John Gambin, M.D.

NMJ Fiber Types InvolvedPathologyTemporal Course Sensory Motor Mixed Axonal Demyelinating Acquired Inherited Hyperacute Acute Subacute Chronic Severity Goals of the EDX Study Muscle Nerve Localization

Neuronopathy Radiculopathy Plexopathy Mononeuropathy Multiple Mononeuropathies Polyneuropathy CNS Proximal Distal Generalized Cranio-bulbar Presynaptic Postsynaptic Localization Myopathic NMJNeuropathic

Elements of the Peripheral Nervous System

Neurons of the Peripheral Nervous System Sensory Nerve Motor Nerve

Post Synaptic Membrane

Muscle Contraction

Motor Unit MUAP

Indications for Nerve Conduction  Peripheral entrapment  Suspicion of polyneuropathy  Suspicion of Myasthenia Gravis  Nerve Trauma Indications for EMG  Suspicion of disorder  Brachial plexus injury  Lumbosacral plexus pathology  Muscle disorder

Patterns of Nerve Conductions Stimulation

Types of Nerve Damage

Nerve Recovery Patterns Muscle Demyelinating Other- Mixed Injury

Measurement Parameters (DML) (PML) Conduction Velocity = Distance (Proximal - Distal) Time (PML –DML)

Entrapment Sites

Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Right Med/Uln/Rad Nerve Patient:Patient ATest Date:02/02/10 Age:49 Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL R L RLR Wrist ACF Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL R L R LR Wrist B.Elbow A.Elbow Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm) C.V. (m/s) Rec SiteL RL R L R L R MedMidPM UlnMidPlm MedSenAnt UlnSenAnti Summary/Interpretation: Normal nerve conduction studies of the upper extremities. Left Median Nerve Left Med/Uln/Rad Nerve Normal Study – Upper Extremities

Patient:Patient CTest Date:10/01/09 Age:87 Motor Nerve Study Left Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist ACF Mid Palm Motor Nerve Study Left Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist B.Elbow A.Elbow Sensory Nerve Study Left Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec Site MedMidPM UlnMidPlm MedSenAnt UlnSenAnti Summary/Interpretation: Nerve conduction studies of the left upper extremity demonstrate a severe left carpal tunnel syndrome. Left Median Nerve Left Ulnar Nerve Left Med/Uln/Rad Nerve Severe Carpal Tunnel Syndrome

Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve Patient:Patient DTest Date:11/04/09 Age:24 History/Comments: Pain and numbness in both upper extremities, right greater than left. Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLRL R L R L R Wrist ACF Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLRL R L R L R Wrist B.Elbow A.Elbow Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm) C.V. (m/s) Rec SiteLRL RL R L R MedMidPM UlnMidPlm MedSenAnt UlnSenAnti Summary/Interpretation: Nerve conduction study of both upper extremities shows minimal slowing across the right carpal tunnel. Left Median Nerve Very Minimal or Mild Carpal Tunnel Syndrome

Left Median Nerve Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad NerveRight Med/Uln/Rad Nerve Patient:Patient E Test Date:10/06/09 Age:82 Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist ACF Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist B.Elbow A.Elbow Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec SiteLRL RLRL R MedMidPM UlnMidPlm MedSenAnt UlnSenAnti Summary/Interpretation: Nerve conduction studies of both upper extremities show changes of a bilateral carpal tunnel syndrome, moderately severe, left worse than right, superimposed on a modest generalized polyneuropathy. Carpal Tunnel Syndrome With Underlying Mild Neuropathy

Patient:Patient F Age:87 History/Comments: Numbness and tingling in both hands, right greater than left. Motor Nerve Study Median Nerve Rec Site: APBLat (ms) Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLR L R L R L R Wrist ACF Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms) Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLR L R L R L R Wrist B.Elbow A.Elbow Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms) Amp (uV) Dist (mm) C.V. (m/s) Rec SiteLR L R LR L R MedMidPM UlnMidPlm MedSenAnt UlnSenAnti Summary/Interpretation: Nerve conduction study of both upper extremities reveals bilateral carpal tunnel syndromes, severe on the right and moderate on the left. Left Median NerveRight Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve Carpal Tunnel Syndrome Severe on the right / Moderate on the left

Ulnar Nerve The most common place for nerve entrapment is in the elbow. Ulnar Neuropathy Cubital Tunnel Tardy Ulnar Palsy

Left Median Nerve Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad NerveRight Med/Uln/Rad Nerve Patient:Patient GTest Date:01/05/10 Age:57 History/Comments: Possible ulnar neuropathy. Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist ACF Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist B.Elbow A.Elbow Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec SiteLRL RLRL R MedMidPM UlnMidPlm MedSenAnt UlnSenAnti Summary/Interpretation: Nerve conduction study of both upper extremities shows an ulnar neuropathy with significant drop in the velocity across the elbow. Ulnar Neuropathy

Patient:Patient I Test Date:11/24/09 Age:57 Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteL RL R L RL R Wrist ACF Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteL RLRL RLR Wrist B.Elbow A.Elbow Sensory Nerve Study Left Med/Uln/Rad Nerve Stim Site: Wrist Lat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec Site MedMidPM UlnMidPlm MedSenAnt UlnSenAnti Summary/Interpretation: Nerve conduction studies of the upper extremities show: 1. Severe ulnar neuropathy at the left elbow, (amplitude and velocity drop). 2. Mild left carpal tunnel syndrome. Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad Nerve Left Median Nerve Severe Ulnar Neuropathy and Mild Carpal Tunnel

Patient:Patient J Test Date:10/05/09 Age:60 Motor Nerve Study Right Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist ACF Motor Nerve Study Right Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist B.Elbow A.Elbow Sensory Nerve Study Right Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec Site MedMidPM UlnMidPlmNR MedSenAnt UlnSenAntiNR Summary/Interpretation: Nerve conduction studies of the right upper extremity show changes of a severe neuropathy at the elbow, predominantly axonal. Right Ulnar Nerve Right Med/Uln/Rad Nerve Right Median Nerve Severe Ulnar Neuropathy

Peroneal Neuropathy Neurology December 2005 MRI Detection of Cysts in the Knee Causing Common Peroneal Neuropathy. Donald J. Iverson, M.D.

Patient:Patient K Test Date:01/29/10 Age:67 Motor Nerve Study Peroneal Nerve Rec Site: EDBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR Ankle B.Fibular A.Fibular Motor Nerve Study Tibial Nerve Rec Site: AHLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR Ankle Pop.Fos Motor Nerve Study Nerve Rec Site: Ant TibialisLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR B.Fibular A.Fibular Sensory Nerve Study Peroneal Nerve Rec Site: dors.ftLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR Lower leg NOTES: Left side: not reliable Right side: not reliable Sensory Nerve Study Sural Nerve Rec Site: AnkleLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR mid calf NOTES: Left side: not reliable Right side: not reliable Summary/Interpretation: Nerve conduction study of both lower extremities shows severe length dependent mixed axonal greater than demylenating polyneuropathy. Right Peroneal Nerve Left Tibial Nerve Right Tibial Nerve Left Right Left Peroneal Nerve Sensory waveforms not shown. Severe (Length Dependent) Polyneuropathy

EMG Studies

Johnny Gambin Age 5

MUAP Morphologies

Spontaneous Waveform Generators

Interference Patterns

End Plate Spikes

Fibrillations

Positive Sharp Waves

Fibrillation Potentials + 1

Fibrillations + 4

Myotonic Discharge

Complex Repetitive Discharge

Fasciculation Potentials

Fasciculation with Reinnervated Potentials

Myokymic Discharge

Cramp

Rest Tremor

Normal Activation and Recruitment

Reinnervation - Long Duration & Polyphasic

Moderately Decreased Recruitment

Myopathic Brief Duration

Abnormal Neuromuscular Function The possible sites of abnormal function of the peripheral nerves and muscle are: Motor neuron cell body, sensory neuron cell body, or both Root Plexus nerve axons, peripheral nerve axons, or both Plexus nerve myelin, peripheral nerve myelin, or both Neuromuscular junction Muscle

Sites of Damage in Nerve and Muscle Site Disorder Neuron cell bodyAmyotrophic lateral sclerosis RootCervical or lumbar radiculopathy Axonal neuropathyToxic neuropathy Demyelinating neuropathyGuillain-Barre syndrome Neuromuscular junctionMyasthenia Gravis MuscleMuscular dystrophy

The End Thank you!

Patterns of Nerve Conductions Normal Axonal Demyelinating Demyelinating with conduction block Distal Latency = 3.0 msec Conduction Velocity = 59 m/sec Distal Latency = 4.4 msec Conduction Velocity = 51 m/sec Distal Latency = 12.7 msec Conduction Velocity = 12 m/sec Distal Latency = 12.7 msec Conduction Velocity = 12 m/sec 5 mV 5 msec

Amplitude Duration Distal Latency Proximal Latency Measurement Parameters