EMG Nerve Conduction Studies in Pain Patients

AmmarAGilani,MD,DABPN
AssociateProfessorandStaffNeurologist DepartmentofMedicine/Neurology McMasterUniversity/HamiltonHealthSciences Hamilton,ON

Disclosure

Pfizer AstraZeneca Allergan Purdue TevaNeurosciences Lilly/BoehringerIngelheim B Bayer Valeant

Objectives
BasicDescriptionofthelaboratoryprocedures Nerveconductionstudies Electromyography El h Electrodiagnostic g abnormalitiesinpainful p peripheral p p nerve

diseases
Pitfalls/limitationsoftechnique

SomatosensoryEvoked Potentials P t ti l (SSEP)

Hasaverylimitedrolein thePostMRIera.
A.SSEPstimulationtotheleft Mediannerve B.SSEPstimulationtotheleft Tibialnerve

EMG and Nerve Conduction Studies

Anextension i of fthe h Physical h i lExamination i i Quantitatesnerveand/ormuscleinjury j y ProvidesUsefulDataRegardingNerveInjury

Site Type Severity D ti Duration Prognosis

Goals of EDX Testing

Localization

Severity

Muscle

NMJ

Nerve

Anterior Horn

N Nerve C Conduction d i S Studies di

Studiesofthewaveformsgeneratedinthe peripheralnervoussystem.
Motornerveconduction
Stimulationofaperipheralnervewhilerecording fromamuscleinnervatedbythatnerve.

Sensorynerveconduction
Stimulationamixednervewhilerecordingfroma mixedorcutaneousnerve

Terminology
LATENCY(DL)
Intervalbetweentheonsetofastimulusandtheonsetofa response

AMPLITUDE(AMP)
Themaximumvoltagedifferencebetweentwopoints Itisproportionaltothenumberandsizeofnervefibersthatare depolarized. Providesanestimateoftheamountofnervetissuethatis electricallyactive

DURATION
Thetimefromonsettotermination. Totaldurationmeasuresthedispersionofallcomponents components. Measuresthedifferencesinconductionofthenervefibers

CONDUCTIONVELOCITY(CV)
Thespeedatwhichthenervefibersarecarryingtheelectrical stimulusbetweentwosites sites. Comparisonofconductionbetweentwosegmentsofthesame nervecanlocalizealesion.

Types of nerve conduction studies

Sensory:typically antidromic Commonly examinednerves: Sural,ulnar,median, occasionally i ll radial di l orsuperficial peroneal

Sensory NCS Parameters

Onsetandpeak

latencies

Conductionvelocity determinedby velocityofaveryfew f fast tfib fibers Amplitude determinedbythe numberoflarge sensoryfibers activated

Motor Nerve Conductions

VitalpartofEDXasthis importantforidentifying demyelination,compression Needtodoproximalanddistal studiestoevaluatefor y, conductionvelocity, conductionblock,temporal dispersion Typicalnerves:ulnar, ulnar median median, peroneal,tibial Lesscommon:radial,femoral, phrenic,spinalaccessory,facial

F-waves and H-reflex

Usefulforidentifying proximalsegmental demyelination Canonlybedone when h motor amplitudeis>1mV D Dependent d ton patientsheight

Fwaves
MotorFwavestudiesp proximalroots:
Antidromic motortotheanteriorhornofthespinalcord; orthodromically tothemuscle.

Puremotortest. test AprolongedasymmetricFwavessuggestaproximal rootlesion. Clinicalapplicationbestforplexopathy.

Quiteprolongedindemyelination,AIDP,mild prolongation p g inaxonalinjury. j y

LesssensitivethanEMGforradiculopathysinceonly shortsegmentofnerveisdemyelinatedin radiculopathy. radiculopathy

HREFLEX
Reflex f loop: p Orthodromicsensory yandmotor UtilizedtoassessforradiculopathyofS1,*C6/7 S1;Poplitealfossa,recordinMedialGastrocnemeus C6/7;Median d nerveatwrist,record datFlexor l Carpi Radialis Unilateraldelay,absentsuggeststibial,sciatic, sacralplexus,cord,S1motororsensoryroots. Onceabnormal,maynotnormalize; Often f absent b inpolyneuropathy l h or>60yearsof f age.

Needle Electromyography: y g p y Techniques q

Needleelectrodeisinsertedintothemuscle
Needleisdisposable,singleuse

Multiplemusclesareaccessibleforexamination Combinationofmusclestested
Dependentuponclinicalquestion

Levelofdiscomfortismild

Needle dl Electromyography: l h Data

InsertionalActivity SpontaneousActivity MotorUnitConfiguration g MotorUnitRecruitment Interference f Pattern

EMGFindings d

NeedleEMG
Insertionactivityincreaseswithinafewdaysofmuscle denervation,whereasabnormalspontaneousactivity t k 24(3) takes ( )weeks k to t develop, d l depending d di onthe th distance di t betweenthenervelesionandthemuscle Abnormal Ab lspontaneousactivity i i and di increased dinsertion i i activityarenotpathognomonicofdenervation,mayoccur incertaindisordersofmuscleortheneuromuscular junction

EMG Recruitment EMG: R i

Whenamuscleisvoluntarilycontractedasinglemotorunitmay fire. Asthemuscleisfurthercontractedmoremotorunitsareadded orrecruited. Normally, y,recruitmentofadditionalmotorunitsoccursat relativelylowlevelsofeffort

IfthereisalossofMUAPswithanydiseaseprocessthenrecruitmentisreduced. Lossofnerveaxons Conductionblockattheneuromuscularjunction Sufficientlossofmusclefibers

EMG
Theelectromyographicfindingsmayprovideaguidetothetimeof onsetofthelesionandtoitschronicity, Ifapatient ti treports t that th tawrist i tdrop d has h developed d l dimmediately i di t l afteranoperativeprocedureandneedleelectromyography performedshortlythereafterrevealsabnormalspontaneous activity y( (fibrillationp potentialsandp positivesharp pwaves) )inthe extensormuscleofthewrist,itislikelythatthelesionisatleast 23weeksoldandthereforeitprecededthesurgery. Similarly,thepresenceoflongduration, Similarly duration largeamplitude, amplitude polyphasicmotorunitpotentialsindicatesthatthedenervation occurredseveralweeksormorebeforesurgerybecausesome reinnervationhasoccurred.

When to order EMG

Mononeuropathy Mononeuropathy Polyneuropathies Cranialneuropathies
TrigeminalMononeuropathy (BlinkReflex)

Multiplex Radiculopathy p y Plexopathy(Brachial orLumbosacral)

Myopathy

EMGFindings;Polyneuropathy
Axonal Sensory+/ Motor NormalCV NormalDL ReducedtoabsentAmp. NormalFWave(ifamp.>1 MV) NeedleEMGinmotoror sensorimotor;Denervation andreinnervationchanges g (slowlyprogressivecan showonlyreinnervation changes) Demyelinating Motor+Sensorychange SlowNCV ConductionBlock DistalLatency:Long SlowFwaves Amplitude:Normalto reduced(late) NeedleEMG:Normal(late withaxonalloss Denervationand/or reinnervation)

PAINFULNEUROPATHIES: DifferentialDiagnosis

Toxic

Hereditary

Alcohol Metals:Thallium;Arsenic Medications: cisplatinum;Disulfiram;Ifosfamide; Nitrofurantoin;Dilantin;Perhexiline; Taxol;Thalidomide;Vincaalkaloids Acuteonset GuillainBarr Diffusepainduringacutecourse Distalpainwithincomplete recovery Immobility Acutepanautonomic AntiSulfatideAntibodyassociated polyneuropathies Connective C ti tissue ti di disease HIV(DILS) Mprotein Ganglionopathies:Sjgren's;Paraneoplastic (Hu)

Immune

galactosidase(Fabry's) GM2gangliosidosis:Lateonset Sensory yNeuropathy p yILancinating gp pains MotorSensoryNeuropathyI&IIFoot deformity Burningfeetsyndrome Amyloidosis Polyneuropathy:Pain& Paraesthesiasinlegs Carpaltunnelsyndrome:Painin hands Porphyria Restlesslegssyndromes:Somewith PNSinvolvement Hereditary(Acromelalgia):12q HSN1 HMSN5 CMT2 Huntingtondiseaselike1 Also:Renalfailure

PAINFULNEUROPATHIES: Differential iff i lDiagnosis i i

Metabolic
Diabetic Acute:LumbarorThoracic radiculopathy;Distalsensory Chronic:"Smallfiber" neuropathy Alcoholic:Acute Pellagra g ( (niacin) ) Beriberi(thiamine) Strachansyndrome(Cuban neuropathy) Postgastroplasty Hypertriglyceridemia Chronicmountainsickness Idiopathic Distalsensorypolyneuropathy syndromes d Erythromelalgia Mononeuritismultiplex

Motordisorderswithpain

Diabeticamyotrophy Polio Polio HIV Nervelesions: Trigeminal Brachialp plexus Lumbosacralplexopathy Thoracicoutletsyndrome Median Posteriortibial(Tarsaltunnelsyndrome) Radiculopathies:Upper&LowerExtremities Burningmouthsyndrome DiabeticAmyotrophy ReflexSympatheticDystrophy(Complexregional painsyndrome) Infections:Herpeszoster Neoplasticinfiltration:Burningpainwith dysesthesia y inareaofsensory yloss Postsurgicallocalizedpainsyndromes Acuteporphyria Toxic:Thallium;Arsenic;Perhexiline;Vinca alkaloids GuillainBarr

Infections

Localizeddisorders

Acuteonsetofpain&paresthesias

DiabetesandPNSDiseases
Symmetric y Polyneuropathies y p Chronic
Distal sensory +/- Autonomic Autonomic Sensory motor Sensory-motor Painful Reversible Lumbosacral plexopathy Mononeuropathies i.e., CTS Mononeuritis multiplex

Acute

Asymmetric y neuropathies p

Predisposition to immune PN
CIDP Diabetic amyotrophy Perineuritis Muscle infarction

Common Mononeuropathies

MedianattheWrist(CTS) UlnarattheElbow(TardyUlnarPalsy) PeronealPalsyattheFibularHead

Plexopathy: Selected Etiologies

Compression Inflammatory f

(CABG) (ParsonageTurner (Radiotherapy) (Traction, (Traction laceration, laceration (Di b ti amyotrophy) (Diabetic t h )

Syndrome)
RadiationInjury TraumaticInjury

missile)
Ischemia I h i

CarpalTunnelSyndrome
prolongationofthemediannervemotor/sensorylatencyupon

stimulationatthewrist("terminal"or"distal"latency),
normalmedianmotorconductionvelocityintheforearm, slowmediansensoryconductionvelocityacrossthewrist, normalmotorandsensoryNCSoftheulnarnerve(notinvolved

inCTS).NCSarepositivein9198%ofpatientswithclinicalCTS
DiagnosedbycomparingMediantoUlnarsensoryandmotor

DLs

58YearoldpatientwithLowBack pain i and dl left f f footd drop

Retiredsteelworkerwithlongstandinghistoryoflowbackfromwork

relatedinjuryandS/Pbacksurgery10yrs.Ago.Presentedwith2 monthhistoryofnumbnesstinglingandpainofdorsalaspectofleft footandweaknessofdorsiflexion dorsiflexion.

NerveConductionStudies MotorNerveConductionstudies:CMAPsonLeft

Tibial Normal Amp.,DL&CV DeepPeroneal ReducedAmp,NormalDLandCVbelowfibular headand12m/sslowingacrossfibularhead,Dispersionan55%dropin ampl.

SensoryNerveConductionStudies:SNAPsonLeft

Sural: Sup.Peroneal:

NormalAmp.,DL&CV Slightlyreducedamp.,NormalDLandCV

58YearoldpatientwithLowBack painandleftfootdrop
NeedleEMGLeftLowerExtremity y
Muscle Insertional Spontaneous Configuration Recruitment Interfennce

Vastus Lateralis Anterrior Tibialis Peroneus Longus MedialGast. Lat Hamst. Lat. Hamst Glut.Med.

N N N N

N N N N

N Large/ g / Poly Large/Poly

Large/poly Large/Poly Large/Poly

RadiculopathyAANEMGuidelines

Guideline:NeedleEMGexaminationofatleast1muscleinnervatedby ytheC5, 5,C6, , C7,C8,andT1spinalrootsinasymptomaticupperlimb,andL3,L4,L5,andS1 spinalrootsinthesymptomaticlowerlimb. Paraspinalmusclesat1ormorelevels,asappropriatetotheclinicalpresentation, shouldbeexamined(exceptinpatientswithpriorcervicallaminectomyusinga posteriorapproach). Ifaspecificrootissuspectedclinically,orifanabnormalityisseenontheinitial needleEMGexamination, ,additionalstudiesasfollows:

Examinationof1or2additionalmusclesinnervatedbythesuspectedrootandadifferent peripheralnerve. Demonstrationofnormalmusclesaboveandbelowtheinvolvedroot.

Optional:PerformFWaveandHReflex(C6,C7andS1).Comparewiththe Optional: contralateralsideifnecessary. Abnormalonlywithaxonalinvolvement. Dennervationin23weeks,reinnervation46weeksafteronsetofsymptoms.

What to Expect From an EMG Report

Aclinicallyandphysiologicallyrelevant

interpretation/diagnosis
Anoutlineofthelocalization,severity,andacuityof

theprocess
Notationofotherdiagnosesthatare

/ detected/excluded
Explanationofanytechnicalproblems

EMG Pittfalls
NerveConductionStudies:limitations

NCSassessdistalsegmentsofnerves Painfulstimulations Temperature T t sensitive iti (S>M) Assessmainlylargefibers Mostusefulfornerveconditions

NeedleEMGinterpretationdependentuponthe

Skillsoftheelectromyographer Timing(Walleriandegeneration)fewweeksuntilfullpicture emerges Painanddiscomfort Multiplemusclesneedtobeexamined Samplingerrorscanleadtoerroneousconclusions

Summary: Utility of EMG/NCS

Sensitiveindicatorofnerveinjury DetectsdynamicandfunctionalinjurymissedbyMRI Providesinformationregardingchronicityofnerveinjury Providesprognosticdata Hi Highly hl l localizing li i Clarifiesclinicalscenarioswhenonedisordermimicsanother Identifies Id tifi combined bi dmulti ltisite it i injury, j avoiding idi missed i ddiagnoses di Identifiesmoreglobalneuromuscularinjurywithfocalonset Provides P id l longitudinal i di ld dataf forcharting h i course,responsetotherapy h

Thankyou