ELECTROMYOGRAPHY

Dr. Joel Vandersluis Neurology Diagnostics

Test question
Typical EMG findings in radiculopathy include a) Low cmap and sensory responses; delayed / absent F wave, and normal needle exam b) Low cmap with normal sensory responses, delayed / absent F wave, and denervation in at least 2 related muscles c) Low cmap with normal sensory responses, enlarged F wave, and denervation in at least 2 related muscles

Components of an EMG
Nerve conduction studies
Motor nerves Sensory nerves Repetitive Stimulation
Left Sensory LeftMedian MedianSen Motor

Electromyography
Qualitative Quantitative

EMG - Left CervPara Mid

P T P R
T R

Wrist 2nd Digit

3rd Digit
R

O P O

T T
P

4th Digit
Elbow 1st Digit

P O

R
T

5000 (V) 20 (V)

5 (ms) (ms) 2

100 (V)

10 (ms

Nerve Conduction Studies

Peripheral nerves are stimulated with a controlled

electrical stimulus Responses are recorded

Compound motor action potential (CMAP) Sensory nerve action potential (SNAP) F wave H reflex

Left Median Motor

O R T

Wrist

P O R T

Elbow

5000 (V)

5 (ms)

Motor NCS Parameters

Distal Latency determined by conduction velocity of the nerve, neuromuscular junction & muscle Amplitude determined by number of muscle fibers activated

Proximal conduction velocity determined by conduction velocity of the fastest fibers

Normal Median Motor Study

DL CV Amp (msec) (m/s) (mV) Wrist-APB 3.2 15.0 Elbow-Wrist 55 14.8

Left Median Sen Sensory

P T P R

2nd Digit 3rd Digit

T T R

O P O

4th Digit 1st Digit

P O T R

Sensory NCS Parameters

Onset and peak latencies
Conduction velocity determined by velocity of a very few fast fibers Amplitude determined by the number of large sensory fibers activated

Normal Median Sensory Study

1 msec/div

Latency CV (msec) (m/s) Wrist-D2 2.2 58

Amp (uV) 44.1

CASE 1
29 y.o. male

Acute right foot drop 4 weeks earlier

No trauma, no hx DM EXAM: MRC 2/5 rt dorsiflex toes 4/5 rt ankle DF and eversion Decr pp dorsum foot Reflexes sym. No tinels at fib head

 Where is lesion

Character (axonal, demyelinating)

prognosis

CASE 2
67 y.o. male

buttock pain to lat thigh, exac with ambulation

Few wks later rt foot drop Exam: 4/5 rt foot df, eversion, pf 5-/5 Trace ankle reflexes Decr sens on dorsum foot SLR neg

F-wave study
small late response from a short duration supramaximal stimulation. It initiates an antidromic motor response to the spinal cord followed

by an orthodromic motor response to the recording electrode. 5% CMAP height The configuration and latency change with each stimulation. This is due to a polysynaptic response in the spinal cord, where Renshaw cells (R) inhibit impulses from traveling the same path each time.

F Waves
Useful to assess proximal nerve to spinal cord

Helpful in the evaluation of: Radiculopathy Guillian-Barre Syndrome Peripheral neuropathy Other demyelinating neuropathies

F Waves: Normal Median

H- reflex study
late response equivalent to achilles reflex. Stimulate tibial

at popliteal fossa, pickup over soleus muscle initiated with a submax stimulus at a long duration (0.5 1.0 ms). preferentially activates the IA afferent nerve fibers (muscle spindle sensory) causing an orthodromic sensory response to the spinal cord, and then an orthodromic motor response back to the recording electrode. The morphology of wave pattern and latency remains constant

Muscle Spindle
Ia - responsive to the rate of change in muscle length, as well to change in velocity

H Reflexes
Useful to assess proximal nerve conduction Criteria: <3msec side to side diff (or >50% diff in

amplitude) Helpful in the evaluation of:

Polyneuropathy
S1 radiculopathy Upper Motor Neuron lesions

Nerve Conduction Studies:

Late Responses F Wave Latency
Retrograde rebound motor impulse
Travels full length of motor axon and back Information about proximal segments Limited sensitivity/specificity

H Reflex
Afferent Path: Sensory axons (group Ia fibers) Efferent Path: Motor Axons (alpha motor neurons) Follows muscle stretch reflex arc Side to side latency most valuable

DDX
Small peroneal motor CMAPs normal sensory

No conduction block
Deep peroneal (spares sensory) vs L5 Absent peroneal F points proximal

Normal tibial CMAP + normal sural sensory

Eliminates tibial, sciatic or plexus Some S1 involvement suggested

H reflex absent with normal M response

Radiculopathy
(Neuro-foraminal Stenosis from L-5 Disc Herniation)

Radiculopathy
(Sarcoidosis)

Radiculopathy
(Electrodiagnostic Features)
Normal or low amplitude CMAP in corresponding

dermatome Normal SNAP in corresponding dermatome Denervation in a segmental myotomal distribution (at least 2 muscles innervated by the same root via more than one peripheral nerve) with or without denervation of paraspinals

Needle Electromyography
Needle electrode is inserted into the muscle Needle is disposable, single use
Multiple muscles are accessible for examination Combination of muscles tested Dependent upon clinical question Level of discomfort is mild

Needle Electromyography
Muscle is studied at rest and at different levels of

sustained, voluntary contraction. At rest, the muscle should be silent--any spontaneous activity may signal a nerve or muscle abnormality.

During activity, the electrical shape and pattern of the response can distinguish between nerve and muscle disease.

EMG - Motor Units

Evaluated during early recruitment
Morphologic parameters studied Amplitude Duration Phases Rule of 5s: as increase effort each unit comes in at ~5hz,

and next added when previous firing ~10hz

Case 3
53 fem, progressive weak distal L hand No neck pain, numb, loss of bowel, bladder PHx: dm x 8years, smoker, htn; no sig fhx Exam: atrophy intrinsics LH Brisk reflexes UE, and rt babinski present Normal sens, cerebellar, gait Init inv: mri c/s mild disk bulging. Emg lt c7-t1 radic. EMG IS REPEATED AT 7M

EMG - Denervation
Recruitment is the pattern of motor unit firing when a

muscle contracts
Reduced - less motor units to draw upon

Configuration size and shape: Large Amplitude more that normal # nerve fibers Large Duration nerve fibers timing is variable

Needle Electromyography:
Neurogenic Motor Unit
EMG - Left VastusLat

This unit demonstrates:

Reduced recruitment Increased amplitude

Increased duration
Polyphasia

100 (V)

10 (ms)

Reinnervation sprouting

collateral

Needle Electromyography:
Muscle at rest
Insertional Activity Burst of electrical activity as needle is inserted into muscle Due to disruption of muscle fiber membranes Prolonged with denervation, some muscle diseases Spontaneous Activity Fibrillations, positive sharp waves, fasciculations Hallmark of denervation, muscle membrane irritation

Needle Electromyography:
Grading of Spontaneous Activity
0 No Fibs/PSWs

+/1+ 2+ 3+

Fibs/PSWs that are not persistent

Persistent Fibs/PSWs in at least 2 areas Persistent Fibs/PSWs of moderate #s in three or more areas Persistent Fibs/PSWs of large #s but not obscuring baseline

4+

Baseline obliterated in all areas examined

EMG - Left AntTibialis

1+

2+

3+

4+

100

(V)

10

(ms)

Spontaneous Muscle Electrical Activity

Examples: Fibrillation potential/positive waves
indicates loss of muscle-nerve connection provides information about the chronicity of the problem

Fasciculation
spontaneous motor unit potential, may indicate irritability in the motor

nerve cell

Fibrillation Potentials and Positive Sharp Waves

Fibrillation Potentials Positive Sharp Waves

Fasciculation

Case 4
76 healthy female, progressive LE numb / wk 1 year

Imbalance cane walker

Recent involvement of hands Exam: Motor: grip 4+, hip flex 4, dorsiflex 4 Sens: marked loss vib and proprioception feet Areflexic Gait wide-based; pos Romberg

 Needle 19

Summary
Sensorimotor polyneuropathy

Cmap loss >> denervation

Conduction blocks Sig slowing

Few fibrillation potentials, some larger unit ->

predominately chronic

DDX Chronic acquired demyelinating neuropathy

CIDP +/- early HIV

Multifocal motor NP with conduction block

Anti MAG, monoclonal gammopathy, MGUS, osteosclerotic myeloma (POEMS syn)

Multiple myeloma, Waldenstroms

Castelmans Amyloidosis

Electrodiagnosis provides
Confirmation of neuropathy Eg vib loss in np vs post cord Fiber type sens, motor, both Pathology demyel vs axonal Chronicity and activity

Test question
Typical EMG findings in radiculopathy include a) Low cmap and sensory responses; delayed / absent F wave, and normal needle exam b) Low cmap with normal sensory responses, delayed / absent F wave, and denervation in at least 2 related muscles c) Low cmap with normal sensory responses, enlarged F wave, and denervation in at least 2 related muscles

The End

Limitations of NCSs/EMG
Generally not helpful in the evaluation/diagnosis of: Pain from joint disease Fibromyalgia or myofascial pain syndromes Central nervous system disorders Disorders that do not arise from the neuromuscular system

What to Expect From an EMG Report

A clinically and physiologically relevant

interpretation/diagnosis An outline of the localization, severity, and acuity of the process Notation of other diagnoses that are detected/excluded Explanation of any technical problems

What to Expect From an EMG Report

The reason for the referral is addressed Pertinent information that may affect management is

provided
Need for re-evaluation in the future Urgent need for medical intervention

What to Expect From an EMG Report

Data obtained during the study: (NCS) Amplitude Distal latency Distance Conduction velocity Normal (Reference) data Side-to-side comparison (when appropriate) Limb temperature during the study

What to Expect From an EMG Report

Data obtained during the study: (EMG) Presence & type of abnormal spontaneous activity Motor unit recruitment Motor unit morphology

EMG Pearls
Electrodiagnostic studies are a supplement to, and not a

replacement, for the history and physical examination Electrodiagnostic results are often time-dependent Electrodiagnostic studies are not standardized investigations and may be modified by the practitioner to answer the diagnostic question

Specialized EDX Testing

Interference pattern analysis

Quantitative motor unit analysis

Single fiber analysis Segmentation studies Cranial nerve testing Brainstem and somatosensory evoked potentials Pelvic floor and respiratory muscles

Outline
What conditions are commonly evaluated/diagnosed by

NCSs/EMG? What are the technical details of these studies? What are some limitations of EMG studies? What can I expect from an EMG report?

What are the indications for electrodiagnostic consultation/testing?

Suspected neuromuscular disease nerve root pathology peripheral nerve/plexus pathology neuromuscular junction pathology muscle pathology

What is the value of NCSs/EMG?

Confirm the clinical impression of a neuromuscular

disorder Rule out certain diagnoses Enhance patient care

Value of NCSs/EMG
When neuromuscular disease is present,

electrodiagnostic testing can:

Clarify the type of pathology (i.e. neuropathy

vs myopathy) Determine severity & extent of pathology Confirm site of pathology Estimate chronicity of pathology

Complaints Suggestive of Neuromuscular Pathology

Numbness or Tingling
Decreased Sensation Pain or Cramping

Weakness
Gait difficulty Fatigue

Disorders Diagnosed/Evaluated by NCSs/EMG

Generalized Neuropathies

Axonal Demyelinating Acquired

Acute: GBS Chronic: CIDP

Hereditary

Mixed Diabetic sensorimotor neuropathy

Polyneuropathies
Polyneuropathies associated with many medical

conditions Multiple investigations often needed NCSs/EMGs: best initial test to clarify underlying pathophysiology (i.e., axonal vs demyelination) Results may help focus rest of work-up

Disorders Diagnosed/Evaluated by NCSs/EMG

Mononeuropathy multiplex Vasculitic/ischemic neuropathies Demyelinating neuropathies Infectious neuropathies Neoplastic infiltration Granulomatous infiltration Compression neuropathy

Disorders Diagnosed/Evaluated by NCSs/EMG

Focal Neuropathies Carpal Tunnel Syndrome (median neuropathy at the wrist) Ulnar Neuropathy Peroneal Nerve Palsy Others: brachial plexus lesions, tarsal tunnel syndrome, etc.

Disorders Diagnosed/Evaluated by NCSs/EMG

Radiculopathy Cervical Lumbar Motor Neuron Disease Amyotrophic lateral sclerosis (ALS) Spinal muscular atrophy (SMA)

Disorders Diagnosed/Evaluated by NCSs/EMG

Muscle Disease Inflammatory
Polymyositis, Dermatomyositis

Metabolic
Hereditary or Congenital

Disorders Diagnosed/Evaluated by NCSs/EMG

Neuromuscular Junction Disease Myasthenia Gravis Lambert Eaton Myasthenic Syndrome Botulism Medications

Disorders Diagnosed/Evaluated by NCSs/EMG

Generalized weakness in the critical care setting Acute/unexplained onset of respiratory failure Neuromuscular cause for failure to wean from

mechanical ventilation Neuromuscular diseases unique to critical care setting

Critical illness neuropathy/myopathy

Disorders Evaluated/Diagnosed by NCSs/EMG

Specialized electrodiagnostic expertise can be useful in

evaluation of:
Ocular muscle weakness Speech difficulties due to weakness of laryngeal muscles

Disorders of movement and tone from central nervous system

disorders

Neuromuscular Junction Testing

Repetitive Nerve Stimulation Stimulate nerve with train of supramaximal stimuli before and after exercise Record from muscle Attention to technical factors important More sensitive recording from proximal muscles

Repetitive Nerve Stimulation:

Normal

3Hz stimulation

Repetitive Nerve Stimulation: Myasthenia Gravis

3 Hz stimulation rate

F-wave study (continued..)

This is not a reflex, because action potentials travels from the

site of the stimulating electrode in a limb to the spinal cord and back to the limb in the same nerve that was stimulated. The F- waves latency can be used to derive the conduction velocity of nerves between the limb and spinal cord, whereas the motor and sensory nerve conduction study in the same segment of the limb. Conduction velocity is derived by measuring the limb length in millimeters from the stimulation site to the corresponding spinal segment (ex: C7 spinous process to wrist crease for median nerve). This is multiplied by 2 as it goes to the cord and returns to the muscle. Limitation: This evaluates a long neural pathway, which can dilute focal lesions and hinder specificity of injury location. It

Radiculopathy
(Spontaneous Activity)
Fibrillation potentials Fasciculations Complex repetitive
EMG - Right LumbPara Mid

Positive sharp waves

Positive Sharp Wave Fibrillation Potential

100 (V)

100 10 (V) (ms)

discharges Myokymia (rare) Myotonia (rare)

Complex Repetitive Discharge

100 (V)

10 (ms)

Needle Electromyography:
Parameters Evaluated
Motor Unit Configuration Muscle is volitionally activated at different force levels Single motor units are assessed Single motor unit: A motor axon and all its muscle fibers Motor Unit Configuration: Amplitude, Duration, Morphology
Motor Unit Recruitment
Pattern of motor unit activation with increasing volitional activation

Interference Patterns Motor unit pattern with full voluntary activation

Needle Electromyography:
Parameters Evaluated
Insertional activity
Spontaneous activity Motor unit configuration

Motor unit recruitment

Interference pattern

Needle Electromyography:
Spontaneous Activity
Fibrillation potentials
Fasciculations
EMG - Right LumbPara Mid

Positive sharp waves

Positive Sharp Wave

Fibrillation Potential

100 (V)

10 (V) (ms) 100

Complex repetitive

discharges Myokymia Myotonia

Complex Repetitive Discharge

100 (V)

10 (ms)