PM&R Pain docs training ACGME Anesthesia

[medicineman1]

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How many of you PM&R pain docs who trained ACGME anesthesia who didn't get the opportunity to continue practicing/mastering EMG skills regret the ACGME anesthesia choice for this reason.

Secondly, in general, how many pain docs use EMGS often in his/her practice? Is this a tool that can add huge value to the skill set? Its definately billable, and this isn't going to be scrutinized like other pain procedures such as SI Joint injections, which are not even being reimbursed in many states.

So, in choosing a fellowship, do you all see (not maintaining this skill) for a year - a regretful loss? And in reality- is this a tool that can be easily, productively, and profitably utilized in a pain practice?

The pros & cons of ACGME anesthesia vs. ACGME PM&R accredited programs as it translates to real life private practice (the EMG is just one aspect)- any thoughts on this specifically or in general?

 

[pmrmd]

you won't forget how to do an emg. its an extremely valuable tool which you will use all the time.

more importantly, you will still think like an electromyographer when someone has complaint of "sciatica" and will be able to quickly discern if it is truly radicular or merely perceived to be.

 

[lobelsteve]

EMG is overutilized worse than ESI.

I reserve it for when the diagnosis is unclear. If somebody has an HNP encroaching on a root and they are missing a MSR (DTR), I'm pretty sure the EMG will show some denervation potentials for that route.

If somebody has N&T at night in the median distribution and + flick, + CCT, + Phalen's- do I need an EMG/NCV to tell me they have CTS- or should I splint/inject to get things started.

EMG's are profitable- and that's why 90% of them get done.

 

[mille125]

EMG is overutilized worse than ESI.
I reserve it for when the diagnosis is unclear. If somebody has an HNP encroaching on a root and they are missing a MSR (DTR), I'm pretty sure the EMG will show some denervation potentials for that route.

If somebody has N&T at night in the median distribution and + flick, + CCT, + Phalen's- do I need an EMG/NCV to tell me they have CTS- or should I splint/inject to get things started.

EMG's are profitable- and that's why 90% of them get done.

absolutely agree with steve on this one

 

[lobelsteve]

absolutely agree with steve on this one

Uh oh. I take it all back.



That's just good medicine.

 

[drusso]

Ditto the above. You won't forget how to do EDX. Sometimes it's helpful in pain, mostly its just convenient to keep it all under one roof.

 

[pmrmd]

EMG is overutilized worse than ESI.

If somebody has N&T at night in the median distribution and + flick, + CCT, + Phalen's- do I need an EMG/NCV to tell me they have CTS- or should I splint/inject to get things started.


the test is done to gauge severity not for the diagnosis, but i know the point you are trying to make.

 

[lobelsteve]

the test is done to gauge severity not for the diagnosis, but i know the point you are trying to make.

I trained under BC (AANEM) folks. I understand all about EMG/NCV and the indications/utility/etc.

EDX severity is fairly useless except for documentation (for CTS)
See the article by Storm et al.
Clinical severity dictates treatment, and that is what the patient says and does. Everyone gets a splint +/- injection before I'll let the surgeons have a crack at them.

I have a not yet written case report similar to the one that came out of Mayo earlier this year regarding bad outcomes after a CTS injection. I've had to do a lot of reading on the topic to best advise my patient.

 

[brori]

EMG can shed some light on severity and prognosis. As far as diagnosing, I consider it an extension of the history and physical exam. However, I have seen it pick up some zebras masking as radiculopathy (SMA, myopathy, ALS) It was particularily useful last week. I get a referral for 55yo thin smoker with two months of back and right leg pain (referred from ortho). On history and exam, pain was primarily right anterior thigh, but did radiate past the knee. Patient is in 10/10 pain and has been using a cane now for two weeks. Pain described as a sharp "cattle prod sensation" radiating just past the knee worse with ambulation. Ortho had already done LMRI (bulge with 6mm stenosis at L4). Little bit of back pain. EMG completely normal. Get x-rays of right hip and femur. Nondisplaced proximal femoral neck fracture. Patient had a ground level fall about two and a half months ago.

 

[Tenesma]

it AMAZES me how many referrals i get from orthos where they are convinced the etiology of hip/thigh pain has got to be lumbar stenosis the minute the patient admits to concomitant back pain... what amazes me even more is that most of these patients end up being referred back to ortho because of missed hip pathology (acetabular fractures, hip AVN, femoral neck fractures, tgransient osteoporosis)...

CTS injections are not very helpful... and i have had a few where the pain got worse and stayed worse for a long time after injection (and some of those were done under u/s where i was convinced i was perfect)... the ones that go smoothly have given me at best a few weeks of relief...
i don't do CTS injections unless under duress

 

[lobelsteve]

it AMAZES me how many referrals i get from orthos where they are convinced the etiology of hip/thigh pain has got to be lumbar stenosis the minute the patient admits to concomitant back pain... what amazes me even more is that most of these patients end up being referred back to ortho because of missed hip pathology (acetabular fractures, hip AVN, femoral neck fractures, tgransient osteoporosis)...

CTS injections are not very helpful... and i have had a few where the pain got worse and stayed worse for a long time after injection (and some of those were done under u/s where i was convinced i was perfect)... the ones that go smoothly have given me at best a few weeks of relief...
i don't do CTS injections unless under duress

I have seen 3-6 months of good relief routinely.

Arthritis Rheum. 2005 Feb;52(2):612-9.


Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial.

Ly-Pen D, Andréu JL, de Blas G, Sánchez-Olaso A, Millán I.



METHODS:
In a 1-year, prospective, randomized, open, controlled clinical trial, we studied the effects of surgical decompression versus local steroid injection in 163 wrists with a clinical and neurophysiologic diagnosis of CTS. Clinical
assessments were done at baseline and at 3, 6, and 12 months after treatment. The primary end point was the percentage of wrists that reached a >or=20% improvement in the visual analog scale score for nocturnal paresthesias at 3 months of followup.

RESULTS: Both treatment groups had comparable severity
of CTS at baseline. Eighty wrists were randomly assigned to the surgery group and 83 wrists to the local steroid injection group. In the intent-to-treat analysis, at 3 months of followup, 94.0% of the wrists in the steroid injection group versus 75.0% in the surgery group reached a 20% response for nocturnal paresthesias (P = 0.001). At 6 and 12 months, the percentages of responders were 85.5% versus 76.3% (P = 0.163) and 69.9% versus 75.0% (P = 0.488), for local steroid injection and surgical decompression, respectively.

CONCLUSION: Over the short term, local steroid injection is better than surgical decompression for the symptomatic relief of CTS. At 1 year, local steroid injection is as effective as surgical decompression for the symptomatic relief of CTS.

 

[pmrmd]

I trained under BC (AANEM) folks. I understand all about EMG/NCV and the indications/utility/etc.

EDX severity is fairly useless except for documentation (for CTS)
See the article by Storm et al.
Clinical severity dictates treatment, and that is what the patient says and does. Everyone gets a splint +/- injection before I'll let the surgeons have a crack at them.

I have a not yet written case report similar to the one that came out of Mayo earlier this year regarding bad outcomes after a CTS injection. I've had to do a lot of reading on the topic to best advise my patient.

how in the world can you say that?
so how do you know if someone has an amplitude of 2mV vs. 4mV without the NCS? with no motor involvement i can see trying an extended conservative program, but with more motor problems i would be more inclined to have it released.

and saying a physiologic test is useless and relying more on an anatomic test (MRI) will lead down the wrong treatment pathway often enough--the overused ESI for the equivocal exam. i dunno--i trained under ernie johnson, and if you know edx you know that name. i just can't agree with you this time, though usually i do.

 

[Disciple]

EMG/NCV is overutilized, but the reality is that if the OP is planning on doing alot of Worker's Comp, he/she will be doing alot of electrodiagnostics.

 

[lobelsteve]

how in the world can you say that?
so how do you know if someone has an amplitude of 2mV vs. 4mV without the NCS? with no motor involvement i can see trying an extended conservative program, but with more motor problems i would be more inclined to have it released.

and saying a physiologic test is useless and relying more on an anatomic test (MRI) will lead down the wrong treatment pathway often enough--the overused ESI for the equivocal exam. i dunno--i trained under ernie johnson, and if you know edx you know that name. i just can't agree with you this time, though usually i do.

What about reduced amplitudes and mild symptoms. What about minimal prolonged SNAP latency and severe symptoms (with no concurrent radic on needle exam).

I think what the patient says is more importnat than what the machine says.

And then we have to get into the whole PCP, Chiro, Neurometrx debate.
A huge number of these studies are being performed by untrained techs, MA's, PA's, and DC's for profit. Then the patient comes to you saying the have b/l CTS, ulnar neuropathy, and mild radiculopathy (all because of some F-wave abnormalities and no other findings (or waveforms that clearly illustrate poorly grounded leads and a multitude of other technical errors). Do we repeat the study for mild symptoms?

I usually tell the patient that some dipsh*t stole their money to give them a piece of worthless paper.

I'll agree that well ordered studies performed by appropriately trained folks (read PMR MD/DO or fellowship trained Neurologists) will have utility over all other studies. Also, I have no problem performing CTS screens for the hand surgeon who intends to fix it. But I avoid asking the patient about their symptom severity so as not to influence the surgical decision. Oddly, I have no problem discussing the differences between open vs endocsopic CTS release.

 

[pmrmd]

What about reduced amplitudes and mild symptoms. What about minimal prolonged SNAP latency and severe symptoms (with no concurrent radic on needle exam).

I think what the patient says is more importnat than what the machine says.

And then we have to get into the whole PCP, Chiro, Neurometrx debate.
A huge number of these studies are being performed by untrained techs, MA's, PA's, and DC's for profit. Then the patient comes to you saying the have b/l CTS, ulnar neuropathy, and mild radiculopathy (all because of some F-wave abnormalities and no other findings (or waveforms that clearly illustrate poorly grounded leads and a multitude of other technical errors). Do we repeat the study for mild symptoms?

I usually tell the patient that some dipsh*t stole their money to give them a piece of worthless paper.

I'll agree that well ordered studies performed by appropriately trained folks (read PMR MD/DO or fellowship trained Neurologists) will have utility over all other studies. Also, I have no problem performing CTS screens for the hand surgeon who intends to fix it. But I avoid asking the patient about their symptom severity so as not to influence the surgical decision. Oddly, I have no problem discussing the differences between open vs endocsopic CTS release.

i can see the bad side though: mild symptoms with reduced amplitudes--eventually there will be no amplitude and that person will have the hand function of an ape--but they didn't complain.

symptoms will resolve with an injection in my experience, and generally for a 6-12 months or more. unless there is moderate motor involvement, and then i am quicker to advise the patient to have it released.

what do you guys use for injection?

agree 100% last two paragraphs

 

[Tenesma]

i totally agree that >50% of EMGs are useless and are very provider-dependent.... if the symptoms are concerning on exam/history, then i usually get a repeat EMG with somebody i trust...

 

[Mister Mxyzptlk]

The person performing the test is key. There are a lot of itinerant electromyographers around these days sending a tech to do the exam in the referring doctor's office and then they do a read.

I suspect they are giving the referring doctor a kickback, maybe paying "rent" for using the office. Why else would you do it this way?

Anyone who is using such services on their patients is either ignorant about EMGs or just greedy. Either way it's not someone I want to be involved with.

 

[nvrsumr]

There are some anesthesia pain fellowships that will allow you to perform EMGs. The real issue in an academic setting is if the PMR or Neuro dept will allow it(especially if youre not AANEM boarded yet). They will probably see it as an encroachment on their turf. Maybe if you find a program where the anesthesia department allows PMR residents to get some injection experience some quid pro quo could be worked out.

I believe U Mich and know BWH will allow time for EMG. In fact when they combined the PMR and Anesth pain fellowships at U Mich the original plan was to have the anesthesiologist fellows "watch" a month of EMG at the VA(can you say paint drying)! Im not sure how everthing worked out.

 

[Finally M3]

I believe U Mich and know BWH will allow time for EMG. In fact when they combined the PMR and Anesth pain fellowships at U Mich the original plan was to have the anesthesiologist fellows "watch" a month of EMG at the VA(can you say paint drying)! Im not sure how everthing worked out.

It went as well as you can imagine, nvrsumr. Naptime or hooky.

Actually, they were allowed to do the setup for nerves if they were very interested...but only one or two were.