Transcript Electrodiagnostics - Humboldt Neurology

John Gambin, M.D.
Goals of the EDX Study
Localization
Muscle
Fiber Types Involved
Sensory
Motor
Mixed
Severity
Nerve
NMJ
Pathology
Temporal Course
Axonal
Hyperacute
Demyelinating
Acute
Acquired
Inherited
Subacute
Chronic
Localization
Neuropathic
Myopathic
Neuronopathy
Radiculopathy
Plexopathy
Mononeuropathy
Multiple Mononeuropathies
Polyneuropathy
NMJ
CNS
Proximal
Presynaptic
Distal
Postsynaptic
Generalized
Cranio-bulbar
Elements of the Peripheral Nervous System
Neurons of the Peripheral Nervous System
Sensory Nerve
Motor Nerve
Post Synaptic Membrane
Muscle Contraction
Motor Unit
MUAP
Indications for Nerve Conduction
Peripheral entrapment
 Suspicion of polyneuropathy
 Suspicion of Myasthenia Gravis
 Nerve Trauma

Indications for EMG
Suspicion of
disorder
 Brachial plexus injury
 Lumbosacral plexus pathology
 Muscle disorder

Patterns of Nerve Conductions
Stimulation
Types of Nerve Damage
Nerve Recovery Patterns
Demyelinating
Other- Mixed Injury
Muscle
Measurement Parameters
Conduction Velocity = Distance (Proximal - Distal)
Time (PML –DML)
(DML)
(PML)
Entrapment
Sites
Normal Study – Upper Extremities
Patient:
Age:
Patient A
49
Motor Nerve Study
Median Nerve
Rec Site: APB Lat (ms)
Stim Site
L
R
Wrist
2.9 3.3
ACF
6.1 6.6
Test Date:
Amp (mV)
L
R
14.8 16.0
13.6 15.7
Left Median Nerve
Right Median Nerve
02/02/10
Dist (mm)
L
R
80
80
190 195
C.V. (m/s)
L
R
60.0 59.1
Left Ulnar Nerve
Motor Nerve Study
Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
L
R
Wrist
2.6 2.7
B.Elbow
5.4 5.5
A.Elbow
7.2 7.0
Amp (mV) Dist (mm)
L
R
L
R
19.5 17.1 80 80
18.5 16.2 175 175
17.4 15.4 110 115
Sensory Nerve Study
Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms)
Rec Site
L
R
MedMidPM
1.8 2.0
UlnMidPlm
1.9 1.7
MedSenAnt
3.1 3.1
UlnSenAnti
3.4 3.1
Amp (uV) Dist (mm)
C.V. (m/s)
L
R
L
R
L
R
84.3 70.7 80 80 43.6
40.0
43.7 52.0 80 80 42.9
46.2
111. 69.0 140 140 45.7 45.2
48.0 73.0 140 140 41.2 45.2
Right Ulnar Nerve
C.V. (m/s)
L
R
62.5 63.3
63.5 75.0
Summary/Interpretation:
Normal nerve conduction studies of the upper extremities.
Left Med/Uln/Rad Nerve
Right Med/Uln/Rad Nerve
Severe Carpal Tunnel Syndrome
Patient:
Age:
Patient C
87
Motor Nerve Study
Left Median Nerve
Rec Site: APB Lat (ms)
Stim Site
Wrist
8.2
ACF
11.7
Mid Palm
1.7
Motor Nerve Study
Left Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
Wrist
4.2
B.Elbow
7.6
A.Elbow
9.2
Sensory Nerve Study
Left Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms)
Rec Site
MedMidPM
3.8
UlnMidPlm
2.5
MedSenAnt
5.6
UlnSenAnti
4.4
Left Median Nerve
Test Date: 10/01/09
Amp (mV) Dist (mm) C.V. (m/s)
2.8
2.9
4.7
80
185
40
52.9
Left Ulnar Nerve
Amp (mV) Dist (mm) C.V. (m/s)
9.7
8.6
8.7
80
195
85
Amp (uV)
Dist (mm) C.V. (m/s)
19.0
30.0
15.3
18.0
80
80
140
140
56.8
54.3
21.2
32.0
25.1
31.8
Summary/Interpretation:
Nerve conduction studies of the left upper extremity demonstrate a severe left carpal
tunnel syndrome.
Left Med/Uln/Rad Nerve
Very Minimal or Mild Carpal Tunnel Syndrome
Patient:
Age:
Patient D
24
Left Median Nerve
Right Median Nerve
Test Date: 11/04/09
History/Comments:
Pain and numbness in both upper extremities, right greater than left.
Motor Nerve Study
Median Nerve
Rec Site: APB Lat (ms)
Stim Site
L
R
Wrist
3.3 3.9
ACF
6.7 6.9
Amp (mV)
L
R
16.4
15.0
16.3
15.0
Dist (mm)
L
R
80
80
195 190
C.V. (m/s)
L
R
Motor Nerve Study
Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
L
R
Wrist
2.8 2.8
B.Elbow
5.4 5.7
A.Elbow
7.4 7.6
Amp (mV)
L
R
17.2
15.1
16.5
14.7
15.8
14.0
Dist (mm)
L
R
80
80
175 185
125 125
C.V. (m/s)
L
R
Sensory Nerve Study
Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms)
Rec Site
L
R
MedMidPM
1.9 2.2
UlnMidPlm
1.8 1.5
MedSenAnt
3.3 3.6
UlnSenAnti
3.2 3.3
Amp (uV)
L
R
144.
140.
67.5
51.7
76.7
70.0
68.3
48.3
Dist (mm)
L
R
80
80
80
80
140
140
140
140
61.6
67.3
62.5
Left Ulnar Nerve
Right Ulnar Nerve
Left Med/Uln/Rad Nerve
Right Med/Uln/Rad Nerve
61.3
63.1
67.0
C.V. (m/s)
L
R
42.1
36.4
43.6
53.3
42.9
38.5
43.8
42.0
Summary/Interpretation:
Nerve conduction study of both upper extremities shows minimal slowing across
the right carpal tunnel.
Carpal Tunnel Syndrome
Left Median Nerve
With
Right Median Nerve
Underlying Mild Neuropathy
Patient:
Age:
Patient E
82
Test Date: 10/06/09
Motor Nerve Study
Median Nerve
Rec Site: APB Lat (ms)
Stim Site
L
R
Wrist
5.8 5.3
ACF
9.8 9.6
Amp (mV)
L
R
11.0 12.9
10.4 12.4
Dist (mm)
L
R
80
80
205 215
C.V. (m/s)
L
R
Motor Nerve Study
Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
L
R
Wrist
3.8 4.1
B.Elbow
7.8 8.0
A.Elbow
10.3 10.0
Amp (mV)
L
R
14.5 12.9
14.8 11.7
13.6 13.1
Dist (mm)
L
R
80
80
210 200
105 110
C.V. (m/s)
L
R
Sensory Nerve Study
Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms)
Rec Site
L
R
MedMidPM
3.7 2.9
UlnMidPlm
2.4 2.0
MedSenAnt
6.2 4.8
UlnSenAnti
4.8 4.3
Amp (uV)
L
R
20.7 160.
8.9 19.0
7.6 7.3
6.7 14.0
Dist (mm)
L
R
80
80
80
80
140 140
140 140
C.V. (m/s)
L
R
21.6 27.6
33.8 40.0
22.6 29.2
29.0 32.6
51.3
52.1
43.2
50.4
Left Ulnar Nerve
Right Ulnar Nerve
50.8
55.9
Summary/Interpretation:
Nerve conduction studies of both upper extremities show changes of a
bilateral carpal tunnel syndrome, moderately severe, left worse than right,
superimposed on a modest generalized polyneuropathy.
Left Med/Uln/Rad Nerve
Right Med/Uln/Rad Nerve
Carpal Tunnel Syndrome
Left Median Nerve
Right Median Nerve
Left Ulnar Nerve
Right Ulnar Nerve
Severe on the right / Moderate on the left
Patient:
Patient F
Age: 87
History/Comments:
Numbness and tingling in both hands, right greater than left.
Motor Nerve Study
Median Nerve
Rec Site: APB Lat (ms)
Stim Site
L
R
Wrist
4.8 5.5
ACF
9.5 10.0
Amp (mV)
L
R
9.8 9.2
9.3 9.1
Dist (mm)
L
R
80
80
245
225
Motor Nerve Study
Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
L
R
Wrist
3.0 3.3
B.Elbow
7.0 8.0
A.Elbow
9.6 10.4
Amp (mV)
L
R
14.6 17.7
14.1 17.3
13.5 16.1
Dist (mm)
L
R
80
80
220 235
130 125
Sensory Nerve Study
Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms)
Rec Site
L
R
MedMidPM
3.0 3.6
UlnMidPlm
2.2 2.2
MedSenAnt
4.5 5.8
UlnSenAnti
3.6 3.6
C.V. (m/s)
L
R
54.0 48.6
C.V. (m/s)
L
R
55.5 50.0
50.6 52.1
Left Med/Uln/Rad Nerve
Amp (uV)
L
R
30.3 13.7
26.0 79.3
27.7 8.0
28.3 17.3
Dist (mm)
L
R
80 80
80 80
140 140
140 140
C.V. (m/s)
L
R
27.0 22.2
36.4 38.7
31.3 24.3
39.3 38.9
Summary/Interpretation:
Nerve conduction study of both upper extremities reveals bilateral carpal
tunnel syndromes, severe on the right and moderate on the left.
Right Med/Uln/Rad Nerve
Ulnar Nerve
The most common place
for nerve entrapment is in
the elbow.
Ulnar Neuropathy
Cubital Tunnel
Tardy Ulnar Palsy
Ulnar Neuropathy
Patient:
Age:
Patient G
57
Left Median Nerve
Right Median Nerve
Left Ulnar Nerve
Right Ulnar Nerve
Left Med/Uln/Rad Nerve
Right Med/Uln/Rad Nerve
Test Date: 01/05/10
History/Comments:
Possible ulnar neuropathy.
Motor Nerve Study
Median Nerve
Rec Site: APB Lat (ms)
Stim Site
L
R
Wrist
3.4 3.8
ACF
7.1 7.3
Amp (mV)
L
R
10.8 9.4
10.3 9.3
Dist (mm)
L
R
80
80
220 200
C.V. (m/s)
L
R
Motor Nerve Study
Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
L
R
Wrist
3.7 3.4
B.Elbow
6.3 6.5
A.Elbow
8.5 8.1
Amp (mV)
L
R
16.3 16.5
16.2 16.6
12.4 16.8
Dist (mm)
L
R
80
80
185 180
80
110
C.V. (m/s)
L
R
Sensory Nerve Study
Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms)
Rec Site
L
R
MedMidPM
2.2 2.4
UlnMidPlm
2.1 1.9
MedSenAnt
3.4 3.8
UlnSenAnti
3.8 3.5
Amp (uV)
L
R
79.7 72.0
30.7 25.7
124.2 38.7
22.5 34.7
Dist (mm)
L
R
80
80
80
80
140 140
140 140
59.5
63.8
36.9
56.1
60.7
71.7
C.V. (m/s)
L
R
36.9 32.9
42.9 38.7
41.6 36.8
37.5 37.2
Summary/Interpretation:
Nerve conduction study of both upper extremities shows an ulnar neuropathy
with significant drop in the velocity across the elbow.
Severe Ulnar Neuropathy and Mild Carpal Tunnel
Patient:
Age:
Patient I
57
Right Median Nerve
Test Date: 11/24/09
Motor Nerve Study
Median Nerve
Rec Site: APB Lat (ms)
Stim Site
L
R
Wrist
4.4 3.8
ACF
8.3 7.7
Amp (mV)
L
R
12.7 12.0
12.7 12.3
Dist (mm)
L
R
80 80
215 235
C.V. (m/s)
L
R
Motor Nerve Study
Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
L
R
Wrist
4.0 3.7
B.Elbow
7.7 7.0
A.Elbow
11.5 9.1
Amp (mV)
L
R
10.4 16.7
9.4 15.5
1.8 14.7
Dist (mm)
L
R
80
80
230 220
100 140
C.V. (m/s)
L
R
Amp (uV)
Dist (mm)
C.V. (m/s)
125.7
21.6
28.3
44.7
80
80
140
140
33.8
36.4
38.2
35.9
Sensory Nerve Study
Left Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms)
Rec Site
MedMidPM
2.4
UlnMidPlm
2.2
MedSenAnt
3.7
UlnSenAnti
3.9
Left Median Nerve
59.7
62.4
Left Ulnar Nerve
61.6 66.0
26.5 68.9
Summary/Interpretation:
Nerve conduction studies of the upper extremities show:
1. Severe ulnar neuropathy at the left elbow, (amplitude and velocity drop).
2. Mild left carpal tunnel syndrome.
Left Med/Uln/Rad Nerve
Right Ulnar Nerve
Severe Ulnar Neuropathy
Patient:
Age:
Patient J
60
Motor Nerve Study
Right Median Nerve
Rec Site: APB Lat (ms)
Stim Site
Wrist
3.9
ACF
8.2
Right Median Nerve
Test Date: 10/05/09
Amp (mV)
Dist (mm)
C.V. (m/s)
12.7
12.2
80
210
49.6
Right Ulnar Nerve
Motor Nerve Study
Right Ulnar Nerve
Rec Site: ADM Lat (ms)
Stim Site
Wrist
5.0
B.Elbow
11.0
A.Elbow
19.5
Amp (mV)
Dist (mm)
C.V. (m/s)
1.4
.967
1.1
80
200
100
33.3
11.8
Dist (mm)
C.V. (m/s)
80
34.8
140
36.8
Sensory Nerve Study
Right Med/Uln/Rad Nerve
Stim Site: Wrist Lat (ms) Amp (uV)
Rec Site
MedMidPM
2.3
36.7
UlnMidPlm
NR
MedSenAnt
3.8
43.7
UlnSenAnti
NR
Right Med/Uln/Rad Nerve
Summary/Interpretation:
Nerve conduction studies of the right upper extremity show changes of a
severe neuropathy at the elbow, predominantly axonal.
Peroneal Neuropathy
Neurology
December 2005
MRI Detection of Cysts
in the Knee Causing
Common Peroneal
Neuropathy.
Donald J. Iverson, M.D.
Severe (Length Dependent) Polyneuropathy
Patient:
Age:
Patient
67
K
Test Date:
Left Peroneal Nerve
Right Peroneal Nerve
01/29/10
Motor Nerve Study
Peroneal Nerve
Rec Site: EDB
Stim Site
Ankle
B.Fibular
A.Fibular
Lat (ms)
L
R
6.1
5.4
16.8 16.1
19.4 19.4
Amp (mV)
L
R
.383 1.1
.408 .617
.433 .583
Dist (mm)
L
R
80
80
315 290
90
110
C.V. (m/s)
L
R
29.5
33.8
27.2
33.0
Motor Nerve Study
Tibial Nerve
Rec Site: AH
Stim Site
Ankle
Pop.Fos.
Lat (ms)
L
R
5.7
5.9
21.5 20.3
Left Tibial Nerve
Amp (mV)
L
R
.100 .117
.333 .300
Dist (mm)
L
R
80
80
470 420
C.V. (m/s)
L
R
Amp (mV)
L
R
10.1 8.9
10.1 9.7
Dist (mm)
L
R
C.V. (m/s)
L
R
90
33.8
Lat (ms)
Amp (uV)
L
R
L
R
4.7
4.1
3.3
2.0
NOTES:
Left side: not reliable
Dist (mm)
L
R
140 140
C.V. (m/s)
L
R
30.0 33.9
Dist (mm)
L
R
140 140
C.V. (m/s)
L
R
31.1 33.1
29.7
Right Tibial Nerve
29.3
Motor Nerve Study
Peroneal@AT Nerve
Rec Site: Ant Tibialis
Stim Site
B.Fibular
A.Fibular
Lat (ms)
L
R
3.5
3.6
6.2
6.5
110
37.7
Sensory Nerve Study
Peroneal Nerve
Rec Site: dors.ft
Stim Site
Lower leg
Left Peroneal@AT
Right side: not reliable
Sensory Nerve Study
Sural Nerve
Rec Site: Ankle
Stim Site
mid calf
Lat (ms)
Amp (uV)
L
R
L
R
4.5
4.2
4.2
2.7
NOTES:
Left side: not reliable
Right side: not reliable
Summary/Interpretation:
Nerve conduction study of both lower extremities shows severe length
dependent mixed axonal greater than demylenating polyneuropathy.
Sensory waveforms not shown.
Right Peroneal@AT
EMG Studies
Johnny Gambin Age 5
MUAP Morphologies
Spontaneous Waveform Generators
Interference Patterns
End Plate Spikes
Fibrillations
Positive Sharp Waves
Fibrillation Potentials + 1
Fibrillations + 4
Myotonic Discharge
Complex Repetitive Discharge
Fasciculation Potentials
Fasciculation with Reinnervated Potentials
Myokymic Discharge
Cramp
Rest Tremor
Normal Activation and Recruitment
Reinnervation - Long Duration & Polyphasic
Moderately Decreased Recruitment
Myopathic Brief Duration
Abnormal Neuromuscular Function
The possible sites of abnormal function of the peripheral nerves and
muscle are:
•Motor neuron cell body, sensory neuron cell body, or both
•Root
•Plexus nerve axons, peripheral nerve axons, or both
•Plexus nerve myelin, peripheral nerve myelin, or both
•Neuromuscular junction
•Muscle
Sites of Damage in Nerve and Muscle
Site
Disorder
Neuron cell body
Amyotrophic lateral sclerosis
Root
Cervical or lumbar radiculopathy
Axonal neuropathy
Toxic neuropathy
Demyelinating neuropathy
Guillain-Barre syndrome
Neuromuscular junction
Myasthenia Gravis
Muscle
Muscular dystrophy
The End
Thank you!
Patterns of Nerve Conductions
5 mV
5 msec
Normal
Distal Latency = 3.0 msec
Conduction Velocity = 59 m/sec
Axonal
Distal Latency = 4.4 msec
Conduction Velocity = 51 m/sec
Demyelinating
Demyelinating with
conduction block
Distal Latency = 12.7 msec
Conduction Velocity = 12 m/sec
Distal Latency = 12.7 msec
Conduction Velocity = 12 m/sec
Measurement Parameters
Amplitude
Duration
Distal Latency
Proximal Latency