1. ELECTRODIAGNOSTIC TESTING: BLIND SPOTS, PITFALLS, AND OVERCALL Timothy R. Dillingham, M.D. William J. Erdman Professor and Chairman Department of Physical Medicine and Rehabilitation Chief Medical Officer Penn Institute for Rehabilitation Medicine The University of Pennsylvania

2. OBJECTIVES: LIMITATIONS, PITFALLS Understand the important limitations in electrodiagnostic medicine Nerve conduction reference values not well standardized –Interrater reliability low without standards Understand EMG has modest sensitivity, but very high specificity – complementary to MRI Overcall in its many forms –Polyphasics, excessive testing, poor technique

4. NERVE CONDUCTION STUDIES

5. Nerve Conduction Challenges with Performance Skin prep minimizes impedance missmatch between active and reference electrodes Overstimulation of adjacent nerves Stimulus artifact – optimize ground Captured motor unit can look like a SNAP –Repeatability over three tracings –Be careful with averaging, can “Lock In” artifact

6. NERVE CONDUCTION PITFALLS Multiple Entrapments found, eg; median, ulnar –MOST LIKELY A POLYNEUROPATHY –STUDY A LOWER LIMB

7. NERVE CONDUCTION TESTING –Too many tests, increasing probability of one false positive –If you do 7 tests; 16% chance of a false positive –Probability of TWO false positives with 7 tests is 1% Two findings is MUCH more compelling for a diagnosis –Use caution with overcalling with just one abnormality

8. NORMATIVE DATA: REFERENCE VALUES No standardization in our field regarding reference values and techniques for Nerve conduction testing Older norms plagued by; –Low sample sizes –Statistics not matching non- Gaussian distributions – Analog machines –Poor study designs

10. NORMATIVE DATA: BETTER REFERENCE VALUES AANEM NORMATIVE DATA TASKFORCE ALL YOU NEED TO KNOW: RALPH BUSCHBACHER, MD NORMATIVE STUDIES IN THE 1990’s AND 2000’s TOWER ABOVE MOST OF THE LITERATURE REGARDING NORMS

12. ELECTRODIAGNOSIS: PITFALLS

13. EMG Motor units can look like PSWs depending on geometric position of needle PSWs and FIBs are REGULARLY FIRING POTENTIALS Don’t move the needle too quickly, thrust and stop Caution calling radiculopathy based upon polyphasicity

14. EMG Do not assess motor unit morphology in PSM, no norms Cervical PSM low false positives IF: Lumbar PSM low false positives IF: –IMPOSE CRITERIA OF REGULAR FIRING PSM - ONLY LOOK FOR: FIBS, PSW, CRDs

15. PARASPINAL MUSCLE EMG: PREVALENCE OF FIBRILLATIONS IN NORMALS Dumitru, Diaz, and King (2001) Prospective study 50 normals L4/L5 levels Monopolar needle, recorded potentials Examined firing rate and rhythm Fibrillation inclusion criteria; regular firing rate 4% false positive fibrillations in paraspinal muscles

16. NEUROLOGICAL CONDITIONS MIMICKING CERVICAL RADICULOPATHY Entrapment/Compression neuropathies –Median, Radial, and Ulnar Brachial Neuritis Multifocal Motor Neuropathy Need Extensive EDX study to R/O other conditions ALS if upper motor neuron signs and atrophy/weakness Myopathy, Myasthenia Gravis

17. NEUROLOGICAL CONDITIONS MIMICKING LSR Diabetic Amyotrophy Mononeuropathies –Femoral –Tibial –Common Peroneal Need Extensive EDX study

18. EMG SENSITIVITIES FOR LUMBOSACRAL RADICULOPATHIES Varies widely Ranges from about 50% to 80% Various diagnostic standards

19. StudySample size Gold standardEMG sensitivity % Lumbosacral radiculopathy Weber and Albert [55] Nardin et al [28] Kuruoglu et al [8] Khatri et al [56] Tonzola et al [57] Schoendinger [58] Knutsson [45] Young et al [3] Linden and Berlit [3] 42 47 100 95 57 100 206 100 19 Clinical+imaging HNP Clinical Surgically proven Clinical an imaging Myelography and CT 60 55 86 64 49 56 79 84 78

20. EMG SENSITIVITY FOR CERVICAL RADICULOPATHIES Varies widely About 50% to 70% Usually clinical and/or myelographic

21. Study Sample size Gold standardEMG sensitivity % Lumbosacral spinal stenosis Hall et al [46] Johnsson et al [59] 68 64 Clinical+myelogram 92 88 Cervical radiculopathy Berger et al [60] Partanen et al [61] Leblhuber et al [9] So et al [62] Yiannikas et al [18] Tackman and Radu [15] Hong et al [63] 18 77 24 14 20 108 Clinical Intraoperative Clinical+myelogram Clinical Clinical/radiographic Clinical 61 67 71 50 95 51

22. SPECIFICITY Tong, Haig, Yamakawa, Miner. Amer J of PM&R 2006 Assymptomatic volunteers 55 and older Standardized monopolar EMG with blinded researcher –Five leg muscles and paraspinal muscles When only PSW and Fibs were considered abnormal –By criteria: i)Two limb muscles plus PSM or ii)two limb muscles or iii) one limb and PSM –100% specificity If use polyphasicity –97%, 90%, 87% specificity EMG has excellent specificity for LSR

24. CAVEATS AND LIMITATIONS Needle EMG is not an effective screening test alone (Radiculopathy) MRI better screen for structural causes Better specificity-Diagnosis confirmation Motor Axonal loss is necessary for fibs A purely sensory radiculopathy will not result in FIBS on EMG

25. EMG Hard signs, better interrater reliability –FIBS –PSWs –CRDs Softer signs, more tendency to overcall –Polyphasicity –Reduced recruitment –Amplitudes of MUAPs

26. EMG Normative data for needle EMG are rare and old –Mostly for CONCENTRIC NEEDLES –Monopolar needles – Chu textbook Wide range of normal variation. The extremes are clearer –Amplitudes over 8K with reduced recruitment –Firing ratio of 20Hz

27. FALSE NEGATIVE (no fibs or PSW) ON EMG IN RADICULOPATHY Sensory root involvement only Motor root involvement without axonal loss –Demyelination, conduction block Motor axonal loss balanced with reinnervation

28. MUSCLE INJURY CAUSING FIBRILLATIONS Partanen et al 1982 Muscle & Nerve Study of 43 patients with EMG before and after Muscle biopsy 50% had fibrillations 6-7 days after biopsy At 16 days 100% had fibrillations Fibrillations persisted up to 11 months post biopsy

29. Symptom Duration is not Related to Fibrillation Potentials Long held notion in the electrodiagnostic literature regarding radiculopathies Paraspinal (PSM) muscles denervate first, then more distal Reinnervation thought to occur first in PSM then distal No evidence to support this model

30. SYMPTOM DURATION AND EMG FIBRILLATIONS Dillingham et al, 1998, 1998, 2000; Pezzin et al 1999 Four separate investigations –Two retrospective (Cervical and Lumbosacral) –Two prospective (Cervical and Lumbosacral) Probability of finding fibrillations in a muscle (proximal or distal) was not related to symptom duration. Simplistic model of symptom duration doesn’t explain the complex pathophysiology of radiculopathies and their EMG correlates

31. PROGRESSION OF CERVICAL SPONDYLOTIC CORD COMPRESSION Bednarik et al Spine 2004 Symptomatic cervical radiculopathy and EMG showing motor axonal loss in 2 myotomes predicted with 90% accuracy those who progressed to symptomatic myelopathy. Odds ratio 12.5 (p<0.001) for EMG

32. Needle electromyography predicts outcome after lumbar epidural steroid injection (LESI) Annaswamy TM, Bierner SM, Chouteau W, Elliott AC. Muscle Nerve. 2012Annaswamy TMBierner SMChouteau WElliott ACMuscle Nerve. 89 subjects prospectively studied Predictor variables regarding response to LESI Abnormal EMG is a strong and independent predictor of a positive response to LESI – long term pain relief

33. CONCLUSIONS EMG and NCS are excellent diagnostic tests Use solid reference foundation Realize limitations Don’t overcall