EMG not clean - who knows more...help

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EMG not clean - who knows more...help

Postby German2 on September 14th, 2014, 6:52 am

Hi there,

I was one week in hospital now. I am diagnosed with both sides ulnar nerve syndrom.
All investigations (sep, mep, clinical) were ok. Apart from a slight weakness in left hand and a positive Hofmann-tinel sign above the ulnar nerve.

But not the EMG (just left hand, lower arm and neck).
I had big amplitudes in the tested hand muscles (they say referring to SUS), one with polyphasic aspect.
They also checked my upper back muscles. Here is no amplitude mentioned. Which scares me, too!
In all muscles no spontanous activity...

I have to add that I have pain in my left hand, where the sulcus should be..and sometimes in my wirst.

I am so scared now, that they didn't tell me the truth.
I have symptoms since 2 years now...twitching since 14 month..

I very much apreciate the answers from those who know more about that..
Thanks, German
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Re: EMG not clean - who knows more...help

Postby TwitchyDoc on September 14th, 2014, 7:30 am

Hi German,
did they explain the cause of the bilateral ulnar nerve issue (it is usual when unilateral). I am sure you know about Hoffman and Tinel signs so I will not discuss these.

First, no spontaneous activity on the EMG is a good sign. Sure I agree it does not mean there is no nasty thing going on and I understand you are scared but at least, it is good that nothing was detected (not even fasciculations?).
Increased amplitude of motor units occurs in reinnervation and the polyphasia suggest that too. But again, no spontanneous activity would point away from MND. By the time MUPs amplitude is higher, one would expect to detect other signs. In addition, pain is not common in ALS.
What was the conclusion of the EMG>?

As for the clinical, you mentioned positive Hoffman, Tinel. Any other signs above or below this spinal level? (above C5/ C6) What about pectoralis muscle reflex? I ask because it seems you have findings restricted to a certain level, which would too point away from MND (especially after 14 months).
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Re: EMG not clean - who knows more...help

Postby German2 on September 14th, 2014, 7:41 am

Dear Twichydoc,

they did not explain anything about the both side ulnar nerve. Just that it is no pnp. That would have shown up in the mep, which was fine.
The explain that the amplitude findings together with the NCV would proof the SUS. But I don't understand, why they did the EMG just in one hand, when there is a second ulnar nerve damage is indicated in the right...
Why did'nt they comment what was measured in my upper back..?
They have also tested one muscle in my lower left arm...I have seen that one time, when they put the needle with another ancle there were also big amplitudes. And I heard the doctor saying that, too. This was not mentioned in the report.

No, they have not seen any fasciculations in the EMG..

I am scared as hell!!
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Re: EMG not clean - who knows more...help

Postby German2 on September 14th, 2014, 7:44 am

As far as I understood from Dr. google, Hofman Tinel sign indicates a compression syndrom, correct?
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Re: EMG not clean - who knows more...help

Postby German2 on September 14th, 2014, 7:48 am

TwitchyDoc wrote:
Increased amplitude of motor units occurs in reinnervation and the polyphasia suggest that too. But again, no spontanneous activity would point away from MND. By the time MUPs amplitude is higher, one would expect to detect other signs. In addition, pain is not common in ALS.

As for the clinical, you mentioned positive Hoffman, Tinel. Any other signs above or below this spinal level? (above C5/ C6) What about pectoralis muscle reflex? I ask because it seems you have findings restricted to a certain level, which would too point away from MND (especially after 14 months).


Dear TwitchyDoc, do you mean denervation or reinnervation? They told me, there were no signs of new denervation. It seemed to the doctor, that the denervation was a bit older....
The interference patterns were all tight or almost tight...

What the clinical is concerned, they did not mention any other abnormal findings. Muscle own reflexes where midle brisk...
Last edited by German2 on September 14th, 2014, 7:52 am, edited 1 time in total.
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Re: EMG not clean - who knows more...help

Postby TwitchyDoc on September 14th, 2014, 7:51 am

I am sorry you they did not answer your questions. Be that as it may, the findings are not something you would see in MND. In general, Hoffman represents hyperreflexia in upper extremities with various causes, including compressive issues.

As I said, reinnervation. In that case the MUPs amplitude and duration get higher. And that is the point - there is no ongoing, new denervation which would appear in MND. That is the most important thing you should focus on - in MND, the denervation is ongoing, continous process that is being compensated by reinnervation as long as possible.
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Re: EMG not clean - who knows more...help

Postby German2 on September 14th, 2014, 7:57 am

But if reinnervation goes along with MND, than this finding might also be compatible with MND, too?
Oh I feel like a mess..
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Re: EMG not clean - who knows more...help

Postby TwitchyDoc on September 14th, 2014, 8:07 am

Reinnervation goes with any nerve damage (meaning damage causing denervation). You cannot judge this finding alone - in MND it occurs, yes, but in presence of active, ongoing denervation. So what your doctor said was correct - denervation that was there was older, hence they detected reinnervation potentials. In MND, there are both reinnervation AND active denervation potentials. So not, this is not really compatible with MND.

In other words - MND is a degenerative, continuous process causing damage which the body repairs (reinnervation). In your case, there was a damage (caused by something non-progressive, as it seems) that was repaired (as confirmed by the increased amplitudes of MUPs) and that does not happen anymore - this is the key! The same findings would be after any spinal injury. This is NOT how the EMG in MND looks! Try to understand the process, it is not that difficult. Hope that helps!
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Re: EMG not clean - who knows more...help

Postby German2 on September 14th, 2014, 8:15 am

Thanks a lot for your helpful comments!! I try to think understand. My brain is not working that propper actually...Maybe one day they find a pnp..Because there must be something going on..It is not my first compression syndrom..I have had meralgia paresthetica a few years ago...
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Re: EMG not clean - who knows more...help

Postby German2 on September 16th, 2014, 6:02 am

Hi,

a second EMG was taken yesterday, from another neuro (private). He reviewed the performed EMG of the hospital and did furthermore the muscle at the bottom of small finger because he thinks that muscle is directly corresponding with the sulcus ulnar nerve. Outcome: slight spontanous activity (sharp waves), normal amplitude, tight interference pattern. I asked him to do also a foot muscle of which I think it is slightly declined and that muscle was totally normal in the EMG..

His point of view: discrete ulnar nerve syndrom left side. He could not confirm at the right side due to NCV was fine there, when he was measuring.

Ok, total confusion from my side....In hospital they even measured a conduction block on the right side...
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Re: EMG not clean - who knows more...help

Postby TwitchyDoc on September 16th, 2014, 6:19 am

I told you so! Sharp waves as being the only signs of spontaneous activity are not signifficant (from MND point of view), normal amplitude is a great sign too. Indeed, no finding on the muscle you suspected to be atrophied rules out any neurogenic process. With the interference pattern, I assume you meant "full" instead of tight - normally, we say "recruitment pattern" but once again, patients with neurodegenerative diseases cannot achieve it completely.

Unilateral ulnar nerve syndrom makes more sense than bilateral, as I told you.

I think you can be pretty much relaxed now!

Docen
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Re: EMG not clean - who knows more...help

Postby German2 on September 16th, 2014, 6:54 am

Dear Twitchydoc,
thank you so much for interpreting me this...!! No one else did or could.
I try to relax...but in the last days my twiches came back. I am caught in an evil circle.
after two years of fears it is hard to find out....but i try to live my daily life as good as i could...Thank you so much..
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Re: EMG not clean - who knows more...help

Postby German2 on September 16th, 2014, 8:28 am

To gather all my thoughs, I summarize all the findings and confusions and questions which came to my mind:
- als ambulance did not found anything...normal NCV
-hospital diagnosed me with double sided sulcus ulnar syndrom (based on NCV) but doctors there think it is no pnp (fine clinical). The antibodies against my nerve system would be misleading and were not important.
-They did EMG just in left hand. Why not in right hand when they suspected an ulnar nerve syndrom there, too? And to check whether there are further abnormalities?
- Private neuro did NCV on both sides too and found just left ulnar nerve syndrom (which would be normal), did EMG testing in corresponding muscle in left hand (findings).
- I asked him to test also a foot muscle. I did not decide for the twitching and buzzing foot but for the one I suspected atrophie (no findings). (Maybe I should have chosen the other one...?)
- My local neuro (not private) today shortly commented the findings in the hospital. He says they did a great job there. And it would be important to wait on the pending lab report about antibodies and bacteria culture...(Hospital did it, but doctors told me it is not important to wait on that!). In addition I cannot confront him with the private based measures..then he would think I do not trust him.
- In the hospital they told my my MRI was fine. No findings. But in their report they mentioned widening liquor rooms left frontal. No further comments wether this is in a normal range... My hopsistal doctor is in holiday now...No requests possible in the moment.

I have a lot experience with hospitals in my life. But this story is so confusing.....No testing can somehow be reproduced or has similar outcome.....

Meanwhile my twitching pattern changed slightly. Now I have twitching in area of my jaw, lip (but just about one time a day) and yesterday in bad very long twiching in the area of collarbone...

Thanks to Twitchydoc, who helped me with explanations for the few, confusing outcomes I have.....!!!

I don't know what to do now....

How can I further trust ...
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Re: EMG not clean - who knows more...help

Postby TwitchyDoc on September 16th, 2014, 9:09 am

German2 wrote:Dear Twitchydoc,
thank you so much for interpreting me this...!! No one else did or could.


You were always kind to me and hence I am glad I can use my knowledge and help you. Thank you for public appreciation, although my ''haters'' always ignore these :) But you know me, I do not suger coat things but according to your results, thee is no concern for MND.

Docen
Last edited by TwitchyDoc on September 16th, 2014, 10:03 am, edited 1 time in total.
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Re: EMG not clean - who knows more...help

Postby misterjuanperalta on September 16th, 2014, 9:54 am

Change your username to friendlytwitcher. :D
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Re: EMG not clean - who knows more...help

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