Criteria for conduction block based on computer simulation studies of nerve conduction with human data obtained in the forearm segment of the median nerve
1 Department of Clinical Neurophysiology, Neuromuscular Research Group, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht The Netherlands 2 Department of Neurology, Neuromuscular Research Group, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht The Netherlands.
Correspondence to: H. Franssen, MD, PhD, Department of Clinical Neurophysiology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands E-mail: h.franssen{at}umcutrecht.nl
The finding of conduction block (CB) on nerve conduction studies supports the diagnosis of potentially treatable immune-mediated neuropathies. CB in a number of axons may result in reduction of the compound muscle action potential (CMAP) on proximal versus distal stimulation (decrement). Decrement may also result from increased temporal dispersion (TD) as this leads to desynchronization and phase cancellation of the motor unit action potentials (MUAPs) out of which the CMAP is built up; polyphasia of MUAPs possibly yields additional decrement. To prove the occurrence of CB, decrement has to be larger than can be explained by increased TD or increased phase cancellation. This was established previously by simulations using MUAPs recorded in rats assuming maximal TD. Unfortunately, criteria based on human data and criteria for nerves with limited TD are not available. In the present study, criteria for CB were derived using simulations with thenar surface recorded MUAPs affected by collateral reinnervation that were obtained in patients with lower motor neurone disease (LMND). The effect of TD on decrement was determined for a wide range of TDs in the forearm segment of the median nerve and the segment distal to this. Our criteria for CB were based on area decrement because this was less influenced by TD and more by CB than amplitude decrement. The maximal area decrement in the forearm segment increased as TD in the forearm segment increased but decreased as TD in the distal segment increased. This suggests that, when desynchronization and phase cancellation occur in the distal segment due to TD, less phase cancellation and, therefore, less decrement can occur due to TD in the forearm. The finding that duration prolongation on proximal versus distal stimulation reflected TD within the forearm segment and that distal duration reflected TD in the distal segment allowed proposal of a more flexible set of criteria for forearm segments when TD in the forearm segment is limited or TD in the distal segment is pronounced. A separate investigation showed that the maximal TD in chronic inflammatory demyelinating polyneuropathy was within the range of our simulations, indicating that these were realistic. Our criteria were validated retrospectively in patients with multifocal motor neuropathy and patients with LMND. In the forearm segment of the median nerve, our criteria were more sensitive and equally specific for CB as compared with criteria for CB based on the study using rats. Our criteria have to be evaluated prospectively.
Key Words: conduction block; diagnosis; neuropathy
Abbreviations: CB, conduction block; CIDP, chronic inflammatory demyelinating polyneuropathy; CMAP, compound muscle action potential; LMND, lower motor neurone disease; MMN, multifocal motor neuropathy; MUAPs, motor unit action potentials; TD, temporal dispersion
Received October 29, 2005. Revised June 22, 2006. Accepted June 26, 2006.