AANEM Connect

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id="ContentPlaceholder_T22D6209E001_interiorLayoutTitle" class="sf_colsIn interior-layout__title" data-sf-element="Title" data-placeholder-label="Title"> <h1>AANEM Connect</h1><div class="breadcrumbs"> <a href="/">Home </a> <span> / </span> <a href="/membership">Membership </a> <span> / </span> <a href="/membership/benefits-of-membership">Benefits of Membership </a> <span> / </span> AANEM Connect</div> </div> <div id="ContentPlaceholder_T22D6209E001_interiorLayoutNav" class="sf_colsIn interior-layout__nav" data-sf-element="Nav" data-placeholder-label="Nav"> <div class="in-this-section"> <button type="button" class="in-this-section__toggle" data-toggle-target="next"> In This Section <span class="toggle-indicator"> <span class="toggle-indicator__piece toggle-indicator__piece--1"></span> <span class="toggle-indicator__piece toggle-indicator__piece--2"></span> <span class="toggle-indicator__piece toggle-indicator__piece--3"></span> </span> </button> <ul> <li class="is-current"> <a 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Use this platform as a sounding board to seek advice for navigating challenging cases or career decisions, and receive expert guidance from generous peers who want to help you succeed.</p></div> </div> <style> div.thread-container { border: 1px solid #414042; padding: 14px; border-radius: 12px; overflow: hidden; margin-bottom: 12px; } div.thread-title { font-size: 1.4em; font-weight: 600; margin-bottom: 8px; margin: -14px -28px 5px -14px; padding: 14px 14px 14px 14px; background-color: #E0E2DB; line-height: 1.1; } span.aanemconnect-contact { font-weight: 900; font-size: 1.1em; color: #284875; margin-right: 30px; } span.time { font-size: .9em; font-weight: 300; } div.thread-analytics { font-size: .8em; font-weight: 500; } div.thread-description-container { width: 100%; margin-bottom: -5px; } div.thread-description-container div.thread-options a { font-size: .9em; font-weight: 600; cursor: pointer; } div.breaking-line div.breaking-line-item.breaking-line-item { flex-basis: auto; } div.breaking-line div.breaking-line-item a.button.button--action { margin-bottom: 10px; } </style> <p>In order to comment on posts and view posts in their entirety, please <a href="https://www.aanem.org/account/login?redirect_uri=https%3a%2f%2fwww.aanem.org%2fmembership%2fbenefits-of-membership%2faanem-connect">login</a> with your AANEM member account information.</p> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/5e049439-aa04-ee11-8f6e-000d3a314d9a/">OPEN ACCESS - Measuring temperature.</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Manuel Marrufo-Salazar</span><span class='time'>12/31/21 1:41 PM (CST)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Simon Zimnowodzki</span> <span class='time'>3/6/22 9:20 PM (CST)</span> </div> <div class="thread-analytics">Views: 1291&emsp;Comments: 30</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="5e049439-aa04-ee11-8f6e-000d3a314d9a">Show more</a></div> <div class="thread-description" style="display: none;"> How much does trying to normalize the temperature, to avoid slowing of conduction velocity and dista latencies, have an inpact on patient care? I do not think that cool (not extreme) skin temperature will create the characteristic abnormalities noted by demyelinating polyneuropathies with quite prolonged temporal dispersion and significant slowing of velocities. Trying to warm up extremities cause delay and dyscomfort on patients given the extra time spent on performing the studies. Has there been a study that address this issue?<br /> <br /> Manuel. </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/279a6d89-83d1-ee11-9079-000d3a314cf4/">OPEN ACCESS - Warming limb techniques</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Lawrence Bluth</span><span class='time'>2/22/24 7:08 AM (CST)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Nicole Wiley</span> <span class='time'>6/5/24 12:00 PM (CDT)</span> </div> <div class="thread-analytics">Views: 178&emsp;Comments: 13</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="279a6d89-83d1-ee11-9079-000d3a314cf4">Show more</a></div> <div class="thread-description" style="display: none;"> <p>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? </p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/2688385a-1ca0-ee11-be37-000d3a314693/">OPEN ACCESS - New EMG lab and electrical interference</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">James Dorman</span><span class='time'>12/21/23 10:17 AM (CST)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Gautam Malhotra</span> <span class='time'>3/22/24 10:54 AM (CDT)</span> </div> <div class="thread-analytics">Views: 236&emsp;Comments: 28</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="2688385a-1ca0-ee11-be37-000d3a314693">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Hello, </p> <p>Soon I will be tasked with setting up a new EMG lab at a satellite hospital. I've been thinking about choice of location of the lab in the new hospital and have been wondering about electrical interference. </p> <p>Is there a way to measure/predict if this will be a problem? That is, short of setting up the EMG machine and using it in the new location? </p> <p>I know folks are familiar with this problem in ICU settings, but once or twice I've run across the problem during inpatient studies, and have concluded the interference must have come from a room above or below where I was located......</p> <p></p> <p></p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/61beb5d7-89aa-ef11-b8e9-000d3a5986e6/">Unusual Findings in EMG of a Post-Traumatic Shoulder Luxation Case</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Abdelhamid Naili</span><span class='time'>11/24/24 11:30 AM (CST)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Bassam Bassam</span> <span class='time'>11/30/24 1:45 PM (CST)</span> </div> <div class="thread-analytics">Views: 51&emsp;Comments: 5</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="61beb5d7-89aa-ef11-b8e9-000d3a5986e6">Show more</a></div> <div class="thread-description" style="display: none;"> <p><strong>Case Presentation:</strong><br />I am presenting the case of a 44-year-old male who sustained an anterior shoulder luxation while playing football. After reduction by an orthopedist, he developed noticeable deficits in shoulder and arm strength, as well as paresthesias in the hand.</p> <p><strong>Clinical Findings:</strong></p> <ul> <li><strong>Motor Deficits:</strong> Weakness in arm flexion, shoulder abduction, wrist extension, abductor pollicis brevis (APB), and abductor digiti minimi (ADM).</li> <li><strong>Sensory Deficits:</strong> Diminished sensation in the distribution of the radial, third digit, and fifth digit nerves.</li> </ul> <p><strong>NCS Findings:</strong></p> <ul> <li>Slightly reduced amplitude in APB.</li> <li>Markedly reduced amplitude in ADM.</li> <li>Reduced sensory responses in digit 3, radial nerve, and digit 5—more pronounced in radial and digit 5.</li> </ul> <p><strong>EMG Findings (15 Days Post-Injury):</strong><br />This is where I encountered a puzzling observation:</p> <ul> <li><strong>Muscles Examined:</strong> Deltoid, biceps, wrist extensors, APB, first dorsal interosseous (FDI), long supinator, and ADM.</li> <li><strong>Findings:</strong> No fibrillations or spontaneous activity were observed.</li> <li><strong>Recruitment Activity:</strong> Absent in all muscles except the biceps, where limited activity was present.</li> </ul> <p>Given the deficits and the NCS findings, I initially suspected a brachial plexopathy, likely affecting the upper trunk. However, the absence of fibrillations 15 days post-injury raises questions, as one would typically expect early signs of denervation by this time.     </p> <p></p> <p><strong>My Questions:</strong></p> <ol> <li>Is the absence of fibrillations at this stage consistent with a plexopathy, or should I consider an alternative explanation?</li> <li>Could the lack of EMG activity be attributed to technical factors or perhaps a central nervous system contribution?</li> <li>Would you recommend any additional studies (e.g., imaging, repeat EMG at a later time) to clarify the diagnosis?</li> </ol> <p>I appreciate any insights or similar experiences the community can share, as I aim to better understand the underlying mechanisms in this case.</p> <p>Thank you</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/7cdf7f7d-4a95-ef11-8a6a-000d3a5af798/">Sensory Radiculitis?</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Vinay Agarwal</span><span class='time'>10/28/24 11:34 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Sanjiv Sahoo</span> <span class='time'>11/28/24 11:18 AM (CST)</span> </div> <div class="thread-analytics">Views: 76&emsp;Comments: 4</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="7cdf7f7d-4a95-ef11-8a6a-000d3a5af798">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Seen a lady with mild diabetes <br />2 months back <br />Perineal area pain.No fever,skin rash<br />Followed by asymmetrical sensory involvement <br />Left more than right of lower limbs of acute onset <br />She is a known case of post polio residual paralysis<br />No increase of motor deficit <br />MRI spine and brain is normal it is a contrast MRI <br />NCV sensory normal <br />Bilateral Sural snaps are normal <br />Considering acute sensory Lumbo sacral radiculitis<br />What can be the possibly etiolgies please guide</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/e05ce615-4f34-ef11-8409-000d3a36cb89/">C5 radiculopathy vs plexopathy: utility of Rhomboid involvement</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Andrew Clarke</span><span class='time'>6/27/24 1:32 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Andrew Haig</span> <span class='time'>11/28/24 8:52 AM (CST)</span> </div> <div class="thread-analytics">Views: 211&emsp;Comments: 8</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="e05ce615-4f34-ef11-8409-000d3a36cb89">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Hi all,</p> <p>I have had two cases recently which I would love the group's thoughts on. Both patient's had an atraumatic onset of severe pain through the shoulder/scapular/lateral arm region. This involved some sensory symptoms and weakness. The pain was so severe to keep them awake for a few days. They both then developed significant atrophy through C5 myotomes in the coming months with scapula winging. </p> <p>I saw them month approx 5 months post event. The NCS demonstrated recordable lateral cutaneous nerve responses, both within allowable symemtry of the contralateral side. The remainder of the NCS were normal (sensory/motor studies of median, ulnar, radial, antebrachial bilaterally). </p> <p>The EMG demonstrated involvement of seemingly fairly isolated C5 muscles (Rhomboids, supraspin, infraspin, deltoid, biceps with sparing of brachioradialis, triceps, EDC, FDI, serratus anterior) with both spontaneous neurogenic changes and neurogenic units with reduced recruitment. </p> <p>The MRI Cx spines for these patients demonstrated a mild, and a moderate (respectively) C5 formainal stenosis without nerve impingement. </p> <p>The MRI plexus was normal (but this was a delayed scan post my assessment, so approx 5-6 months post event)</p> <p>My questions for the group</p> <p>1) Historically, involvement of Rhomboids was used to demonstrate pre-plexus localisation. There have been a number of case reports in recent times, with people documenting involvement in later diagnosed plexopathies. How many people would still use Rhomboid involvement as evidence of pre-plexus localisation? </p> <p>2) Severe onset, atraumatic pain keeping patients awake with then progressive atrophy is not restricted to Brachial Plexopathies, but would make one think this, rather than a Radiculoapthy. These two patients have a very C5 isolated picture, Rhomboid involvement, seemingly spared peripheral nerves (including LABC), with mild and moderate formainal stenosis. Acknolwedging that you would be trusting my  ncs skills/report, who would lean towards a radiculopathy and who towards a C5/very early upper plexoapthy. </p> <p>Thank you all</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/304b8f0c-de92-ef11-ac21-000d3a5986e6/">Thoughts on complex case: HNPP + CIDP?</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Cole Denkensohn</span><span class='time'>10/25/24 9:33 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Cole Denkensohn</span> <span class='time'>11/25/24 9:38 AM (CST)</span> </div> <div class="thread-analytics">Views: 62&emsp;Comments: 4</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="304b8f0c-de92-ef11-ac21-000d3a5986e6">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Good afternoon,</p> <p>I'm interested in hearing others' thoughts on this case I have.</p> <p>25yoM with severe back injury while lifting a heavy object in August but with worsening weakness and clumsiness in his legs thereafter. Exam with preserved reflexes except absent achilles and reduced patellars. 2/5 ankle dorsiflexion, otherwise 4- great toe extension 4+ knee flexion and 5s elsewhere. Romberg with step off and decreased proprioception in toes and patchy temp/LT loss in legs. Normal MRI L-spine x2. I did an EMG/NCS 1 month after injury and found (abnormals bolded):</p> <p>LUE:</p> <p>- Median digit 2 SNAP latency 3.9 amplitude <strong>5.2,</strong> motor distal latency<strong> 5.2</strong>, amplitude 8.1</p> <p>- Ulnar digit 5 SNAP latency 3.9, amplitude <strong>4.6</strong>, motor CV <strong>24</strong> across elbow, amplitude 11.6 distally</p> <p>- Radial SNAP latency 2.6, amplitude 11.6</p> <p>LLE:</p> <p>- Sural latency <strong>4.7</strong>, amplitude 4.4</p> <p>- Superficial peroneal latency 3.8, amplitude 6.3</p> <p>- Peroneal - EDB distal latency <strong>8.0</strong>, amplitude 2.6, distal segment CV <strong>34</strong>, across fibular head 42</p> <p>- Tibial AH distal latency <strong>6.7</strong>, amplitude 2.8</p> <p>RLE</p> <p>- Sural peak latency <strong>5.3</strong>, amplitude 5.9</p> <p>- R superficial peroneal latency 4.2, amplitude 6.6</p> <p>- R peroneal - EDB latency <strong>7.3</strong>, amplitude <strong>1.2</strong>, distal segment CV <strong>37</strong>, across fibular head 46</p> <p>- R tibial - AH latency<strong> 7.5</strong>, ampliotude <strong>1.9</strong>, NR at popliteal fossa</p> <p>I (regretably but due to time constraints did not do any F-waves or H-reflex)</p> <p>EMG</p> <p>- L FCR 1+ fibs/positives, 1+ amplitude</p> <p>- L APB 1+ fibs/positives</p> <p>- L tib ant 2+ fibs/positive, 2+ amplitude/duration, reduced recruitmet</p> <p>- L gastroc medial head 2+ fibs/positives, 1+ amplitude/duration</p> <p>- R tib and 2+ fibs/positives, 1+ amp/duration</p> <p>- R gastroc medial 2+ fibs/positives, 1+ amp/duration</p> <p>- Normal: L delt, L biceps, L triceps, L FDI, L vastus, L EIP, R vastus, R lumbar paraspinals</p> <p></p> <p>At this point I was concered about a mixed polyneuropathy but also noted the severe ulnar at the elbow and median at the wrist (FCR spontaneous noted...) and sent genetics for HNPP. No M-spike, B12 238 (started supplementation), TSH >16 (started thyroid replacement), A1c 5%.</p> <p></p> <p></p> <p>He deteriorated and became wheelchair bound with 2/5 dorsiflexion, inversion/eversion, and some scattered weakness elsewhere. Reflexes went away even in the uppers. I did an LP and whites were 9 with protein 150-170. Admitted for IVIG 2g/kg. Second outpatient IVIG 1g/kg reflexes returned but strength remained the same, L leg slightly worsening (dorsiflexion/inversion/eversion 1/5).</p> <p></p> <p>Genetics returned HNPP positive for heterozygous PMP22 deletion.</p> <p></p> <p>So now here I am left with a variety of questions, and I'm wondering the thoughts of the community. Does he have CIDP? There are some arguments for this, but it isn't clean. Could this be a nodopathy justifying Ritux? I'm gearing up to send for the antibodies but haven't pulled the trigger yet. Could this all be HNPP? It seems unlikely, but so is HNPP + an acquired mixed polyneuropathy. It's almost as if the arms look like HNPP and the legs look like an acquired polyneuropathy (maybe DADS-I looking at L peroneal EDB and R sural, but I can't ignore the axon loss).</p> <p></p> <p>I will also repeat the EMG after his next dose of IVIG.</p> <p></p> <p>Thanks for any thoughts on this complex case!</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/8a4bd2d6-a9a9-ef11-b8e9-000d3a5af798/">facility versus non facility emg</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Stephanie Kopey</span><span class='time'>11/23/24 8:47 AM (CST)</span> </div> <div class="thread-last-post"> Last Post: <strong>No comments yet</strong> </div> <div class="thread-analytics">Views: 10&emsp;Comments: 0</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="8a4bd2d6-a9a9-ef11-b8e9-000d3a5af798">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Currently two of our emg labs reside in multi-disciplinary outpatient buildings considered non facility. My employer is looking to change this to facility based. We use technologists for nerve conductions but they are directly supervised. Do you know what, if any, impact this will have on the physicians working in our labs from a wrvu standpoint or where I might find this information? Currently the ambulatory physicians receive the wrvu for the ncv and the emg. </p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/f220373f-9ca2-ef11-8a6a-000d3a5af798/">Inclusion Body Myositis and Testosterone</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Semira Ramic</span><span class='time'>11/14/24 9:22 AM (CST)</span> </div> <div class="thread-last-post"> Last Post: <strong>No comments yet</strong> </div> <div class="thread-analytics">Views: 9&emsp;Comments: 0</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="f220373f-9ca2-ef11-8a6a-000d3a5af798">Show more</a></div> <div class="thread-description" style="display: none;"> <p>A patient is asking me to prescribe topical testosterone for inclusion body myositis. Is there evidence behind this? Do you prescribe this? Why or why not?</p> <p></p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/40f8539e-d5e2-ee11-904d-000d3a314cf4/">Botox injection into piriformis muscle</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Eric Floranda</span><span class='time'>3/15/24 9:09 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Benjamin Sucher</span> <span class='time'>10/31/24 9:52 AM (CDT)</span> </div> <div class="thread-analytics">Views: 116&emsp;Comments: 8</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="40f8539e-d5e2-ee11-904d-000d3a314cf4">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Looking for someone who does Botox injection into piriformis muscle (ultrasound guided or not). Need to refer a patient. I am practicing in Virginia, but patient is willing to travel.  Thanks.</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/7dec9fac-f08c-ef11-ac21-000d3a5986e6/">CRITICAL CARE NEUROPATHY</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Eric Awad</span><span class='time'>10/17/24 8:31 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Eric Awad</span> <span class='time'>10/29/24 2:26 PM (CDT)</span> </div> <div class="thread-analytics">Views: 40&emsp;Comments: 2</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="7dec9fac-f08c-ef11-ac21-000d3a5986e6">Show more</a></div> <div class="thread-description" style="display: none;"> <p>39 year old man came in a few days ago for history of weakness in all four extremities worse in the left leg proximally. He has a long history of months of being bed bound in hospitals after undergoing many GI procedures/sugeries with many complications requiring more surgeries ICU admissions for months and rehab inpatient for months with little resolution. He has pain, sensory deficits and weakness in limbs. The clinical picture and exam suggested critical care neuropathy. EMG showed no response to stimulation of any of the motor nerves in the legs (no response at all). Interestingly, all the muscles tested (seven in each leg) showed no spontaneous activity whatsoever. There is decreased recruitment in all muscles but normal motor units and a few polyphasic ones. No PW or fibs or fascs! The study was limited to the legs. Can I make this a demyelinating type of neuropathy? Would he be a candidate for IVIg? I may bring him back for upper extremities study. Thoughts?</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/605d70cc-841f-ef11-840a-000d3a340cd3/">Has anyone seen this apparent Zio patch artifact on EMG?</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Cole Denkensohn</span><span class='time'>5/31/24 2:34 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Cole Denkensohn</span> <span class='time'>10/29/24 8:11 AM (CDT)</span> </div> <div class="thread-analytics">Views: 79&emsp;Comments: 3</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="605d70cc-841f-ef11-840a-000d3a340cd3">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Hey all,</p> <p></p> <p>Im not sure if this is the right forum for this question, but I figured I'd give it a shot.</p> <p></p> <p>I did an EMG on a young patient with a clinical history of left UNE, and the nerve studies confirmed that localization. I proceeded to a root screen with the needle to evaluate for additional radiculopathy, and all muscles were normal except for one finding. When I inserted the needle in the left biceps at rest, I saw/heard what looked like a fib firing quite regularly at around 1 hz. There was some subtle variability to it, and it remained as I moved the needle around to sample different regions. <br /><br /></p> <p>He was wearing a zio patch, and while I didn't think this device put out any signal (just read), I put my finger on his radial pulse and the "fib" seemed to follow his pulse. <br /><br /></p> <p>The above led me to consider that maybe this could somehow be a zio-patch related artifact. Has anyone seen this?</p> <p></p> <p>I think a true fib is less likely because of the subtle variability (not just linear slowing or speeding up) and the fact that it continued as I moved the needle around.</p> <p></p> <p>I think a volitional motor unit is less likely because of the morphology and firing speed.</p> <p></p> <p>Thank you for any thoughts!</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/8c28d22d-f544-ef11-8409-000d3a5c39c4/">Abducted right fifth finger </a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Arne Hautekiet</span><span class='time'>7/18/24 6:02 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Richard Ball</span> <span class='time'>10/24/24 8:22 PM (CDT)</span> </div> <div class="thread-analytics">Views: 201&emsp;Comments: 11</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="8c28d22d-f544-ef11-8409-000d3a5c39c4">Show more</a></div> <div class="thread-description" style="display: none;"> <p>I have a peculiar case on which i would like to have sought some advice. </p> <p>30y old male, electrician with no medical Hx. with since 3 weeks abducted little finger on the right side. Unable to bring the finger in adduction. No paresthesia, no other loss of strength. Doesn't remember a trauma or pain. </p> <p> Clinical examination shows preserved reflexes, strength (FDI / ADM / FPL / FCU / FDP5 / Orther interossei), esthesia. Tests for UNE are negative  No UMN signs. </p> <p>Needle Emg: no denervation potentials in FCU / FDI / ADM / APB / EIP/ 3rd palmaf IO, decreased recruitment in 3rd palmar IO with two rapid firing MUAPs  </p> <p>Ultrasound: normal configuration ulnar nerve from the axilla down to just distal of the pisohamate lig. Further course could not be evaluated but no ganglion cyste or other masses in the palm. Impression of possible myotendinous injury 3rd palmar IO on US but this is not my expertise so MRI is planned.</p> <p>I had 2 questions about this case:</p> <p>- Could you have a selective neuroraxia of the branch to the 3rd palmar explaining the clinical image a d findings on EMG? Patient reported repitive use of clipper the day he noticed the paresis  </p> <p>-What would your findings be on needle emg after of musculotendinous / muscular injury? I've searched pubmed but can't find any literature on this. I think this woud give a dcreased recruitment but would this also influence firing rate? </p> <p></p> <p></p> <p></p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/2fce84f9-b380-ef11-ac21-000d3a5af798/">Cleaning non-disposable surface electrodes</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Ryan Drake</span><span class='time'>10/2/24 6:46 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Richard Ball</span> <span class='time'>10/24/24 2:43 PM (CDT)</span> </div> <div class="thread-analytics">Views: 131&emsp;Comments: 13</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="2fce84f9-b380-ef11-ac21-000d3a5af798">Show more</a></div> <div class="thread-description" style="display: none;"> <p>We have historically cleaned resuable surface electrodes after use with isopropryl alcohol. I have a new employee that questioned if it was sufficient, including on intact dry skin.</p> <p>Are there any resources or guidelines that review this topic?</p> <p>Long time reader, first post.   Thanks, Ryan </p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/dd8ef15d-0889-ef11-ac21-002248088a86/">Per Special Request please enjoy this video, we hope you enjoy it as much as we did making it</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Collin Grant</span><span class='time'>10/12/24 9:10 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Channarayapatna Sridhara</span> <span class='time'>10/21/24 10:24 AM (CDT)</span> </div> <div class="thread-analytics">Views: 65&emsp;Comments: 4</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="dd8ef15d-0889-ef11-ac21-002248088a86">Show more</a></div> <div class="thread-description" style="display: none;"> <p>please enjoy this rendition of YMCA, with a EDX theme:)</p> <p>https://youtu.be/x6-eY5HKOxc?si=rbNQT-kSrBmI7PLc</p> <p><br />Written and directed by Dr. Peter Grant. Editing by my dear wife Martusha. </p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/95af15b1-7c81-ef11-ac20-6045bd03ff0d/">Old EMG Machine for Free</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Brian Foley</span><span class='time'>10/3/24 6:43 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Brian Foley</span> <span class='time'>10/17/24 6:40 PM (CDT)</span> </div> <div class="thread-analytics">Views: 59&emsp;Comments: 4</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="95af15b1-7c81-ef11-ac20-6045bd03ff0d">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Let me know if you have interest in a TECA/Synergy EMG machine. The software is likely out of date so I don't connect it to the internet. Otherwise it works great. I can print reports or store to the HD or USB.</p> <p>It has served me well for thousands of studies. But now I must retire.</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/8106d222-cb7a-ef11-a670-000d3a5986e6/">EMG Talk: Spike and Wave are seeking creative examples of EMG reports – by October 6.</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Lawrence Robinson</span><span class='time'>9/24/24 6:17 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Lawrence Robinson</span> <span class='time'>10/15/24 12:55 PM (CDT)</span> </div> <div class="thread-analytics">Views: 95&emsp;Comments: 11</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="8106d222-cb7a-ef11-a670-000d3a5986e6">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Since ancient times EMG reports have evolved from cave-dwellers drawing nerve injuries on walls, to paper charts, to now electronic reports, sometimes even in the form of poems or limericks.</p> <p>What will come next? </p> <p>We want to see your most creative and fun report for the following scenario.  Maybe it's Instagram, TikTok or X?  Maybe it’s a rap song, or a watercolor drawing?</p> <p>If you are at AANEM this year you might be asked to present this live at EMG Talk! And you could win a valued EMG talk hat or other apparel. </p> <p style="padding-left: 30px;"><strong>A 57 year old male fell from a ladder while installing a satellite dish on his home one month ago; he wanted to get a good livestream from the AANEM meeting.  He sustained a left humeral fracture and radial nerve injury.</strong></p> <p style="padding-left: 30px;"><strong>Physical exam shows an intact triceps, but no strength in brachioradialis, wrist, thumb or finger extensors.  All other muscles in the upper limb are strong.  Sensation is decreased on the back of the hand.</strong></p> <p style="padding-left: 30px;"><strong>EDx demonstrated no radial CMAP or SNAP, although median and ulnar responses were normal.  Needle EMG demonstrated fibrillations and no MUAPs in brachioradialis, extensor carpi radialis, extensor digitorum or extensor indicis.</strong></p> <p><strong> </strong>Please provide a creative impression for your EMG report – this can be written, video, tweets, drawings - any media you choose.</p> <p> </p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/5f59c399-527f-ef11-ac20-000d3a5cefe6/">A neuromuscular syndrome</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Elias Ragi</span><span class='time'>9/30/24 12:37 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Channarayapatna Sridhara</span> <span class='time'>10/3/24 12:35 PM (CDT)</span> </div> <div class="thread-analytics">Views: 48&emsp;Comments: 2</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="5f59c399-527f-ef11-ac20-000d3a5cefe6">Show more</a></div> <div class="thread-description" style="display: none;"> <p style="font-weight: 400;">As January’s ‘What could this mean? remains open, I am revisiting the closely related neuromuscular syndrome of abnormalities of female reproductive hormones.<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn1" target="_blank" rel="noopener noreferrer">[1]</a> To keep the principal message succinct, substantial amount of text is in footnotes.</p> <p style="font-weight: 400;">These patients, exclusively women (mostly 30 to 60), present with predominantly sensory symptoms in an upper limb. They describe a spectrum<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn2" target="_blank" rel="noopener noreferrer">[2]</a> of aching, pain, tightness around the shoulder and adjacent side of the neck. Aching and pain radiate onto the forearm and hand, but there is not much numbness – as of the carpal tunnel syndrome or an ulnar neuropathy, and no specific weakness. Symptoms usually begin about 2 months after a distinct gynecological event (including medicinal or surgical).<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn3" target="_blank" rel="noopener noreferrer">[3]</a> Unless the syndrome, however, is recognised – contingent on such events being elicited, often by direct questioning, it would be missed, or misdiagnosed, with unnecessary surgery to follow.<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn4" target="_blank" rel="noopener noreferrer">[4]</a>  </p> <p style="font-weight: 400;">Almost all these patients are referred for the (implicitly) true neurogenic (or vascular) thoracic outlet syndrome, cervical radiculopathy, benign fasciculation syndrome or median or ulnar neuropathy. When, however, it is the neuromuscular syndrome (of this post), the patient turns out to have none of these pathologies.<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn5" target="_blank" rel="noopener noreferrer">[5]</a>   </p> <p style="font-weight: 400;">In fact, nerve conduction (including the cutaneous nerves of the forearm) and EMG are usually negative;<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn6" target="_blank" rel="noopener noreferrer">[6]</a>except for discharges (yet to be explained, beyond the postulate they reflect muscle or nerve hyperexcitability) that follow the F-waves.<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn7" target="_blank" rel="noopener noreferrer">[7]</a></p> <p style="font-weight: 400;">Symptoms, however, persist for several months after withdrawal of the medicinal hormone. I do not know the explanation;<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn8" target="_blank" rel="noopener noreferrer">[8]</a> the phenomenon is perhaps akin to ‘coasting’ in drug-induced neuropathies, but I also postulate another mechanism.<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn9" target="_blank" rel="noopener noreferrer">[9]</a> This lag is important: (a) suspicion of the syndrome would, not unreasonably, be questioned and no specific treatment, or withdrawal of the hormone would be instigated; and (b) even if it was possible to withdraw the hormone,<sup> </sup>the patient, or doctors may decide this was not the culprit and reverse the withdrawal. </p> <p style="font-weight: 400;">But I might be wrong.<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn10" target="_blank" rel="noopener noreferrer">[10]</a> Many women are on medicinal hormones, and the association might be coincidental – even granting it is in over two hundred patients I have seen where the association is distinct?<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn11" target="_blank" rel="noopener noreferrer">[11]</a> There might also be other factors yet unknown that contribute – Swiss cheese model – to produce the syndrome.</p> <p style="font-weight: 400;">I am hoping that wider recognition of the syndrome may clarify the association with hormones and with the electrophysiological correlates of (putative) neuromuscular hyperexcitability.<a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftn12" target="_blank" rel="noopener noreferrer">[12]</a>        </p> <p style="font-weight: 400;"></p> <p style="font-weight: 400;">Footnotes:</p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref1" target="_blank" rel="noopener noreferrer">[1]</a> The phenomenon may also occur in other conditions.</em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref2" target="_blank" rel="noopener noreferrer">[2]</a> Constraints of language; many women note what they feel is difficult to describe – hence several adjectives. Tightness sometimes likened to a blood pressure cuff or elastic bands squeezing the upper arm. Twitching, muscles feel knotted, and a patient volunteering that the pain in the shoulder is unique: ‘only a woman would recognise, being similar to that of contractions of the gravid womb.’ </em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref3" target="_blank" rel="noopener noreferrer">[3]</a> The very first patient (Thomas and Cushing’s, Johns Hopkins Hosp Bull (14):315–319, 1903) may have been such an example. Also, about a quarter of the women I have seen have had hysterectomy, while the precipitating event can sometimes be just a change in the brand of the medicinal hormone.</em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref4" target="_blank" rel="noopener noreferrer">[4]</a> Possibly as the case of the ‘What could this mean?’, where it would be useful to know what the symptoms were – before release (relief lasting only five weeks), how did symptoms become worse, and what medicines (hormones may need to be asked about specifically) the patient might have been on. </em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref5" target="_blank" rel="noopener noreferrer">[5]</a> Some slowing across the carpal tunnel (or of the ulnar nerve across the elbow) is not infrequently detected, but usually short of the constituting the entrapment syndromes (as corroborated by appropriate symptoms). Nevertheless, slowing may be misconstrued – even by the referring clinician receiving the report – as either of these entrapments. It is also possible either of these entrapments coexist, although short of explaining the overwhelming (hormonal) symptoms. Also, fixation with a structural (rib or band) anomaly may override other considerations.</em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref6" target="_blank" rel="noopener noreferrer">[6]</a> As also imaging and vascular ultrasound.</em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref7" target="_blank" rel="noopener noreferrer">[7]</a> F-wave display needs to be at least 100ms long. But other electrophysiological methods for reflecting neuromuscular hyperexcitability (possibly due to nerve or muscle cell-membrane ion-channel dysfunction secondary to hormonal imbalance) might already, and more will be available.   </em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref8" target="_blank" rel="noopener noreferrer">[8]</a> As also for why the presentation is unilateral. Sometimes, the ipsilateral lower limb is included (as it also was in Thomas and Cushing’s Case I).    </em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref9" target="_blank" rel="noopener noreferrer">[9]</a> Although symptoms have been precipitated by the exogenous hormone (medicinal, such as the HRT) but also to which the ovaries and uterus would have responded by modifying their own ‘endogenous’ production of hormones (possibly explaining the delay of few months before symptoms appear), when the medicinal hormone is withdrawn, the ovaries and uterus are not expected to switch off instantly; they may take several (28-days) cycles to go back to their ‘normal’, innate pre-hormone-replacement production.</em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref10" target="_blank" rel="noopener noreferrer">[10]</a> Emphasising in my report that, although my suspicion is based on numerous patients I had seen over several years, I might still be wrong, and deferring to the opinion of the referring clinician and other specialists the patient might be seeing – including for decision on withdrawing the hormones.</em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref11" target="_blank" rel="noopener noreferrer">[11]</a> Many of these women had, in the few months preceding symptoms, started on a medicinal hormone (orally, implant), for contraception or replacement. In fact, it is as much on the woman herself that, on recounting her medicines, dawns the association. (Some women do not consider these hormones medicines, and the question may need to be specific.) </em></p> <p><em><a href="applewebdata://F80D5B5D-1805-4983-ACC4-EBCF1A8CD4A3#_ftnref12" target="_blank" rel="noopener noreferrer">[12]</a> For why I am also presenting this thread, from a patient: ‘Dr Ragi believes I may have a neuromuscular syndrome. I wondered if it's possible to get any information regarding this please as I can't find much online myself, other than a letter (133-135-JFPRHC April 07)… As I'm still (five months after onset, following hysterectomy) experiencing the same symptoms, it would be really useful to have more info to know where to go from here.’</em></p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/ef751d06-864b-ef11-a317-002248096dd3/">Botox and EMG</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Steven Lovitt</span><span class='time'>7/26/24 2:34 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Daniel Dumitru</span> <span class='time'>8/25/24 7:26 AM (CDT)</span> </div> <div class="thread-analytics">Views: 129&emsp;Comments: 7</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="ef751d06-864b-ef11-a317-002248096dd3">Show more</a></div> <div class="thread-description" style="display: none;"> <p>I performed EMG with nerve conduction study on a lady who is treated regularly with Botox for dystonia due to Parkinsonism. From an electrical standpoint she had L5-S1 radiculopathy, With fibrillations and positive sharp waves in limb muscles, as well as the paraspinous musculature. I do not know what muscles are injected with Botox (she receives it at a different institution) So I do not know what percentage of electrical changes could be due to Botox. Proximal muscles that are involved make me comfortable diagnosing radiculopathy, but I felt a little uncertain with some of the distal findings. How much of a concern do you think this is, and how do you handle this?</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/b15a65d7-ae58-ef11-a316-6045bd00f1a7/">ICD 10 COde for Long Thoracic Neuropathy </a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Jit Mookerjee</span><span class='time'>8/12/24 8:29 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Rachel Volbrecht</span> <span class='time'>8/16/24 9:43 AM (CDT)</span> </div> <div class="thread-analytics">Views: 26&emsp;Comments: 1</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="b15a65d7-ae58-ef11-a316-6045bd00f1a7">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Hello,</p> <p>What ICD 10 code should I use for a long thoracic neuropathy?</p> <p>G58.9? </p> <p>Thanks</p> <p></p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/6f68f227-76f0-ee11-904c-000d3a314cf4/">What could this mean?</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Isvan Alvarez Herrera</span><span class='time'>4/1/24 5:21 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Elias Ragi</span> <span class='time'>5/18/24 12:51 PM (CDT)</span> </div> <div class="thread-analytics">Views: 286&emsp;Comments: 11</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="6f68f227-76f0-ee11-904c-000d3a314cf4">Show more</a></div> <div class="thread-description" style="display: none;"> <p>While recording F waves on left APB, stimulating at wrist, I noticed the waveforms in question. I made the screen capture at two different sweeps, with increased F-wave gain for better visualization. The patient is a 69 year-old female that had a left carpal tunnel release aprox. 13 weeks prior. She did well after CTR for around 4-5 weeks when she developed worsening hand symptoms.</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/7ed1d39d-1d2d-ef11-840a-6045bd000ee9/">CTS question</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Anonymous</span><span class='time'>6/18/24 8:00 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Chris Rink</span> <span class='time'>8/14/24 9:35 PM (CDT)</span> </div> <div class="thread-analytics">Views: 211&emsp;Comments: 7</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="7ed1d39d-1d2d-ef11-840a-6045bd000ee9">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Good evening,</p> <p>I recently encountered an unusual case of carpal tunnel syndrome (CTS) that I found quite challenging, and I am seeking some insights from this esteemed group.</p> <p>A 77-year-old right-handed woman presented with various right hand symptoms, including paresthesias, stiffness, and coldness, which were sometimes worse at night. A cursory examination was normal, except for mild APB atrophy.</p> <p>Her nerve conduction studies (NCS) showed the following:</p> <ul> <li>Median motor potential: Normal latency (3.8 ms), low amplitude (3.0 mV), and normal velocity (53 m/s)</li> <li>Right median SNAP: Borderline increased peak latency (3.60 ms), borderline low amplitude (19.5 μV), and normal velocity (53 m/s)</li> <li>Radial SNAPs were normal</li> <li>Palmar studies and studies to the fourth digits were entirely normal</li> </ul> <p>I did not perform the ulnar motor potential or a needle EMG due to time constraints and the assumption that the low median motor potential was artefactual. I concluded with an essentially normal report, attributing her symptoms to musculoskeletal issues.</p> <p>She was later evaluated at another institution, where her history was described as more typical of CTS. Their NCS results were also normal, but a restricted EMG examination revealed severe chronic neurogenic changes in the APB and a normal FDI. They diagnosed severe CTS and referred her for surgery.</p> <p>I was surprised by this conclusion and would have considered a radicular or myeloradicular origin, likely imaging the cervical spine.</p> <p>My questions are:</p> <ul> <li>Can CTS present solely with axonal motor findings, even with sensory symptoms?</li> <li>Is this potentially a case of isolated thenar motor branch involvement?</li> <li>How would you have proceeded with a case like this?</li> </ul> <p>Thank you for your guidance.</p> <p>Sincerely,<br />Repentant EMGer</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/aa170baa-1554-ef11-a317-000d3a5c39c4/">Conference speaker</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Cory Hansen</span><span class='time'>8/6/24 12:02 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <strong>No comments yet</strong> </div> <div class="thread-analytics">Views: 19&emsp;Comments: 0</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="aa170baa-1554-ef11-a317-000d3a5c39c4">Show more</a></div> <div class="thread-description" style="display: none;"> <p>Good morining everyone. I wanted to reach out to anyone interested in presenting at a small conference virtually. We are looking for someone who can speak about the growing need for EMG/NCS and challenges of availability in both urban and rural communities. Anyone intersted please reach out to me at</p> <p>cory.hansen2@imail.org</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/e22b1b99-bf4a-ef11-a317-000d3a314d9a/">Billing</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Janet Balbierz</span><span class='time'>7/25/24 2:53 PM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <strong>No comments yet</strong> </div> <div class="thread-analytics">Views: 22&emsp;Comments: 0</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="e22b1b99-bf4a-ef11-a317-000d3a314d9a">Show more</a></div> <div class="thread-description" style="display: none;"> <p style="font-weight: 400;">I have posted on this before.  The AANEM office suggested I post this to the forum to see if there are other physicians experiencing this issue. </p> <p style="font-weight: 400;">I am starting to see billing warnings from other insurance companies (besides Humana who flat out denies) saying a patient can’t have carpal tunnel syndrome and cervical radiculopathy at the same time.  This combination frequently occurs in patients. </p> <p style="font-weight: 400;">And now the software system is also saying/warning that patients can’t have lumbosacral plexopathy and radiculopathy, even though there are patients with symptoms and findings that could be possible plexus and possible radiculopathy clinically where the EMG doesn’t definitively rule out one or the other and additional anatomical imaging or other work up is needed. </p> <p style="font-weight: 400;">This is looking like a trend where the insurance company will deny if these diagnoses are submitted together but will also deny higher nerve conduction codes like 95913 saying it isn’t necessary for “just” carpal tunnel or “just” cervical radiculopathy or any other limited diagnosis codes submitted. </p> <p style="font-weight: 400;">Perhaps AANEM would have more clout in going to insurance companies on this.  I have submitted position letters from AANEM with appeals, but many times it doesn’t work.  The insurance companies don’t give a s… about me as a solo practitioner and they have no incentive to do what is fair. </p> <p style="font-weight: 400;"> Thank you. </p> <p style="font-weight: 400;">Janet Balbierz, M.D.</p> </div> </div> </div> <div class="thread-container"> <div class="thread-title"> <a href="/membership/benefits-of-membership/aanem-connect/Thread/ee8cad83-4839-ef11-8409-002248043ee7/">Small fiber neuropathy with MGUS</a> </div> <div class="thread-by-line"> by <span class="aanemconnect-contact">Justin Willer</span><span class='time'>7/3/24 9:28 AM (CDT)</span> </div> <div class="thread-last-post"> Last Post: <span class="aanemconnect-contact">Justin Willer</span> <span class='time'>7/25/24 8:27 AM (CDT)</span> </div> <div class="thread-analytics">Views: 60&emsp;Comments: 2</div> <div class="thread-description-container"> <div class="thread-options"><a onclick="ShowMoreClicked(this);" data-id="ee8cad83-4839-ef11-8409-002248043ee7">Show more</a></div> <div class="thread-description" style="display: none;"> <p>I have a patient with a small fiber neuropathy who started with constant severe burning pain in his feet. After 2 or 3 infusions of Rituximab his pain intensity is now 20% of the original intensity and his pain is no longer constant with the pain lasting from 2 or 3 hours a day up to 11 hours (2 or 3 hours the most common duration.</p> <p>He has a sustained response to the Rituximab but seems to be hitting a plateau in terms of response. Would switching him to another agent possibly produce additional benefit? If not how long should I continue the Rituximab. He has had 3 infusions so far?</p> </div> </div> </div> <select id="pageddl" onchange="location.href = '/membership/benefits-of-membership/aanem-connect/Index/' + this.value + '/';"> <option value="1" selected>1</option> <option value="2" >2</option> <option value="3" >3</option> <option value="4" >4</option> <option value="5" >5</option> <option value="6" >6</option> <option value="7" >7</option> <option value="8" >8</option> <option value="9" >9</option> <option value="10" >10</option> <option value="11" >11</option> <option value="12" >12</option> <option value="13" >13</option> </select> <div class="breaking-line" style="justify-content: flex-end;"> <div class="breaking-line-item" style="flex: none; align-content: flex-end;"><a class="button" style="margin-bottom: 10px;" href="/membership/benefits-of-membership/aanem-connect/Index/2/">Next</a></div> </div> <script> function ShowMoreClicked(link) { if (link.innerText.toLowerCase().includes('show more')) { link.innerText = 'Hide description'; $(link).closest('div.thread-description-container').find('div.thread-description').css('display', 'block'); $.ajax({ type: "GET", url: '/membership/benefits-of-membership/aanem-connect/IncrementThreadView/' + link.dataset.id + '/', contentType: false, cache: false, processData: false, timeout: 5000 }); } else { link.innerText = 'Show more'; $(link).closest('div.thread-description-container').find('div.thread-description').css('display', 'none'); } } </script> <div > <div class="sfContentBlock sf-Long-text" ><a href="/membership/benefits-of-membership/aanem-connect/aanem-connect-terms-of-use">AANEM Connect Terms of Use</a></div> </div> </div> <div id="ContentPlaceholder_T22D6209E001_interiorLayoutAside" class="sf_colsIn interior-layout__aside" data-sf-element="Aside" data-placeholder-label="Aside"> <div > <div class="sfContentBlock sf-Long-text" ><blockquote class="pull-quote"><p>I enjoy participating in the AANEM Connect Forum for a number of reasons. 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