AANEM Connect

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 :)  

 

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.