AANEM Connect

Hey colleagues,

Most texts show that the median nerve is supplied by the C5-T1 roots, ulnar C8-T1, and radial C5-T1.

What does the C5 root supply to the median nerve (in a non-prefixed plexus)?

The ulnar head of the Flex Dig Prof is said to be C7-8, where does the C7 root supply come from?

What is the T1 supply to the radial nerve (in a standard plexus)?

It's been a puzzle and I've not come across a definitive answer.

Thanks,

Harold Lesser

I would be grateful for any advice please from those of you with experience in the Gulf of Mexico.

I have just seen a 58 yo male who was walking in the sea off the coast of Cuba 2 years ago. He cut the lateral border of his left ankle, just below the lat malleolus on what he assumes was a rock. Following this he developed painful sensory loss in the left lateral foot extending up the left lower antero-lateral leg and a "scab-like" lesion over a patch on the shin which coincides with a red patch on a tattoo. This lasted a few weeks and after it settled the hairs of this part of the leg turned white and have remained white since. His strength is normal, but his left ankle jerk is absent.

Neurophysiologically the only abnormality is the left sural SNAP is 14uV, whilst it is 26uV on the right. Superficial peroneal (fibular) nerves and motor responses are normal.

Here in the UK we can get a painful neuropathy from standing on a weaver fish, but I have not heard of anything matching this description of events. Any ideas as to aetiology? Is there any useful advice as to management?

Hello all,

Our Neurosurgeon is evaluating pediatric patients for Selective Dorsal Rhizotomy.  My partner and I are looking for training in the Neuromonitoring portion, EMG set up and interpretation of stimulation , for the surgery.  We will also be evaluating patients in clinic , monitoring during surgery and following post operative.  

Does anyone know of training for physicians for the neuromonitoring, interpretation and reporting for this type of surgery?  

 

Thank you, 

Elena Caron

Le Bonheur Children's Hospital 

Opportunity to support genetic counseling student research! As a practicing neurologist or neuromuscular physician, you are invited to participate in a research study that is seeking to better understand the current landscape of genetic testing for neuromuscular disease in neurological patient care. 

 

Please consider completing this 10-15 minute survey. All participants who complete the survey will have the option to enter a drawing to win one of several $25 Amazon gift cards. Participants that choose to do a single follow-up interview over Zoom to elaborate on the themes addressed in the survey will be entered into an additional drawing for more $25 Amazon gift cards.

 

Study Survey Link: https://redcap.vcu.edu/surveys/?s=4MNY9JL498A3LCLJ

 

This project is approved by VCU’s IRB. If you have any questions or concerns about your participation in this research, please reach out to the lead student investigator Ashley Smith at smithan13@vcu.edu.

This may be a silly question, but I can't find much information on it, so I figured I would ask my EDX colleagues here.  I know of the safety regarding performing NCS with ICDs and internal pacemakers and am aware of the AANEM position statement on this, but I am curious on the safety of NCS for patients with LVADs.  Any reason that this would be a contraindication, or any special safety procedures for performing NCS/EMG studies on patients with LVADs?  Thanks for any guidance or discussion here.  

NIV is CPAP and BiPAP not used for noninvasive ventilatory support (NVS), NVS settings are PIPs of about 20 cm H2O and no EPAP/PEEP. Since we have ALS patients iwth 90% of normal VC who are 24/7 NVS dependent and others with 7% of VC with normal blood gases and asymptomatic without vents, nasal NIV recommendations for VC under 80% or 50% are inappropriate and should normally be based on supine VC anyway and not the sitting VC of PFTs. Most of our MND patients become NVS dependent without ARF or even going to a hospital, not to mention our 18 with SMA1 between 18-30 years old with 0 ml VC and no trach and many DMDs over age 50 who have never been to a hospital. Use NVS not polysomnographic titrations that don't adequately rest muscles during sleep.

Disclaimer: I have asked the site administrator and been told I can post this. This is NOT a job offer and I am NOT trying to hire anyone to work for me.

I live in Durango, CO. It's nice here.  I have a solo PM&R practice and have an office with 3 exam rooms.  I have room in my office for 1 (possibly more) providers to share on a full or part time basis.  We have the following resources in town:

-5 physiatrists, heavy in spine.  4 of us do EMG, 1 is very skilled in neuromuscular u/s. I'm trying to be more general spine/msk, EMG and work comp

-1 full time neurologist who is neuromuscular specialized at the local Mercy hospital.  He's super busy and hard to access.

-1 newer neurologist who just started a cash only practice.  He may or may not get busy but with the model he has excluded the vast majority of potential patients

-No endocrinologist

-not enough rheumatologists 

-no pain-psychology

-no neuropsychologists

-we have a full-service regional hospital, a smaller surgical hospital, infusion center, 3 facilities with MRI including a 3-tesla unit

If there is anyone interested (or you know anyone) in discussing a move to Durango and setting up your own practice within my space, please let me know.  After working in groups for about 12 years, I opened my own practice 4 years ago and it's the best thing I've ever done, and easier than I thought.  Overhead is very low and modern EMR systems are a game changer.  

A general neurologist would be instantly busy, as would any of the above list that are willing to take insurance. Given the number of us who alredy do EMG, a neurologist who isn't interested in EMG would be a better fit.

 

robert_wallach@yahoo.com

 

Dear Colleagues,

 

I am writing to let you know that we are actively recruiting a neuromuscular medicine fellow to begin this summer, July 2024, at Rush University in Chicago.

We are a newer fellowship program currently training our first NM fellow. However, we have a strong track record of education, mentorship, and a well-established neurophysiology/EMG fellowship. Our program includes outstanding clinical exposure with multidisciplinary clinics in ALS, CMT, muscular dystrophy and nerve injuries. Our trainees also get strong exposure to EMG throughout their training. Rush is a top notch, well-run medical center with outstanding, new facilities as well.

Our program is ACGME-approved. We can recruit fellows who are graduates of US neurology or PM&R residencies.  This position went unfilled in the 2023 AANEM match which we will participate in again this coming year. 

For more information, please feel free to reach out to me directly at ryan_jacobson@rush.edu.

 

Thanks!

 

Ryan Jacobson

 More and more we are having patients referred who are upwards of 500-600#.   Is it acceptable for patients who exceed the weight limit of our table to perform the examination in a wood chair? is there any risk in using an aluminum chair?  What about wheelchair dependent patients who are unable to transfer to the bed? Is it acceptable to do the EMG in the wheelchair? Do you have any equipment recommendations for positioning these patients for the test. I currently have a NCT who is 7 months pregnant and struggling to do the occasional chair patients when it is lower extremities in a chair when the exceeed out table weight limit.   I wasn’t sure what options there were or what other clinics were doing.

I've looked for a good paper with these stats without luck. Cervical data easier to find. Anyone have one?

I recently saw a 13 y/o young lady who somehow managed to fall backward off of a moving golf cart. She had a mTBI and painful right shoulder. She now can voluntarily dislocate the right shoulder. There is right scapular inferior angle winging. EMG of the serratus anterior, upper trapezius and rhomboid major were normal. My question is how do you produce non neurological scapular winging.

It is difficult to miss the serratus anterior on EMG in the mid axillary line since the serratus is the only muscle there, once you touch the rib periosteum with the EMG needle.. There are some oddities on examination. Forward flexion is strong but winging increases especially as she lowers the arm. The inferior angle rotates laterally and the scapula abducts on forward flexion like normal. With a SA palsy forward flexion should be weak, and scapular rotation and abduction reduced.

Abduction of the shoulder laterally reduces the winging. Shoulder retraction is strong. 

I would like to say something more specific than "probably related to the ligament injuries that destabilized the gleno-humeral joint" but haven't found anything in the literature to help.

Over the years I have seen a number of patients with scapular winging, without shoulder dislocation, in whom EMG of the appropriate muscles was normal. On some occasions I could not find the serratus and assumed it had completely atrophied. So this young lady was not an isolated case. 

How do you produce scapular winging without neurological, i.e. nerve, injury ?

I have a Natus UltraPro S100.  I am looking for the extendable arm that holds the receiver and stimulator.  I can't seem to find it online.  I'm open to alternative or DIY solutions!

Thanks for your assistance.

Has anyone ever seen anti-MAG associated neuropathy or MMN cause neuromuscular respiratory weakness?

Good evening!

I'm curious if anyone has established or attempted a non-insurance based/cash based model for EMG.  

I would be happy discuss offline if necessary!

Thanks in advance.

Fred Bagares

Hello all,

I have a non-academic, business related question.  I hope it is ok to post on this forum, but feel free to remove if this is the wrong place to ask.  For those that work in wRVU model systems, do you know of any information on average $ per wRVU for NCS/EMG?  I don't see that it is broken down granularly with MGMA, etc. specifically for Electromyographers.  Any guidance as to where one could find this type of data?  Thanks for any help    

I was hoping the practice improvement requirement for ABPMR would go away, but it has not. I am looking at the options available through AANEM. I would appreciate any advice regarding the three options available report writing, carpal tunnel syndrome, cubital tunnel syndrome.  I would like to make the best of this board requiremnt 

In discussion with a fellow recently-graduated trainee, we were discussing anesthetic nerve blocks and the immediate effect on EDX. Hypothetically, if a person got their proximal median nerve blocked with lidocaine above the elbow, what would the effect be on the median antidromic sensory NCS to digit 2, the median motor NCS to APB, and the needle EMG of APB or pronator teres be?

I would assume, for the EMG, that you would have no spontaneous activity, no neurogenic changes, but (if truly blocked) you would have no activation of median-innervated muscles distal to the block, correct?

For the NCS, would a proximal median nerve block with lidocaine above the elbow appear like a severe post-ganglionic injury (like a brachial plexus injury), resulting in an absent SNAP? Or, conversely would the portion stimulated at the wrist and recorded at digit 2 be intact? Thoughts on CMAP?

Any clarification would be awesome. Thank you!

Hello peers!

I am an Emeritus member who has a TECA B2 in working condition, but without all the accessories.  I would like to donate it to someone who will cherish it, as I trained on this type unit at the former Letterman Army Medical Center in San Francisco.  I realize there are earlier, more collectible models, but with vacuum tubes and fluorescent markers, it is still quite intriguing. One day my children will be scratching their heads, wondering what to do with it. If you are interested, or know of an EMG museum, please let me know.  I live in the southeastern US, and my email is mdredmond@prodigy.net. Thanks!

Hello all,

Members of the AANEM APP Committee are conducting an informal survey on Advance practice provider (APP)/physician practice models in neuromuscular medicine. If you are a physician working with an APP (physician assistant or nurse practitioner) or an APP working in neuromuscular medicine, I invite you to take a couple minutes to fill out our brief survey below.

Survey Link: https://forms.office.com/r/DVSCJCXYuC

Thank you, 

 

Margaret Naclerio, PA-C

Email: mnaclerio1@bwh.harvard.edu

I am trying to find any data that exists on parspinal needle EMG abnormalities in chronic LBP (without radic, stenosis, etc). I cannont find any data specific to that question.  Does anyone have references on this topic?

is there any association with an acute onset of an axonal neuropathy associated with the use of high dose steroids or in association with polymyalgia rheumatica? I could not find any clinical studies, but on a mayo clinic patient blog site, there were several entries similar to my patients history of abrupt onset of numbness, paresthesis of the feet and a feeling of unsteadiness afer initiating steroids for the treatment of PMR. her electrodiagnostic studies were noted for significant reduction of the peroneal motor responses, absent bilateral sural and superficial peroneal sensory responses, but normal tibial motor responses. she also had significant spontanous activity isolated to the EDB bilaterally.

Hi all,
I currently run a relatively high volume NCS/EMG practice and my current EMG machine is coming to its end of life. My hospital system is planning to purchase two new machines, looking into both Natus and Cadwell options.
I have only ever used Natus machines and software, but wondering if anyone has any insight into the differences, pros/cons of Cadwell vs Natus. Any opinions/insight would be appreciated, thanks!

I have a referral on a 61-year-old female with a stated history of Charcot-Marie-Tooth (type not specified) with progressive symptoms and loss of function, ambulation, etc. Clinical question regarding possibility of carpal tunnel given hand intrinsic atrophy and numbness median distribution right greater than left.  I have not seen the patient yet. I am just thinking about how one might be able to tell if there is carpal tunnel on top of Charcot-Marie-Tooth?  I have only seen a couple of patients with inherited demyelinating neuropathies in my 20-year career but my understanding is that I should expect significantly prolonged distal latency, very slow conduction velocities, probably absent sensory responses and probably chronic denervation on needle EMG. Does anybody have a take on how I might determine electrodiagnostically if there is also carpal tunnel?  My assumption is the clinical symptoms might be revealing as well so I will be interested to hear what the patient says from that standpoint.

 More and more we are having patients referred for EMG who are upwards of 500-600#.   Is it acceptable for patients who exceed the weight limit of our table to perform the examination in a wood chair? is there any risk in using an aluminum chair?  What about wheelchair dependent patients who are unable to transfer to the bed? Is it acceptable to do the EMG in the wheelchair? Do you have any equipment recommendations for positioning these patients for the test. I currently have a NCT who is 7 months pregnant and struggling to do the occasional chair patients when it is lower extremities and they either exceed our exam table weight limit or are physically unable to transfer to the bed. I am looking for recommendations what other clinics might have been doing with this situation. 

Good afternoon

first time posting although have followed for many years with interest and valuable education. Would like to present a case which has left me quite puzzled.

This is a 63 year old lady seen for EMG 3/22 for arm and hand pain and numbness. Findings st that time showed left CTS, but also had multiple muscles with 1-2+ fibs and PWs in C-6,7 bilaterlly (PT, FCR, ECRL, APB and C-PS) without clinical symptoms. Had left CTS surgery with good outcome. Returned 3/29/2023 with right digit 2,3 pain and numbness. No cervicall pajn but intermittent right shoulder and upper arm pain. Nerve conductions, including right axillary, MC and radial to triceps all normal, both motor and sensory. However, Emg today showed diffuse 1-2+ rest activity in all muscles, including bilat C-PS bilaterally.  No neck pain, normal MMT, nl stretch reflexes, nl sensation (light touch and pin), no myotonia or fascics. No family history of NMDZ, negative drug including excessive caffeine history.

Appreciate thoughts on etiology, differential diagnosis and further testing. Thanks in advance for all your input.