomatic sides if there is
the hand should be spared.
reason to suspect a brachial plexopathy. In most cases the lesion is at
the elbow, however, lesions at the wrist or more proximal locations 2. Pure sensory syndrome (Type 2). Clinically, there is loss of sensation
over the palmar surface of the little and medial ring fingers. Sensation
(brachial plexus or root) should be excluded by the EDX study.
is spared over the hypothenar eminence. Motor fibers are not affected.
There is no weakness associated with this lesion.
Treatment. The treatment of patients with ulnar neuropathy at the
elbow may consist of conservative or surgical measures. Nonoperative 3. Pure motor syndromes.
management should include avoidance of pressure on the elbow A. Lesion affecting the deep palmar and hypothenar motor branches
and/or prolonged elbow flexion and utilization of an elbow splint. (Type 3). This lesion affects the motor trunk proximal to the takeoff
In certain cases, steroid injections into the cubital tunnel may be of the hypothenar branches. As a result, all ulnar innervated
helpful. In patients who have significant or progressive neurological muscles of the hand are involved. Because the sensory branch is
not affected, sensation is spared.
deficits, surgical decompression is recommended. There are a number
of procedures utilized.3 B. Lesion affecting the deep palmar motor branch only (Type 4).
Clinically, there is weakness of lumbricals 1 and 2, as well as ulnar-
innervated muscles of the thenar eminence. This type of lesion
Ulnar Neuropathy at the Wrist spares the muscles of the hypothenar eminence.
C. Lesion affecting only the distal deep palmar motor branch (Type 5).
Entrapment of the ulnar nerve at the wrist is rare relative to compres- This type of lesion occurs just proximal to the branches innervating
sion at the elbow. The common site of entrapment occurs within the adductor pollicis and first dorsal interosseous muscles resulting
in weakness of these muscles.
Guyon’s canal. Five different syndromes have been described second- Table 5 summarizes typical EDX findings in each of the various
ary to entrapment in this region (See Table 3). Patients may present syndromes. Magnetic resonance imaging (MRI) may be useful in de-
with sensory and/or motor involvement confined to the distal ulnar tecting structural abnormalities affecting the ulnar nerve in Guyon’s
nerve distribution. They may have sensory loss, paresthesias, or pain canal. A variety of different causes have been described.11 A ganglion
in the region supplied by the distal ulnar sensory branch. The region cyst or traumatic wrist injury account for the majority of cases.12 In
supplied by the dorsal ulnar cutaneous sensory branch is spared. cases in which a structural lesion is identified, surgical removal is rec-
Motor deficits are limited to the muscles of the hand with sparing ommended. In certain cases, surgical exploration may be considered
of the proximal ulnar-innervated muscles. Examination may demon- even when MRI fails to identify a lesion.
strate weakness with atrophy or fasciculations of the intrinsic hand
muscles. Tinel’s sign may be present over Guyon’s canal.
The electrophysiology in this entrapment is often complex. Table 4

outlines a testing protocol for possible ulnar nerve lesions at the
wrist. The set up for these studies are the same as for evaluations at
the elbow, with the addition of lumbrical–interosseous (See Fig. 7)
comparisons. This study allows us to compare ulnar to median nerve
conduction across the wrist due to the fact that the 2nd lumbrical
muscle (median innervated) overlies the 1st palmar interosseous
muscle (ulnar innervated). With this study, disc electrodes are placed
with G1 just lateral to the middle of the 3rd metacarpal and G2 over
the MCP joint of the index finger. The median nerve and the ulnar
nerve are stimulated supramaximally at their usual wrist locations
using identical distances.1
Table 4 Electrodiagnostic evaluation of ulnar neuropathy at the wrist1

A. Ulnar nerve studies Figure 7 Lumbrical–interosseous motor study. Top: Stimulating the
median nerve recording at the 2nd lumbrical muscle. Bottom: Stimulating
i. Ulnar motor study stimulating at the wrist, below elbow, and above the ulnar nerve at the recording interosseous muscle.
elbow sites while recording from the abductor digiti minimi muscle.
ii. Ulnar motor study (bilateral) stimulating at the wrist while
recording from the first dorsal interosseous muscle. Table 5 Nerve conduction study findings in ulnar neuropathy at
iii. Ulnar F responses. the wrist10
iv. Ulnar sensory study stimulating at the wrist while recording from the
little finger. 1. Combined motor and sensory syndrome (Type 1). Decreased ulnar
v. Dorsal ulnar cutaneous sensory study stimulating forearm while sensory amplitude. Ulnar motor amplitude is decreased with prolonged
recording from the dorsolateral hand. distal latency. Needle electromyography (EMG) shows denervation of
all intrinsic hand muscles.
B. Median nerve studies
2. Pure sensory syndrome (Type 2). Decreased ulnar sensory amplitude.
i. Median motor study stimulating at the wrist and elbow sites while
Ulnar motor study will be normal. Needle EMG is normal.
recording from the abductor pollicis brevis muscle.
3. Pure motor syndromes
ii. Median F responses.
A. Lesion affecting the deep palmar and hypothenar motor branches
C. Ulnar–median comparison studies
(Type 3). Ulnar sensory response is normal. Ulnar motor amplitude
i. Lumbrical (2nd)–interosseous (first palmar) comparison study. is decreased with prolonged distal latency. Needle EMG shows
2. Needle Electromyography denervation of all intrinsic hand muscles.
A. Routine B. Lesion affecting the deep palmar motor branch only (Type 4). Ulnar
sensory response is normal. Ulnar motor amplitude is decreased
i. One deep palmar motor muscle (e.g., first dorsal interosseous).
with prolonged distal latency when recording from the first dorsal
ii. One hypothenar branch muscle (e.g., abductor digiti minimi). interosseous muscle. Needle EMG shows denervation of the first
iii. Two forearm muscles (e.g., flexor carpi ulnaris and flexor dorsal interosseous muscle with sparing of the hypothenar muscles.
digitorum profundus III/IV). C. Lesion affecting only the distal deep palmar motor branch (Type
B. If testing of any of the routine muscles is abnormal, then additional 5). Ulnar sensory response is normal. Ulnar motor amplitude is
needle examination should include: decreased with prolonged distal latency when recording from the
first dorsal interosseous muscle. Needle EMG shows denervation
i. At least two nonulnar lower trunk, C8-T1 muscles (e.g., abductor of the first dorsal interosseous and adductor pollicis muscles with
pollicis brevis, flexor pollicis longus, and extensor indicis proprius). sparing of the hypothenar muscles.
PART II: RADIAL NEUROPATHY

from vasculitis. Patients with this particular entrapment, typically
present with wrist and finger drop and decreased sensation over
Anatomy
the posterolateral hand in the distribution of the superficial radial
sensory nerve. Patients typically have weakness of supination and
The radial nerve receives fibers from all three trunks of the brachial elbow flexion. However, elbow extension (triceps muscle) will be
plexus (C5-T1 roots). The posterior divisions of these three trunks spared.1,3
unite to form the posterior cord, which, in turn, gives off the radial
nerve. The radial nerve exits the lateral wall of the axilla and travels
distally through the proximal arm, just medial to the humerus. Posterior Interosseous Neuropathy
Proximally, three sensory nerves arise from the radial nerve: the Patients with posterior interosseous neuropathy also present with
posterior cutaneous nerve of the arm, the lower lateral cutane- wrist drop. However, there are several distinct features of this en-
ous nerve of the arm, and the posterior cutaneous nerve of the trapment that distinguish it from lesions at the spiral groove. In a
forearm. These nerves provide sensation to the posterolateral posterior interosseous neuropathy, there is sparing of radial-inner-
portions of the arm, as well as a small strip along the middle vated muscles proximal to the takeoff of the posterior interosseous
posterior aspect of the forearm. Muscular branches arise next to nerve (triceps, anconeus, brachioradialis, and long head of the
supply the long, lateral, and medial triceps muscles, as well as the extensor carpi radialis muscles). Entrapment usually occurs at the
anconeus muscle. Moving distally, the radial nerve wraps around proximal tendinous border of the supinator (Arcade of Frohse).
the humerus, traveling in the spiral groove, before giving off ad- When the patient extends the wrist, they may do so weakly, and
ditional branches to the supinator, the long head of the extensor with radial deviation. This occurs because the extensor carpi ulnaris
carpi radialis, and the brachioradialis muscles. is weak, but the extensor carpi radialis is preserved. These patients
typically do not experience sensory deficits. Patients may complain
A few centimeters further, the radial nerve divides into the of forearm pain resulting from the deep sensory fibers of the PIN
superficial radial sensory nerve and the posterior interosseous that supply the interosseous membrane and joint capsule.1,3
nerve (PIN). The superficial radial sensory nerve travels along
the radius, and emerges approximately 5-8 cm proximal to radial Superficial Radial Sensory Neuropathy
styloid to provide sensation over the dorsolateral hand and proxi-
mal portions of the dorsal aspect of the thumb, index, middle, In the forearm, the superficial radial sensory nerve travels sub-
and ring fingers. The PIN travels through the supinator muscle cutaneously next to the radius. Its superficial location makes it
and passes under the Arcade of Frohse. The PIN, in turn, sup- susceptible to injury. Sensory disturbances occur over the dor-
plies muscular branches to the short head extensor carpi radialis, solateral surface of the hand and fingers. Various objects such as
extensor digitorum communis, extensor carpi ulnaris, abductor tight fitting bands, watches, bracelets, or handcuffs may lead to a
pollicis longus, extensor indicis proprius, extensor pollicis longus, superficial radial neuropathy. As this is a pure sensory neuropathy,
and extensor pollicis brevis muscles.1,2,3,4 these patients do not develop weakness.1,3
Differential diagnosis of wrist drop. The differential diagnosis

Radial Neuropathy at the Axilla of wrist drop should include the various radial nerve lesions dis-
cussed above. In addition, more proximal lesions such as a pos-
Radial neuropathy at the axilla results from prolonged compres- terior cord brachial plexopathy, C7-C8 radiculopathy, or even a
sion of the nerve as it courses through the axilla. A common central lesion should be considered. A careful clinical examination
presentation is the patient on crutches who uses them incor- is invaluable in localizing the lesion causing wrist drop.
rectly thereby applying prolonged pressure to the axilla. Because
the lesion occurs proximal to muscular branches supplying the Electrophysiology. The electrodiagnostic (EDX) study should
triceps muscle group, the clinical presentation is similar to radial identify the presence of a radial neuropathy and properly localize
neuropathy at the spiral groove (see below), with the addition the level of dysfunction. The radial motor study should be per-
of triceps muscle weakness. Additionally, sensory disturbance formed and compared to the contralateral side. A protocol out-
extending into the posterior arm and forearm due to compression lining EDX recommendations for evaluating radial neuropathy is
of the posterior cutaneous sensory nerves of the forearm and arm outlined in Table 1.
is usually seen.1,3
The radial sensory study (See Fig. 1) is most commonly per-
formed using disc electrodes placed over the superficial radial
Radial Neuropathy at the Spiral Groove nerve. G1 is placed over the nerve in the region of the anatomic
snuffbox as it travels over the extensor tendons of the thumb. The
Radial neuropathy at the spiral groove is the most common site nerve can often be palpated as it is very superficial in this loca-
of radial nerve injury. This usually occurs in the person who has tion. G2 is placed 3-4 cm distal over the thumb. The superficial
draped an arm over a chair or bench during deep sleep or in- radial sensory nerve is then stimulated 10 cm proximal over the
toxication (“Saturday Night Palsy”). Other cases can occur after distal midradius.1
strenuous muscular effort, fracture of the humerus, or infarction
Table 1 Electrodiagnostic evaluation for evaluating radial

neuropathy1

A. Radial nerve studies
i. Radial motor study stimulating at the forearm, elbow, below spiral
groove, and above spiral groove sites while recording from the
extensor indicis proprius muscle.
ii. Superficial radial sensory study. Stimulating at the forearm while
recording over the extensor tendons of the thumb. Bilateral
studies are recommended. Figure 1 Radial sensory conduction study. The active recording electrode
B. Median nerve studies is placed over the palpable portion of the superficial radial nerve. The nerve
can be palpated over the extensor pollicis longus tendon. The inactive or
i. Median motor study stimulating at the wrist and below elbow sites
reference electrode is placed 3-4 cm distally on the thumb. The ground is
while recording from the abductor pollicis brevis muscle.
placed over the dorsum of the wrist between the stimulating and recording
ii. Median sensory study stimulating at the wrist while recording electrodes. The nerve is stimulated the dorsal edge of the radius, 10 cm
from the 1st digit. from the active recording electrode, with the cathode distal to the anode.
iii. Median F responses.
C. Ulnar nerve studies
i. Ulnar motor study, stimulating at the wrist, below elbow, and
above elbow sites while recording from the abductor digiti minimi
muscle.
ii. Ulnar F responses.
iii. Ulnar sensory study stimulating at the wrist while recording from
the 5th digit.
2. Needle electromyography
A. At least two posterior interosseous nerve-innervated muscles (e.g.,
extensor indicis proprius, extensor carpi ulnaris, extensor digitorum
communis).
Figure 2 Radial motor conduction study recording from the extensor
B. At least two radial-innervated muscles proximal to the posterior indicis proprius stimulating at the forearm. The recording electrodes are
interosseous nerve, but distal to the spiral groove (e.g., placed over the extensor indicis muscle with the active electrode over
brachioradialis, long head extensor carpi radialis). the belly of the muscle and the reference electrode at least 3 cm distal to
C. At least one radial-innervated muscle proximal to the spiral groove the active electrode, over the tendon. The ground is placed between the
(e.g., triceps). recording electrodes and the stimulation site on the forearm. The nerve
is stimulated distally over the lateral forearm, with the cathode distal to
D. At least one nonradial, posterior cord-innervated muscle (e.g.,
the anode. There is no fixed distance. The radial nerve is stimulated more
deltoid).
proximally at the elbow, lateral to the biceps tendon, beneath the bra-
E. At least two nonradial, C7-innervated muscles (e.g., flexor carpi chioradialis muscle. It can be stimulated more proximally over the lateral
radialis, pronator teres, flexor pollicis longus, or cervical paraspinal aspect of the arm at the spiral groove, and also in the supraclavicular
muscles). fossa (Erb’s point). Proximal stimulation may be associated with an initial
positive deflection of the compound muscle action potential because of
The radial motor study is performed using disc electrodes with activation of other muscles innervated by the radial nerve.
G1 placed over the belly of the extensor indicis proprius muscle
(approximately 2-3 finger breadths proximal to the ulnar styloid)
while G2 is placed over the ulnar styloid. The radial nerve can then
be stimulated in four locations: 1) forearm (See Fig. 2): over the
ulna approximately 4-6 cm proximal to G1; 2) elbow (See Fig. 3):
in the groove between the brachioradialis and biceps muscles; 3)
below spiral groove (See Fig. 4): at the midlateral arm between
the triceps and biceps muscles; and 4) above spiral groove (See
Fig. 5): over the proximal posterior humerus near the axilla.1
Comparison of the radial compound muscle action potential
(CMAP) with the asymptomatic side is most useful.
Examine at least: two PIN-innervated muscles (e.g., extensor

indicis proprius, extensor carpi ulnaris, or extensor digitorum Figure 3 Radial motor conduction study recording from the extensor
communis muscles); two radial-innervated muscles that are proxi- indicis proprius stimulating at elbow.
mal to the PIN, but distal to the spiral groove (e.g., long head
REFERENCES (PART I)
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Figure 4 Radial motor conduction study recording from the extensor
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www.wheelessonline.com/ortho/radial_nerve.
indicis proprius, extensor digitorum communis, and extensor carpi
4. Carlson N, Logigian EL. Radial neuropathy. Neurol Clin 1999
ulnaris muscles
Aug;17(3):499-523. [PMID: 10393751].
2. Radial neuropathy at the spiral groove
A. Nerve conduction studies. Superficial radial sensory response is low
(if axonal). Radial motor study may show low amplitude response (if
axonal) or conduction block at the spiral groove (if demyelinating).
B. Needle EMG. Denervation as in posterior interosseous neuropathy
plus long head extensor carpi radialis, brachioradialis, and supinator
muscles.
3. Radial neuropathy at the axilla
A. Nerve conduction studies. Superficial radial sensory response is low
(if axonal). Radial motor study may show low amplitude response (if
axonal).
B. Needle EMG. Denervation as in spiral groove, plus triceps muscle.

21
The Tibial and the Common

Peroneal Nerves
Kimberley B. Butler, R.NCS.T., R. EP T., CNIM
Electroneurodiagnostic Technologist
Hartford Health Care
Willimantic, Connecticut
INTRODUCTION BASIC NERVE LOCALIZATION
The major motor nerves of the lower extremities include the sciatic The sciatic nerve is formed by the union of the L4-S2 roots. It is
nerve, which becomes the tibial and the common peroneal nerves. important to be aware that the sciatic nerve actually is two separate
The common peroneal nerve eventually splits into the superficial nerves traveling together: the common peroneal nerve, which origi-
peroneal and deep peroneal nerves. Other important lower extrem- nates from the posterior division of the sacral plexus, and the poste-
ity nerves include the femoral nerve and the obturator nerve. rior tibial nerve, which originates from the anterior division of the
sacral plexus. As the two nerves travel together down the thigh, the
The major proximal sensory nerves of the lower extremity include peroneal portion is lateral to the tibial. Knowing the placement of
the lateral femoral cutaneous nerve, and the terminal sensory these nerves is important when encountering lesions of the sciatic
branch of femoral nerve, the saphenous nerve. The “gold standard” nerve (see below). Another important anatomical fact is although
of sensory nerve conduction studies (NCSs) in the lower extremi- the superior and inferior gluteral nerves arise from similar nerve
ties is the sural nerve, which most literature agrees has contribu- roots, they do not travel with the sciatic nerve. This is important
tions from both the tibial and the common peroneal nerves. Other in localization, because a lesion involving an L5 root would impact
important sensory nerves of the lower extremity are the terminal both L5-innervated muscles supplied by the sciatic nerve and the
sensory nerve branches of the common peroneal nerve, in particu- gluteal nerves, whereas a lesion localized to the sciatic nerve would
lar the superficial peroneal sensory nerve. spare the gluteal nerve-supplied muscles. Another clinical point of
interest is the lumbosacral trunk, a small branch which connects
All of these nerves have in common an origin from the lumbosacral the lumbar plexus to the sacral plexus. This lumbosacral trunk
plexus. Although not as important in localization during NCSs arises from the L4 root level and travels with the sciatic nerve. Of
as the brachial plexus, a good overall knowledge base of the lum- interest, the only muscle which is supplied by the sciatic nerve and
bosacral plexus is important. At first glance, the lumbosacral plexus commonly thought to contain a significant L4 component is the
can be a bit intimidating, a giant snarl that seems daunting to break tibialis anterior.
down into pieces small enough to reproduce. The best way is to
break it down into two separate plexi: the lumbar plexus and the
sacral plexus. Because the focus here is on the peroneal and poste- Dermatomes
rior tibial nerves, this paper will concentrate on the sacral plexus
as this is the area from which most of the axons originate and thus Dermatomes are the areas of cutaneous sensation supplied by the
give rise to these nerves. individual nerve root levels. The dermatomes are relatively easy to
22 The Tibial and the Common Peroneal Nerves AANEM Course
remember and extremely helpful from a clinical perspective. If you femoris is the only muscle above the knee innervated by the peroneal
remember that the dermatome (which supplies the lateral aspect nerve. The clinical importance of this will be discussed below.
of foot posterior to the medial maleous) is S1, then you know that
the sural nerve derives its axons from the S1 root level. They are Any local entrapment or injury of the sciatic nerve in the upper
also helpful in assessing involvement of individual nerve roots in thigh generally is produced by trauma. Prolonged pressure may
radicular lesions. If the patient complains of sensory changes on produce a syndrome referred to as rhabdomyolysis, the breakdown
the dorsum of the foot, an understanding of the L5 dermatomal of muscle fibers resulting in the release of muscle fiber contents
pattern distribution allows a differential diagnosis with possibility (myoglobin) into the bloodstream which can have severe conse-
of L5 nerve root involvement. Another simple way to remember quences not only to muscle but also to the kidneys. Trauma can
the dermatome arrangement is to envision the human body with also be caused by knife and gun shot wounds, hematomas, and
the arms out stretched and the legs positioned into a split and then iatrogenic injury, such as stretch injuries following hip replacement
send it through a meat slicer at a deli! The dermatomes for the most and other surgeries.
part form fairly straight lines, and, hence, could be easy to identify
and thus to remember. At about the level of the knee, in the popliteal fossa the sciatic nerve
bifurcates into the tibial and the common peroneal nerve. The
tibial nerve decends deep into the calf, and the common peroneal
Cutaneous Distribution wraps around the fibular head laterally.
Understanding the cutaneous distribution of individual lower ex- The tibial nerve originates from the L5, S1, and S2 nerve roots. It
tremity sensory nerves also is important in localization. Lesions of innervates the plantar flexors and inverters of the foot at the ankle.
individual peripheral nerves have distinct areas of sensory changes. The sensory nerves arising from the tibial nerves are the medial
A solid understanding of dermatomes will give rise to a list of dif- and lateral plantar nerves which provide cutaneous sensation to the
ferential diagnoses. In the earlier case of an individual with numb- bottom of the foot, the calcaneal nerve which provides cutaneous
ness of the dorsum of the foot, this area of distribution is not only sensation to the bottom of the heel, and the sural communicat-
the L5 root dermatome but also the sensory distribution of the ing branch to the sural nerve. The important tibial-innervated
superficial peroneal sensory nerve. This knowledge will provide a muscles in the lower leg include the medial gastrocnemius (S1-S2),
good starting point to design a planned study with a differential the lateral gastrocenemius (L5-S1), the soleus (S1-S2), the tibialis
diagnosis of L5 root involvement versus peroneal nerve palsy. These posterior (L5-S1), the flexor hallucis longus (L5-S1-S2), and the
cutaneous distributions are addressed further in the discussion of flexor digitorum longus (L5-S1-S2) muscles. At the level of the
individual nerves. medial malleolus, the tibial nerve divides into the medial and lateral
plantar nerves. These two nerves innervate most of the muscles of
the foot, similar to the median and ulnar nerves in the hand. The
INDIVIDUAL NERVES AND COMMON NERVE discussion below illustrates medial and lateral plantar innervated
CONDUCTION STUDIES muscles.
Working from proximal to distal starting with the sciatic nerve, Motor NCSs of the tibial nerves are performed routinely and are
individual nerves and the NCSs commonly performed will now be fairly easy. Most literature recommends using the abductor hallucis
addressed. First, a note on normal values. There are a number of (AH) muscle on the medial aspect of the foot, two finger widths
published normal values which can be utilized depending on the distal to the navicular bone, as an active recording site (G1) and
preference of the examiner. The most important aspect of normal reference (G2) placed distally using the “belly tendon” method,
values is that the exact technique the original author described be ensuring that the reference is completely off the muscle. The
reproduced. This includes recording and stimulation sites and set fascicles of the lateral plantar nerve can be evaluated by placing
distal stimulation sites. Although some laboratories routinely utilize the recording electrodes on the lateral aspect of the foot over the
“anatomical” sites for distal stimulation most literature recom- abductor digiti minimi (ADM) muscle. Stimulation is conducted
mend using a set distance with published normal values to be the at a preset distance from G1 posterior to the medial malleolus.
best technique. As stated earlier, the sciatic nerve arises from root Proximal stimulation is conducted in the popliteal fossa (see Fig. 1).
levels L4-S2. It is two separate nerves traveling side by side. The Because the nerve at times lies very deep at the popliteal fossa, in-
peroneal portion is lies more to the lateral and the tibial stays more creased pressure and increased stimulus duration is often required
to the medial side. This is an important point because oftentimes to overcome this potential submaximal stimulation. Generally, a
in a lesion of the sciatic nerve, the peroneal portion will be more compound muscle action potential (CMAP) of at least 50% of the
involved clinically because of its fascicle placement, which is more amplitude of the CMAP acquired distally is considered acceptable.
lateral and thus more prone to pressure type injury. In the upper Careful observation to ensure plantar (downward) flexion should
thigh the sciatic nerve innervates (supplies) the semimembranosus, be noted. When dealing with difficult cases, placing an ancillary
semitendinosus, biceps femoris, and adductor magnus muscles. electrode into the anode insertion of the stimulator and placing the
Most needle electromyography (EMG) studies of this muscle group surface electrode anteriorly (on the knee) may help in acquiring
is performed on the long and short heads of the biceps femoris. An adequate stimulation to depolarize the nerve.
important point of localization here is that the long head is inner-
vated by the tibial portion of the sciatic nerve and the short head Sensory contributions of the tibial nerve include the sural commu-
is innervated by the peroneal portion. The short head of the biceps nicating branch, which provides cutaneous sensation to the lateral
Figure 1 Tibial motor study.3 Figure 2 Sural sensory study.3
aspect of the foot, the medial and lateral plantar nerves, and the cal-
caneal nerve. As stated earlier, the sural nerve is considered the gold
standard of sensory responses that can be recorded in the lower ex-
tremity. Although primarily from tibial nerve, it is thought to have
some contributions from the deep peroneal nerve as well. Routine
nerve conduction velocity (NCV) studies of the sural nerve can be
recorded placing G1 just posterior to the lateral malleous and G2
3-4 cm distal. Stimulation is performed midcalf at a set distance
(often 14 cm) (see Fig. 2). Medial and lateral plantar responses
can also be recorded routinely, both antidromically and othodro-
mically. The orthodromic technique is performed by placing G1
on the main trunk of the tibial nerve at the level of the ankle and Figure 3 Orthodromic method for medial and lateral plantar studies.3
G2 3-4 cm proximal. Stimulation is then performed on both the
medial and lateral aspect of the plantar surface of the foot (see Fig.
3). Generally speaking this study is performed with a “side-to-side” volved but oftentimes the fascicles of the peroneal nerve have a pre-
comparison rather than a pre-set distance technique. Technical dif- dilection to sustain more severe injury. Distal tibial nerve injuries
ficultly can occur because of high resistance of the plantar surface at the ankle, including “tarsal tunnel syndrome,” often resemble
of the foot creating stimulus artifact. Although some literature has carpal tunnel-like syndrome in their symtomatology. Iatrogenic
reported performing NCSs on the calcaneal nerve, the possibility of injury following surgery can also produce injury to the tibial nerve
volume conduction from the main trunk of the tibial nerve makes in the lower leg and foot.
its reliability questionable.
The common peroneal nerve originates from the L4, L5, and S1
Injuries to the posterior tibial nerve in the lower leg are often trau- root levels. It bifurcates below the knee into the deep peroneal and
matic in nature: direct trauma, such as knife or gun shot injuries, superficial peroneal nerves. The level of this bifurcation can vary
and stretch injuries involving the knee, which often involve both somewhat, having a potentially large impact on selective fascicular
the common peroneal and tibial nerves. In such cases, often the involvement in peroneal nerve injuries at the fibular head. Normal
peroneal is more involved than the tibial nerve. Some injuries result variations of bifurcation of the common peroneal nerve can affect
in a compartment syndrome, which is the compression of nerves, which muscles are clinically weak in a peroneal palsy. Recording
blood vessels, and muscle inside a closed space (compartment) from various deep and superficial peroneal-innervated muscles may
within the body, leading to tissue death due to lack of oxygenation be helpful in such cases.
as the blood vessels are compressed by the raised pressure within
the compartment. Again, both the tibial and peroneal nerves are in-
24 The Tibial and the Common Peroneal Nerves AANEM Course
The deep peroneal nerve travels deeply into the anterior compart- clinical movement of the foot to stimulation is critical to avoid
ment of the foreleg and innervates the muscles of ankle dorsiflex- volume conduction response. When performing deep peroneal
ion, including the tibialis anterior, extensor hallucis longus, and motor studies from the EDB, the examiner should always be on
peroneus tertius muscles. In the foot it innervates the extensor the look out for possible accessory peroneal anomaly. This occurs
digitorum brevis (EDB) and the first dorsal interosseous (FDI) when the lateral aspect of EDB is innervated by fibers following the
muscles and provides cutaneous sensation to the wedge between the superficial rather than the deep peroneal nerve. In such instances,
first and second toes. The superficial peroneal nerve innervates higher amplitude is noted with proximal rather than with distal
muscles of ankle eversion, including the peroneus longus and stimulation. To confirm, stimulate just posterior to lateral mal-
peroneus brevis. It provides cutantneous sensation to the dorsum leolus. If an accessory peroneal anomaly is present a small CMAP
of the foot and to the lateral lower leg. will be recorded from the EDB (see Fig. 5). Motor studies also can
be acquired recording from the tibialis anterior and the peroneus
Injuries to the common peroneal nerve and its branches include longus while stimulating at the fibular head. Such studies can be
many of the same types of injuries affecting the posterior tibial very helpful in acquiring additional information about selective fas-
nerve, such as direct trauma. Because of its position it often has cicular involvement to individual muscles innervated by both the
a predilection to compression injuries and often is more clinically deep and superficial peroneal nerve. Such information may be very
involved in lesions affecting both the tibial and peroneal nerves. helpful in confirming localization of a peroneal palsy. Oftentimes
The common peroneal nerve is also subject to compression at conduction block (abnormal amplitude drop over a short segment)
the fibular head, where it becomes quite superficial, and may be or focal slowing of conduction velocity may be noted.
damaged in stretch injuries involving the knee and in compartment
syndromes. Distal superficial peroneal nerve injuries sometimes Sensory NCSs of the superficial peroneal nerve can be performed
referred to as anterior tarsal tunnel syndrome and iatrogenic injury both antidromically and orthodromically. The antidromic method
are all seen. is performed by placing the active (G1) electrode over the dorsum
of the foot slightly lateral to midline. The reference electrode is
NCSs of the deep peroneal nerve are commonly performed record- placed 3-4 cm distal. Stimulation is performed at a preset distance
ing from the EDB using the belly tendon method of motor NCSs. in the groove just posterior to the insertion of the peroneus longus
Stimulation is performed at the ankle at a preset distance and below (see Fig. 6). This sensory study can be invaluable in evaluating
and above the fibular head (see Fig. 4). Conduction velocities are demyelination in peroneal nerve injury at the fibular head. In a
measured between the ankle and a site below the fibular head, and purely demyelinating lesion, everything below the lesion will be
from below to above the fibular head. The distance between the completely normal. If a patient presented with a completely flaccid
below and above fibular head segment ideally should be around foot unable to dorsiflex the foot at all, a normal superficial peroneal
10 cm but often a shorter distance is required to ensure no volume sensory study would strongly suggest a demyelinating injury at the
conduction to the posterior tibial nerve. Careful observance of the fibular head. This is because there is a conduction block-type injury
and the axons themselves remain intact. This type of scenario
(i.e., a normal superficial peroneal sensory study and a completely
flaccid foot) would suggest a complete conduction block. When
performing motor studies on this type of injury no response would
be obtained at the stimulation site above the site of the injury (e.g.,
the fibular head). Such lesions are often incomplete or “mixed”
type lesions. In a partial conduction block injury, for instance, an
abnormal amplitude CMAP would be obtained above the site of
the lesion. Usually, at least a 50% drop in amplitude is needed to
diagnose partial conduction block. Milder injuries can cause weak-
ness and sensory change. If only the largest myelinated axons were
affected, a slowing in conduction velocity may be the only abnor-
mality noted. Usually a slowing of greater than 10% is considered
significant. Because certain fascicles can be affected differently,
performing studies from multiple muscles may be helpful. It is not
unusual to note partial conduction block to some fascicles and only
conduction slowing to others. For practical purposes, no reliable
sensory study routinely is obtained from the deep peroneal nerve.
From an electrodiagnostic (EDX) standpoint, the short head of the

biceps femoris should be mentioned in the discussion of peroneal
nerve palsy localized at the fibular head as it is the only muscle
innervated by the peroneal portion of the sciatic nerve above the
knee. This is extremely useful in localizing peroneal mononeu-
ropathies. In severe (complete) peroneal neuropathies in which the
Figure 4 Common peroneal motor study.3 NCSs are not helpful in localizing the lesion to the fibular head
needle examination of the short head of the biceps femoris maybe
Figure 5 Accessory peroneal study.3
All figures used with permissions from Oh.3
SUGGESTED READING
1. DeLagi EF, Perotto A. Anatomic guide for the electromyographer,

2nd ed. Springfield, IL: Charles C. Thomas; 1980.
2. Wilbourn AJ, Aminoff MJ. AAEM Minimonograph #32: The
electrodiagnostic evaluation in patients with radiculopathies. Muscle
Fibula Nerve 1998;21:1612-1631.
3. Oh S. Clinical electromyography, nerve conduction studies, 3rd ed.
Philadelphia: Lippincott Williams & Wilkins; 2002.
Lateral 4. Stewart J. Focal peripheral neuropathies, 2nd ed. Philadelphia: WB
malleolus Saunders; 1993.
Lateral
malleolus
Figure 6 Superficial peroneal sensory studies.3
the only localizing evidence. A normal needle examination of this

muscle indicates that the lesion is distal to the branch supplying
this muscle, and this is likely at or below the fibular head.
26 AANEM Course

Median Nerves and Nerves

of the Face
Jerry Morris, MS, R.NCS.T.
Electrodiagnostic Technologist
Neurodiagnostic Laboratory
Willis-Knighton Medical Center
Shreveport, Louisiana
PART ONE: FACIAL NERVE, TRIGEMINAL NERVE, AND Facial Nerve

BLINK REFLEXES: ANATOMY, TECHNIQUES, AND
The facial nerve (CN VII) has both sensory and motor compo-
APPLICATIONS nents. The sensory portion includes taste from the anterior two
thirds of the tongue. The motor component becomes the nerve of
Anatomy facial expression.
For electrodiagnostic (EDX) studies on the face, two particular

studies may be performed. The first study, the facial nerve motor
study, uses cranial nerve (CN) VII. Even though the facial nerve
has both sensory and motor components, this discussion will focus
only on the motor component. The second study, the blink reflex
study, utilizes the sensory portion of the trigeminal nerve (CN V)
a motor and sensory nerve, and the motor component of the facial
nerve (CN VII).
Trigeminal Nerve
The trigeminal nerve (CN V) is the largest of the cranial nerves.

It is composed of three divisions, hence the name trigeminal. The
third division is the mandibular division which has both motor and
sensory components. The second division is the maxillary division
which has only a sensory component. The first division is the oph-
thalmic division, also a purely sensory division. The ophthalmic
division forms three nerves: the nasociliary, lacrimal, and frontal
nerves. The frontal nerve then becomes the supraorbital nerve,
the nerve stimulated in blink reflex studies. The supraorbital nerve
emerges onto the forehead at the supraorbital notch, just above the
eye. It then sends medial and lateral branches to the skin of the
eyelid and scalp (see Figs. 1 and 2). Figure 1 Trigeminal nerve.
From wikipedia.org (originally from Gray’s Anatomy, fig. 778).

28 Median Nerves and Nerves of the Face AANEM Course
Figure 2 Dermatome distribution of the trigeminal nerve.

Figure 3 Facial nerve branches.
The facial nerve motor components arise from the pons while the From wikipedia.org, Patrick J. Lynch, medial illustrator, with permission.
sensory component arises from the nervus intermedius. The facial
nerve leaves the brainstem at the cerebropontine angle (CPA) and
enters the petrous temporal bone and the internal auditory meatus.
It then courses through the facial canal and emerges at the stylo-
mastoid foramen. It then passes through, but does not innervate,
the parotid gland. It then divides into five branches on the face.
From top to bottom they are the temporal branch, the zygomatic
branch, the buccal branch, the marginal mandibular branch, and
the cervical branch.
The temporal branch innervates the frontalis muscle which elevates

the eyebrows and wrinkles the forehead. The temporal and zygo-
matic branches innervate the orbicularis occuli muscle, the muscle
that closes the eyelids. This muscle will be the recording site for
blink reflex studies and one of the sites for facial motor studies.
The buccal branch then innervates two muscles, the nasalis which
flattens the nose and flares the nostrils and the orbicularis occuli
which purses the lips. This is the “kissing muscle.” The marginal
mandibular branch innervates the mentalis muscle which elevates
the skin of the chin. The cervical branch innervates the platsyma
muscle which draws the corner of the mouth inferiorly as in sadness
and fright and draws down the skin of the lower lip when grimac-
ing (see Fig. 3 and 4). Figure 4 Facial nerve.
Technique From wikipedia.org (originally from Gray’s Anatomy, fig. 790).
In performing a facial study, the orbicularis occuli muscle will be

used as the active recording site. The reference electrode will be the distal latency is measured from the onset of the response. The
orbicularis occuli muscle on the side opposite the stimulation site. amplitude is measured from the baseline to the peak of the nega-
The ground is placed on the chin. Once one side is completed, tive deflection. Normal distal latencies should be between 3-4 ms
switch the stimulator to the other side while switching the active with amplitudes between 1-4 K. Most often in abnormalities the
recording and reference electrodes. Always perform side-to-side amplitude drops by greater than 50% when compared to the other
comparisons. Use a sweep speed of between 2-5 ms/div, a gain of side. The latency may also be prolonged by 20-30% on the affected
500 μV to 2 mV, and motor nerve filter settings of 1.6 Hz-8 kHz side (see Figs. 5 and 6).
(low to high). The stimulator is placed slightly off the mandible.
This is where the facial nerve emerges from the skull at the sty-
lomastoid foramen. Once the maximal response is obtained, the
• Infections of the ear
• Diabetes
• CPA tumors
• Viral infections
• No cause determined (the majority of cases)
The facial nerve may be used as a proximal nerve to stimulate

for repetitive stimulation. Many patients with myasthenia gravis
demonstrate a decrement on repetitive nerve stimulation here
despite normal repetitive stimulation studies of more distal nerves
such as the median and ulnar nerves of the hand. The setup for
this procedure is the same with multiple stimuli given instead of
Figure 5 Placement of electrodes in a facial study. single shocks. Exercise is performed by tightly closing the eyes
(see Fig. 7).
© 2010 Jupiterimages Corporation
Blink Reflex
A blink reflex is a polysynaptic reflex consisting of two com-

ponents. The afferent arc of this reflex is the stimulation of the
sensory division of the trigeminal nerve and the efferent arc is the
corresponding motor axon response by the facial nerve. This arc
checks two cranial nerves: the 5th or trigeminal nerve and the 7th
or facial nerve. Blink reflexes are one of the least understood of
the cranial EDX procedures, probably because their mechanisms
and pathways are poorly understood. With a little knowledge and
time, the blink reflex may become one of the easiest EDX tests to
perform. It will also provide added information to the physician
about certain neuropathies and diseases involving the face. Two
components of the response will show up on the stimulated side
and one component on the opposite side in normal subjects. Delays
in these components will help locate the area of the lesion and help
the physician with diagnosis.
Technique
Figure 6 Facial motor nerve study of the orbicularis occuli muscle.
In recording blink reflexes, both eyes may be set up at the same
time. For Channel 1, place an active recording electrode on the
Amp = amplitude, Elecl = electrical, Lat = latency, Mast = mastoid, Mot = orbicularis occuli muscle, just directly below the pupil of the eye.
motor, Norm = normal, OrbOcc = orbicularis occuli, PW = pulse width, R =
The reference electrode is placed on the outer canthus of the eye.
right, Seg = segment, Vel = velocity
For Channel 2, repeat the above procedure for the other eye. The
ground is placed on either the chin or the forehead, between the
Applications two recording sites.
The facial nerve motor study is most often helpful in patients with Care should be used in stimulating for the blink reflex. If possible,
Bell’s palsy (cranial mononeuropathy of CN 7). This usually affects a smaller stimulator with smaller prongs needs to be used. This
one side and is characterized weakness of the entire side of the face, area of stimulation above the eye is very sensitive therefore, it is
with inability or weakened ability to wrinkle the forehead, close the essential to be very careful while stimulating. Place the cathode
eye, or smile on the affected side. Many causes have been found for directly over the supraorbital branch of the trigeminal nerve at the
Bell’s palsy: point on the eyebrow where the nerve goes through the frontal
notch. This notch can be felt by rubbing a finger along the upper
• Early Guillain-Barré syndrome eyebrow. The cathode should be on the forehead. Sweep speeds
should be between 10-15 ms/div with a gain setting of between
• Any trauma, especially to the ear area 100-500 μV. Use sensory study stimulus intensity, allowing 3-4 s
Right median
Pre-1 minute exercise
0 minutes
1 minute
2 minutes
3 minutes
4 minutes
5 minutes
Figure 7 Repetitive nerve stimulation of the facial nerve.
Amp = amplitude, Diff = difference
between shocks. In normal subjects an R1 component should providing that the stimulus and recording parameters are the same
appear between 8-13 ms ipsilaterally. An R2 component should (see Figs. 8 and 9).
also appear between 28-42 ms ipsilaterally. In addition, an R2
component should appear between 29-44 ms contralaterally. Give Applications
several series of stimuli, rotating the anode until the best response
is obtained. When finished with stimulation on this side, leave the Blink reflexes are performed in conjunction with facial nerve
recording electrodes where they are and stimulate the opposite side. stimulation. Several proven usages for blink reflexes have been
This allows observation of the R1 response on this side as well. This recognized:
R1 component is thought to be a response of the pathway between
the trigeminal nerve sensory nucleus and the ipsilateral facial nerve • The blink reflex is a more sensitive study than the facial nerve
(disynaptic response). It is only seen on the side of stimulation. The study alone. It provides information about both proximal and
R2 component is a representation of the polysynaptic connection distal conduction within the facial nerve.
between the trigeminal nerve spinal nucleus and the facial nerve
nuclei bilaterally. Thus, in normal subjects, it should be seen on • Blink reflexes are especially helpful in evaluating Bell’s palsy.
both sides. Latencies from R1 and R2 should be seen on both sides.
Latencies from R1 and R2 should be compared on a side-to-side • Blink reflexes may aid the diagnosis of early Guillain-Barré
basis. Although amplitudes of R1 and R2 are not measured, it may syndrome, because this may be the earliest detectable abnor-
be useful to notice if there is a side-to-side amplitude difference,
PART TWO: THE MEDIAN NERVE: ANATOMY,

TECHNIQUES, AND ENTRAPMENTS
Anatomy
The median nerve arises from C6-T1 roots. It is formed by the

lateral and medial cords of the brachial plexus. After exiting the
plexus, the median nerve travels with the brachial artery down the
medial aspect of the biceps muscle to the biceps tendon. It then
courses down the center of the forearm, innervating the pronator
teres muscle and the flexor muscles of the forearm, and branches
off to form the anterior interosseus nerve, a pure motor nerve. It
then passes between the flexor carpi radialis and palmaris longus
tendons. It next passes through the carpal tunnel, a region located
Figure 8 Blink reflex electrode placements.
distal to, and in the middle of, the wrist crease. The motor branch
then innervates the abductor pollicis brevis (APB) and the thenar
© 2010 Jupiterimages Corporation eminence. The sensory branches then provide sensation to the
palm, the thumb, the index, and the middle fingers. It also provides
sensation to the lateral aspect of the 4th finger. The sensory poten-
tial from the thumb may be used to specifically access the C6-C7
nerve roots, upper and/or middle trunk, and lateral cord of the
brachial plexus (see Fig. 10).
Median Motor Nerve Study Technique
The following is the procedure for the median motor nerve study
(see Fig. 11).
• Active: Place over the center of the APB muscle, one-third

of the distance between the metacarpal–carpal crease and the
metacarpal–phalangeal joint of the thumb.
• Reference: Place on the metacarpal–phalangeal joint, 4-5 cm

distal to the active.
• Ground: Place on the back of the hand.
Stimulating electrodes
• Distal: Place 6.5-8 cm proximal to the active electrode between

Figure 9 Blink reflex study.
the flexor carpi radialis and palmaris longus tendons.
Diff = difference • Proximal: Place over the brachial pulse at the elbow, between
the biceps tendon and the medial epicondyle.
mality. It may also aid in diagnosing other demyelinating dis- Measurements

eases such as multiple sclerosis.
• Distances, latencies, and amplitudes of all sites.
• Blink reflexes are extremely helpful in diagnosing CPA tumors
such as acoustic neuromas. • Conduction velocity between wrist and elbow.
Anode
Cathode
Anode
Cathode
6.5 cm
Active (APB)
Ground (back of hand)
Reference
Figure 11 Electrode placement for a median motor nerve study.
APB = abductor pollicis brevis
• Reference: Place 3-4 cm proximal to the active site.
• Ground: Place on the back of the hand.
• Cathode: Place on the proximal phalanx of the index finger.
• Anode: Place on the middle phalanx of the index finger.

Figure 10 The median nerve.
Measurements
• Distances, amplitudes, and latencies for sites.
Median Orthodromic Sensory Nerve Study Technique for Median Antidromic Sensory Nerve Study Technique for
the Index Finger the Index Finger
The following is the procedure for the median orthodromic sensory The procedure for the median antidromic sensory nerve study for
nerve study of the index finger (see Fig. 12). the index finger is the reverse of the procedure for the orthodromic
study.
• Active: Place between the flexor carpi radialis and palmaris

longus tendons 11-13 cm from the stimulation site.
Reference Reference
Active Active
Ground (back of hand) 8 cm

13 cm Ground (back of hand) Cathode
Anode
Cathode
Anode
Figure 12 Electrode placement for a median orthodromic sensory nerve Figure 13 Electrode placement for a median palmar sensory nerve study.
study of the index finger.
Median Palmar Sensory Nerve Study Technique
• Place the electrodes the same as for median orthodromic
The following is the procedure for the median palmar sensory nerve sensory nerve studies.
study (see Fig. 13).
• Cathode: Place at the base of the thumb.
• Place the electrodes the same as for median orthodromic
sensory nerve studies. • Anode: Place at the interphalangeal joint.
Stimulating electrodes Measurements
• Place on the thenar crease and the 2nd metacarpal interspace • Distances, amplitudes, and latencies for each site.
in the palm. Place them 8-10 cm from the active electrode.
Measurements Median Nerve Entrapments
• Distances, amplitudes, and latencies for each site. A common diagnosis in the neurodiagnostic laboratory is that of
carpal tunnel syndrome (CTS). This is entrapment of the median
nerve at the wrist. The nature of CTS will be discussed in detail
Median Orthodromic Sensory Nerve Study Technique for later in this course. However, one must remember there are also
the Thumb three other sites along the median nerve that it may become
trapped (see Fig. 14).
The following is the procedure for the median orthodromic sensory
nerve study for the thumb. This study may be used to assess C6-C7 The following are the median nerve entrapment sites from distal
roots, upper or middle trunk, and lateral cord of the brachial to proximal:
plexus.
Figure 14 Transverse section across the wrist and digits.
1. At or around the elbow: Ligament of Struthers, pronator syn- the index and long fingers. Patients will be unable to make the
drome, and anterior interosseus syndrome. “OK” sign with their thumb and index finger, instead making a
“triangle” sign.
A. Ligament of Struthers: Here a fibrous band attached to a bony
spur on the humerus entraps the median nerve. Routine nerve 2. In the shoulder region: Fractures, dislocations, and soft tissue
conduction studies (NCSs) from the wrist and elbow may be involvement may result in median nerve entrapments here. These
normal with the pathology consisting of focal slowing and am- cases are rare but may be seen more often in a laboratory that has
plitude loss between the the elbow and axilla stimulation. This a great amount of access to a trauma unit or emergency room.
entity is rare.
3. In the plexus or root area: Crutch palsy, aneurysms , and carcino-
B. Pronator syndrome: This is caused by the median nerve be- mas as well as trauma may contribute to lesions at the root and
coming entrapped between the two heads of the pronator teres brachial plexus areas. In the brachial plexus the median nerve
muscle. Motor distal latencies and sensory nerve action poten- pathology may come from trauma to the lateral and/or medial
tials (SNAPs) are normal. Conduction velocity (CV) is slowed cords of the plexus. NCSs will show median CV slowing due to
across the proximal forearm. Needle electromyography (EMG) demyelination and/or amplitude loss if there is axonal involve-
is abnormal in the flexor pollicis longus (FPL) and the flexor ment if the lesion is in the plexus. Depending on the location of
digitorum profundus (FDP). The pronator teres is normal. This the lesion(s) in the plexus, other nerves may also be affected.
syndrome is aggravated by pronation of the forearm.
CTS is one of the most common diagnoses that will be made in
C. Anterior interosseous syndrome: This is caused by compression an EDX laboratory. At the wrist, the median nerve is surrounded
of the anterior interosseus nerve, a motor branch of the median by bones on the sides and thick ligaments on the top. Inside this
nerve, by fractures, dislocations, trauma, etc. in the forearm. area, along with the nerve, are tendons which occupy a great deal
Routine NCSs show normal motor unit action potentials of space. Any space-occupying lesion, edema, fractures, bleeding,
(MUAPs) and SNAPs. There will be a delay in latency when pregnancy, or constant repetitive movement may cause compres-
recording motor studies from the pronator quadratus (PQ). sion to the median nerve in this area.
Needle EMG abnormalities occur in the PQ, FPL, and FDP to
Table 1 Studies of normal control subjects at Willis-Knighton Medical

Electrodiagnostic Studies
Center EMG Laboratory
In CTS, the sensory response is usually the first to become in-
Motor and F wave studies volved. For digital sensory NCSs, a latency of greater than 4.0 ms is
Nerve Distal latency Conduction velocity Amplitude Distance used. For motor nerve studies, a distal motor latency of greater than
(ms) (m/s) (mV) (cm) 4.4 ms is considered abnormal. These values may differ depending
Median < 4.4 > 49 > 4.2 6.5 on the distal distance used. Remember, most CTS occurs bilater-
ally, so compare both median nerves to the ulnar nerve on the same
F wave < 31
side to rule out some sort of neuropathy. There are three types of
Ulnar < 3.5 > 49 > 5.6 6.5 CTS ranging from the mild type where only occasional symptoms
F wave < 31 are seen to the patients with positive physical examination (i.e.,
Sensory studies numbness, tingling, pain) and positive electrical findings to finally
the severe type where there is atrophy, chronic denervation, absent
Nerve Distal latency Conduction velocity Amplitude Distance
sensories, and prolonged to absent motor studies. It is in this last
(ms) (m/s) (mV) (cm)
type in which needle EMG studies are of the most help. Because
Median sensory studies are usually the first to be affected, the poorer the
Palm < 2.2 > 40 8.0 sensory study, in general, the worse the prognosis.
2nd digit < 3.5 > 10 13.0
There are several other NCS techniques that may be used in the
Ulnar
diagnosis of CTS. The technique is to perform antidromic median
Palm < 2.2 > 20 8.0 and ulnar sensory studies from the ring (4th) finger. Record from
5th digit < 2.9 >5 13.0 the metacarpal–phalangeal (m–p) joint using the same distal dis-
tance (12-14 cm) to the median wrist stimulation site and the ulnar
wrist stimulation site. In normal subjects the difference in distal
Figure 15 Right median motor nerve study of the abductor pollicis brevis muscle.
ABP = abductor pollicis brevis, Amp = amplitude, Elecl = electrical, Lat = latency, Mot = motor, Norm = normal, PW = pulse width, R = right, Seg = segment,
Vel = velocity
Table 2 Median nerve reference sites at Willis-Knighton Medical

Treatment for CTS covers a wide range of modalities. At one time,
Center EMG Laboratory
surgical intervention was considered the first method of treatment.
Today steroids, wrist splints, and other conservative measures are
Stimulation Recording Reference Ground often tried successfully. Job retraining to decrease repetitive move-
Motor ment has also been highly effective.
Wrist APB 3 cm distal Between active and
Elbow or proximal to active stimulator
BIBLIOGRAPHY
Axilla
Erb’s point 1. Aids to the examination of the peripheral nervous system, 2nd ed.
Sensory Pendragon House: Medical Research Council of the UK; 1976.
2. Crout B, Flicek C. Nerve conduction studies From A to Z.
Thumb Wrist Same as above Same as above Kansas City, MO: American Society of Electroneurodiagnostic
Index finger Thumb Technologists; 1997.
3. Dawson DM, Hallet M, Millender LH. Entrapment neuropathies.
Middle finger Index finger
Little, Brown & Company, 1983.
Palm Middle finger 4. Goodgold J. Anatomical correlates of clinical electromyography.
Wrist Baltimore: Williams & Wilkins; 1974.
5. Haymaker W, Woodhall B. Peripheral nerve injuries. In: Principles of
Elbow
diagnosis, 2nd ed. Philadelphia: Saunders; 1953.
6. Johnson E, ed. Practical electromyography. Baltimore/London:
ABP = abductor pollicis brevis Williams & Wilkins; 1980.
7. Kimura J. Electrodiagnosis in diseases of nerve and muscle: prin-
latencies between the two sites should be < 0.5 ms. This study may ciples and practice. Philadelphia: Oxford University Press; 2001.
also be done orthodromically. 8. Ma DM, Liveson JA. Nerve conduction handbook. Philadelphia: FA
Davis; 1983.
The second technique is to use the second lumbrical and first 9. Practical Electrodiagnosis Seminar. University of Texas Health
palmar interosseous as a recording site for median and ulnar anti- Science Center at San Antonio, 1990.
10. Preston D, Shapiro B. Electromyography and neuromuscular junc-
dromic sensory studies. Use the same distal distance (8-10 cm) to
tion disorders. Philadelphia: Elsevier; 2005.
the median and ulnar wrist stiulation sites. Again the difference in 11. Wikipedia.
distal latencies should be < 0.5 ms for normal subjects. This study 12. Woodburne R. Essentials of human anatomy. New York: Oxford
is also useful for detecting an ulnar neuropathy at Guyon’s canal University Press, 1978.
(see Fig. 15).

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Neuroanatomy for Nerve Conduction Studies

Kimberley Butler, R.NCS.T, CNIM, R. EP T.

AANEM 57th Annual Meeting

Copyright © October 2010

Printed by Johnson Printing Company, Inc.

Neuroanatomy for Nerve Conduction Studies

Ulnar and Radial Nerves 13

The Tibial and the Common Peroneal Nerves 21

Median Nerves and Nerves of the Face 27

Release Date: January 10, 2011

Accreditation and Designation Statements

Neuroanatomy for Nerve Conduction Studies

Kimberley B. Butler, R.NCS.T, R. EP T., CNIM Jerry Morris, MS, R.NCS.T.

Dr. Simmons is a consultant for Neuralstem, Inc. Any conflict

Course Chair: Zachary Simmons, MD

Kevin R. Scott, MD, MA Zachary Simmons, MD

The Spinal Accessory Nerve and

Table 1 Causes of spinal accessory neuropathy

Table 2 Causes of Brachial Plexopathy

MAC neuropathies generally arise from lesions that affect the

Lesions: Clinical Presentation

MAC neuropathy occurs in lesions of the medial cord or lower

Utility of Electrodiagnostic Testing

Lesions: Etiology Electrodiagnostic Testing

Normal values (Preston)9

1. To distinguish a radiculopathy from a plexopathy: As with the

2. To distinguish isolated musculocutaneous nerve involvement from

Lateral antebrachial cutaneous nerve9 (see Fig. 4) AXILLARY NERVE

Recording electrodes Anatomy

Lesions: Etiology Utility of Electrodiagnostic Testing

spinoglenoid notch.26,27 Causes of suprascapular nerve entrapment

Entrapment at the suprascapular notch usually is accompanied by

Electrodiagnostic Testing18 (see Figs. 6 and 7)

Table 3 Causes of lumbosacral plexopathy

THE LUMBOSACRAL PLEXUS: THE KEY TO Radiation

Table 4 Causes of femoral neuropathy

tive damage, either as a direct result of damage during varicose vein

Lesions: Clinical Presentation

Entrapment of the lateral femoral cutaneous nerve may occur as it

Ulnar and Radial Nerves

Kevin R. Scott, MD, MA

PART I: ULNAR NEUROPATHY

pected of an ulnar neuropathy at the elbow includes: a lower trunk or

Electrophysiology. As with other mononeuropathies, the electrodi-

Ulnar sensory responses are obtained and are usually compared to

Table 1 Common causes of ulnar neuropathy at the elbow

1. Old fracture with joint deformity

(i.e., a motor nerve conduction velocity < 50 m/s, or a motor nerve

Table 2 Electrodiagnostic evaluation of ulnar neuropathy at the

1. Nerve conduction studies (See Figs. 1-6)

The electrophysiology in this entrapment is often complex. Table 4

Table 4 Electrodiagnostic evaluation of ulnar neuropathy at the wrist1

1. Nerve conduction studies (See Figs. 1-7)

PART II: RADIAL NEUROPATHY

Differential diagnosis of wrist drop. The differential diagnosis

Table 1 Electrodiagnostic evaluation for evaluating radial

1. Nerve conduction studies (See Figs. 1-5)

Examine at least: two PIN-innervated muscles (e.g., extensor

Table 2 Electrodiagnostic findings in radial neuropathy1 REFERENCES (PART II)