John Gambin, M.D.. NMJ Fiber Types InvolvedPathologyTemporal Course Sensory Motor Mixed Axonal...
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Transcript of John Gambin, M.D.. NMJ Fiber Types InvolvedPathologyTemporal Course Sensory Motor Mixed Axonal...
ELECTRODIAGNOSTICS
John Gambin, M.D.
NMJ
Fiber Types Involved Pathology Temporal Course
Sensory
Motor
Mixed
Axonal
Demyelinating
Acquired Inherited
Hyperacute
Acute
Subacute
Chronic
Severity
Goals of the EDX Study
Muscle Nerve
Localization
Neuronopathy
Radiculopathy
Plexopathy
Mononeuropathy
Multiple Mononeuropathies
Polyneuropathy
CNS
Proximal
Distal
Generalized
Cranio-bulbar
Presynaptic
Postsynaptic
Localization
Myopathic NMJNeuropathic
Elements of the Peripheral Nervous System
Neurons of the Peripheral Nervous System
Sensory Nerve
Motor Nerve
Post Synaptic Membrane
Muscle Contraction
Motor Unit
MUAP
Nerve Conduction or EMG ?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
Nerve Root
Patterns of Nerve Conductions Stimulation
Types of Nerve Damage
Nerve Recovery PatternsMuscle Demyelinating
Other- Mixed Injury
Measurement Parameters
(DML)
(PML)
Conduction Velocity = Distance (Proximal - Distal)Time (PML –DML)
Entrapment Sites
Right Median Nerve
Left Ulnar Nerve Right Ulnar Nerve
Right Med/Uln/Rad Nerve
Patient: Patient A Test Date: 02/02/10Age: 49
Motor Nerve StudyMedian NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 2.9 3.3 14.8 16.0 80 80ACF 6.1 6.6 13.6 15.7 190 195 60.0 59.1
Motor Nerve StudyUlnar NerveRec Site: ADM Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 2.6 2.7 19.5 17.1 80 80B.Elbow 5.4 5.5 18.5 16.2 175 175 62.5 63.3A.Elbow 7.2 7.0 17.4 15.4 110 115 63.5 75.0
Sensory Nerve StudyMed/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Rec Site L R L R L R L RMedMidPM 1.8 2.0 84.3 70.7 80 80 43.6 40.0UlnMidPlm 1.9 1.7 43.7 52.0 80 80 42.9 46.2MedSenAnt 3.1 3.1 111. 69.0 140 140 45.7 45.2UlnSenAnti 3.4 3.1 48.0 73.0 140 140 41.2 45.2
Summary/Interpretation:Normal nerve conduction studies of the upper extremities.
Left Median Nerve
Left Med/Uln/Rad Nerve
Normal Study – Upper Extremities
Patient: Patient C Test Date: 10/01/09Age: 87
Motor Nerve StudyLeft Median NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim SiteWrist 8.2 2.8 80ACF 11.7 2.9 185 52.9Mid Palm 1.7 4.7 40
Motor Nerve StudyLeft Ulnar NerveRec Site: ADM Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim SiteWrist 4.2 9.7 80B.Elbow 7.6 8.6 195 56.8A.Elbow 9.2 8.7 85 54.3
Sensory Nerve StudyLeft Med/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Rec SiteMedMidPM 3.8 19.0 80 21.2UlnMidPlm 2.5 30.0 80 32.0MedSenAnt 5.6 15.3 140 25.1UlnSenAnti 4.4 18.0 140 31.8
Summary/Interpretation:Nerve conduction studies of the left upper extremity demonstrate a severe left carpal tunnel syndrome.
Left Median Nerve
Left Ulnar Nerve
Left Med/Uln/Rad Nerve
Severe Carpal Tunnel Syndrome
Right Median Nerve
Left Ulnar Nerve Right Ulnar Nerve
Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve
Patient: Patient D Test Date: 11/04/09Age: 24
History/Comments:Pain and numbness in both upper extremities, right greater than left.
Motor Nerve StudyMedian NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 3.3 3.9 16.4 15.0 80 80ACF 6.7 6.9 16.3 15.0 195 190 61.6 61.3
Motor Nerve StudyUlnar NerveRec Site: ADM Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 2.8 2.8 17.2 15.1 80 80B.Elbow 5.4 5.7 16.5 14.7 175 185 67.3 63.1A.Elbow 7.4 7.6 15.8 14.0 125 125 62.5 67.0
Sensory Nerve StudyMed/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Rec Site L R L R L R L RMedMidPM 1.9 2.2 144. 140. 80 80 42.1 36.4UlnMidPlm 1.8 1.5 67.5 51.7 80 80 43.6 53.3MedSenAnt 3.3 3.6 76.7 70.0 140 140 42.9 38.5UlnSenAnti 3.2 3.3 68.3 48.3 140 140 43.8 42.0
Summary/Interpretation:Nerve conduction study of both upper extremities shows minimal slowing across the right carpal tunnel.
Left Median NerveVery Minimal or Mild Carpal Tunnel Syndrome
Left Median Nerve Right Median Nerve
Left Ulnar Nerve Right Ulnar Nerve
Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve
Patient: Patient E Test Date: 10/06/09Age: 82
Motor Nerve StudyMedian NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 5.8 5.3 11.0 12.9 80 80ACF 9.8 9.6 10.4 12.4 205 215 51.3 50.4
Motor Nerve StudyUlnar NerveRec Site: ADM Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 3.8 4.1 14.5 12.9 80 80B.Elbow 7.8 8.0 14.8 11.7 210 200 52.1 50.8A.Elbow 10.3 10.0 13.6 13.1 105 110 43.2 55.9
Sensory Nerve StudyMed/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Rec Site L R L R L R L RMedMidPM 3.7 2.9 20.7 160. 80 80 21.6 27.6UlnMidPlm 2.4 2.0 8.9 19.0 80 80 33.8 40.0MedSenAnt 6.2 4.8 7.6 7.3 140 140 22.6 29.2UlnSenAnti 4.8 4.3 6.7 14.0 140 140 29.0 32.6
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.
Carpal Tunnel Syndrome With
Underlying Mild Neuropathy
Patient: Patient F Age: 87
History/Comments:Numbness and tingling in both hands, right greater than left.
Motor Nerve StudyMedian NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 4.8 5.5 9.8 9.2 80 80ACF 9.5 10.0 9.3 9.1 245 225 54.0 48.6
Motor Nerve StudyUlnar NerveRec Site: ADM Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 3.0 3.3 14.6 17.7 80 80B.Elbow 7.0 8.0 14.1 17.3 220 235 55.5 50.0A.Elbow 9.6 10.4 13.5 16.1 130 125 50.6 52.1
Sensory Nerve StudyMed/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Rec Site L R L R L R L RMedMidPM 3.0 3.6 30.3 13.7 80 80 27.0 22.2UlnMidPlm 2.2 2.2 26.0 79.3 80 80 36.4 38.7MedSenAnt 4.5 5.8 27.7 8.0 140 140 31.3 24.3UlnSenAnti 3.6 3.6 28.3 17.3 140 140 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.
Left Median Nerve Right Median Nerve
Left Ulnar Nerve Right Ulnar Nerve
Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve
Carpal Tunnel Syndrome
Severe on the right / Moderate on the left
Ulnar Nerve
The most common place for nerve entrapment is in the elbow.
Ulnar Neuropathy
Cubital Tunnel
Tardy Ulnar Palsy
Left Median Nerve Right Median Nerve
Left Ulnar Nerve Right Ulnar Nerve
Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve
Patient: Patient G Test Date: 01/05/10Age: 57
History/Comments:Possible ulnar neuropathy.
Motor Nerve StudyMedian NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 3.4 3.8 10.8 9.4 80 80ACF 7.1 7.3 10.3 9.3 220 200 59.5 56.1
Motor Nerve StudyUlnar NerveRec Site: ADM Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L R L RWrist 3.7 3.4 16.3 16.5 80 80B.Elbow 6.3 6.5 16.2 16.6 185 180 63.8 60.7A.Elbow 8.5 8.1 12.4 16.8 80 110 36.9 71.7
Sensory Nerve StudyMed/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Rec Site L R L R L R L RMedMidPM 2.2 2.4 79.7 72.0 80 80 36.9 32.9UlnMidPlm 2.1 1.9 30.7 25.7 80 80 42.9 38.7MedSenAnt 3.4 3.8 124.2 38.7 140 140 41.6 36.8UlnSenAnti 3.8 3.5 22.5 34.7 140 140 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.
Ulnar Neuropathy
Patient: Patient I Test Date:11/24/09Age: 57
Motor Nerve StudyMedian NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R
L R L R
Wrist 4.4 3.8 12.7 12.080 80
ACF 8.3 7.7 12.7 12.3215 235 59.7 62.4
Motor Nerve StudyUlnar NerveRec Site: ADMLat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R
L R LR
Wrist 4.0 3.7 10.4 16.780 80
B.Elbow 7.7 7.0 9.4 15.5230 220 61.6
66.0A.Elbow 11.5 9.1 1.8 14.7
100 140 26.568.9
Sensory Nerve StudyLeft Med/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV)
Dist (mm) C.V. (m/s)Rec SiteMedMidPM 2.4 125.7
80 33.8UlnMidPlm 2.2 21.6
80 36.4MedSenAnt 3.7 28.3
140 38.2UlnSenAnti 3.9 44.7
140 35.9
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.
Right Median Nerve
Left Ulnar Nerve Right Ulnar Nerve
Left Med/Uln/Rad Nerve
Left Median NerveSevere Ulnar Neuropathy and Mild Carpal Tunnel
Patient: Patient J Test Date: 10/05/09Age: 60
Motor Nerve StudyRight Median NerveRec Site: APB Lat (ms) Amp (mV) Dist (mm)
C.V. (m/s)Stim SiteWrist 3.9 12.7
80ACF 8.2 12.2
210 49.6
Motor Nerve StudyRight Ulnar NerveRec Site: ADM Lat (ms) Amp (mV) Dist (mm)
C.V. (m/s)Stim SiteWrist 5.0 1.4
80B.Elbow 11.0 .967
200 33.3A.Elbow 19.5 1.1
100 11.8
Sensory Nerve StudyRight Med/Uln/Rad NerveStim Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Rec SiteMedMidPM 2.3 36.7
80 34.8UlnMidPlm NR
MedSenAnt 3.8 43.7140 36.8
UlnSenAnti NR
Summary/Interpretation:Nerve conduction studies of the right upper extremity show changes of a severe neuropathy at the elbow, predominantly axonal.
Right Ulnar Nerve
Right Med/Uln/Rad Nerve
Right Median NerveSevere Ulnar Neuropathy
Peroneal Neuropathy
Neurology December 2005
MRI Detection of Cysts in the Knee Causing Common Peroneal Neuropathy.
Donald J. Iverson, M.D.
Patient: Patient K Test Date:01/29/10Age: 67
Motor Nerve StudyPeroneal NerveRec Site: EDB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L
R L RAnkle 6.1 5.4 .383 1.1 80
80B.Fibular 16.8 16.1 .408 .617 315
290 29.5 27.2A.Fibular 19.4 19.4 .433 .583 90
110 33.8 33.0
Motor Nerve StudyTibial NerveRec Site: AH Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L
R L RAnkle 5.7 5.9 .100 .117 80
80Pop.Fos. 21.5 20.3 .333 .300 470
420 29.7 29.3
Motor Nerve StudyPeroneal@AT NerveRec Site: Ant Tibialis Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)Stim Site L R L R L
R L RB.Fibular 3.5 3.6 10.1 8.9
A.Fibular 6.2 6.5 10.1 9.7 90110 33.8 37.7
Sensory Nerve StudyPeroneal NerveRec Site: dors.ft Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Stim Site L R L R L
R L RLower leg 4.7 4.1 3.3 2.0 140
140 30.0 33.9NOTES:
Left side: not reliable Right side: not reliable
Sensory Nerve StudySural NerveRec Site: Ankle Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)Stim Site L R L R L
R L Rmid calf 4.5 4.2 4.2 2.7 140
140 31.1 33.1NOTES:
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.
Right Peroneal Nerve
Left Tibial Nerve Right Tibial Nerve
Left Peroneal@AT Right Peroneal@AT
Left Peroneal Nerve
Sensory waveforms not shown.
Severe (Length Dependent) Polyneuropathy
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
Normal
Axonal
Demyelinating
Demyelinating with conduction block
Distal Latency = 3.0 msecConduction Velocity = 59 m/sec
Distal Latency = 4.4 msecConduction Velocity = 51 m/sec
Distal Latency = 12.7 msecConduction Velocity = 12 m/sec
Distal Latency = 12.7 msecConduction Velocity = 12 m/sec
5 mV
5 msec
Amplitude
Duration
Distal Latency
Proximal Latency
Measurement Parameters