Surface recording of orthodromic sensory nerve action potentials in median and ulnar nerves in normal subjects

Antidromic vs orthodromic sensory median nerve conduction studies

Objective

Median sensory nerve conduction studies are arguably the most often performed electrodiagnostic tests worldwide. Routine tests in clinical practice are done using either antidromic or orthodromic techniques type of stimulation, with no universal agreement on the use of one or the other technique.

Methods

We review the advantages and drawbacks of antidromic and orthodromic as well as their particularities for clinical application and research.

Results

The two techniques differ on how physical and physiological changes affect the action potential. Near-nerve recording is better suited for the orthodromic than for the antidromic technique, while studies of nerve excitability are better suited for the antidromic than for the orthodromic technique.

Conclusion

Both techniques are equally suitable for routine tests but research studies may specifically demand one or the other.

Compound sensory action potential in normal and pathological human nerves

The compound sensory nerve action potential (SNAP) is the result of phase summation and cancellation of single fiber potentials (SFAPs) with amplitudes that depend on fiber diameter, and the amplitude and shape of the SNAP is determined by the distribution of fiber diameters. Conduction velocities at different conduction distances are determined by summation of SFAPs of varying fiber diameters, and differ in this respect, also, from the compound muscle action potential (CMAP) for which conduction velocities are determined by the very fastest fibers in the nerve. The effect and extent of temporal dispersion over increasing conduction distance is greater for the SNAP than CMAP, and demonstration of conduction block is therefore difficult. In addition, the effect of temporal dispersion on amplitude and shape is strongly dependent on the number of conducting fibers and their distribution, and, with fiber loss or increased conduction velocity variability changes of the SNAP may be smaller than expected from normal nerve. The biophysical characteristics of sensory and motor fibers differ, and this may to some extent determine divergent pathophysiological changes in sensory and motor fibers in different polyneuropathies. In this review, different factors that characterize sensory fibers and set the SNAP apart from the CMAP are discussed to emphasize the supplementary and complementary information that can be obtained from sensory conduction studies. Sensory conduction studies require particular effort and attention to theory and practical detail that may be time consuming.

Large amplitude sensory action potentials in myelopathy: an observation

Subjects with at least one sensory action potential (SAP) amplitude greater than 2 SD above the age-matched mean during standard nerve conduction tests were evaluated for evidence of spinal cord disease. From a total of 153 subjects, 16 had at least one large amplitude SAP and 12 of 16 (75%) had a documented myelopathy. While a mechanism has yet to be determined, this observation suggests that SAP amplitudes greater than 2 SD above normal may be correlated with clinical evidence of injury to the central nervous system.

The optimal recording electrode configuration for compound sensory action potentials

There is no uniformity in the published literature from different laboratories on the optimal electrode configuration for recording nerve action potentials, and a number of standard texts omit any reference to the effects that interelectrode distance and electrode orientation can have on the shape, amplitude and latency of nerve action potentials. The sensory action potential from the digital nerves of the index finger was recorded at wrist and elbow using bipolar electrodes with the "active" electrode over the median nerve and the "reference" placed 4 cm laterally or proximally along the nerve using interelectrode distances of 4, 3 and 2 cm. These potentials were compared with that recorded using a remote reference on the ipsilateral shoulder, the assumption being that this configuration eliminated the contribution of the reference electrode to the compound nerve action potential. With different electrode configurations, there were significant differences in the shape of the potential, the latencies to onset and peak and the rising- and falling-phase amplitudes. The shorter the distance between the electrodes the greater the distortions. Overall, the distortions were least with the 4 cm interelectrode separation, particularly for short conduction distances.