EMG/NCS...any help is appreciated!

[slipnslide]

Hi all,

I frequent the Spinal Disorders forum and posted this thread on there. I was hoping I might find some answers here too.

To make a long story short, I had neck, shoulder, upper arm, and hand pain, and tingling in both hands, also my butt bones feel like they've been beaten with a baseball bat and bruised, along with dull pain into the backs of the thighs, and tingling in the feet. I also have mild burning pain in my mid and upper back (like a sunburn feeling). I had all of this before surgery, and unfortunately I'm still having it after my ACDF C5/6 & C6/7 surgery back on 6/22/06.

My OS sent me for a new EMG/NCS....here is what the report reads:

Summary and Findings:
The bilateral median and ulnar sensory nerves revealed prolonged peak latency, normal amplitude and decreased conduction velocity. The bilateral radial sensory nerves revealed borderline prolonged peak latency, normal amplitude and normal conduction velocity.

The bilateral ulnar motor nerves revealed normal distal latency, normal amplitude and decreased conduction velocity across the cubital tunnel w/ a drop of > 10m/s.

To assess for polyneuropathy third limb sensory and motor nerve were tested (right peroneal motor and sural sensory). These were WNL.

Monopolar needle EMG was performed in selected bilateral upper extremities, innervated by C5-T1 nerve roots inclusive. No spontaneous activity was seen in any muscles tested in the form of fibrillations, positive sharp waves or fasciculations. Voluntary motor unit morphologies are otherwise normal.

Impression: Inconclusive study. There is new evidence of global sensory slowing in the upper extremities, however the slowing is more pronounced for the median and ulnar nerves and more likely related to CTS and potentially Ulnar Neuropathy at the elbows. The lack of slowing in a third limb (RLE) reduces the likelihood of polyneuropathy as a source. There is no evidence for acute cervical radiculopathy on EMG.

Basically...I'd love to know what this all means??? Anyone have a clue or experience with the same? Any ideas? How about taking a shot in the dark?...lol:D Could it mean that the nerves are still being affected somewhere in my neck or spine? What's been ruled out?.....anything?

All comments welcome since I'm totally lost!

Thanks,

Kim

[nide44]

Seems like it could be a type of neuropathy (prolonged peak latency, normal amplitude and decreased conduction velocity), but more likely carpal tunnel in hand/wrist. (Inconclusive study. There is (new evidence of global sensory slowing in the upper extremities, however the slowing is more pronounced for the median and ulnar nerves and more likely related to CTS and potentially Ulnar Neuropathy at the elbows.)Did they do your legs? For the feet tingling?(lack of slowing in a third limb (RLE) ) I don't know what the RLE is, but the WNL is 'within normal limits' - that one always raises a red flag- low normal? high? whose criteria used?
That's my best take on the results. Maybe Glenntaj or someone else will have a better interpretation.

[slipnslide]

nide44,

Thank you for responding. They did test my right leg from just below knee level, in the back of my leg, down to the top of my right foot. It was told it was to get a "baseline reading". I know what you meant about the WNL...lol Normal for whom???:rolleyes:

Before my spine surgery, a Neurosurgeon said that the butt bone pain and the tingling feet is a common complaint with his C-spine patients, but then my OS who did my surgery attributes the tingling feet to my lumbar degenration of the facet joints. My OS sent me for this new EMG since I am still having pains and symptoms after the surgery. My first EMG was 7 months ago and it only showed :

Summary and Findings:
The bilateral median nerves revealed prolonged peak latency, normal amplitude and decreased conduction velocity. The rest of the sensory and motor nerve conduction studies were within normal limits.
Impression:
The above electrodiagnostic study reveals evidence of a mild bilateral carpal tunnel syndrome (median nerve intrapment at wrist) affecting sensory components. No electrodiagnostic evidence for acute radiculopathy in the upper extremeties.

Here it is 7 months later, and the discs that were pressing on my nerve roots and spinal cord have been removed and the spine plated and screwed, but yet there are more nerve problems than before. Now it's the ulnar and median nerves, with the ulnar being affected more so than the median nerve. Could it be a nerve problem progressing like this or is something somewhere in the neck, shoulder, or upper arms now affecting the ulnar nerves too?

Anyone ever hear of this kind of situation or similar?

[curiousforever]

EMG/NCV' s are subjective. I had one that showed demylination, then the next one showed NO problems even with pain/tingling, etc.

Did the same doc do both?

[slipnslide]

Curiousforever,

The same physiatrist did both of my EMG/NCS's. He was the doctor who first started treating me for whiplash after a MVA last Nov., then ordered MRI's that showed the problems in my neck and sent me over to a Spinal OS for surgery.

Best wishes,

Kim

[LizaJane]

The reading of the NCS seems to support a problem of large nerve groups, rather than individual nerves. In peripheral neuropathy you see a more random and diffuse pattern of nerve loss than this, I think he is saying. So this looks more like large nerves are being damaged by compression than all nerves throughout your body being hurt by toxins, antibodies, or an unhealthy metabolic state.

How's your thyroid? Hypothyroidism can cause diffuse nerve compression symptoms? Do you have arthritis? Thoracic Outlet?

[slipnslide]

LizaJane,

The EMG/NCS report suggested referral to a Neurologist and a Rheumatologist. During the EMG I was asked if I had ever had my thyroid checked. During pre-op testing for the c-spine surgery, my white counts were repeatedly elevated, so surgery was postponed and I was sent to a Hema/Onc who did a bone marrow biopsy with extensive blood tests & a DNA test for a bone marrow disorder. It came back inconclusive , they were not able to prove or disprove the possibility of the disorder and now I go back to the Hema/Onc every 6 months to watch my WBC's, RBC's, and platelet counts. The hematologist's blood tests did list something about thyroid, which also came back normal. I have DDD in my c-pine and facet hypertrophy in my lumbar, both are forms of arthritis. I've not been diagnosed with TOS. I've done some reading about it and have many of the symptoms, but not all, and I'm not sure what EMG/NCS readings would point toward TOS. Would you, or anyone else, happen to know?

Best wishes,

Kim

[LizaJane]

I think the NCS would just look like compression, rather as yours do, IF there was real nerve irritation from it.

If you have TOS, there can be major improvement with myoafascial release physical therapy. In fact, given your studies, you might want to investigate this. It's a massage physical therapy focussed on releasing connective tissue "restrictions"--little injuries where the connective tissue/fascia loses its give. It can release pressure around vessels and nerves. I had TOS for as long as I can remember, which I never really thought about, until I was getting myofascial treatments for other problems, and the TOS went away after work in my armpit and over my chest.

I'm a believer that with pn, in general, our nerves become more sensitive, and keeping them free from pressure is important in allowing them to get the nourishment they need to function well and grow.

[slipnslide]

Thank you LizaJane,

It definitely sounds like something I need to investigate! God only knows how enticing the word "massage" is to me!!!:D Would you happen to know if you need a referral for myoafascial release physical therapy?

I'm assuming my Spinal OS is going to refer me to a Neurologist and Rheumatologist, as suggested in the report, to rule out any contributing factors before he gives me a referral for any type of massage therapy, since he's already sent me to Physio-therapy, which I failed out of due to increases in pain. The PT sent me back to my OS & he ordered the EMG, and that's where I'm at right now. I go back to him this week and he's to discuss the EMG/NCS with me then.

Best wishes,

Kim

[glenntaj]

--I'm curious about the hematological tests you've been given and continue to be given, and exactly what they may have shown, as there a re anumber of neuropathic conditions linked to blood disorders, most prominently those caused by either blood cnacers (whihc I'm assuming you do not have) or by non-cancerous or precancerous myeloproliferative disorders, such as MGUS (monoclonal gammopathy of uncertain significance, in which an overproduction of monoclonal antibodies from the bone marrow cause neuropathy; see:
http://www.neuro.wustl.edu/neuromuscular/antibody/mprotein.htm ).

I do agree with Liza Jane that the most recent nerve studies seem to indicate compressive forces rather than a system-wide problem, but nerve studies can be somewhat variable depedning on the conditions under which they're done and the skill of the technicians and interpreters.

Moreover, there's no reason one could not be "co-morbid"--have similar symptoms from more than one source. Problems with the spine itself, or with the nerve roots near the spinal column, can produce symptoms almost exactly like those you can feel with peripheral nerve problems, which is why with your history it would make sense to do a nerve conduction study all the way back to your spine, and of your legs as well, if you could tolerate it.

There are many systemic conditions that could make you more prone to compressive type symptoms in areas where nerves pass through "cramped quarters" (wrist, thoracic outlet, ankle, pelvis); as LizaJane hints, once nerves are damaged they seem more prone to such compressive effects. Thyroid is certainly a possibility, as are many vasculitic autoimmune diseases, diabetes/imparied glucose tolerance . . .

It would be a good idea to get copies of ALL your testing as far back as you can and organize them with a tool such as Liza Jane's spreadsheets at www.lizajane.org to see if any patterns could be noticed.

[slipnslide]

glenntaj,

During my pre-op testing, my WBC's were continuously elevated. AMAZING! You hit the nail on the head!!:) I was tested for a myeloproliferative disorder. The Hema/Onc suspected Polycythemia Vera. My WBC's have been elevated and documented back to 2002 when I had a hysterectomy. I had requested copies of all my lab reports, so I do have copies of everything thus far and had also given them to the Hema/Onc.

He did a bone marrow biopsy from the iliac crest. The tests came back inconclusive. I don't have the Philadelphia chromosome and my counts are not extreme. He felt I could just be outside the bell curve of what would be considered a "normal high" count and this is just what's normal for me, but because they are high, we'll monitor the counts every six months to make sure they don't drastically increase. If I start to notice any symptoms of Polycythemia Rubra Vera, other than the tingling extremeties, then I am to call him.

I've done alot more reading and have looked into TOS and Brachial Plexus compression which both seem to be a possibility.

You seem to have alot of knowledge about hematology, so would a myeloproliferative disorder possibly give the EMG/NCS results that I got?

Thank you so much,

Kim

[glenntaj]

A number of the autoimmune neuropathies that result from monoclonals/cryoglobulins attack myelin sheathing more than they directly do axons (nerve fibers themselves), and often these neuropathies first manifest with NCV/EMG's that show latencies or lower amplitude signal conduction.

Polycythemia is not often associated with neuropathy per se, but considering the red blood cell increases are rarely an isolated event--they are usually accompanied by increases in other types of blood cells, which often ARE associated with neuropathies if monoclonal M-proteins or immature plasma cells are involved--this is a definite thing to watch.

Taking the bone marrow sample was a good idea, and I'm assuming as part of the analysis an immunoglobulin profile was performed. If nothing way out of the ordinary was found, you're in that "watchful waiting" group that, as you mentioned, should be retested frequently.

[slipnslide]

I've gone thru the labs and reports that I have copies of and am not sure what to be looking for.

I have labs and reports for: Bone Marrow Examination Report, Flow Cytometry Report, Bone Marrow Differential, Chromosome Hematolog, CMP, Erythropoietin (EPO) Serum, Ferritin, FT4, Iron Panel, Leukemia, CLL/Lymphoma, Leukocyte Alkaline Phos Score, TSH, Vit B12, and many CBC’s.

Is an Immunoglobin profile an individual test or is it part of one of the work-ups I've already had done?

I'm sorry to be such a pain with all these questions, I'm just trying to avoid being zapped, poked, prodded, punctured, and cut any more than I have to be...lol:rolleyes:

Thanks so much,

Kim

[glenntaj]

--would have a total immunoglobulin number and then breakdowns for IgA, IgG, and IgM classes, at least; some more advanced tests may also list IgE (the type that promotes short-term allergic reaction). If the test was really sophisticated, it may list subtypes within each of these classes.

This is for the gamma class, which is most active in immunity (gammaglobulins); usually alpha and beta globulins are examined in an extended CBC.

The idea is to look for sharp elevations (or declines) in the antibody IgA, IgG, and/or IgM classes, which might be evidence of overproduced monoclonal antibodies characteristic of blood disorders. If this is found, generally an immunofixation electrophoresis of serum and protein is done to determine the m-Protein types (though many labs will do this automatically with an immunoglobulin profile--the best outcome is to have no abnormnal monoclonals detected).

This may have been done as part of the bone marrow examination/differential. (The flow cytometry is also important, as it is done to reveal immature leuckocytes or those with abnormal antibody markers.)

I would imagine if you had these in any appreciable quantity the result would have been flagged and yo'd know about it, but I've learned never to assume.

[slipnslide]

glenntaj,

The Bone Marrow Diff. Report stated:

Final Pathologic Diagnosis - MILDLY HYPERCELLULAR BONE MARROW WITH MILDLY INCREASED NUMBERS OF MEGAKARYOCYTES

Microscopic Description - Bone marrow aspiration smears, clot section, and unilateral decalcified biopsy are submitted for review. The cellularity is somewhat over 60%. The ME ratio is normal. There is complete maturation in both the myoloid and erythroid series. Blasts account for less than 5% of the total cell population. Megakaryocytes are mildly increased in number. There is only minimal clustering of megakaryocytes. There is no increase in lymphocytes or plasma cells. There are no granulomas. The bony trabeculae are unremarkable. An iron stain reveals iron to be in reduced amounts. No ring sideroblasts are seen. There is no evidence of metastic carcinoma, acute leukemia, or lymphoma.

The histologic findings are those of a mildly hypercellular bone marrow with mild megakaryocytic hyperplasia. The histologic findings alone are not specific. Clinical correlation and appropriate follow-up is recommended.

The Flow Cytometry Report states: Immunophenotyping fails to identify any unique cell populations. (This listed a bunch of antigens tested)

The only things I see flagged are the Erythropoietin as Low, and the WBC as High.

All of this is Greek to me, so would any of the things found in my labs cause my symptoms to your knowledge?

Thank you,

Kim

[glenntaj]

--they did the cell type differentials and did not find any appreciable numbers of immature cells: There is complete maturation in both the myoloid and erythroid series. Blasts account for less than 5% of the total cell population. . . . There is no increase in lymphocytes or plasma cells. . . Immunophenotyping fails to identify any unique cell populations. . .There is no evidence of metastic carcinoma, acute leukemia, or lymphoma.

That last part is, of course, the most improtant part for now.

The increased megakaryocyte number is a more inspecific finding than a lot of others would have been, so you should be monitored closely, as has been recommended, but I don't think you're in any threatening situation.

To my knowledge, it is unlikely that just this series of findings would completely explain your symptoms. Of course, there may be intervening factors not yet discovered. It's often very hard to find the "chicken/egg" distinction in these types of conditions.

Have you ever had a full thyroid series (TSH, T3, Free T4, thyroid antibody screen, basal temperature) done? What was your TSH number most recently? The American Academy of Endocrinology recently recommended that the "normal" TSH lab ranges be modified downward to "catch" more people who may have subclinical hypothyroid dysfunction. (Not all docs are aware of this; I've been prodding my wife's hematologist--she has iron deficiencies and low platelets--to look into this further.)

[slipnslide]

glenntaj,

A couple of the tests that you mentioned for the thyroid are listed in my reports:

Test --- Observed Value --- Ref. Range
TSH-------2.444--------- 0.350-5.550
T4,FREE(DIRECT)-1.18 -------0.61-1.76

Neither of their values were flagged since they are within reference range.

My blood counts have been out of whack since at least 2002. In May 2002 I had a hysterectomy because of a large uterine fibroid. In June 2002, my WBC (12.8),RDW (18.0) & Absolute Neutrophils (8704) were high, and Absolute Eosinophils (0) were low. The platelet count (389) was circled even though it was within range. The comments at the end of the report stated: Poikilocytosis 1+, Hypochromasia 1+, Large Platelets Present.

They retested me every 2 weeks, for 6 weeks, and each time the labs came back with the same results. They wanted to retest me in another 2 weeks at the time and I finally said "enough". I had no health insurance at the time and between the surgery and all the labs, I was financially tapped out. I felt fine, so I did not pursue it any further.

Basically, I know that my counts have been out of range for at least 4 1/2 years with no extreme increases, and WBC's never within the reference range.

Could I just be an anomaly?

[glenntaj]

--as the reference ranges for "normal" when it comes to lab results are usually set as ranges that 95% percent of the population falls into, and somebody has to be in that 5%. :)

I'd monitor that TSH, though--it's not out of range, but the new guidelines suggest a range of .3--3.0, rather than the older one you listed, and many endocrinologists believe that the optimal range clusters around 1, so you may be producing a bit of TSH beyond optimality. Your pituitary is trying to encourage your thyroid to produce more hormone, and since both are very sensitive to blood level hormonal feedback, that's probably at least a hint that your metabolic level is not quite optimal. (This is quite a common finding, BTW--the argument comes among doctors as to what levels, in conjunction with thryoid hormone levels and symptomology, indicate a need for treatment. Your weight history/caloric intake and basal temperature would also be factors to take into account on that score.)

[slipnslide]

glenntaj,

Thank you so much for being so patient with me and answering all of my questions.:) You've been more than helpful, and it's appreciated!

I plan on seeing the Hema/Onco, a Neurologist, and a Rheumatologist in the next few weeks. I'll be sure to question the TSH level and ranges with my doc, just out of curiosity to see what the response will be. Hopefully I (they) can pinpoint what's causing what with my neck, back, arms and feet.

Best wishes,

Kim