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| Please submit cases for consideration to: Gary R. Smith, DC, DIBE |
The case below is submitted for your review and discussion with the recognition that there are many ways
in which to approach a patient who presents to our offices for evaluation. The flow used is an example of
the thought process that I have employed over the years, understanding that the electrodiagnostic
evaluation cannot be used in isolation from the history and clinical examination. However, when performed
appropriately, the EMG/NCV is often critical in providing the necessary information to allow accurate
distinction between numerous disorders that may present similarly.
This case will be presented in two parts. Part I, which follows, discusses the relevant historical, clinical,
and electrophysiologic findings and will additionally pose questions that need to be answered by the
electrodiagnostician. Part II will review the diagnosis, and discuss the differentials involved in this case,
further highlighting main discriminating characteristics between the diagnostic possibilities which were
considered.
in which to approach a patient who presents to our offices for evaluation. The flow used is an example of
the thought process that I have employed over the years, understanding that the electrodiagnostic
evaluation cannot be used in isolation from the history and clinical examination. However, when performed
appropriately, the EMG/NCV is often critical in providing the necessary information to allow accurate
distinction between numerous disorders that may present similarly.
This case will be presented in two parts. Part I, which follows, discusses the relevant historical, clinical,
and electrophysiologic findings and will additionally pose questions that need to be answered by the
electrodiagnostician. Part II will review the diagnosis, and discuss the differentials involved in this case,
further highlighting main discriminating characteristics between the diagnostic possibilities which were
considered.
 |
CASE HISTORY:
A 49 year old, healthy appearing male, presented to the office with a 4 week history of numbness and
tingling of all four limbs, and occasionally the face. Over the preceding 2 weeks he had begun to
experience increasing amounts of diffuse aching pain, much of which was generalized through the spine,
but also having aching discomfort in the shoulder and pelvic girdle. There was no clearly defined trauma
involved. He recalled first noticing mild tingling in his fingertips which became more persistent, eventually
spreading to his feet. He further noticed that with stretching of his wrist or arm he would get an immediate
“prickling” throughout that extremity. At the time of presentation, he felt that his situation was worsening,
although not rapidly. In describing how he felt he was worse, he noted that it was mainly due to the aching
discomfort and the increased persistence of the tingling sensations. He did report some “mild” non-
specific weakness. He did not feel that his balance was impaired and, in fact, 1 week prior to presenting
for his examination had gone skiing on extremely difficult slopes without any noticeable adverse affect.
The patient had first seen his primary care physician who did not provide a diagnosis. Laboratory work
was not performed. He subsequently was seen at a local chiropractic office, immediately after which, he
was referred for advanced neurologic consultation and testing.
SYSTEMS REVIEW:
In essence, the patient’s systems review was entirely normal. He denied any weight loss, fever, or other
“constitutional” symptoms. He denied any difficulty speaking, swallowing, headache, tingling sensations
with neck movement, diplopia or dysphagia. His balance and coordination were normal. He denied any
cramping or fasciculations. The patient had not noticed any skin texture changes. No rashes. His thermo-
regulatory function was normal. Bowel and bladder function were normal. The patient denied any
abdominal pain, nausea, etc. The patient had no dyspnea either at rest or with exertion.
PAST MEDICAL HISTORY:
On the intake sheet, the patient’s prior history was entirely benign with no prior surgeries or illnesses.
However, upon direct questioning, the patient did admit that about a month prior to the onset of his
symptoms, he had been “under the weather” with a flu-like illness that had lasted approximately one
week. He “rested” it off, never having felt it severe enough to consult his family physician. He denied any
prior history of sexually transmitted diseases.
FAMILY HISTORY:
Benign. Specifically, there was no known family history of neurologic disorders. There was no history of
early myocardial infarction or death due to cancer. All children (3) were healthy.
MEDICATION HISTORY:
The patient stated that he did not take medications. He had been taking vitamin supplements as a “one a
day” specially formulated for middle aged men. He was asked to bring in the container specifically to
evaluate the level of B6 intake. He did not smoke or use illegal drugs.
OCCUPATIONAL HISTORY:
He worked in the human resources department for a major corporation and did travel quite frequently. He
had not been overseas for more than a year. His most recent travel was restricted to the Midwest, primarily
in urban areas. His job did not involve any exposure to known toxic substances.
CLINICAL EXAMINATION:
PRE-TEST CLINICAL DISCUSSION/SUMMARY:
At this point in the assessment, and prior to the electrophysiologic exam, a differential diagnosis needs to
be formulated based upon what has been learned from both the history and examination. Rather than just
listing the possibilities, I have found it most helpful to first summarize the findings acquired.
In this patient, we have what appears to be an acute to sub-acute illness that may have reached a plateau
and does not appear to be worsening to any great extent. He shows no evidence of co-existent systemic
disease nor does he have any evidence of CNS involvement in terms of typical signs or symptoms that are
often seen. There is no family history of neurologic disease, nor any known exposure to toxic substances
or neurotoxic medications.
Clinically, the patient’s examination has shown evidence of some distal weakness, seemingly affecting
the arms slightly more than the legs. He has evidence of depressed reflexes, affecting the legs (especially
the Achilles) but not the arms. Despite his complaints of numbness and tingling, his sensory exam was
only equivocally abnormal, and only in the arms. Again, the lack of spasticity, clonus, increased tone,
and/or a Babinski argue against a process affecting the CNS.
In general, the patient appears to have a pattern that would be consistent with some form of peripheral
nerve disease, yet without a readily identifiable etiology. The abrupt onset would suggest an acquired (as
compared to hereditary disorder) and one with a possible underlying toxic, infectious, metabolic or
immunologic cause. At the present time, an immunologic cause is suspected as the patient has no other
features of systemic disease as is often seen with infectious etiologies, and has no known exposure to
toxins or neurotoxic medications. Metabolic causes are felt less likely as disorders in this category are
usually more insidious and also associated with other systemic manifestations. In acute to sub-acute
presentations, paraneoplastic syndromes also warrant consideration.
TEST PLANNING:
With the above information in hand, it is important to now recognize not only what the purpose of the
EMG/NCV is, but the information that is necessary to help make an accurate diagnosis. The primary
purposes of electrophysiologic testing, in this case, are as follows:
b. Sensory involvement versus motor involvement or both.
c. Distribution: Distal, proximal, generalized, multifocal.
With the above stated, I offer the following electrophysiologic data on this patient:
CLICK HERE TO PROCEED TO ELECTROPHYSIOLOGICAL DATA
A 49 year old, healthy appearing male, presented to the office with a 4 week history of numbness and
tingling of all four limbs, and occasionally the face. Over the preceding 2 weeks he had begun to
experience increasing amounts of diffuse aching pain, much of which was generalized through the spine,
but also having aching discomfort in the shoulder and pelvic girdle. There was no clearly defined trauma
involved. He recalled first noticing mild tingling in his fingertips which became more persistent, eventually
spreading to his feet. He further noticed that with stretching of his wrist or arm he would get an immediate
“prickling” throughout that extremity. At the time of presentation, he felt that his situation was worsening,
although not rapidly. In describing how he felt he was worse, he noted that it was mainly due to the aching
discomfort and the increased persistence of the tingling sensations. He did report some “mild” non-
specific weakness. He did not feel that his balance was impaired and, in fact, 1 week prior to presenting
for his examination had gone skiing on extremely difficult slopes without any noticeable adverse affect.
The patient had first seen his primary care physician who did not provide a diagnosis. Laboratory work
was not performed. He subsequently was seen at a local chiropractic office, immediately after which, he
was referred for advanced neurologic consultation and testing.
SYSTEMS REVIEW:
In essence, the patient’s systems review was entirely normal. He denied any weight loss, fever, or other
“constitutional” symptoms. He denied any difficulty speaking, swallowing, headache, tingling sensations
with neck movement, diplopia or dysphagia. His balance and coordination were normal. He denied any
cramping or fasciculations. The patient had not noticed any skin texture changes. No rashes. His thermo-
regulatory function was normal. Bowel and bladder function were normal. The patient denied any
abdominal pain, nausea, etc. The patient had no dyspnea either at rest or with exertion.
PAST MEDICAL HISTORY:
On the intake sheet, the patient’s prior history was entirely benign with no prior surgeries or illnesses.
However, upon direct questioning, the patient did admit that about a month prior to the onset of his
symptoms, he had been “under the weather” with a flu-like illness that had lasted approximately one
week. He “rested” it off, never having felt it severe enough to consult his family physician. He denied any
prior history of sexually transmitted diseases.
FAMILY HISTORY:
Benign. Specifically, there was no known family history of neurologic disorders. There was no history of
early myocardial infarction or death due to cancer. All children (3) were healthy.
MEDICATION HISTORY:
The patient stated that he did not take medications. He had been taking vitamin supplements as a “one a
day” specially formulated for middle aged men. He was asked to bring in the container specifically to
evaluate the level of B6 intake. He did not smoke or use illegal drugs.
OCCUPATIONAL HISTORY:
He worked in the human resources department for a major corporation and did travel quite frequently. He
had not been overseas for more than a year. His most recent travel was restricted to the Midwest, primarily
in urban areas. His job did not involve any exposure to known toxic substances.
CLINICAL EXAMINATION:
- Mental Status: Normal affect. Speech fluent with the patient being a very good historian. No
evidence of dysarthria. No evidence of non-organic behaviors. Though content was goal directed. - Head: Facial symmetry was normal. No scleral injection or peri-orbital rash. No proptosis.
- Neck: No cervical adenopathy. No bruits over carotid or vertebrals.
- Extremities: Generalized orthopedic screen of the arms and legs was normal. There were no
tremors or evidence of rash, synovitis, or other skin lesions. Distal hair pattern were normal. No
asymmetrical swelling seen in the arms or legs. No low extremity peripheral edema. Nail beds
were normal and without Mee’s lines. There was no scapular winging. - Muscle Tone: No fasciculations or other abnormal movements such as myokymia seen. No
atrophy, spasticity, or rigidity. - Cranial Nerves: As noted, patient spoke fluently, had good eye movement and normal facial
expression. Formal assessment revealed no deficits. Fundus showed no atrophy or pallor. - Gait: Patient walked normally without any evidence of ataxia or spasticity. Arm and leg swing were
normally coordinated. Slow and rapid gait were normal. Ability to turn corners was normal. - Coordination: Tandem walk, finger to nose, rapidly alternating movements, fine finger dexterity, and
Trendelenberg’s test were all normal. - Reflexes: Tricep, Bicep, and BR were +2 bilaterally, and easily obtained. Patella responses were
obtained bilaterally, but felt to be very sluggish for such an athletic appearing individual. Achilles
reflexes were absent (even with reinforcement). Plantar responses were normal. Superficial
abdominal reflex was normal in all quadrants. - Muscle Strength: 4+/5 weakness was evident in the EHL bilaterally. TA possibly weak. All other LE
muscles were normal. UE revealed 4/5 weakness of the APB, ADM, and thumb and finger
extensors. No other UE weakness seen. - Sensation: Legs showed normal pin and touch as well as clearly normal joint position and
vibratory perception. There was no loss of pin prick over the posterior spine or abdomen. Upper
extremities showed only a equivocal decreased pin prick over the pads of all 5 digits bilaterally and
symmetrically. There was no astereognosis of either hand or the plantar aspect of the feet.
PRE-TEST CLINICAL DISCUSSION/SUMMARY:
At this point in the assessment, and prior to the electrophysiologic exam, a differential diagnosis needs to
be formulated based upon what has been learned from both the history and examination. Rather than just
listing the possibilities, I have found it most helpful to first summarize the findings acquired.
In this patient, we have what appears to be an acute to sub-acute illness that may have reached a plateau
and does not appear to be worsening to any great extent. He shows no evidence of co-existent systemic
disease nor does he have any evidence of CNS involvement in terms of typical signs or symptoms that are
often seen. There is no family history of neurologic disease, nor any known exposure to toxic substances
or neurotoxic medications.
Clinically, the patient’s examination has shown evidence of some distal weakness, seemingly affecting
the arms slightly more than the legs. He has evidence of depressed reflexes, affecting the legs (especially
the Achilles) but not the arms. Despite his complaints of numbness and tingling, his sensory exam was
only equivocally abnormal, and only in the arms. Again, the lack of spasticity, clonus, increased tone,
and/or a Babinski argue against a process affecting the CNS.
In general, the patient appears to have a pattern that would be consistent with some form of peripheral
nerve disease, yet without a readily identifiable etiology. The abrupt onset would suggest an acquired (as
compared to hereditary disorder) and one with a possible underlying toxic, infectious, metabolic or
immunologic cause. At the present time, an immunologic cause is suspected as the patient has no other
features of systemic disease as is often seen with infectious etiologies, and has no known exposure to
toxins or neurotoxic medications. Metabolic causes are felt less likely as disorders in this category are
usually more insidious and also associated with other systemic manifestations. In acute to sub-acute
presentations, paraneoplastic syndromes also warrant consideration.
TEST PLANNING:
With the above information in hand, it is important to now recognize not only what the purpose of the
EMG/NCV is, but the information that is necessary to help make an accurate diagnosis. The primary
purposes of electrophysiologic testing, in this case, are as follows:
- Determine if evidence of peripheral nerve disease exists. In a patient such as this, the lack of such
evidence would mandate at least a reconsideration of the diagnosis. - If peripheral nerve disease is present, evaluate:
b. Sensory involvement versus motor involvement or both.
c. Distribution: Distal, proximal, generalized, multifocal.
With the above stated, I offer the following electrophysiologic data on this patient:
CLICK HERE TO PROCEED TO ELECTROPHYSIOLOGICAL DATA