An Electrophysiological Method for Examining Lumbosacral Root Compression

Electrodiagnostic studies and new diagnostic modalities for evaluation of peripheral nerve disorders

Electrodiagnostic studies (EDx) are frequently performed in the diagnostic evaluation of peripheral nerve disorders. There is increasing interest in the use of newer, alternative diagnostic modalities, in particular imaging, either to complement or replace established EDx protocols. However, the evidence to support this approach has not been expansively reviewed. In this paper, diagnostic performance data from studies of EDx and other diagnostic modalities in common peripheral nerve disorders have been analyzed and described, with a focus on radiculopathy, plexopathy, compressive neuropathies, and the important neuropathy subtypes of Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), vasculitic neuropathy and diabetic neuropathy. Overall EDx retains its place as a primary diagnostic modality in the evaluated peripheral nerve disorders. Magnetic resonance imaging and ultrasound have developed important complementary diagnostic roles in compressive and traumatic neuropathies and atypical CIDP, but their value is more limited in other neuropathy subtypes. Identification of hourglass constriction in nerves of patients with neuralgic amyotrophy may have therapeutic implications. Investigation of radiculopathy is confounded by poor correlation between clinical features and imaging findings and the lack of a diagnostic gold standard. There is a need to enhance the literature on the utility of these newer diagnostic modalities.

Ultrasound-guided caudal epidural steroid injection in chronic radicular low back pain: short-term electrophysiologic benefits

OBJECTIVE

To assess the short-term efficacy of ultrasound-guided caudal epidural steroid injections (ESIs) in improving pain, and nerve function as measured by electrophysiological testing in chronic radicular low back pain.

METHODS

Patients diagnosed with chronic radicular low back pain were randomized into one of two groups. The injection group (n = 20) underwent a single ultrasound-guided Caudal ESI of 1 ml of 40 mg ml-1 Triamcinolone Acetonide (Kenacort-A), with local anesthetic. The control group (n = 20) underwent a 12-session physiotherapy program. Both groups were evaluated before and 2 weeks after the intervention using visual analog scale for pain and electrophysiological testing comprising peroneal and tibial terminal motor latencies and F-response latencies and chronodispersion.

RESULTS

Both groups showed significant pain reduction on the visual analog scale after the intervention. The injection group showed a significant reduction in F wave chronodispersion post-treatment (<0.01). In the control group, there were no significant differences in F wave parameters pre- and post-treatment (p > 0.05).

CONCLUSION

Caudal ESIs were shown to provide short-term improvement of nerve function as evident by improvement in the electrophysiological parameters sensitive to radiculopathy. It was found to be superior to standard physical therapy in this regard.

ADVANCES IN KNOWLEDGE

This work shows a novel electrophysiologic evidence of the short-term efficacy ultrasound-guided caudal ESI.

Beneficial effects of footbaths in controlling spasticity after stroke

Footbaths are considered to provide beneficial thermal therapy for post-stroke patients with spasticity, but their anti-spastic effects have not been investigated comprehensively. The present study aimed to evaluate alterations in motor-neuron excitability using F-wave parameters in post-stroke patients with spastic hemiplegia. Subjects' legs below the knee joint were immersed in water at 41 degrees C and F-wave recordings were made over the abductor hallucis muscle before, immediately after, and 30 min after thermal treatment. Antidromic stimulation was performed on the tibial nerve at the ankle. Measurements included F-wave amplitude, F-wave/M-response ratio, changes in modified Ashworth scale (MAS), body temperature and surface-skin temperature. The mean values of both F-wave parameters were higher on the affected side before footbath treatment. In post-stroke patients, the mean values of F-wave parameters were significantly reduced after footbath treatment (P < 0.01). The anti-spastic effects of footbath treatment were indicated by decreased F-wave parameters, in parallel with decreases in MAS. Body temperature was significantly increased both immediately after, and 30 min following footbath treatment in both groups, which appeared to play an important role in decreased spasticity. Surface-skin temperature increased immediately after footbath treatment in both groups and returned to baseline 30 min later. These findings demonstrate that the use of footbaths is an effective nonpharmacological anti-spastic treatment that might facilitate stroke rehabilitation.

Factors influencing F-wave latency detection of lumbosacral root lesions using a detection theory based model

OBJECTIVE

To evaluate the F-wave dilution hypothesis; which implies that absolute F-wave latencies obscure the much smaller delay associated with slow intra-lesion conduction, such is caused by nerve root compression in lumbosacral radiculopathy. A corollary objective is to determine how F-wave measurement and pathological factors influence diagnostic accuracy.

METHODS

An analytical model is developed based on signal detection theory and a number of simplifying assumptions. Diagnostic accuracy, quantified by the area under the receiver operating characteristic (ROC) curve, is determined for various model realizations derived from the clinical and experimental neurophysiology literature. A preliminary experimental validation of model predictions is also performed.

RESULTS

Absolute F-wave latency does not influence the accuracy of focal lesion detection. F-wave latency variance and lesion pathology are the determinant factors. F-wave latencies and distal latencies are estimated to have qualitatively similar detection characteristics, although distal latencies have quantitatively better diagnostic efficacy for comparable focal pathology. Preliminary experimental results support the modeled dependence of diagnostic accuracy on latency variance and lesion severity.

CONCLUSIONS

Absolute F-wave latency does not dilute slow conduction within focal lesions, such as in lumbosacral radiculopathy. The dominant measurement factor is F-wave latency variance.

SIGNIFICANCE

To maximize the diagnostic utility of F-wave latencies, focus must be placed on reducing latency variance, such as through correction for demographic covariates. This model calls into question the F-wave dilution hypothesis.

Short-term effects of thermotherapy for spasticity on tibial nerve F-waves in post-stroke patients

Thermotherapy is generally considered appropriate for post-stroke patients with spasticity, yet its acute antispastic effects have not been comprehensively investigated. F-wave parameters have been used to demonstrate changes in motor neuron excitability in spasticity and pharmacological antispastic therapy. The present study aimed to confirm the efficacy of thermotherapy for spasticity by evaluating alterations in F-wave parameters in ten male post-stroke patients with spastic hemiparesis (mean age: 49.0+/-15.0 years) and ten healthy male controls (mean age: 48.7+/-4.4 years). The subjects were immersed in water at 41 degrees C for 10 min. Recordings were made over the abductor hallucis muscle, and antidromic stimulation was performed on the tibial nerve at the ankle. Twenty F-waves were recorded before, immediately after, and 30 min following thermotherapy for each subject. F-wave amplitude and F-wave/M-response ratio were determined. Changes in body temperature and surface-skin temperature were monitored simultaneously. The mean and maximum values of both F-wave parameters were higher on the affected side before thermotherapy. In the post-stroke patients, the mean and maximum values of both parameters were significantly reduced after thermotherapy (P<0.01). Hence, the antispastic effects of thermotherapy were indicated by decreased F-wave parameters. Body temperature was significantly increased both immediately after and 30 min after thermotherapy in all subjects. This appeared to play an important role in decreased spasticity. Surface-skin temperature increased immediately after thermotherapy in both groups and returned to baseline 30 min later. These findings demonstrate that thermotherapy is an effective nonpharmacological antispastic treatment that might facilitate stroke rehabilitation.

F-waves: neurophysiology and clinical value

This review deals with F responses, which are late responses obtained by supramaximal stimulation of virtually all the motor and mixed peripheral nerves. They are recorded over a muscle innervated by the stimulated nerve. The first description of F-waves was published in the fifties. Their neurophysiological mechanisms have been abundantly discussed in the literature leading to a current consensus, whereby F-waves are considered as antidromic responses produced by a pool of motoneurons activated by peripheral nerve stimulation. In the first part of this review, the neurophysiological mechanisms of F-waves as well as the distinction between these and H reflexes are described from a historical point of view. Other late responses are intentionally not reported; nevertheless A-waves are discussed since they are frequently ill-described in a number of conditions. Stimulation and recording procedures as well as F-wave parameters analysis are detailed, with emphasis on measures most useful for clinical purposes. A rigorous F-wave recording method is mandatory for reliable and meaningful analyses. Physiological factors, which influence F-waves such as ageing, drugs and sleep, must be known and their effects discussed. Also, as maturation is an important factor in clinical neurophysiology, data on F-wave ontogenesis are reviewed and discussed. Finally, the different F-wave alterations described so far in the literature, in either peripheral or central disorders, are listed and commented. It is emphasised that F-waves are particularly useful for the diagnosis of polyneuropathies at a very early stage and for the diagnosis of proximal nerve lesions. F-wave recording is indeed one of the rare methods in routine examination allowing at the same time the functional assessment of motor fibres on their proximal segment, and contributing to the evaluation of motoneuronal excitability.

Detection of lumbosacral nerve root compression with a novel composite nerve conduction measurement

STUDY DESIGN

Multivariate logistic regression techniques were used to develop a composite nerve conduction measurement that detects lumbosacral (L5, S1, or both) nerve root compression.

OBJECTIVES

To evaluate the diagnostic efficacy of a composite nerve conduction measurement for detection of lumbosacral nerve root compression.

SUMMARY OF BACKGROUND DATA

Nerve root involvement is characterized by clinical abnormalities and confirmed by radiologic and electrodiagnostic studies. Imaging studies visualize structural abnormalities; however, they are associated with high false-positive rates. Electrodiagnostic methods assess the physiologic integrity of the nerve roots. One form of electrodiagnostic testing, nerve conduction studies, is widely used for evaluation of musculoskeletal and neuromuscular complaints. Although similar clinical value is expected for the evaluation of nerve root compromise, prior applications of nerve conduction studies have yielded widely varying results.

METHODS

Two groups of subjects were compared. The L5-S1 compression group was composed of 25 patients with magnetic resonance imaging-confirmed lumbosacral (L5, S1, or both) nerve root compression and symptoms in the appropriate segmental distribution. The majority of subjects (22) had at least one of the following findings on physical examination: positive straight-leg raise test, diminished ankle reflexes, sensory loss, or weakness. The control group consisted of 35 asymptomatic individuals with no history of radiculopathy or potentially confounding neuropathology. The posterior tibial and deep peroneal nerves were evaluated bilaterally in all study subjects using standard nerve conduction procedures, which consisted of the measurement of distal motor latencies and F-wave latencies that assess nerve root pathophysiology. A composite nerve conduction measurement was determined using multivariate logistic regression analysis. The efficacy of the composite measurement was assessed by receiver operating characteristic curve analysis and by the diagnostic sensitivity and specificity.

RESULTS

Five F-wave latency parameters (peroneal mean F-wave latency, odds ratio = 0.42; peroneal seventh F-wave latency decile, odds ratio = 2.71; tibial mean F-wave latency, odds ratio = 8.90; tibial first F-wave latency decile, odds ratio = 0.47; tibial maximum F-wave latency, odds ratio = 0.44) were found to be predictive of nerve root compression. A composite nerve conduction measurement, NC composite, constructed from these five parameters (NC composite = exp(phi)/(1 + exp(phi)), phi = -31.2 + 1.0 * Per7 Decile - 0.88 * PerMean + 2.2 * TibMean - 0.88 * Tib1 Decile - 0.83 * TibMax) yielded an area under the receiver operating characteristic curve of 0.91. At a threshold of 0.20, NC composite had a diagnostic specificity of 84.3% and a sensitivity of 83.3%.

CONCLUSION

This preliminary study suggests that a novel composite nerve conduction measurement, based on F-wave latency parameters, may be highly effective at detecting magnetic resonance imaging-confirmed lumbosacral nerve root compression. Because these measurements provide objective evidence of functional nerve root compromise and are noninvasive, they may be of diagnostic value to clinicians evaluating patients presenting with low back and leg pain.

H reflexes and F waves. Fundamentals, normal and abnormal patterns

H reflexes and F waves have become integral parts of the electrodiagnostic examination in general, and nerve conduction studies in particular. They supplement the sensory and motor conduction studies by assessing the entire nerve segments including proximal portions of the motor and sensory axons. H reflexes and F waves have their own advantages and limitations, similarities and differences. These "late" responses are useful in patients with radiculopathies, plexopathies, and peripheral polyneuropathies, including the Guillain-Barre syndrome. They are also helpful in spinal cord disorders.

Electrophysiology of radiculopathies

The anatomy, pathophysiology, and clinical evaluation of radiculopathies are discussed. Defining whether root injury is present and which roots are involved can be difficult but critical for patient management. In conjunction with clinical and radiological information, studies that establish physiological abnormalities of roots should be helpful and important. Clinical neurophysiological studies for radiculopathies are performed frequently but have yet to achieve a universally accepted role in the evaluation of these patients. Electrophysiological techniques for the evaluation of radiculopathies are reviewed. Needle electromyography is the best established of these procedures but has the disadvantage of requiring injury to motor fibers of both a certain degree and distribution. Nerve conduction studies may rarely be abnormal in radiculopathies but are needed to be certain other conditions that may produce similar symptoms and signs are not present. H reflexes and F waves probably have roles in the evaluation of radiculopathies but published reports about F waves in radiculopathies have been marred by inadequate methodology. There is evidence based on large series of patients that somatosensory evoked potentials can be helpful for evaluating patients with multilevel injury such as spinal stenosis, patients where electrophysiological studies may have their greatest clinical utility. Further work using either electrical stimulation with needles or magnetic stimulation of roots seems warranted. The demonstration of meaningful electrophysiological changes with activities that reproduce radicular symptoms may be a promising experimental approach. Available information does not necessarily answer critical questions about the role of electrophysiology in patients with radiculopathies. This cannot be done using analyses based on current ideas about evidence based medicine given the absence of a 'gold standard' for defining radiculopathies as well the absence of blinded studies. The available information provides strong arguments for further investigations evaluating different clinical neurophysiological techniques in the same patient, and for evaluating the value of these techniques by concentrating on their clinical import.

Radial nerve F-waves: normative values with surface recording from the extensor indicis muscle

OBJECTIVES

In the present study we set out to obtain normative values for radial nerve F-waves, with surface recording from the extensor indicis muscle.

METHODS

Forty-nine patients with unrelated complaints were tested. Surface recording electrodes were placed on the extensor indicis muscle. This was found by asking the patient to extend the second digit against resistance. The active surface recording electrode was placed over the most distal portion of the muscle, near the radial border of the ulnar bone near the wrist. Stimulation was performed near the lateral epicondyle between the radial and ulnar bones.

RESULTS

The mean F-wave minimum latency was found to be 20.55 ms, with an upper limit of 24.35 ms. The absolute interside minimum latency difference was found to have a mean of 0.55 ms, with a maximum of 1.7 ms. The mean amplitude of the F-waves was 145.61 microV and the mean mF/M ratio was 0.022. F-waves were unobtainable in 2/62 (3.2%) of limbs. Normative values for the radial nerve motor response were also obtained. Three cases are described to illustrate the usefulness of the above technique.

CONCLUSIONS

It is technically feasible to record radial nerve F-waves from the extensor indicis muscle.

Comparison of motor conduction abnormalities in lumbosacral radiculopathy and axonal polyneuropathy

We compared the frequencies and types of motor conduction abnormalities found in peroneal and tibial nerves of patients with either L5/S1 radiculopathies (n = 47) or axonal polyneuropathies (n = 49). In axonal neuropathies, compound muscle action potentials (CMAPs) were more likely to be either unobtainable or, if present, of low amplitude, prolonged in distal latency or both. F responses were more often absent, impersistent, or prolonged in minimal latency. In contrast, CMAPs in lumbosacral radiculopathies were more likely to be normal in both amplitude and distal latency. The most frequent F-response abnormality in radiculopathies was a prolonged maximum-minimum latency range rather than abnormalities of minimal latency or persistence. Logistic regression analysis demonstrated that different patterns of motor conduction abnormalities result from lumbosacral radiculopathy and distal axonopathies. The model was able to correctly classify disease state in 76% of subjects with a sensitivity of 74% and specificity of 80%.

Clinical neurophysiologic studies: which test is useful and when?

Neurophysiological studies test the integrity of nerve roots and nerves at different points from the spinal cord to the periphery. EMG is the most sensitive neurophysiological test for evaluating patients with radiculopathy, providing information on diagnosis, location, and prognosis. F-wave and H-reflex studies may be abnormal, but the information that they provide is nonspecific and usually redundant because the needle examination is abnormal anyway. Somatosensory evoked potentials are less sensitive and specific than EMG for diagnosing a radiculopathy, but uncommonly may be the only abnormality. Magnetic stimulation, paraspinal mapping, and cervical root stimulation are investigational techniques of uncertain utility.

AAEM minimonograph 32: the electrodiagnostic examination in patients with radiculopathies. American Association of Electrodiagnostic Medicine

The anatomy and pathophysiology of radiculopathies are reviewed, and the electrodiagnostic approaches used in evaluating patients with suspected root lesions are discussed. Such electrophysiologic procedures include motor and sensory nerve conduction studies, late-response studies, somatosensory and motor evoked potentials, nerve root stimulation, and needle electromyography. The value and limitations of these different procedures are considered. At the present time, needle electromyography is the single most useful approach. The findings in patients with radiculopathies at different levels are summarized.

The value of magnetic stimulation in the diagnosis of radiculopathies

We studied 42 patients with cervical and lumbar radiculopathies using magnetic stimulation. Prolonged latencies following magnetic stimulation of the brain, the paravertebral spinal nerve, or both, showed a highly significant correlation with muscle weakness in clinical testing (24 of 26 patients with weakness had pathological motor evoked potentials) as well as with spontaneous activity of the target muscles in needle electromyography (24 of 25 subjects). The determination of both the central and the peripheral motor conduction time was found to be essential in patients with radiculopathies, because different patterns of latency changes correlated with different morphological results in computed tomography: in patients diagnosed as having a lateral compression of the nerve root the peripheral nerve latency was delayed; whereas, in patients with more medially localized herniations, a prolonged central motor latency was the most frequent finding. This study posits that combined magnetic stimulation of the brain and nerve root is an effective and painless technique for the noninvasive evaluation of nerve root function.

AAEM Minimonograph #13: H reflexes and F waves: physiology and clinical indications

Motoneurons can be activated both reflexly and antidromically following electrical stimulation of peripheral nerves. These H reflexes and F waves are clinically useful responses which interface at the level of the peripheral nerves and the spinal cord. Because these responses are commonly employed in the electrodiagnostic evaluation of patients, an understanding of their physiology and clinical applications is important. These are reviewed. Reasoning from the physiology, both the value and limitations of H-reflex and F-wave studies are considered for disorders of peripheral nerves, roots, and the central nervous system. Theoretical concepts about the physiology and pathophysiology of the nervous system based on H-reflex and F-wave data are also discussed.

Somatosensory evoked potentials from cervical and lumbosacral dermatomes

A method for recording the somatosensory evoked potentials after stimulation of the cervical and lumbosacral dermatomes is described. Normative values and their ranges are given for each dermatome including left-right differences. A significant correlation was found between latencies and conduction distance. Dermatomal SEPs may play a role in diagnosing cervical and lumbosacral radiculopathies.

Motor evoked responses after lumbar spinal stimulation in patients with L5 or S1 radicular involvement

Motor evoked responses were recorded bilaterally in the tibialis anterior and soleus muscles after lumbar spinal stimulation in 45 patients suffering from L5 or S1 radiculopathies due to disc protrusion, and in 25 healthy controls. A significant prolongation (P less than 0.01) of motor evoked response latency was observed in 72% of the patients with L5 radiculopathy and in 66% of the patients with S1 radiculopathy. These anomalies were observed in patients with objective neurological signs as well as in patients free of objective signs. These findings indicate that subclinical compressive radiculopathy can be detected by this method which represents a useful adjunct in the assessment of radicular pain of discopathic origin.

AAEE minimonograph #32: the electrophysiologic examination in patients with radiculopathies

A brief history of the evolution of radiculopathy as a clinical entity, and the use of electrodiagnostic studies to diagnose it, are provided. Root anatomy and the concept of myotomes and dermatomes are reviewed, as is the pathophysiology of radiculopathy. The value and limitations of the various electrophysiologic procedures used in the diagnosis of radiculopathies are discussed, including motor and sensory nerve conduction studies, late responses, somatosensory evoked potentials, nerve root stimulation, and the needle electrode examination. The specific muscles are enumerated which most often appear abnormal on needle electromyography with lesions of the various roots. The electrodiagnostic differentiation of root lesions from plexus lesions is described, and the various electrodiagnostic findings with lumbar canal stenosis are discussed. Finally, the value and limitations of the electrodiagnostic assessment in the evaluation of patients with suspected radiculopathies are reviewed.

Somatosensory evoked potentials from posterior tibial nerve and lumbo-sacral dermatomes

Techniques for recording the somatosensory evoked potential following stimulation of the skin of L5 and S1 dermatomes are described and validated. Normal data and their range are given for 54 subjects (108 legs). The latency of the peak of the first positive wave (P40) can be predicted from the subject's height from the regression formulae: P40 latency in msec = height in metres X 23.7 + 8.6 for the L5 dermatome. P40 latency in msec = height in metres X 24.5 + 8.7 for the S1 dermatome. P40 latency in msec = height in metres X 15.0 + 14.6 for the posterior tibial nerve. The standard deviations are 2.90 for L5; 2.95 for S1 and 1.60 for the posterior tibial nerve. Age and sex of the subjects had no significant effect. The data will have value when dermatomal somatosensory evoked potentials are used to investigate radiculopathies.

F-response behaviour in a control population

Various parameters of the F-response including minimal and maximal latency, chronodispersion, amplitude (absolute and F%M) and duration have been determined for a sample of 20 responses in the median and ulnar nerves bilaterally in normal healthy subjects of both sexes aged between 12 to 81 years. Side to side comparisons revealed no significant differences in any of the parameters except for slightly longer minimum F latencies in the right median nerve. Strong correlations were found between minimal and maximal F latencies and height, while much weaker relationships were found between these parameters and age. There was a slight but significant relationship between F%M and age, but no age or sex related changes were noted for any of the remaining F-response parameters.

Principles and pitfalls of nerve conduction studies

This report reviews the fundamental principles and the changing concepts of nerve stimulation techniques, and discusses the proper application of these techniques in the differential diagnosis of peripheral nerve disorders. Nerve conduction studies help delineate the extent and distribution of the neural lesion and distinguish two major categories of peripheral nerve disease: demyelination and axonal degeneration. Although the method is based on simple principles, pitfalls abound in practice. Variability in nerve conduction measurement may result from temperature change, variations among nerve segments, and the effects of age. Other sources of error include excessive spread of stimulation current, anomalous innervation, temporal dispersion, and inaccuracy of surface measurement. Unlike a bipolar derivation, which selectively records near-field potentials, a referential recording may give rise to stationary far-field peaks from a moving source. Overlooking this possibility can lead to an incorrect interpretation of findings. Conventional nerve conduction studies deal primarily with measurements of the distal nerve segments in an extremity. More recent techniques are applicable to less accessible anatomical regions, as illustrated by elicitation of the blink reflex, F wave, and H reflex, and the use of the inching technique. Other methods used to assess special aspects of nerve conduction include the ischemic test and studies of slow-conducting fibers.

Is the F wave elicited in a select group of motoneurons?

The F wave represents only a small percentage of the motoneuron pool invaded antidromically by any single impulse. We studied 22 median nerves from 11 healthy subjects to determine whether the recurrent discharges are preferentially generated in a select group of motoneurons with certain physiologic characteristics. Partial excitation of the nerve elicited the F wave with no consistent bias toward either the lower or higher threshold motor fibers. When the fast conducting axons were progressively blocked using a collision technique, the F wave continued to appear in the remaining slow conducting axons which escaped the collision. We conclude that the recurrent discharges occur in approximately 1% of antidromically activated motoneurons irrespective of their peripheral excitability or conduction characteristics.

Evaluation of radiculopathies by segmental stimulation and somatosensory evoked potentials

Thirty-six patients with suspected or myelographically proven radiculopathies were investigated with motor and sensory conductions, F-waves, needle electromyography, and somatosensory evoked potentials (SEPs). SEPs were elicited by cutaneous nerve stimulation representative of input from individual cervical and lumbosacral dorsal roots. A myelographic defect was present in 83% of 30 patients who had myelograms. Overall 78% of patients had one or more abnormal electrophysiologic tests, the needle EMG giving the best diagnostic yield (75%). F-waves and SEPs were abnormal in 43% and 57% of cases respectively. Motor deficit correlated best with abnormal EMGs, whilst abnormal SEPs occurred most frequently when sensory deficit predominated. Prolonged latency of the SEP occurred rarely, reduced amplitude or abnormal morphology being the most useful characteristics. SEPs evoked by cutaneous nerve stimulation are a useful addition to conventionally available electrophysiological methods of evaluating radiculopathies, especially in the absence of motor deficit.

Somatosensory conduction times and peripheral, cervical and cortical evoked potentials in patients with cervical spondylosis

Peripheral, cervical and cortical somatosensory evoked potentials after median or ulnar nerve stimulation were recorded in 21 patients with cervical spondylosis with radiculopathy or myelopathy. The test was normal when pain and paraesthesias were the only symptoms, while pathological in radiculopathy with objective neurological signs. The results varied in patients with cervical myelopathy.

Distal slowing of motor nerve conduction velocity in diabetic polyneuropathy

Using the latencies of M response and F wave, motor nerve conduction was assessed along the entire course of the nerve from the spinal cord to the muscle in 102 diabetics and 74 control patients. In diabetics, latencies were increased and conduction velocity decreased over both proximal and distal segments. However, the latency ratio of the proximal to distal segment (F ratio) was slightly but significantly smaller in diabetics (mean +/- SD:0.93 +/- 0.14, 1.35 +/- 0.20, 1.09 +/- 0.19 and 1.02 +/- 0.19 for median, ulnar, tibial and peroneal nerves, respectively) than in control patients (1.05 +/- 0.09, 1.41 +/- 0.12, 1.17 +/- 0.13 and 1.08 +/- 0.12). These findings suggest that motor conduction abnormalities in diabetic polyneuropathy are diffuse over the total length of the nerve, but more intense in the distal than proximal segment. An additional finding in diabetics was that both proximal and distal segments were more frequently affected in the lower than in the upper extremities.

Characteristics of the F response: a single motor unit study

Trains of 100 to 200 stimuli result in F discharges from less than one half of motor units of hand muscles. The maximum observed F discharge frequency was 10%. There was no relation between the surface voltage of motor unit potentials and the frequency of F discharge. The motor unit potentials of larger surface voltage were recruited at higher stimulus intensity levels, usually supramaximal for the antidromic sensory nerve action potential. No correlation was observed between F latency and the surface voltage of the motor unit potentials. In only one pathological example was a clear interaction observed between the frequency of F discharge in motor unit potentials and the recruitment of other single motor unit potentials by increments in the stimulus intensity. The observations suggested that caution should be exercised before the F discharge is accepted as a method for measuring proximal conduction times in human motor nerves.

F-wave and cervical somatosensory response conduction from the seventh cervical spinous process to cortex in multiple sclerosis

Transit (conduction) times from the wrist to the seventh cervical spinous process (C7) were measured by using the F-wave response (TA) and the cervical somatosensory response (SEPC). The mean values obtained in 25 controls were 10.1 +/- 0.9 s-3 and 10.9 +/- 1.0 s-1 respectively. The 0.8 +/- 1.0 s-3 difference between the two methods represents central delay of SEPC, possibly at the level of the dorsal root ganglion. The mean onset latency of the cortical somatosensory response (SEPA) evoked by median nerve stimulation in the same subjects was 15.5 +/- 1.0 s-3. Transit time from C7 to the cortex (TB) given by either SEPA - TA or SEPA - SEPC - 0.8, where 0.8 is the necessary corrective factor for central delay of SEPC, WAS 5.3 +/- 1.0 S-3. These techniques were applied to 10 patients suspected of having multiple sclerosis, but without clinical evidence of involvement above C7. Six of the 10 cases showed prolongation of TB. In 4 of these, this could only be calculated by the F-wave method since SEPC was absent. It is concluded that transit times derived from either the F-wave or SEPC are equally valid and interchangeable. The absence of one response allows for its replacement by the other.

Analysis of evoked lumbosacral potentials in man

Surface electrodes have been used to record potentials evoked in the lumbosacral region of 15 healthy volunteers after tibial nerve stimulation. By monitoring the M waves and H reflexes in the triceps surae muslces and by comparing the responses recorded over the roots with those over the lower cord, it was possible to identify the neural substrates responsible for several of the components in the responses. The findings are compared with those of previous studies in man and in other mammalian preparations.