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I would like to have a colleague review an EDX study with a diagnosis of "severe demyelinating sensory motor polyneuropathy" in a patient with severe diabetic polyneuropathy.
I lead a PM&R training program for doctors across Sub-saharan Africa through the International Rehabilitation Forum www.rehabforum.org. November is our neuromuscular month and I'm hoping to get some on-line teachers. Also, if anyone has interest in teaching other areas, or in self-funded road trips to teach, please let me know: andyhaig@umich.edu.
The details:
With zero PM&R trained doctors in the region, we launched this 2-year, mostly on-line fellowship for physicians who are either already board certified (FP, neuro, ortho, etc.) or have a few years working in a rehab setting. It's now the official board-certification in Ghana and Ethiopia, and we've got about 220 graduates in South Africa, with other countries joining in. Under fellowship director Yunna Sinskey (Mary Free Bed PM&R) Fellows do local 'rotations', attend 3 hours of on-line lectures wednesday morning 7-10 a.m. EST, have research and other requirements, exams, etc.
The training is a challenge because of the mixed experience and current exposure of the clinicians. One might be world-class in amputee but not know where the median nerve is. Another may be doctor for a national soccer team but never run into a polyneuropathy. At this stage most do not have access to an EMG machine. Yet we (the African leaders and I) feel that its critical that they all become competent in diagnosing and treating focal nerve issues and neuromuscular disorders. We also feel that this first generation needs to at least know the language and logic of EMG, so that those who follow may choose a career.
Very basic EMG/neuromuscular is contained in 5 lectures I put YouTube (BTW, the technical intro video and EMG-1 video are great intro for American med students rotating through your lab...). However they need to get a pragmatic sense of diagnosis and treatment. so we're hoping to get experts who can do an hour of teaching-semi-lecture but cases and audience participation. If you're interested, drop me a note with your area of focus. Great for your fellows/junior faculty to get some CV-fillers.
Also, though...working with West Virginia's Ken Wright, M.D., we're trying to organize longer-term mentorships and road trips for neuromuscular experts to visit and teach in person. No, we have no money whatsoever for travel. but we know places to get good fu-fu, Ethiopian Coffee, and visit the South African elephants! so let me know that, too.
Hi everyone, Looking for your thoughts on a puzzling case.
I'm seeing a 54-year-old right-handed woman on long-term disability.
Her history includes type 2 diabetes, hypertension, hypothyroidism, OSA (on CPAP), nodular thyroid hyperplasia, DVT/PE and, most importantly, a lateral medullary stroke in 2021. She also underwent bariatric surgery and has bilateral knee prostheses.
She is a past smoker, and drinks only rarely.
After her stroke, she had stable non-painful hypoesthesia of the right face and left hemibody. However, in late May 2025, she experienced rapid onset (over a few days) of paresthesias in all fingertips, followed shortly by paresthesias in the soles of both feet. She also reported left hand weakness—mainly grip issues, such as difficulty holding a knife. Around the same time, she developed new low back pain (not clearly radicular), worsening balance (now needs two canes instead of one), and four falls in the span of a few weeks—whereas she hadn't fallen at all in the preceding year.
She has long-standing urinary urgency since her stroke, but feels it has worsened; more concerningly, she now reports new-onset fecal incontinence. No orthostatic hypotension is present. MRI cervical spine showed only mild spondylosis, without myelopathy. Brain MRI revealed no new findings.
On exam, there’s mild atrophy of the left first dorsal interosseous with 2/5 weakness in that muscle, the ADM, and APB on the left. The rest of the motor exam is intact. Reflexes are symmetric at 2+ except for an absent right Achilles. Light touch is reduced over the fingertips bilaterally and soles of the feet. Vibration at the toes lasts 6–7 seconds.
EMG/NCS revealed severe bilateral median neuropathies at the wrist (markedly prolonged distal motor latencies, at 13-14 ms, and collapsed CMAPs), bilateral ulnar neuropathies at the elbow (more severe on the left, with both demyelinating and axonal features), and absent median and ulnar SNAPs. Tibial and right fibular motor responses are intact, as well as radial, sural (6-7 microvolts) and superficial fibular sensory responses.
Needle EMG showed chronic neurogenic changes in the left FDI and APB, with normal C5-C7 muscles. In the legs, there were chronic neurogenic changes in bilateral TA and medial gastroc, with the left TA and right MG more affected and showing active denervation. There were also changes in the left vastus lateralis, equivocal findings in the left tensor fascia lata, and mild denervation in the left L5 paraspinals.
Altogether, we’re looking at:
Bilateral median and ulnar entrapment neuropathies
Axonopathic changes suggestive of chronic L5 > S1 > L4 involvement (bilateral, asymmetric), possibly radicular in origin
I interpreted the relatively robust sural amplitudes (6–7 µV) as not suggestive of an obvious large-fiber polyneuropathy.
Although the simplest hypothesis would be a combination of mechanical entrapment neuropathies and lumbar radiculopathies, I remain somewhat puzzled by the rapid and simultaneous onset of symptoms in all four limbs, which seems hard to reconcile with purely mechanical explanations like cane use.
It makes me wonder whether something more systemic is at play, amyloidosis being one of the possibilities I'm considering, especially given the massively prolonged median motor latencies and fecal incontinence.
My plan is to pursue a workup for amyloidosis (including serum protein electrophoresis, free light chains, etc.), inflammatory/vasculitic workup, and to push for expedited carpal tunnel release surgery with biopsy of the flexor retinaculum—though this isn’t always straightforward to obtain in my setting.
I would appreciate any insights—particularly on whether you'd explore additional imaging, consider nerve biopsy, or look into other systemic causes. Any suggestions or advice would be very welcome.
Why are the sensory axons affected first in carpal tunnel syndrome? I know that in acute compression, motor axons are typically affected first. Is it different for carpal tunnel syndrome or in chronic compression in general. Is it the location of the axons?
Would appreciate advice regarding the use of paralytics in an 82 year old patient with a history of breast cancer and newly diagnosed AChR positive MG. She had transient diplopia prompting lab testing by opththalmology. She reports those symptoms were very fleeting and had not recurred but she was having balance impairment and burning in her thighs. On my exam she had medial rectus weakness with upgaze only, mild hip flexión weakness and hyperreflexia. C-spine demonstrated cord compression at C5-C6 and severe lumbar spinal stenosis at L3-L4. Unfortunately she has an FDG avid pulmonary nodule and needs an ION guided lung biopsied that requires a paralytic. Would suggammadex be reasonable given her low symptom burden? She is not currently on any immunosuppressive therapy or pyridostigmine.
Is anyone having issues with getting paid when you do two limbs with EMG? Lately i am being told to bill 95886 x RT and 95886 x LT on two separate lines based on what insurances want to see, rather than 95886 x 2.
I just saw a patient who is 29 y/o diagnosed with stage III kidney disease in 2022 then kidney failure that needed dialysis in June of 2023. In October 2024, he noticed numbness in both feet that rapidly progressed to just below the knees. In Feb 2025, he lost all kind of mobility around his ankles. He has floppy feet. DTRs are 2 + throughout including the knees while absent at the ankles. He tells me that he lost central vision in both eyes at the same time.
He had EMG by a neurologist with no sensory or motor responses in LE. Reduced amplitudes in upper. Diagnosed with severe neuropathy. The whole process was completely painless. MRI lumbar is unrevealing. Reveiwed his labs, all are ok except for very high Kappa, Lambda light chain. Faint band in the gamma region.
Etiology of kidney failure is not certain. It was thought that it is IgA nephropathy. Kidney biopsy was not helpful as it did not show any viable tissue to test (all scar tissue)
He is coming to see me as his Transplant team cancelled his kidney transplant that was scheduled for today because "rejection meds may worsen his neuropathy".
What do you think has happened. He has been stable since February. Nothing has changed. He gets peritoneal dialysis daily.
Recently made aware of denial of payment due to CMS only covering 1 limb EMG/NCS charges per year. Interstingly had a request for another limb 4 mo after 1st in different calendar year, they still denied despite appeal. so you may do 2-4 limbs at a sitting but not sequentially or serially by this criteria. anyone else noticing this trend? our advocates for CMS need further education if possible gievn current environment.
I just sent a case last week and got NO response. Would you please read it and help with any idea or differential.
I have another case of a 25 year old who had a right leg DVT and saddle PE s/p thrombectomy. Found to have Factor V Leiden. Started Elequis. He slept all the time after D/C. A week later noticed right foot drop followed a week later with left foot drop .
EMG for this patient showed normal sural and super peroneal sensory with severe denervation of all muscles below the knees. I do not want to do a biopsy as his surals are normal. I do not want to add to his problems an iatrogenic numbness.
It can be vasculitis but how can you explain bilateral vasculitis at the same exact location.
I m very concerned about these 2 very young adults with severe bilateral and symmetric feet drop
When PCP has a patient with rectal bleeding, the patient is never given a script for colonoscopy nor would a gastroenterologist do a colonoscopy without a clinical evaluation first . Shouldn't Edx studies be preceded by a neurological consult then do the EMG?
I was referred a patient who is 71 years old with a history of Gullian barre syndrome diagnosed 3 years ago in Pennsylvania treated with IVIG treatment with good recovery but with residual left side weakness. She is now ambulating with cane. At the time she had acute ascending paraplegia. Was admitted and did not need vent Current EMG is showing mixed sensory motor peripheral polyneuropathy left worse than right predominantly demyelinating. Similar picture in upper extremities. patient is clinically stable with no recent worsening of the weakness. I just reported it as a sensory motor neuropathy, without commenting on possible diagnosis. Could I call it CIDP? Or is that more clinical diagnosis. Any ideas or inputs?
I have years' worth of journals and I would like to donate them, but I don't know that anyone takes them. Has anyone heard of a place that will take donated journals? If not, I'll just recycle them. Thank you. Janet Balbierz
When billing NCS/EMG and NMUS Limited study 76882, (performed on the same day), Medicare ( for Northeast region) is returning the bills as incomplete claim, as MODIFIERS were not used with 76882. They do not specify which Modifiers ( 59,? XU, ? RT...????) are missing.
Does anyone have any specific experience to advise which modifiers to use for Medicare when NCS/EMG is performed on the same day, (same limb) for example.
Does anyone have a machine they no longer need and are getting rid of?
I am working thru the AAP to develop the EDX curriculum for Nepal's first PM&R training program, directed by Raju Dhakal. The department in Nepal is in need of an EMG machine for training the fellows. I would be bringing it down with me for a workshop in August.
Thanks in advance for any leads or if you would like to help with this project. Feel free to reach out to me directly at onealegf@upmc.edu.
A 76-year-old male with a remote history of a lumbar decompression at L5, presented to the Sports Medicine Clinic for a painless right foot drop that presented acutely November 2024. Of note, the patient also had a left-side foot drop with prolonged recovery after lumbar decompression in 2023. Exam on the right side demonstrated 4/5 dorsiflexion and big toe extension but 5/5 foot eversion and inversion.
A recent MRI of the lumbar spine still demonstrated bilateral right greater than left L5-S1 foraminal stenosis in the setting of grade 1 degenerative spondylolisthesis.
The NCS/EMG findings revealed the following abnormalities: decreased right superficial fibular sensory nerve amplitude, bilaterally decreased fibular CMAP amplitudes with slowed conduction velocity but no conduction block or focal slowing, and abnormal spontaneous activity with decreased recruitment only in the right tibialis anterior and extensor digitorum brevis. The other L4-S1 muscles were WNLs.
The spine surgeon is ready to do a decompression; however, these findings suggest a right fibular neuropathy at the knee level with ongoing denervation but no evidence of radiculopathy or tibial neuropathy.
I would appreciate your thoughts on this case to help guide management. I have never seen a painless fibular neuropathy predominately involving the deep branch at the knee.
I hope this message finds you well. I am reaching out to seek your insights on whether there is a standardized template or guideline for interpreting and reporting single fiber electromyography (SFEMG) findings in clinical practice. If such resources are available, I would greatly appreciate it if you could share a few example reports or templates utilized at your institutions. Your expertise and assistance in this matter would be invaluable to me. Thank you very much for your time and consideration.
Does anyone know of any issues with doing NCV studies on an extremity that has a Dexcom monitor? This came up for the first time today. The patient had it on the medial arm and I had planned to test that extremity, but held off.
Hello everyone! Thank you for taking the time to read this.
It seems that many practices want a NM neurologist to perform autonomic testing and muscle/nerve biopsies.
How would a neuromuscular practitioner/fellow obtain training in this if not offered by the fellowship in which they were/are trained? Also where can one be trained to do core needle muscle biopsies?
The Myositis International Health and Research Collaborative Alliance (MIHRA) is hosting a scientific seminar on Inclusion Body Myositis on March 26, 8-10 am CST, dedicated to both providers and patients. It is cost free.
What do you use to warm limbs. I have seen and read about heating lamps, heating pads, hydocollators, hair dryers. Are there any standards on this issue from AANEM?
I enjoy participating in the AANEM Connect Forum for a number of reasons. There are very fundamental questions posed on a frequent basis that cause me to pause and ask myself, ‘Why didn’t I think of that?’ Also, I continue to learn
new things when others contribute their thoughts and experiences. Connect is an excellent opportunity for members to interact and to address any topic, including those that may not be discussed
at an annual meeting or journal article.
