Wrist, Elbow – Digit II, III; Wrist – Digit II, III

and Mario Di Napoli1



(1)
Neurological Service, S. Camillo de’ Lellis General Hospital, Rieti, Italy

 




Original Settings

Sensitivity was 10–20 μV/division, and the machine used was a TECA model B. Sweep speed, low frequency filter, high-frequency filter, duration of pulse, and rate of pulse were not specified.


Position

This study was performed in the supine position, with the elbow and fingers slightly flexed.


Recording

Following the antidromic method [1], signals were recorded 14 cm distally from the wrist to digit II and digit III (Figs. 1 and 2). Each recording was made separately. The active electrode (A) was placed to the base of the digit, and the reference (R) was placed 4 cm proximally to the active electrode, slightly distal to the distal interphalangeal joint. Ground (G) electrode was usually placed over the midforearm, and on occasion, it was placed between the stimulating cathode and the active electrode to diminish a shock artifact, on the palm of the hand (the figure shows the ground electrode placed on the palm). The authors used moistened pipe cleaner for recording from the distal sensory fibers of the median nerve.

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Fig. 1
Antidromic sensory nerve action potentials (SNAPs) recorded to digit II, stimulation of the wrist (upper trace) and of the elbow (lower trace)


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Fig. 2
Antidromic sensory nerve action potentials (SNAPs) recorded to digit III, stimulation of the wrist (upper trace) and of the elbow (lower trace)


Stimulation

For both digit II and digit III recordings, the median nerve was stimulated at the wrist (S1) and at the elbow (S2). At the wrist (S1), the active stimulating electrode (cathode) was applied 14 cm proximal to the active electrode at the base of the digit, over the median nerve at the wrist, between the tendons of the flexor carpi radialis (FCR) and the palmaris longus (PL) muscles (ideally proximal to the distal wrist crease). The anode (+) was proximal. Distal stimulation (S1) determined distal evoked sensory nerve action potentials (SNAPs), while proximal stimulation at the elbow (S2), just above the crease of the antecubital fossa and medial to the biceps tendon at the elbow, allowed the determination of the forearm mixed nerve conduction velocity. In case of stimulation at the elbow (S2), the authors suggested 2–4-cm separation between the cathode (−) and anode (+), using a pair of standard 0.6-cm-diameter electroencephalograph electrodes mounted on a plastic block for stimulating the nerve. Sensory antidromic nerve conduction study to digit II and digit III can be also performed by wrist stimulation alone (Figs. 3 and 4). Supramaximal stimulation was used; stimulus in all determinations was at least 30 % greater than that which elicited a maximum response.

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Fig. 3
Antidromic sensory nerve action potential (SNAP) recorded to digit II, stimulation of the wrist


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Fig. 4
Antidromic sensory nerve action potential (SNAP) recorded to digit III, stimulation of the wrist


Measurements

Distal peak latency (ms) was measured from the beginning of the shock artifact to the peak of the negative deflection of the SNAP. Measurement of length was made using a metal tape measure; the nerve length was measured with the arm in the position of stimulation. The finger–wrist segment was measured with the wrist as close as possible to a 180° position. Sensory nerve conduction velocity (SNCV) was calculated in the conventional way and measured meter per second (m/s). Temperature was not controlled (studies were done at room temperature). The authors studied 48 healthy subjects (Table 1); separate digit II and digit III values were not reported.


Table 1
Reference values [1]













Normal values (21 subjects)

Mean ± SD

Digit–wrist, peak latency (ms)

3.2 ± 0.25













Normal values (36 subjects)

Mean ± SD

Digit–wrist, SNCV (m/s)

57.4 ± 3.8


Comment

Melvin et al. [1] studied a group of 48 healthy subjects, and antidromic sensory studies were performed in 36 of them. They described no important differences between antidromic and orthodromic conduction velocities, although the antidromic velocities generally were slower and require less time when done in conjunction with a motor latency and were usually somewhat easier to obtain. They did not specify sensory digit II and digit III values. It can be useful if active recording electrode is placed slightly distal to the base of the digit in order to avoid volume-conducted muscle response from the activated adjacent hand intrinsic muscles innervated by the median nerve. The authors did not perform this nerve conduction technique on patients, and pathological values were not reported.

Mavor and Shiozawa [2] recorded antidromic median sensory responses in 21 normal (Table 2) subjects (16 men and 5 women, age range 15–71 years) using surface ring electrodes for recording to the first interphalangeal joint of digit II. The reference electrode was placed 3 cm distally to the same finger. The authors used 30 % supramaximal stimulation with 0.2-ms duration. Skin temperature was measured using a thermistor at the elbow, wrist, palm, and finger before and after each test in all subjects. When necessary, the arm was immersed in 40 °C water for ten minutes. Latency was measured from the onset of stimulus to the initial negative deflection of the sensory response, and latencies between the elbow and wrist were calculated by subtraction. The distances between cathode stimulation sites and active recording sites at the levels of the wrist and elbow were measured using a millimeter tape. They also performed antidromic nerve conductions recording from digit III (R) and stimulating at the level of the wrist (S1) and at the elbow (S2). They did not use a fixed distance between the recording and stimulation sites. Distances between wrist (S1) and elbow (S2) stimulations were taken using a measuring tape, and latencies for antidromic conduction between the elbow and wrist were calculated by subtraction. In all subjects, careful attempts were made to control skin temperature; right hands were warmed in 40 °C hot water before each test. The authors used supramaximal stimulation (greater than 30 %) and 0.2-ms duration. Onset latencies, negative peak latencies, negative peak amplitude, peak to peak amplitude, and nerve conduction velocity (in the wrist–elbow and wrist–digit III segments) were calculated. Values for two subjects were eliminated because of substantial interference by muscle action potential after elbow stimulations.


Table 2
Reference values [2]












































Normal values

Mean ± SD

Range

Wrist–digit III, SNCV – onset latency (m/s)

53 ± 4.7

43–63

Wrist–digit III, SNCV – peak latency (m/s)

44 ± 4.0

36–56

Elbow–wrist, SNCV – onset latency (m/s)

60 ± 5.9

49–71

Elbow–wrist, SNCV – peak latency (m/s)

57 ± 6.0

46–71

Wrist–digit III, negative peak amplitude (μV)

21 ± 9.1

10–42

Wrist–digit III, peak to peak amplitude (μV)

17 ± 10.5

5–44

Elbow–digit III, negative peak amplitude (μV)

10 ± 4.7

5–23

Elbow–digit III, peak to peak amplitude (μV)

33 ± 17.6

13–76

Melvin et al. [3] studied 24 dominant hands of 24 healthy volunteers (Table 3) and 17 dominant wrist from 17 patients (Table 4) with carpal tunnel syndrome (CTS), using surface ring electrodes for recording to digit II (active and reference electrodes were placed 4 cm apart on the finger) and stimulating the cathode placed 14 cm proximal to the active electrode at the wrist. They measured distal latencies (ms), forearm velocities (m/s), amplitudes at the wrist and at the elbow (μV), and the duration of the antidromic sensory responses at the wrist and at the elbow (ms). Separate digit II and digit III values were not reported.


Table 3
Reference values [3]




































Normal values

Mean ± SD

Range

Wrist–digit, distal latency (ms)

3.2 ± 0.2

2.9–3.7

Elbow–wrist, SNCV (m/s)

56.9 ± 4.0

48.0–64.9

Wrist–digit, amplitude (μV)

41.6 ± 25.0

10.0–90.0

Elbow–digit, amplitude (μV)

29.2 ± 20.9

7.0–75.0

Wrist–digit, duration (ms)

1.8 ± 0.4

1.2–2.4

Elbow–digit, duration (ms)

2.4 ± 0.7

1.5–3.5



Table 4
Reference values [3]


















Pathological values

Mean ± SD

Range

Wrist–digit, distal latency (ms)

4.9 ± 8.5

3.7–6.2

Elbow–wrist, SNCV (m/s)

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May 25, 2017 | Posted by in NEUROLOGY | Comments Off on Wrist, Elbow – Digit II, III; Wrist – Digit II, III

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