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I have a patient who is scheduled to get a lumbar epidural and a lumbar/lower EMG in close proximity. Can an epidural alter EMG findings?
I have a patient who is scheduled to get a lumbar epidural and a lumbar/lower EMG in close proximity. Can an epidural alter EMG findings?
It's funny you mention demyelinating disorder, because her paresthesia is non-dermatomal and bilateral, and has been progressing proximally from the plantar surfaces to the knees over the last few weeks. Motor normal and no hyperreflexia. No diabetic issues, although her internist just ordered some add'l labs. Denies visual changes. She's involved in a work-comp situation, so I have only limited control over her care but I've been pushing for the EMG. I've had MS on my mind since she started describing her symptoms to me.
PS She is also seeing an ortho and a pain mgmt doc (anesth.) for the work-comp injuries.
And you patient will have an Adonai and demyelinating neuropathy affecting the incompetent electromyograher.
you will have the jewish name of the lord? how do you treat THAT?!?!
MS will not show up on an EMG study. there will be essentially normal findings (sometimes there is some decreased muscle activation, but this is subtle and can easily be missed)
She does have a prior hx of lumbar disc herniation and radiculopathy. The EMG would only be to get current/comparative findings on this and assess for multilevel radiculopathies. In the absence of radicular findings, demyelinating would have to remain on the list.
I'm trying to get her to a neuro on her private insurance, but with the work-comp overlap it's a bit tricky.
wait. what? you are not really making any sense here.
lets define things. radiculopathy = objective evidence of injury to the radicle. this means a finding of weakness on exam, decreased reflex, or previous EMG finding. it is not correct to call leg pain with evidence of a disc herniation a "radiculopathy".
now, "radicular findings" can mean anything. any pain, numbness, tingling, or weakness shooting down the leg may be "radicular" but not necessarily radiculopathy. a demyelinating process, therefore, may be radicular as well.
its not clear if your patinet has had a previous EMG.
"demyelinating" can be central or peripheral, and my point was that central CNS lesions (like MS) will be normal on an EMG.
im not trying to be high and mighty here, just making sure we are talking the same language.
Sorry for being vague. This patient is a 50 year old female with a recent work-comp related back injury (actually it was a fall, and there are bilateral wrist and left shoulder injuries as well), for which she is under the care of a WC-appointed ortho and pain mgmt doc. I've been treating her on/off for years for neck and back pain. Prior hx includes two MVAs, multilevel cervical disc herniations, EMG + cervical radiculopathy, at least one lumbar disc herniation (L3-4 as I recall, going from memory right now), and I believe a + EMG for lumbar radic.
So now she falls a few months ago at work and, among other things, she has recently been complaining of the paresthesia I described in my prior post: had begun distally at the plantar surface bilaterally, described as a "cold, wet" sensation, non-dermatomal. Over the last few weeks, per her description, this paresthesia has been creeping proximally and is now at about the knee level bilaterally. No motor or reflex abnormalities.
Pain doc wants to do a lumbar epidural, which is why I asked if an epidural would alter an EMG if she were to undergo an EMG shortly afterward. I don't think the EMG will be particularly helpful, but given her past hx may shed some light on the status on her lumbar spine. As noted earlier, I'm trying to get her to a neurologist because of the distribution of the paresthesia, which just seems weird to me (yes, it is work comp but I don't think she's fakin' it; never know though).
Uggh...I have to jump in here, because this thread is fraught with incorrect statements, and this forum has repeatedly knocked non-anesthesiology-trained pain physicians, most recently by an anesthesia-trained pain fellow.
I don't know how many times I've had anesthesiology-trained pain fellows and attendings make annoying comments about how they are so advantaged doing procedures because they did epidurals all throughout their training, yada yada...
Just as annoying is the fact that so many of the same idiots have no clue how to perform a neuro exam, read an MRI or understand the purpose of EMG/NCS.
For clarification:
MS is NOT a peripheral nerve problem, it implicates oligodendroglia (CNS), not schwann cells (PNS).
EMG's don't diagnose central disorders.
Acute, ascending, bilaterally symmetric sensory dysfunction begs an urgent EMG and LP.
Demyelinating disorders of the peripheral nervous system? AIDP, CIDP, MMN, anti-sulfatide, anti-GM2, POEMS, amyloid, DM2, MGUS, monoclonal gammopathies, cryoglobulinemia, multiple myeloma, waldenstrom's, glycogen storage diseases, paraneoplastic (anti-Hu, anti-MAG), etc. to name a few...
The other day, in an attempt to teach a senior anesthesia resident the importance of a good neuro exam, I described a garden variety case of an older patient who over 6 months gradually developed neck pain (no arm symptoms), progressively worsening bilateral lower extremity weakness, spasticity, proprioceptive loss, hyperreflexia, clonus and babinski signs, with a wide-based ataxic gait (just to make things more obvious). I asked her where the lesion was...she said "Parkinson's"? Wow...really? There are so many things wrong with that answer I don't know where to begin. Sadly enough, even radiology residents/fellows would question why a cervical MRI was ordered since "it just couldn't be a cervical cord lesion because they had no arm symptoms", and would further schedule a lumbar MRI instead... worthless.
We all have our skillsets, and we all are idiots in fields that we're not trained in.
he is a question then, if these fellowships are suppose to be multi-discliplinary, and the big bad anesthesia doctors are forced to train all the PMR, neurology folks these procedures, etc., then how come the PMR and neurology guys dont teach anesthesia folks how to do EMGs?
seems fair that we should teach everyone everything, right? If EMGs are part of pain management (at least PMR and neurology folks will say they are) then shouldnt this be taught to those that didnt train primarily in these fields?
im mainly playing devils advocate here, as i could give a **** about EMGs as i believe they basically worthless and overutilized for "pain" issues. They are definitly helpful in some neurological issues, but when i hear of someone doing an EMG on a 30 year old with 3 weeks of pain in the low back and the posterior leg with a huge L5-S1 disc, it seems silly.
I thought you could see positive sharps and fibs in the paraspinals near the epidural site. Am i remembering that wrong. I agree though, it certainly wouldn't effect any other aspect of the test
I thought you could see positive sharps and fibs in the paraspinals near the epidural site. Am i remembering that wrong. I agree though, it certainly wouldn't effect any other aspect of the test