AANEM Connect

Would appreciate ideas about what is the appropriate way to deal with a bleeding spot at the site of needle insertion.  Is taping a cotton ball over it appropriate? Thanks to all.

I have seen 2 cases of sciatic nerve damage following foot/ankle surgery over the past few years.  In both cases, the surgery involved popliteal block and tourniquet, with post-op complaints of motor and sensory loss from the knee down. The first case was a few years ago and I don't recall all the Edx details, other than there were abnormalities below the knee c/w tibial/fibular injury.  The second case I saw this week 15 y/o with dense sensory loss globally below the knee and global weakness following ankle ligament reconstruction 7 months ago.  The patient described some improved sensory in the proximal 1/3 of the leg but no feeling in the distal leg and foot.  Motor exam with marked weakness (2/5 DF, toe flex/ext, eversion, PF).  NCS with absent superficial fibular, sural and fibular motor.  Interestingly, tibial motor WNL and no side to side difference (so tibial weakness seems out of proportion to the motor nerve study).  Needle EMG c/w denervation short head bicep, gastroc/soleus, TA and fibularis longus (small amplitude spontaneous activity, long duration polyphasic motor units) and normal EMG quad and proximal hamstring.

Question:  Other than the Edx study, does anyone have a take on whether these need to be further worked up? The case I had a few years ago I recall getting MRI of either the femur or leg and then did the other part of the limb when the first study was unremarkable in terms of obvious abnormality around the sciatic (memory not totally clear). However, it was a work comp case and studies were approved, so no issue with $$ for the patient.  In the current patient, any thoughts?  In the cases that the community has seen, have you figured out etiology?

Good evening!

I am a sports and spine physiatrist that completed fellowship in 2012.  When I was in residency, it was common for PM&R graduates to continue practicing EMG.  However, I have noticed (anecdotally) that younger physiatrists in my area are no long practicing EMG.  They are often part of a ortho, neuro, or multispecialty group so I know that referrals are probably not a factor.  The wait time to EMG also seems to be increasing and I'm wondering if there are is a connection here.

Are there more EMG referrals or less people actually performing them?

I know the reimbursement cut several years ago was a major event that signficantly affected EMG practice.

I have also noticed (coincidentally) that there are more PTs now performing EMGs as well.  Quite a common practice in the military system but I'm starting to see it more and more in the civilian sector as well.  

I would be curious to hear thoughts from the group.

Thank you.

Good morning to all. I will try to present a case as summarized as possible. An 81-year-old woman presented with progressive loss of muscle strength in her left hand, ascending to the shoulder, a clinical condition that began 7 months ago. muscle weakness has compromised the left lower limb to a lesser extent. She has a history of severe left trigeminal neuralgia a few months earlier, which required several interventions, including infiltrations. In June of last year she had an electromyography with a possible diagnosis of C8, T1 radiculopathy. Clinical doctors have dismissed the electromyographic findings, whether due to images of the cervical spine without signs of disc pathology that explains the compression of the lower cervical roots, presence of old infarction in the territory of the left PICA and in brain MRI with small vessel disease Fazekas 2-3. They manage it as sequelae of cerebrovascular disease. an orthopedist requests the examination again. physical examination with signs of upper and lower motor neuron in the left hemibody, the motor conductions of the left median and ulnar nerves are absent, no further striking alterations are evident in the motor and sensory conductions. The study with a monopolar needle shows signs of denervation in the left first interosseous and abductor pollicis brevis, and in the left tibialis anterior with neuropathic units. What do you think, dear colleagues? Do you think it's ALS vs MNN? . What other diagnostic option could I have?
I appreciate the attention provided

I have recently been doing EDX studies at our Hand Clinic for several months.  We prefer to do the ulnar conduction with the arm "raised", resting on a pillow.  Our fellow noticed a device in their clinic that made our ulnar positioning much easier to maintain the limb in a comfortable, fixed position. This is an arm support that the Hand Clinic uses for their purposes, but I think nicely adapts to nerve conductions.  This is best shown in the picture provided. The elbow is in a 90 degree position which does not show well in the photo.  We also show the picture of the support with arm placed directly on it for clarity- in clinical use the support is placed in a pillow case.  The attachment lists a couple of sites where they can be purchased.  It goes to show that sometimes a fresh set of eyes sees a better way of doing things! We hope that you may also find this a convenience in your practice.  

Hi all,

I like the median D2 or D3 segmental sensory study for the CTS evaluation. I usually measure 14cm to the wrist and 7cm to the palm. It's the only way that I'm aware of to distinguish sensory axon loss from sensory conduction block across the wrist. It also seems to be very sensitive in detecting focal slowing that was diluted over the larger distance. However, it can be technically challenging to produce a flat baseline, especially in the palm. And there is often significant variability in onset latencies with repeated attempts, so I will typically take the average 4-6 responses at each site before looking at the segmental conduction velocities. My question for this group: Why not use the peak latency difference between wrist and palm instead of conduction velocity?  It would have to be standardized for distance of course but most hands fit the 7/14cm montage. Does anyone use peak latency difference or know of reference values for this? 

I have a question regarding an issue that came up recently and would appreciate any and all thoughts.

 We had a consult to perform a bilateral facial nerve study (NCV/ENOG & needle EMG) on a patient with active TB for “immediate surgical intervention purposes” in an isolation negative pressure room.  Appropriate medication had just been started but no idea if it is/will be effective or if the patient will be resistant.

 The concern is regarding taking our EDX equipment into the room with respect to multiple fans running in the laptop/base unit.  Clearly any beasties in the air will potentially be sucked into the machine, possibly become lodged in there for some time; then when we take our instrument out of the room and back to the outpatient clinic there is a potential for blowing out nasties into the clinic.  This seems like a setup for a potential “hot zone” of community based contamination. 

 The hospital’s “infection control” are not concerned in the least and state that “machines” go into and out of those rooms all the time and into an adjacent room or ICU rooms “without issue”.  To be sure, this is true.  For example those portable X-ray units go all over the hospital from a TB room, to a Covid room, then into an possibly immunocompromised patient’s room without concern.  I am not aware if those portable X-ray units have removable HEPA filters or not;  I doubt it.  It’s the “without issue” that bothers me.  There are no studies I am aware of that have swabbed machines or rooms to ensure there is no cross contamination “issues”.

 I know our EDX instruments are running fans and there are no filters of any kind on the vents for the base unit or computers.  Having changed both batteries and memory drives I know most computers with some exceptions have fans running in them (laptops PCs/Macs) and for sure tower units have fans.

I would have thought with the recent CoVid issues that someone would have a concern or policy regarding this issue.  I am not aware of any EDX manufacturer that has a policy or recommendation as to this issue.  Also, I do not think the AANEM has a policy or SOP for this type of scenario.  It’s probably not a good idea to douse the instrument’s internals with a fluid disinfectant risking electrical issues or voiding the manufacturer’s warranty.

In short given the above scenario and no doubt other scenarios, is there a concern here or is this in the line of what the great Bard once said, “Much Ado About Nothing”?  Maybe it is just me that has an unwarranted concern and it is well known and documented that these instruments are NOT a potential source for disease spread.  Appreciate any thoughts.

Hi friends, new attending here looking for any advice:

I was asked to do NCS under sedation for a 3 month old with krabbe disease. I have not seen a patient with this diagnosis before nor have I done a NCS on a baby this small. Any suggestions are appreciated! I will likely also bring the ultrasound with me, more out of my own curiousity as I have read that the cross sectional areas of the nerves can correlate with NCS findings and I am working on incorporating NMUS into my practice. Any tips/suggestions for the US part is also greatly appreciated!

Looking for help/thoughts from those in RVU based system that personally perform the nerve conduction portion of studies without a technician.  

Essentially RVU targets changed at the beginning of the year by 700+.  Some of us in the group do not have technicians but it just does not seem right that we only get the "physician work" portion of the RVU when personally performing the nerve conductions.  Thinking that some percentage of the technical component as well would be more fair and act as a "buffer" of sorts. 

Have heard of some groups who give flat rates like $55 for each nerve conduction that is physician performed.

Have also heard of other groups that do $35 for the nerve conduction and $35 for EMG and this is with technician performing the NCS.  

Anyone have thoughts or willing to describe what is done, if anything, to compensate for the physician performed NCS.  Thanks in advance!!

I have a complicated patient, 54 y/o male, diabetic currently under good control. h/o C5/6 ACDF August 2021 with some residual right hand numbness in the thumb/index which interstingly completely resolved following right rotator cuff repair in January 2023.  Shortly after the surgery, he started to have left arm and hand paresthesias and subjective numbness radiating from the L neck and shoulder. This was intermittent for a few months but then progressed to both arms and hands, all fingers. constant.  Cervical MRI did not show correlating findings but was technically limited from the hardware.

I did EMG LUE in May:

-Absent median sensory studies to index and middle

-normal ulnar and superficial radial sensory

-Median motor, 8 cm, latency 9.5 ms, amplitude 5.6 mv, CV 46 m/s

-ulnar motor, 8 cm, normal except mild decreased CV across elbow 46 m/s

-EMG:  ABP with decreased recruitment but no spontaneous activity

CTR done in June with no change in symptoms.

Spine surgery obtained CT myelogram and concluded that neck not causing the bilateral symptoms

Brain MRI was also obtained in May due to these symptoms and development of motion sickness following the shoulder surgery in January 2023 and was read as unremarkable.

Spine surgeon referred him to neurology, who saw him August 31 and did bilateral UE EMG:

LUE:

-absent median transcarpal

-Median motor, 7 cm, latency 8.1ms, amplitude 3.8 mv, CV 46 m/s

Question:  Given the CTR was done 3rd week of June and new EMG 9+ weeks post op shows basically no change in motor latency, I can't help but wonder if the CTR was not complete and he still has focal compression. I realize that demyelinting issues can take up to 3 months to recover, but in general I expect the latency to look better this far after CTR. Does anyone have a take/suggestions on what to do with these data?

Found the answers. Thanks

Understanding that using full noninvasive ventilatory support (NVS) settings for sleep ventilation, rather than Bipap, permits patients to extend it into, and throughout daytime hours for up to continuous (C)NVS without going into respiratory failure, requiring hospitalizations, or trach tubes. These patients can also be extubated to CNVS with mechanical in-exsufflation used via tubes and post-extubation to clear secretions to permit definitive noninvasive managment of most NMDs. We now have 18 SMA1s 18 to 30 years old with only residual eye movement, 0 ml VC, also 4 DMDs over 50 years old with 2 never having been hospitalized despite 30 years of CNVS, ALS patients on CNVS for 14 years, and have extubated all 254 simple vent pump failure patients with as little as 0 ml of VC without resort to trach tubes. This perserves QOL, community living, and saves enormous sums of money for nursing care alone. While this approach is increasingly popular in S Amer, Mexico, Japan, and elsewhere, there is no financial incentive for it in the U.S. but the patients invariably appreciate it. The following article and books summarize what can be done. No one ever needs a trach tube for only being too weak to breathe and it can always be avoided as I tell my patients with dystrophies, SMA, SCI, etc., on their first visits and for the next 42 years is some cases.

 Bach JR. Noninvasive respiratory management of patients with neuromuscular disease. Ann Rehabil Med 2017:41(4):1-20. doi: 10.5535/arm.2017.41.4.519.

 Bach JR, Gonçalves Compendium of Interventions for the Noninvasive Management of Ventilatory Pump Failure: for Neuromuscular Diseases, Spinal Cord Injury, Morbid Obesity, and Critical Care Neuromyopathies. Second Issue, Ventilamed.com, 2023, 706 pages, ISBN 978-3-70-2401450.

Dear EDX Colleagues,

I'm writing to ask for some input regarding study design with a colleague in our Urology dept.  We are interested in studying the anthropometric and hand indices differences among urologists performing flexible ureteroscopy and its effect on muscle strain and fatigue.  Prior work on this subject utilized surface EMG electrodes over the neck extensors, trapezius, deltoid, triceps, biceps, forearm extensors, forearm flexors and thenar muscles using muscle activation (expressed as %MVCRM - maximal voluntary contraction root mean square) as a surrogate for physical strain during the procedure. 

My understanding is that a higher %MVC is an indicator of higher muscle activation.  A lower median frequency (MDF) of the EMG signals from the muscles involved is an indicator of increased musclular effort (not sure I understand why).  To analyze muscle fatigue, higher %MVC tasks for longer intervals would need to be analyzed???

Here is our problem ... my colleague is a female urologist with a smaller hand size forced to use instruments designed for male surgeons with bigger hands.  We endeavor to look more closely at thumb and wrist movements which I don't think we would be able to do utilizing conventional surface EMG electrodes.  I was thinking that we may be able to isolate individual thumb and wrist movements more precisely using needle EMG placed under US guidance to speak to the contribution each muscle to strain patterns, pain and fatigue?  Theoretically, we could then place a pin in the FPL, EPL, FCR, FCU, EDC, etc. 

I'm not sure this would get past an IRB but I don't have much experience with the matter.

I appreciate any thoughts 

Todd Lefkowitz, DO

There has been discussion in my lab about calling a CV of 38 M/S across the fibular head as normal or abnormal based on the the AANEM Reference Value chart.  The chart says 38 for all age/height.  Across the fibular head it says 42.  How are others listing their norms for foreleg CV vs across Fib head CV?  I call 38 normal and my partner calls it abnormal.  My other question would be for someone to explain to me, if possible, how these numbers came about and why the CV would be considered faster across the fibular head compared to foreleg?

I have had several claims (usually 95886 (1 or 2 units) and 95913) completely denied with Humana when the patient has both cervical radiculopathy and carpal tunnel. These are patients with very complicated histories and I have findings supporting diagnoses of both carpal tunnel and cervical radiculopathy (not to mention trauma histories that might expand the differential diagnosis to include plexopathy).  The claim is denied saying that the two codes (carpal tunnel and cervical radiculopathy) may not be billed together. I have written extensive appeal letters pointing out that patients can, and do, have more than one diagnosis including carpal tunnel and cervical radiculopathy. However, they still deny the entire claim. If I were only to bill one of those codes, I suspect they would deny part of the claim saying that  the number of nerve studies done is not justified by the code submitted. I also bill codes for neck pain. arm pain, numbness, hand pain etc, depending upon the details of the history and the findings). The Caretracker billing program will also flag claims that have those two codes but other insurance companies like Blue Cross will pay when those two codes are submitted together.  Only Humana has denied the entire claim.  I copied my last letter of appeal to the insurance commission but that hasn't helped either.  Has anyone else seen this and figured out how to handle it?  Thank you.

What kind of electrodes do you use? I have been using the reusable ring, bar and disc with ground strap. I m being pushed to use the adhesive with the clips or the disposable. I m not very comfortable and also not sure about the accuracy.. 

What do you use in your lab? 

Does anyone uses these adhesive electrodes? How do you measure the distance? I started a new job and these are what they got me.

It is a Natus machine.

Would appreciate information about the sensitivity of various types of studies for ulnar neuropathy at the elbow? For example, sensitivity of motor NCS to FDI vs ADM, of sensory study to digit 5, ulnar F wave minimum latency vs median F wave minimum latency, which muscle needle exam has highest sensitivity. Thanks to all.

I have always tried to find ways to make the EMG/NCS test more comfortable for patients.  Years ago, I saw an orthopedist using Ethyl Chloride spray before he would do his injections in the office.  Ethyl chloride gives the skin a quick freeze, so it makes the needle injection more comfortable for the patient.

When I went into my own private practice, I started using it for the EMG needle exam. I spray it on the skin and then insert the EMG needle into the muscle. Patients seem to have much more comfort with the EMG test using the spray.  I'm just curious if anyone else has used this technique or perhaps something else to make the needle exam more comfortable for patients.  

Hello Everyone!

I work at a county hospital that wants me to present to them a bullet point list of duties that are needed for management of an electrodiagnostic lab. I work with a very talented technician. We have developed policies and procedures that are quite extensive for her. However, I was hoping not to have to reinvent the wheel for an extensive inclusive list of duties. I couldn't find much in the accreditation section of the AANEM site. Do any of you already have a list of admin duties for running a lab? Or if you just have any random ideas to put on the list, I would be grateful. Thank you in advance.

I cannot understand why the Martin-Gruber, or any other two-nerve connection, is called "anastomosis.” This word, from Latin, is used when two tubes, such as a colon with air inside, are connected. Joao Aris Kouyoumdjian, MD, PhD - Brazil. 

Thank you to the entire AANEM community for making our 25th presentation of EMG talk a success!

Although Bill and I have had the pleasure and honor of leading EMG Talk since 1995, in reality we are only the facilitators.  Each EMG Talk show is uniquely co-created by our entire AANEM community. It is both unpredictable and inspirational. It can be educational, but it can also highlight areas to be further explored, such as how we describe severity and chronicity.

Great presentations from our guest stars further engage our whole community –limericks from Sandra Hearn, waveforms from Devon Rubin and ultrasound images from Jeff Strakowski.  We even enjoyed being handcuffed by “FBI agent” Peter Grant!  Entries on AANEM Connect have inspired our shows.  The AANEM staff have been wonderful in setting the stage for our shows and our loyal sponsors have been consistently supportive over many years.

Most importantly we appreciate the comments and contributions from the audience who have consistently brought humor, curiosity, playfulness and wisdom to the show.  As an added benefit, we raised $1,200 for our foundation (ANF) through the hat auction this year.

Thank you for making this another great show and we look forward to co-creating future EMG Talk shows with our AANEM family.

Is there research on the effect of nerve conduction with respect to torsion and tension on nerves?

I have had a string of patients with rapid weight loss with compressive neuropathies.  Aside from entrapment sites, I am wondering what is the effect of excessive tissue or fatty tissue has on the nerves.  When I think of the effect of weight, I usually think of joints mainly.  However, if the nerves have 20-50 pounds of weight hanging from them, can this be a source of tension or compressive neuropathy? 

Thanks for everyone's thoughts!

As the EMG Talk brothers (Spike and Wave) are preparing their annual EMG Talk show, we want to know what term you see or hear commonly in electrodiagnosis that just irritates you the most. 

For one of us, it’s "peroneal nerve".  Everyone knows, or should know, that it’s now called fibular nerve – that’s the nerve the courses around the peroneal head to supply the dorsiflexors and evertors of the foot!

For the other of us, it’s "chronic".  The misuse, or maybe more correctly the misunderstanding, of the word chronic is acutely chronic and it is chronically used as an obfuscating description in EMG reports.

Let us know what term gets your blood boiling and we may discuss it at EMG Talk in Phoenix.

Are there workshops either through you or other programs for techs?

Congratulations to these 2 doctors... Dr. Bassam and Dr. Kincaid!

I'm always so thrilled when my favorite doctors are awarded AANEM awards. 

  Dr. Bassam and Dr. Kincaid are certainly 2 of my favorite doctors.    So many others who are my favorites have also been awarded, and I'm always thankful for the kindness and support for us-techs, no matter what it is--answer to my AANEM connect funky NCS questions, giving advice or instruction when I've needed it, talks/workshops at AANEM, talks for our tech societies, and in general sharing y'all's  knowledge.  I'm honored and humbled.

Thank you to all you doctors :)