Who orders and performs nerve conduction studies?

Who Performs Nerve Conduction Studies

Nerve conduction studies (NCS) are ordered by physicians—most commonly neurologists, physiatrists (physical medicine and rehabilitation specialists), orthopedic surgeons, and primary care physicians—and are performed by trained electrodiagnostic physicians, which typically include neurologists and physiatrists who have completed specialized training in electrodiagnostic medicine. 1, 2, 3

Ordering Providers

The following physicians commonly order nerve conduction studies based on clinical indications:

• Neurologists order NCS when evaluating patients with suspected peripheral neuropathy, radiculopathy, plexopathy, or focal nerve entrapments 4, 1
• Primary care physicians order NCS for patients presenting with numbness, tingling, weakness, or pain in the extremities that suggests peripheral nerve involvement 4, 5, 6
• Orthopedic surgeons order NCS to localize nerve dysfunction (root versus plexus versus peripheral nerve) and to evaluate nerve injuries in the context of musculoskeletal disorders 2, 3
• Physiatrists order NCS as part of comprehensive neuromuscular evaluations 2, 3
• Rheumatologists order NCS when vasculitic neuropathy or inflammatory conditions affecting peripheral nerves are suspected 4

Performing Providers

• Board-certified neurologists with electrodiagnostic training perform the majority of nerve conduction studies and needle electromyography 1, 7, 3
• Physiatrists (PM&R physicians) with electrodiagnostic certification are equally qualified to perform comprehensive electrodiagnostic studies 2, 3
• Specialized training in electrodiagnostic medicine is required, as interpretation demands thorough knowledge of peripheral neurophysiology, anatomy, and related pathological conditions 6, 3

Clinical Context and Indications

When NCS Should Be Ordered

• Atypical presentations including asymmetric distribution, rapid progression over weeks to months, or predominant motor weakness warrant electrodiagnostic evaluation 1, 8
• Diagnostic uncertainty after initial clinical and laboratory work-up requires NCS to differentiate between axonal and demyelinating patterns 1, 8
• Suspected entrapment neuropathies such as carpal tunnel syndrome or ulnar neuropathy at the elbow benefit from NCS to confirm diagnosis and localize the lesion 9, 7, 3
• Evaluation of mononeuritis multiplex in conditions like polyarteritis nodosa requires combined nerve and muscle biopsy along with NCS 4

When NCS Is NOT Required

• Classic distal symmetric diabetic neuropathy with stocking-glove distribution, reduced ankle reflexes, and known risk factors can be diagnosed clinically without electrodiagnostic testing 4, 1, 8
• Routine monitoring of stable peripheral neuropathy should rely on serial neurologic examinations rather than repeated NCS, as the latter adds cost without changing management 4, 8
• Clinical examination using 10-g monofilament testing combined with at least one other neurological assessment (vibration, proprioception, or ankle reflexes) is sufficient to diagnose loss of protective sensation in typical cases 4, 1, 8

Technical Aspects

• NCS involves delivery of electrical stimuli to peripheral nerves at accessible body locations and recording of electrophysiological responses to quantify nerve conduction velocity and amplitude 5, 7, 3
• Motor nerve conduction studies are the least sensitive type, while sensory studies provide more detailed information about nerve fiber function 3
• Combined NCS and needle EMG are typically performed consecutively to provide comprehensive evaluation of suspected neuromuscular impairment 6, 7, 3
• Studies are performed in approximately 84-90% of electrodiagnostic evaluations for conditions like ICU-acquired weakness 1

Common Pitfalls to Avoid

• Ordering NCS too early in the disease course: Studies performed within the first week of symptom onset may be normal in 30-34% of patients with active demyelinating disease; repeat testing 2-3 weeks later is essential when initial studies are normal but clinical suspicion remains high 1
• Over-reliance on NCS for typical presentations: Ordering electrodiagnostic studies for classic diabetic neuropathy with stocking-glove distribution and normal strength adds cost without changing management 4, 8
• Using NCS for routine serial monitoring: Repeated studies every 6 months in stable neuropathy (e.g., polyarteritis nodosa) do not improve management and should be replaced by clinical examination 4, 8
• Misinterpreting normal NCS: Normal conventional nerve conduction studies do not exclude neuropathy, as small fiber neuropathy affecting unmyelinated C-fibers will show normal results and requires skin biopsy for diagnosis 4, 1, 8