[Electrodiagnosis and electrotherapy in the orthopedic practice. I. Electrodiagnosis].
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Action Potentials↗
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[Electrodiagnosis of stimulation and electrodiagnosis of detection in peripheral neurogenic disorders. Attempt at correlation].
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Action Potentials↗
The electrodiagnosis of ulnar nerve entrapment at the elbow.
Entrapment of the ulnar nerve at the elbow is the second most common focal peripheral neuropathy. Recent advances have facilitated the electrodiagnosis of this common nerve entrapment. The goals of electrodiagnosis are to localize ulnar nerve dysfunction, confirm that the disturbance is confined to the ulnar nerve, and assess the severity of ulnar nerve dysfunction. The goal of this review is to highlight the important advances in anatomy, neurophysiology and methodology that impact upon the electrodiagnosis of entrapment of the ulnar nerve at the elbow, illustrate the limits of electrodiagnosis, and discuss methodological issues that may be the subject of further study. Careful attention to elbow position, temperature, and conservative estimates of conduction block should be part of common practice. Awareness of anatomical variations in structural anatomy, anomalous innervation and fascicular arrangement of ulnar nerve fibers are required to interpret electrodiagnostic studies accurately. The most reliable finding is slowing of the ulnar across-elbow motor nerve conduction velocity to less than 50 m/sec while recording from the abductor digiti minimi muscle, and should be carefully interpreted in the presence of a polyneuropathy or other neurogenic process. Alternative techniques such as relative ulnar slowing in different ulnar nerve segments, use of alternative muscles, sensory and mixed nerve techniques provide complementary information, and like all nerve conduction studies are highly operator-dependent and should be used on a case by case basis. Recent studies have focused the electromyographer's attention on the use of shorter across-elbow segments (2-5 cm). This may offer a reasonable trade-off between sensitivity and measurement error and may result in improved electrodiagnosis.
Animals↗
Physicians' practice patterns in pediatric electrodiagnosis.
The medical literature contains contradictory reports and recommendations regarding pediatric patients' pain and distress during electrodiagnosis. We surveyed 117 pediatric neurologists and physiatrists regarding their practice patterns in pediatric electrodiagnosis; 84 (72%) responded, of whom 44 (52%) regularly perform electrodiagnosis on children (mean = 85 per year, representing 3,667 examinations per year). Respondents reported extreme behavioral distress (eg, screaming, flailing, requiring additional restraint, or attempting to leave the examination table) in 35% of examinations, most often among 2- to 6-year-olds. Pain medications are never prescribed by 45%, occasionally by 48%, and always by 2%; general anesthesia is never administered by 75%, occasionally by 21%. Only 32% reported that any psychological intervention is routinely offered to enhance child coping. Wide variability was found in physicians' preferences about parental presence, order of examinations, demonstration of procedures, and other aspects of electrodiagnosis.
Adolescent↗
Electrodiagnosis in the management of focal neuropathies: the "WOG" syndrome.
The role of electrodiagnosis in managing patients with focal neuropathies is discussed from the differing perspectives of a peripheral nerve surgeon and a practitioner of electrodiagnostic medicine. Both clinical evaluation and electrodiagnosis are useful methodologies, each having limitations. Dr. Dellon labels the overreliance on electrodiagnosis and the "WOG" (Word of God) syndrome, and describes its signs, symptoms, and treatment. Dr. Brown contends Dr. Dellon's crusade is misdirected. The exchange is an eloquent polemic on the virtues and foibles of these different approaches to evaluating peripheral nerve function and the imperative to practice them in a complementary rather than a contentious manner.
Diagnostic Errors↗
Electrodiagnosis reliability in the diagnosis of infant botulism.
Infant botulism is confirmed by isolation of Clostridium botulinum from stool culture or by toxin assay. Although electrodiagnosis has been described as a diagnostic tool in infant botulism, our 11-year review of toxin-confirmed cases suggests that electrodiagnosis is not a reliable tool. In the case report presented, results of electrodiagnosis were negative but enema effluent contained adequate concentrations of organism and toxin to confirm the diagnosis.
Botulinum Toxins↗
Infantile botulism: pitfalls in electrodiagnosis.
Botulism in infants, unless recognized early, is associated with high mortality and morbidity. The diagnosis is suspected when infants present with sudden onset of weakness, respiratory failure, and constipation and is confirmed by demonstration of botulinum toxin in stool several weeks later. Electrodiagnosis allows quick and reliable confirmation of botulism. Low-amplitude compound muscle action potentials, tetanic or post-tetanic facilitation, and the absence of post-tetanic exhaustion support the diagnosis. Two infants with confirmed botulism did not exhibit the characteristic electrodiagnostic features, demonstrating the pitfalls in electrodiagnosis of infantile botulism.
Biopsy↗
Neuromuscular rehabilitation and electrodiagnosis. 2. Localized peripheral neuropathy.
This self-directed learning module highlights advances in diagnosis and treatment of focal injuries to peripheral and cranial nerves. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Nerve conduction and electromyographic techniques are employed as extensions of the physician's senses in clinical examination and diagnosis. The findings are used to plan treatment, and to predict and measure outcomes. Electrodiagnosis and medical and surgical treatments of nerve injuries are discussed in light of the managed-care utilization review of services.
Cranial Nerve Injuries↗
AAEM minimonograph #26: the electrodiagnosis of carpal tunnel syndrome. American Association of Electrodiagnostic Medicine.
The electrodiagnosis of carpal tunnel syndrome (CTS) is reviewed, including discussions of old and new techniques of motor and sensory nerve conduction, anomalous innervation, and needle electrode examination. A variety of sensitive nerve conduction studies (NCSs) are available for the evaluation of a patient with suspected CTS. For any particular patient, the NCS method chosen by the clinical neurophysiologist may vary for a number of reasons, including the severity of the deficit and the presence of superimposed conditions.
Carpal Tunnel Syndrome↗
AAEE minimonograph #26: The electrodiagnosis of carpal tunnel syndrome.
The electrodiagnosis of carpal tunnel syndrome is reviewed, including discussions of old and new techniques of motor and sensory nerve conduction, anomalous innervation, needle electrode examination, and one method of examining a patient with suspected carpal tunnel syndrome. The results of electromyographic testing of 505 patients with carpal tunnel syndrome in Rochester, Minnesota, from 1961 to 1980 are compared with results from previous studies. In the appendixes, a method of performing median motor and sensory nerve conduction studies and Mayo Clinic normal values are provided.
Carpal Tunnel Syndrome↗
Electrodiagnosis of human dorsal sacral nerve roots by recording afferent and efferent extracellular action potentials.
Single extracellular nerve action potentials from afferent fibres with various functions were recorded from human sacral nerve roots. It was shown that the potentials from these fibres can have different wave forms (amplitude, duration) and conduction velocities. The smaller potentials with longer durations have lower cut-off frequencies for certain identification than the larger potentials of shorter duration. The conduction velocity diagnosis covers a range of velocities with a factor of about 10. The slowest measured conduction velocities were between 4 and 10 m/sec. The identification of the functions of afferents in nerve roots is possible by calculating conduction velocities and stimulated activity increase measurements. Besides touch and pain fibres from the skin, afferents from mechano-receptors of the urinary bladder and the anal canal could be detected in dorsal sacral roots. There is evidence of motoneurons in the dorsal sacral roots supplying fatigue resistant muscle fibres. Sacral nerve root electrodiagnosis can be used in operations to identify physiologically-stimulated afferents and reflex activated motoneurons and, therefore, possibly will be useful in nerve anastomoses and nerve root stimulations in paraplegia.
Action Potentials↗
Usefulness of segmental and comparative tests in the electrodiagnosis of carpal tunnel syndrome: the Italian multicenter study. Italian CTS Study Group.
The Italian CTS Study Group performed a wide multicentric and multiparametric study to quantify the increase of electrodiagnostic sensitivity using an extended neurophysiological protocol and particularly segmental and comparative tests. The study also evaluated the clinical features of carpal tunnel syndrome (CTS) diagnosed by these tests, using validated physician- and patient-oriented measurements. The study group was composed of 740 patients for a total of 1123 idiopathic CTS hands. Overall, the sensitivity of standard tests (median digit-wrist sensory conduction velocity and wrist-thenar distal motor latency) was 83.5%. Comparative/segmental tests disclosed abnormal findings in a further 11.4% of cases, providing CTS electrodiagnosis in about 7 of 10 "standard negative" cases. The overall sensitivity of the electrodiagnostic protocol was 94.9%. The CTS population diagnosed by segmental/comparative tests had a clinical picture characterized by a high percentage of pain, and severe discomfort but no limitation in functional daily activity. Our data confirm the usefulness of a complete neurophysiological assessment by using segmental/comparative tests when standard tests yield normal results.
Adult↗
Electrodiagnosis in spinal cord injured persons with new weakness or sensory loss: central and peripheral etiologies.
OBJECTIVE: To assess the prevalence and causes of late neurologic decline of persons with spinal cord injury (SCI). DESIGN: Retrospective review of persons with SCI over a 9-year period. Those with complaints of new weakness or sensory loss were grouped into three categories based on clinical examination, electrodiagnosis, and imaging: (1) central pathology (ie, brain, spinal cord, or nerve root); (2) peripheral pathology (plexus or peripheral nerve); or (3) no identifiable etiology. The specific diagnoses of late neurologic decline were identified. SETTING: Regional Veterans Affairs Spinal Cord Injury Service. PATIENTS: Five hundred two inpatient and outpatient adults with SCI. RESULTS: Nineteen percent of the study population complained of new weakness and/or sensory loss. Neurologic abnormalities were noted in 13.5%, 7.2% with central and 6.4% with peripheral causes. The most common pathologies were posttraumatic syringomyelia (2.4%) and cervical (1.6%) and lumbosacral (1.2%) myelopathy/radiculopathy. A specific etiology was not determined in 6 cases (1.6%). Peripheral involvement was mostly from ulnar nerve entrapment (3.4%) and carpal tunnel syndrome (3.0%). CONCLUSIONS: Late-onset neurologic decline is common after SCI and can result from central or peripheral pathology. Regular neurologic monitoring of SCI patients is recommended, since many with neurologic decline respond favorably if diagnosed and treated early.
Adult↗
The changing role of pediatric electrodiagnosis.
Electrodiagnosis is one of several useful diagnostic tests in infants and children who have anterior horn cell disease, neuropathy, neuromuscular junction disorders, or myopathy. It is also used for intraoperative monitoring in children. For hypotonic infants and for older children with a nonspecific presentation of weakness, EDX may provide direction for more specific diagnostic testing, such as DNA testing with or without muscle biopsy. Genetic testing has an increasingly important role in the diagnosis of children with neuromuscular disorders. Future improvements in motor unit quantitation, which do not require active patient cooperation and require less time than current methodologies, may make EDX more specific and useful for diagnosing neuromuscular disease in children.
Electrodiagnosis↗
Electrodiagnosis and recovery of function.
The study of electrodiagnosis with respect to recovery of function is in its infancy. There is a need for better understanding of the mechanisms of recovery and for better techniques to monitor recovery. This paper reviews the potential uses and limitations of current electrodiagnostic tests to predict and monitor neuromuscular recovery. It illustrates the use of these techniques in patients with spinal cord injury.
Adult↗
Fuzzy classification of patient state with application to electrodiagnosis of peripheral polyneuropathy.
A methodology which accounts for uncertainty or imprecision in experimental observations and both norm and pathology definitions is developed on the basis of a distance measure between fuzzy numbers. These fuzzy numbers may represent, respectively, the measurements, norm, and pathology. The distance measure, called normalized fuzzy pathology index (NFPI), evaluates the difference of distance between observed experimental values for a given patient and norm on the one hand, and pathology on the other hand. The NFPI characterizes patient state as a continuous index; however, to conform to medical usage, categories of values are defined. Each of these categories corresponds to a linguistic variable. The case study used to illustrate the methodology is the electrodiagnosis of peripheral polyneuropathy in diabetic patients. Here, four initial linguistic categories are defined by a physician, namely: normal state, borderline state, clear-cut, and severe pathology. The NFPI is calculated in three cases that provide a sensitivity analysis on measurement fuzziness and distance function weighting. The model is calibrated using 203 cases and validated using 291 different cases. The results correspond very closely to the physician's diagnosis. The loss of information in discretizing the continuous state of patients is discussed. Transferring this fuzzy approach to other cases where the concept of distance is relevant offers no difficulty.
Diabetic Neuropathies↗
Electrodiagnosis of infantile botulism.
Analysis of the literature on the electrophysiologic features of infantile botulism was undertaken. Small compound muscle action potential amplitude is a very sensitive feature but lacks specificity. The decremental response to 2- to 3-Hz repetitive nerve stimulation is inconsistent and not a reliable sign. Tetanic and posttetanic facilitation are highly sensitive and highly specific. Absence of posttetanic exhaustion is also highly specific for infant botulism and shared only by hypermagnesemia. We conclude that the findings of low compound muscle action potential amplitude in combination with tetanic facilitation or posttetanic facilitation and absence of posttetanic exhaustion constitute the triad on which the electrodiagnosis of infantile botulism can be supported.
Botulism↗
Telematic electrodiagnosis.
Using the Electrodiagnostic Neurophysiological Automated Analysis (ENAA) telematic system, 1560 standardized electrodiagnostic tests have been performed on 70 normal subjects and 320 patients in five laboratories in three European countries. The data from each patient have been transmitted from the five satellite laboratories to the Bristol Telematic Electrodiagnostic Centre (BRITEC), housed in the Bristol Eye Hospital, where they were evaluated and the conclusions transmitted to the place of origin. The results from the normal subjects were not significantly different between laboratories. Also patients with specific types of disease had similar results in all laboratories. The results from both the normal subjects and the patients show that a working prototype for providing telematic electrodiagnosis is available and has been well received by both clinicians and patients.
Adult↗