Tricky case... need help!

[topwise]

Patient is a 50 year old man with a long term history of DM, as well as a history of hydrocephalus for the past year. He's had recent worsening b/l hand weakness and shoulder pain as well as decreased ROM, despite injections and PT. He also gets intermittent swelling in his hands, but denies any numbness.

On examination, he has only about 90 degrees of abduction in his shoulders, although abduction strength is normal for that range. Strength is normal proximally, but he has 3/5 grip and finger abduction strength bilaterally. There is very noticeable atrophy in both the thenar eminance and the FDI. Sensation is intact. Reflexes 2+. Lower extremity strength and sensation were intact.

An abridged EMG had to be done because the patient couldn't tolerate much. NCS were done on medial/ulnar motor/sensory, which were normal except for low median motor amplitude bilaterally, at wrist and elbow. EMG showed 3+ fibs/PSW at APB, 2+ fibs/PSW at FDI and ADM. Some increased polyphasics, although recruitment was good. EIP, PT, biceps, triceps, deltoid were normal. At that point, the patient declared the study to be over, but I talked him into the paraspinals, which seemed clean but incomplete relaxation. Couldn't get in a lower extremity due to refusal.

These findings don't make tremendous sense to me. Can any EMG veterans help out?

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[Taus]

Sensation clinically and ncs intact... Pure motor findings... Bilateral 8/1....h/o hydroceph... Has there been a c spine MRI? This could be syrinx hitting the b/l ant horn cells at level

No other s/s of myelopathy?

 

[topwise]

No c-spine MRI. Some b/b symptoms but this is confounded by the hydrocephalus.

 

[PMR 4 MSK]

I would think central process and it localizes to C8-T1 based on the info. Agree MRI C-Spine ASAP.

He may also have adhesive capsulitis of shoulders. How is his internal and external rotation of the shoulders - passive and active?

 

[SSdoc33]

brachial plexopathy possible, but unlikely. need a c-spine MRI, which is most likely cause.

 

[RUOkie]

+1 on the need for c-spine imaging. Why does he have hydrocephalus? NPH or was pressure high? Does he have a shunt? His differential is pretty broad, but the MRI should reveal all.

 

[topwise]

Yeah, I think he definitely had adhesive capsulitis. And yes, he was shunted.

I was just confused by the findings being bilateral. Also, I thought it was odd that the median CMAP was low but the ulnar CMAP was normal. I was thinking about a possible TOS but that should have low ulnar SNAP, and it seems odd for that to be bilateral.

 

[RUOkie]

Yeah, I think he definitely had adhesive capsulitis. And yes, he was shunted.

I was just confused by the findings being bilateral. Also, I thought it was odd that the median CMAP was low but the ulnar CMAP was normal. I was thinking about a possible TOS but that should have low ulnar SNAP, and it seems odd for that to be bilateral.

What kind of shunt? That could be the problem right there. Let us know what the C Spine MR shows.

 

[neurodoc]

Bilateral denervational changes in ADM and APB and FDI on EMG? Doubt brachial plexopathy. SNAPs normal? Starting to think about MND, especially if no radicular type pain. Syrinx is possible, but would expect segmental changes on sensory exam. What about the UE reflexes? 2+ there as well as in the LE's? Would expect brisk LE DTR's with a C-cord lesion and decreased UE DTR's at the level of the lesion. It would make a lot more sense if there were decreased UE DTR's.

DM raises specific concerns, especially multifocal motor neuropathy, but again would expect it to affect DTR's. Same goes for MND, including SMA.

Next steps must include brain and C-spine MRI and LP.

Nick

 

[PMR 4 MSK]

Next steps must include brain and C-spine MRI and LP.

Nick

Since LP gives much higher risk than MRI, would you do MRIs, see what they show, and then do LP if still indicated, or do you feel that you will do an LP no matter what the MRI shows, so you might as well do it? Or is there something potentially urgent we're not thinking of that LP might catch?

 

[kitsunepixie]

Sounds like cervical spondylotic myelopathy to me

 

[topwise]

I can't imagine anything would be that urgent, considering it's been going on for over a year.

 

[neurodoc]

Since LP gives much higher risk than MRI, would you do MRIs, see what they show, and then do LP if still indicated, or do you feel that you will do an LP no matter what the MRI shows, so you might as well do it? Or is there something potentially urgent we're not thinking of that LP might catch?

Well, LP is probably more "risky" than MRI, though MRI is not completely without risk (e.g. if the patient has someferrormagnetic foreign body that could be tugged on or heated by the MRI magnet). I know of one patient who had a nasty experience when he went into an MRI machine with an intraocular bit of metal in his eyeball...

If the MRI doesn't answer your question, LP could help. There is a lot of pathology that could be revealed in the CSF that might not be evident on MRI.

LPis not without risk, but is generally safe when performed by a competent physician.