Order Neuromuscular Case Studies Discussion

Order Neuromuscular Case Studies Discussion
Order Neuromuscular Case Studies Discussion
1. A 76-year-old woman presented with numbness and tingling of the hands that had persisted for the
previous 5 weeks. Examination revealedmildlimitation of neck movements. Strength and reflexeswere
normal. She hadmild atrophy of the right thenar muscles. Pain sensation was decreased in the radial 3½
digits; Phalen’s test was positive bilaterally. Neurologic examination was otherwise negative and the
EMG was done.
Motor nerve studies
F-wave studies
Sensory nerve studies
EMG data
Nerve Latency (ms) Normal Latency(ms)
Median nerve R. 39.4 30
Ulnar nerve R. 27.2 30
Median nerve L. 28.1 30
Nerve
Onset
Latency
(ms)
Normal
Onset
Latency
(ms)
Peak
Latency
(ms)
Normal
Peak
Latency
(ms)
Amp
(μV)
Order Neuromuscular Case Studies Discussion
Normal
Amp≥
(μV)
Conduction
Velocity
(m/s)
Normal
Conduction
Velocity≥(m/s)
Median
nerve R.
6.5 2.6 7.0 3.1 5 20 20 50
Ulnar
nerve R.
2.4 2.6 2.9 3.1 25 13 50 50
Median
nerve L.
3.4 2.6 3.9 3.1 26 20 38 50
Nerve and Site Latency (ms) Amplitude (mV) Conduction Velocity (m/s)
Median nerve R. Normal4.2 Normal6 Normal50
Wrist 7.8 1.7 –
Elbow 12.2 1.7 55
Ulnar nerve R. Normal3.6 Normal8 Normal50
Wrist 3.0 11 –
Elbow 6.4 10 56
Median nerve L. Normal4.2 Normal6 Normal50
Wrist 4.3 6 –
Elbow 8.4 6 55
Muscle
Insert
Activity Fibs
Pos
Waves Fasc Amp Dur Poly Pattern
Brachioradialis R. Norm None None None Norm Norm None Full
Flexor carpi
ulnaris R.
Norm None None None Norm Norm None Full
Extensor digitorum
communis R.
Norm None None None Norm Norm None Full
Abductor pollicis
brevis R.
Norm None None None Lg Inc None Red
First dorsal
interosseous R.
Norm None None None Norm Norm None Full
Results from Bertorini TE. Neuromuscular Case Studies, 1st ed., Butterworth-Heinemann, Elsevier, Case 1, 2008.
490 PART VI PERIPHERAL NERVE SURGERY
Which one of the following explains her symptoms?
a. C6 and C7 radiculopathy
b. C6 radiculopathy
c. Carpal tunnel syndrome
d. Musculocutaneous nerve entrapment
Order Neuromuscular Case Studies Discussion
e. Ulnar nerve entrapment
11. A 57-year-old man presented with an 8 week history of progressive weakness and wasting in the
left hand and mild numbness in the little finger. His past medical history was positive for poliomyelitis as a child, which left residual weakness in both legs. He had an almost complete recovery
except for a mild deformity of the left foot. He did have occasional fasciculations in the leg. On
examination, the left hand interossei muscles were wasted but without fasciculations. He had a
positive Froment’s sign and a Tinel’s sign below the left elbow. When extending his fingers,
the last two digits had a tendency to remain flexed. He could not “cup” the left hand. Adson’s
maneuver was negative. There was decreased pain sensation in the left little finger and the ulnar
half of the ring finger with equivocal decreased pain sensation in the ulnar aspect of the dorsum of
the hand. All reflexes were mildly depressed.
Motor nerve studies
F-wave studies
Nerve and Site Latency (ms) Amplitude (mV) Conduction Velocity (m/s)
Median nerve L. Normal4.2 Normal6 Normal50
Wrist 4.7 11 –
Elbow 9.8 10 53
Ulnar nerve L. Normal3.6 Normal8 Normal50
Wrist 3.5 3 –
Below elbow 8.3 3 57
Above elbow 11.4 1 39
Axilla 13.2 1 67
Peroneal nerve L. Normal5.7 Normal3 Normal40
Ankle 5.2 4 –
Fibular head 12.3 4 44
Knee 14.3 4 50
Median nerve R. Normal4.2 Normal6 Normal50
Wrist 4.3 15 –
Elbow 9.3 14 54
Ulnar nerve R. Normal3.6 Normal8 Normal50
Wrist 2.7 10 –
Below elbow 7.2 10 58
Above elbow 9.6 10 50
Nerve Latency (ms) Normal Latency(ms)
Median nerve L. 30.7 30
Ulnar nerve L. 33.0 30
Peroneal nerve L. 54.9 54
Median nerve R. 30.8 30
Ulnar nerve R. 32.1 30
37 PERIPHERAL NERVE 491
Inching technique: ulnar nerve L.
Sensory nerve studies
EMG data
Muscle
Insert
Activity Fibs
Pos
Waves Fasc Amp Dur Poly Pattern
Biceps brachii L. Norm None None None Norm Norm Few Full
Triceps L. Norm None None None Lg Inc None Full
Flexor carpi radialis L. Norm None None None Norm Norm None Full
Flexor carpi ulnaris L. Norm None None None Norm Norm None Full
1st dorsal interosseous L. Inc 2 2 None Lg Inc None Red
Abductor pollicis brevis L. Norm None None None Norm Norm None Full
Flexor digitorum profundus L. Inc 2 2 None Lg Inc None Red
Vastus lateralis L. Inc None 2 None Lg Inc None Red
Tibialis anterior L. Norm None None None Lg Inc None Red
Gastrocnemius L. Inc None 1 None Lg Inc None Full
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