For convenience values outside the normal range are bolded. Normal values for the specified patient are stated below the tables.

Transcription

1 Case tudy 8 or convenience values outside the normal range are bolded. Normal values for the specified patient are stated below the tables. History: 60 year-ol man with a history of left hand weakness and more recent onset of right foot drop. Initial symptoms started at least two years ago. he foot drop started a couple of months ago. Exam reveals normal symmetric reflexes in all limbs with fasciculations in left hand and weakness of left intrinsic hand muscles, left abductor pollicis brevis and right tibialis anterior muscle. EG was requested to evaluate for motor neuron disease versus motor neuropathy. emperatures: Right wrist: C Left wrist: C Right leg:. C Left leg:. C otor Nerve Conduction: Nerve and ite egment Distance Latency mplitude Conduction Velocity Left edian Rec: PB rist bductor pollicis brevis-rist 60 mm. ms. mv Elbow rist-elbow 60 mm 8. ms 0.70 mv.0 m/s Upper arm Elbow-Upper arm mm.0 ms 8.80 mv.8 m/s Erb's point Upper arm-erb's point 80 mm NR NR Rec: D rist D-rist 60 mm. ms 0.6 mv Below elbow rist-below elbow mm m/s bove elbow Below elbow-bove elbow 00 mm mv 0.0 m/s Upper arm bove elbow-upper arm 0 mm NR NR Rec: D P8 8 cm prox elbow 9. ms 9.08 mv P0 0 cm prox elbow. ms.77 mv P cm prox elbow. ms.7 mv P cm prox elbow NR NR Rec: DI rist st dorsal interosseous-rist..0 mv Below elbow rist-below elbow 0 mm 7.9 ms.0 mv 6.8 m/s bove elbow Below elbow-bove elbow 00 mm 0.0 ms.7 mv 7.6 m/s E + cm Prox Below elbow-e + cm Prox mm.6 ms.6 mv 7.8 m/s E + cm Prox. ms. E + 6cm Prox.9 ms.0 mv E + 8 cm Prox NR NR Left Radial Rec: EDC Lateral brachium EDC-Lateral brachium.7 ms.7 piral groove Lateral brachium-piral groove 0 mm.6 ms.6 mv 7.8 m/s xilla piral groove-xilla mm 7.6 ms.8 mv.6 m/s Left Peroneal nkle Extensor digitorum brevis-nkle 90 mm. ms.6 mv ibula (head) nkle-ibula (head) 90 mm. ms 9.7 mv. m/s Popliteal fossa ibula (head)-popliteal fossa 0 mm.9 ms 9. mv.0 m/s Left ibial Rec: H nkle bductor hallucis-nkle 00 mm 6.6 ms.0 mv Popliteal fossa nkle-popliteal fossa 0 mm.9 ms.7 mv 7. m/s Right Peroneal nkle Extensor digitorum brevis-nkle 90 mm.8 ms 6.6 mv ibula (head) nkle-ibula (head) 0 mm. ms 6. mv. m/s Popliteal fossa ibula (head)-popliteal fossa 0 mm.9 ms 6. mv 9.7 m/s Right Peroneal Rec: ibula (head) ibialis anterior-popliteal fossa.9 ms 9.7 mv Popliteal fossa ibula (head)-popliteal fossa 0 mm.9 ms 9. mv 6.6 m/s Page of

2 Right ibial Rec: H nkle bductor hallucis-nkle 00 mm 6.6 ms. mv Popliteal fossa nkle-popliteal fossa mm 7. ms 0.0 mv. m/s Right edian Rec: PB rist bductor pollicis brevis-rist 60 mm. ms 9.9 mv Elbow rist-elbow 70 mm 9. ms.7 mv.7 m/s xilla Elbow-xilla 0 mm.7 ms.6 mv. m/s Right Ulnar Rec: PB rist D-rist 60 mm. 0.8 mv Below elbow rist-below elbow 0 mm 6.6 ms 0.7 mv 8. m/s bove elbow Below elbow-bove elbow 00 mm 7.9 ms 9. mv 76.9 m/s Upper rm bove elbow-upper rm 80 mm 0.8 ms 7.77 mv 7. m/s xilla Upper rm-xilla 0 mm.9 ms. mv 8. m/s -ave tudies Nerve -Latency -Latency Left edian. ms NR. ms NR Left Peroneal. ms. ms Left ibial 6.6 ms 8.0 ms Right ibial 7. ms 68. ms Right edian. ms NR Right Ulnar.9 ms 7.0 ms ensory Nerve Conduction: Nerve and ite egment Distance mplitude Peak Latency Left edian Rec: rist Digit II (index finger) rist-digit II (index finger) 0 mm. µv.0 ms Rec: rist Digit V (little finger) rist-digit V (little finger) 0 mm.7 µv. Left ural Rec: nkle Lower leg Lateral malleolus-lower leg 0 mm. µv.0 ms Right ural Rec: nkle Lower leg Lateral malleolus-lower leg 0 mm. µv.0 ms Right uperficial Peroneal Rec: Dorsum of oot Lower leg nkle-lower leg 0 mm.7 µv.0 ms Right edian Rec: rist Digit II (index finger) rist-digit II (index finger) 0 mm.7 µv.7 ms Right Ulnar Rec: rist Digit V (little finger) rist-digit V (little finger) 0 mm. µv. ms Normal values: edian NC DL:., mp:, CV 9 edian NC Peak Lat:., mp: Ulnar NC DL:.8, mp: 6, CV 9, Ulnar NC Peak Lat:.8, mp: 0 CV across elbow may slow 0 Palmar diff 0. Radial NC Peak Lat:.7, mp: BC NC Peak Lat:.7, mp: 0 LBC NC Peak Lat:.7, mp: Peroneal NC DL: 6.6, mp:, CV: ural NC Peak Lat:., mp: CV across ib head may slow 0 ibial NC DL: 6.6, mp:, CV: uper. Peroneal NC Peak Lat:., mp: Page of

3 ms. -N: mv Left edian NC - 0 uv N: 0 uv N: NC - Orthodromic mp : 0-kHz N N Oth id NC NC N R ti H Left edian NC mp : -0kHz mp : -0kHz Left edian -wave ms. -N: mv 0 ms to D - NC mp : -0kHz O C C. -wave mp : -0kHz O C C 0 ms. to D E mp : -0kHz N N Oth id NC NC N R ti U ms 7.m 87.0m 77.6m mv mv Left ural NC 0 uv N: 6 7 to DI - NC Left Radial to EDC - NC mv Right ural NC 0 uv N: mp : -0kHz O C C. mp : -0kHz O C C -N: 00 uv 0 ms mp : 0-kHz O C 0 ms Left Peroneal to EDB - NC mp : -0kHz 69.0m N N Oth id NC NC R ti UNE C Left Peroneal -wave mp : -0kHz O C C Left ibial to H NC mp : -0kHz Page of

4 -N: 00 uv 0 ms 0 ms. mv mv Rec: mv mv Left ibial -wave 6 Right Peroneal NC 6.0m mv Right ibial to H NC mp : -0kHz ms mp : -0kHz O C C C ms 0.0 mp : -0kHz O C C 0 uv 0 uv N: 7.m Right uperficial Peroneal - Right edian Orthodromic - NC 0 uv N: mp : 0-kHz O C -N: 00 uv 0 ms Right Ulnar Orthodromic - NC mp : 0-kHz O C C 0 uv N: 6.8m 89.m Right edian to PB NC mp : -0kHz O C C 8.m. -N: 00 uv 0 ms 89.m Right edian -wave mp : -0kHz O C C Right Ulnar to D NC mp : -0kHz O C C Right Ulnar -wave mp : -0kHz O C C hat is your conclusion? How do you differentiate this from CIDP? How do you differentiate this from L? Page of

5 NERVE CONDUCION UDIE:. otor conduction studies of the left median nerve revealed normal distal amplitude, latency, and conduction velocity in the forearm. egmental slowing was seen in the left upper arm and there was no response with stimulation at Erb's point. Left ulnar nerve study with recording from the abductor digiti minimi revealed normal distal amplitude, latency, and conduction velocity in the forearm and across the elbow. No left ulnar motor nerve response was seen with stimulation in the upper arm, and thus inching study was performed. here was conduction block between the stimulation sites that were 8 and 0 cm proximal to the olecranon. he left ulnar nerve over the first dorsal interosseous showed normal amplitude with normal latency and velocity in the forearm and across the elbow. here was segmental slowing in the upper arm and upon inching conduction block was demonstrated in the upper arm as outlined in the table. he left radial nerve was normal and no block was demonstrated with proximal stimulation he left peroneal nerve was normal. he left tibial nerve showed normal latency and amplitude with segmental drop in amplitude upon stimulation at the knee. his was present even with maximal stimulus intensity. he right peroneal nerve showed normal amplitude (7% of the amplitude of the left side) with marked slowing of velocity across the knee when recording over the extensor digitorum brevis. he right peroneal nerve showed slightly reduced velocity across the fibular head when recording over the anterior tibialis muscle. he right tibial nerve was normal and no segmental amplitude drop was seen with proximal stimulation. he right median nerve showed normal amplitude and distal latency with partial conduction block upon stimulation at the forearm. here was associated slowing of conduction velocity in the upper arm segment. he right ulnar nerve over the abductor digiti minimi showed normal amplitude and latency with normal velocities in the forearm and elbow segments. here was conduction block and slowing in the proximal ulnar nerve segments. Left median, left ulnar and right median -waves were non-responsive. he left tibial, right tibial and right ulnar -wave latencies were prolonged. he left peroneal -wave latency was normal.. ensory nerve conduction studies of the left median, left ulnar, left sural, right sural, right superficial peroneal, right median and right ulnar nerves were normal and symmetric on side to side comparison. CLINICL CORRELION: his is an abnormal study. here is electrical evidence to suggest the presence of an acquired, multifocal demyelinating process affecting multiple motor nerves. ensory nerves are entirely spared and the needle exam indicates predominantly demyelinating changes with minimal axonal loss. he areas of partial and complete conduction block are limited to proximal segments of the motor nerves and were therefore not detected on the previously performed routine nerve conduction studies. he findings on today's study are consistent with the diagnosis of multifocal motor neuropathy with conduction block. esting for G-antibodies and treatment with immunoglobulin should be considered if clinically indicated. Clinical correlation is recommended. Page of