the role of “emg”...the role of the “emg” kaye sedarsky, md cpt, usa, mc clinical...
TRANSCRIPT
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The Role of the “EMG”Kaye Sedarsky, MD
CPT, USA, MC
Clinical Neurophysiology Fellow
Department of Neurology
Walter Reed National Military Medical Center
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Key Terms
Distal latency
Conduction velocity
Muscle membrane instability
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Who performs EMGs?
PM&R
PTs
Neurologists
General, Clinical Neurophysiology, Neuromuscular
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What can we evaluate?
The peripheral nervous system
Nerves, Muscles
If a normal test, may indicate
Problem is central nervous system
Not neurologic
Error in EMG interpretation
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“Hey Doc! My hand is tingling…”
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Clinical Presentation
Numbness/Tingling
Nocturnal symptoms
Wrist pain
Exacerbated by overuse
Most common in dominant hand, but is commonly bilateral
Grip weakness
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RED Flags
Radicular neck pain
Acute onset
Severe pain
Weakness or sensory
symptoms outside the
hand
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NCS/EMG
Sensory nerve conductions
Motor nerve conductions
Needle EMG
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NCS/EMG
Prolonged distal latency or absent SNAPs
Slowing at the wrist in CMAPs
+/- decreased amplitude of CMAPs
Muscle membrane instability isolated to median innervated muscles OF THE
HAND only (sparing median muscles of forearm)
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Diagnostic criteria for CTS
(median mononeuropathy at the wrist)
Mild
Moderate
Severe
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Mild CTS
• Slow SNAP
• Normal CMAP
• Needle EMG normal
Moderate CTS
• Absent SNAP
• Slow CMAP
• Mild abnormal needle EMG
Severe CTS
• Absent SNAP
• Absent or severely slow CMAP
• Abnormal needle EMG
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Treatment options
Conservative Surgical
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“Hey Doc! I’ve been wearing that wrist
brace you gave me and my hand is still
tingling…”
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Clinical Presentation
Numbness/Tingling in 4th and 5th digits
Nocturnal symptoms
Elbow pain
Exacerbated by leaning on elbow, over-bending, lifting, overuse
Most common in non-dominant hand, but may be bilateral
>> Grip weakness
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RED Flags
Radicular neck/shoulder
pain
Painless weakness
Acute onset
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NCS/EMG
Sensory nerve conductions
Motor nerve conductions
Needle EMG
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NCS/EMG
Normal or mildly abnormal SNAPs
Focal slowing or conduction block across the elbow
Muscle membrane instability isolated to ulnar innervated muscles only
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Treatment options
Conservative Surgical
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When to
send for
EMG?Failed conservative trial
1
Diagnostic ambiguity
2
RED flag symptoms
3
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“Ahhh, my aching back…”
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Clinical Presentation
Pain and paresthesias radiating in the distribution of nerve root
May involve weakness or motor dysfunction
Dermatomes and myotomes*
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RED Flag symptoms
Acute onset
Rapid weakness
Bilateral LE involvement
Dense sensory loss or focal muscle weakness
Bowel or bladder dysfunction
incontinence
incomplete emptying and/or
retention
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NCS/EMG
Sensory nerve conductions
Motor nerve conductions
Needle EMG
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EMG/NCS
Normal SNAPs
Variable CMAPs
Prolonged F waves
Muscle membrane instability in myotomal level corresponding with level of
radiculopathy
Including paraspinal muscles
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Treatment options
Conservative Surgical
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Limitations of the EMG study
If study is too early, may be falsely normal
Difficult to localize to a single lumbar level
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What’s the
bottom line?
1. Conservative treatment
first if clinical diagnosis
is clear.
2. Order the test, we are
happy to objectively
clarify the
issue/symptom ☺
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Thank you!