Electrodiagnostic studies

[Papa Lou]

I have a question for all the PMR guys and anyone else who might have knowledge on this topic.

90% of the time I see a result back from an EMG on one particular doctor he calls it carpal tunnel syndrome in the upper extremities and totally negative in the lower extremities (he suggests eval for discogenic pain). This is even when clinically and by MRI I am convinced the patient has a C6 or C7 or L5 radiculopathy.

I know these are highly subjective from what I've read on this forum. Is this typical that everything is just CTS? I mean people are getting hand surgery left and right without improvement. Auto cases a lot of the times.

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[lobelsteve]

90 percent of time emg is done by a dufus or their tech and a conclusion is cut and pasted by tech then doc signs off for billing. If i dont get waveforms and tabular data, i tbrow out the study.

 

[101N]

I have a question for all the PMR guys and anyone else who might have knowledge on this topic.

90% of the time I see a result back from an EMG on one particular doctor he calls it carpal tunnel syndrome in the upper extremities and totally negative in the lower extremities (he suggests eval for discogenic pain). This is even when clinically and by MRI I am convinced the patient has a C6 or C7 or L5 radiculopathy.

I know these are highly subjective from what I've read on this forum. Is this typical that everything is just CTS? I mean people are getting hand surgery left and right without improvement. Auto cases a lot of the times.

EMG is poor screening test for radiculopathy. The false negative rate is at least 33%. Who is ever ordering it,
shouldn't.

 

[SSdoc33]

to get a true radiculopathy on EMG, it has do be relatively obvious. as in "you can just do a physical exam and figure it out" obvious.

even if you have a clear disc herniation and neural impingement, it may not show up on an EMG. remember, "radiculopathy" means actual damage to the radicle. everything else is radicular pain.

as far as CTS is concerned, thats another ball of wax. a lot of times, CTS is present but incidental. let the hand people worry about that.

if you dont know or trust the electromyographer, the study is not worth the paper it is printed on. it can be helpful in certain situations (brachial plexopathy, determining severity of CTS, etc), but most times it is useless for what we do.

 

[pmrmd]

What Steve said.

 

[NJPAIN]

If you have purely pain and/or a sensory deficit would you expect to see any abnormally at all on EMG? I've always thought the answer is no but like to hear from you guys who do them.
How about TOS and brachial plexus "stretch injury"?? Is EMG/NCV useful/reliable in the hands of most electromyographers to detect those conditions?


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[SSdoc33]

If you have purely pain and/or a sensory deficit would you expect to see any abnormally at all on EMG? I've always thought the answer is no but like to hear from you guys who do them.
How about TOS and brachial plexus "stretch injury"?? Is EMG/NCV useful/reliable in the hands of most electromyographers to detect those conditions?


Sent from my iPhone using SDN mobile app

If you have purely pain and/or a sensory deficit would you expect to see any abnormally at all on EMG? most likely not as far as spine conditions are concerned. yes with CTS and other peripheral nerve entrapments.

How about TOS and brachial plexus "stretch injury"??
TOS stretch injury? huh? if you believe in neurogenic TOS, you can see it on EMG. these are exceptionally rare.
brachial plexus -- yes you will see it if it is a legitimate injury, but subtle cases are hard to pick up, especially if you are a neruologist without any EMG training.

 

[drpainfree]

once I saw a NCS done in a chiro office for a denied work comp case, read by machine, signed off by an IM doc, and no EMG study available. I thought it was fishy.

For the guys who EMG/NCS, what're your thoughts on this "practice"?

 

[jonnylingo]

once I saw a NCS done in a chiro office for a denied work comp case, read by machine, signed off by an IM doc, and no EMG study available. I thought it was fishy.

For the guys who EMG/NCS, what're your thoughts on this "practice"?

Total BS. Fraudulent. Usually some piece of crap pre-fit glove that yields indecipherable waveforms. Doesn't even measure conduction velocity, b/c it only shocks distal (need proximal shock to calculate meters/second).

Insurance is cracking down on this.

 

[jonnylingo]

If you have purely pain and/or a sensory deficit would you expect to see any abnormally at all on EMG? I've always thought the answer is no but like to hear from you guys who do them.
How about TOS and brachial plexus "stretch injury"?? Is EMG/NCV useful/reliable in the hands of most electromyographers to detect those conditions?


Sent from my iPhone using SDN mobile app

Generally, don't order EMG/NCS for sensory complaints only. Will be negative unless there is a peripheral nerve compression or peripheral neuropathy. The exception is C6/median pattern numbness, and you want to r/o CTS before injecting C6/C7 or sending to PT targeting C spine

EMG/NCS helpful for assessing weakness. Is it a radial palsy vs C7 radic? Myopathy vs rotator cuff dysfunction? Weakness from diabetic PN vs symptomatic lumbar stenosis?

Also helpful for teasing out true weakness vs give way. If EMG is normal in young patient with weakness complaints, who has potential secondary gain issues, EMG can r/o true radic (axonal loss). If EMG is normal, you can basically say "No objective e/o nerve injury" and tell patient "nerves are okay," and get them moving again and back to work.

BTW, Neurogenic TOS is as rare as hen's teeth, but EMG/NCS is helpful to assess.

 

[Jitter Bug]

I like EMG as a tie breaker. Is it CTS or ulnar neuropathy at the elbow? Is it peroneal neuropathy or an L5 radic?

Just like every other test in medicine, unless I need the EMG to help me choose between treatment A and treatment B, I don't order it.

If clinically I would treat even with a negative EMG then I won't get an EMG.

 

[tchoupdoc]

I am AANEM boarded, spent $4K to fail an impossibly hard 2 day exam the first time, passed the second time. So if anyone should be biased toward EMG/NCS, it is I.

I quit doing them about one year before the reimbursements dropped, because I felt the most common clinically relevant EMG question, "is there motor nerve injury?" was 99% obvious on exam. The most common clinically relevant NCS question, "is the nerve slowed down at a site of compression?" only applied to carpal and cubital tunnel. I think NCS are still appropriate for this. Otherwise, gabapentin is doing to NCS what MRI did to myelography.

EMG for radic has been found to have variable sensitivity, very good specificity. A negative is a true negative. But I am no longer interested in treating the population where that matters, ie med-legal, work comp.

 

[drusso]

I am AANEM boarded, spent $4K to fail an impossibly hard 2 day exam the first time, passed the second time. So if anyone should be biased toward EMG/NCS, it is I.

I quit doing them about one year before the reimbursements dropped, because I felt the most common clinically relevant EMG question, "is there motor nerve injury?" was 99% obvious on exam. The most common clinically relevant NCS question, "is the nerve slowed down at a site of compression?" only applied to carpal and cubital tunnel. I think NCS are still appropriate for this. Otherwise, gabapentin is doing to NCS what MRI did to myelography.

EMG for radic has been found to have variable sensitivity, very good specificity. A negative is a true negative. But I am no longer interested in treating the population where that matters, ie med-legal, work comp.

I studied my ass off for that exam, but then decided at the last minute NOT to take it. Then, the payment for the service tanked. Still, I think electromyographers and neuromuscular docs are some of the smartest people I know.

 

[ampaphb]

90 percent of time emg is done by a dufus or their tech and a conclusion is cut and pasted by tech then doc signs off for billing. If i dont get waveforms and tabular data, i tbrow out the study.

If you are going to over-read the other guy, why not just do it yourself?

 

[lobelsteve]

If you are going to over-read the other guy, why not just do it yourself?

For the rare instance i want one, it still isnt worth my time.

 

[hyperalgesia]

I have a question for all the PMR guys and anyone else who might have knowledge on this topic.

90% of the time I see a result back from an EMG on one particular doctor he calls it carpal tunnel syndrome in the upper extremities and totally negative in the lower extremities (he suggests eval for discogenic pain). This is even when clinically and by MRI I am convinced the patient has a C6 or C7 or L5 radiculopathy.

I know these are highly subjective from what I've read on this forum. Is this typical that everything is just CTS? I mean people are getting hand surgery left and right without improvement. Auto cases a lot of the times.

Try calling the electromyographer before/after your pt gets the study. You will probably go down a rabbit hole - "Um the tech is out today..." When you find the physiatrist who explains everything to you, how the NCS/EMG corroborated his PE, you have your guy. Neurologists usually use techs which is an inferior method. A medical doctor doing the study will adapt as he goes and get the best info.

 

[Disciple]

EMG for radic has been found to have variable sensitivity, very good specificity. A negative is a true negative. But I am no longer interested in treating the population where that matters, ie med-legal, work comp.

Great if you have a practice where you can avoid work-comp/PI. On the other hand, for the private practice guys, with PI you can set your own rates.

"Doctor, why are your rates substantially higher than what is usual and customary for this area"?

"Because I personally treated this patient and personally performed a thorough, valid study".

 

[ampaphb]

... which will be of far greater help to you when it is presented in court.

 

[SSdoc33]

I studied my ass off for that exam, but then decided at the last minute NOT to take it. Then, the payment for the service tanked. Still, I think electromyographers and neuromuscular docs are some of the smartest people I know.

i think the test went to a 1 day computer based test because membership dropped so low. even so, its still not worth my time/effort to take it. only reason i would is i it was required for insurance/credentialing/etc.

 

[tchoupdoc]

Great if you have a practice where you can avoid work-comp/PI. On the other hand, for the private practice guys, with PI you can set your own rates.

"Doctor, why are your rates substantially higher than what is usual and customary for this area"?

"Because I personally treated this patient and personally performed a thorough, valid study".

Totally agree. It paid really well.

 

[tchoupdoc]

i think the test went to a 1 day computer based test because membership dropped so low. even so, its still not worth my time/effort to take it. only reason i would is i it was required for insurance/credentialing/etc.

i passed on second try in 2013. Anyone else who went through that misery will tell you there was A LOT of money going to ABEM to block out that Hyatt every year. It deserves to go to testing centers. I have dropped my AANEM membership.

All studying for/passage got me in practical terms were a few more items on differentials for weakness, "walking weird", and adult onset dystrophies. I could have gotten them all from CME monographs from AAPMR (won't hold my breath...)