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- Oct 2, 2007
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Young guy, 23, in college, planning to be a professional musician, plays various stinged instruments many hours per day. 6 months to a year of hand cramping, UE variable pains and numbness forearms and hands. Seen by ortho hand surgeon first - opinion is no surgical cause, go see physiatry (smart doc!)
No injuries, no trauma, PMH - nothing. No meds, no allergies, no surgeries. FH neg for similar, just CAD in father. Non-drinker, smokes 1/3 ppd. ROS otherwise normal.
PE on initial presentation 6 months ago - normal cervical exam - full pain-free ROM, non tender, neg spurlings. Normal strength all myotomes, normal reflexes - biceps, triceps and brachirad. No sensory impairment to touch, just feelings of intermitten paresthesias. Tinel's negative at wrists and elbows, Phalen's mildly positive on the left. Tests for epicondylitis normal. Arms non tender, all joints full pain-free ROM. Nothing else focal. Shoulder exams benign as well. He has fine intention tremor bilat hands, not facial or tongue tremors or fasics. Pt mildly anxious, slightly odd affect, but hey, he's an artist.
No improvement with PT, NSAID's or gabapentin to 1800 mg/d. MRI C-spine shows congenital slender canal, mild DDD at C5-6, slight uncovertebral hypertrophy on the left at C5-6 and C6-7, otherwise normal.
I do an EMG about 4 months ago - Median motors and sensories normal through the axilla. Ulnar motors and sensories show mild delays across the elbows - about 47 m/s vs 58 and 61 in forearms for motors, 50 and 52 m/s for sensories across the elbows vs 69 and 62 in the forearms. Radial SNAPs normal. Needle of bilat Delt, Tric, Bic, PT, FDIM and APB's mostly normal, except I note some fasiculations in his right deltoid - just on needle, not visible. I felt he had borderline criteria for cubital tunnel syndrome.
We tried some more PT and Lyrica, still no better. For the hell of it, we inject one of his cubital tunnels - no better. He goes away for a couple months, then comes back 3 weeks ago, with new onset weakness - cant fully extend middle and ring fingers. I recommend we do a more detailed EMG, this time looking at radials. He goes for a second opinion, that doc (also PM&R, in another town, don't know him) agrees with me, and he comes in today for the second EMG.
I do his radials, picking up the EIP with needle in the muscle, stimulating 8 cm prox, antecubital fossa, below spiral groove, above it and Erb's. All latencies, NCVs and amplitudes WNL. I also put the needle in the EDC and stim AC fossa and Below SG, also appear normal.
However, as I'm needling the left EDC, trying to seperate out the digits, I notice some PSWs here and there. Then in the ECU I see one of the most bizzare CRDs I've ever seen - going at about 20 Hz, polyphasic potential (8 - 10 turns), with a leading motor unit that waxes and wanes in size like a common dive bomber, but the polyphasic part doesn't wax or wane - sustained for > 30 seconds. I found it several times in the muscle. Normal MUAP activation otherwise. I find PSWs and some fibs also in the EIP, ECU, deltoid, tricep and a litttle in the bicep, nothing in the forearm flexors or hand (APB, FDIM, ADM). Right side is similar, except no CRD's - just PSWs and fibs in Delt, tric and bic, as well as several of the extensors. All activation patterns are normal. Some increased insertional activity her and ther to complement the PSWs and fibs.
So I get a little more creative and do NCV of proximal muscles - stim Erb's and pickup from Delt, Bic, Tric and Supraspinatus - all amplitudes and latecies normal and similar bilaterally. Cervical paraspinals were normal.
At this point I had to stop, or I was going to give the poor guy an MI - he was having a lot of pain at the end. He took it like a trooper but it was a lot for him.
I'm ordering MRI brain and bilateral brachial plexuses (plexi?). What do you think? Prolonged, slowly developing Parsonage-Turner? Proximal variant of
GBS? MS vs ALS? TOS? Any recs for further W/U. He had some labs by his PCP a few months ago - normal CBC, CMP, TSH.
No injuries, no trauma, PMH - nothing. No meds, no allergies, no surgeries. FH neg for similar, just CAD in father. Non-drinker, smokes 1/3 ppd. ROS otherwise normal.
PE on initial presentation 6 months ago - normal cervical exam - full pain-free ROM, non tender, neg spurlings. Normal strength all myotomes, normal reflexes - biceps, triceps and brachirad. No sensory impairment to touch, just feelings of intermitten paresthesias. Tinel's negative at wrists and elbows, Phalen's mildly positive on the left. Tests for epicondylitis normal. Arms non tender, all joints full pain-free ROM. Nothing else focal. Shoulder exams benign as well. He has fine intention tremor bilat hands, not facial or tongue tremors or fasics. Pt mildly anxious, slightly odd affect, but hey, he's an artist.
No improvement with PT, NSAID's or gabapentin to 1800 mg/d. MRI C-spine shows congenital slender canal, mild DDD at C5-6, slight uncovertebral hypertrophy on the left at C5-6 and C6-7, otherwise normal.
I do an EMG about 4 months ago - Median motors and sensories normal through the axilla. Ulnar motors and sensories show mild delays across the elbows - about 47 m/s vs 58 and 61 in forearms for motors, 50 and 52 m/s for sensories across the elbows vs 69 and 62 in the forearms. Radial SNAPs normal. Needle of bilat Delt, Tric, Bic, PT, FDIM and APB's mostly normal, except I note some fasiculations in his right deltoid - just on needle, not visible. I felt he had borderline criteria for cubital tunnel syndrome.
We tried some more PT and Lyrica, still no better. For the hell of it, we inject one of his cubital tunnels - no better. He goes away for a couple months, then comes back 3 weeks ago, with new onset weakness - cant fully extend middle and ring fingers. I recommend we do a more detailed EMG, this time looking at radials. He goes for a second opinion, that doc (also PM&R, in another town, don't know him) agrees with me, and he comes in today for the second EMG.
I do his radials, picking up the EIP with needle in the muscle, stimulating 8 cm prox, antecubital fossa, below spiral groove, above it and Erb's. All latencies, NCVs and amplitudes WNL. I also put the needle in the EDC and stim AC fossa and Below SG, also appear normal.
However, as I'm needling the left EDC, trying to seperate out the digits, I notice some PSWs here and there. Then in the ECU I see one of the most bizzare CRDs I've ever seen - going at about 20 Hz, polyphasic potential (8 - 10 turns), with a leading motor unit that waxes and wanes in size like a common dive bomber, but the polyphasic part doesn't wax or wane - sustained for > 30 seconds. I found it several times in the muscle. Normal MUAP activation otherwise. I find PSWs and some fibs also in the EIP, ECU, deltoid, tricep and a litttle in the bicep, nothing in the forearm flexors or hand (APB, FDIM, ADM). Right side is similar, except no CRD's - just PSWs and fibs in Delt, tric and bic, as well as several of the extensors. All activation patterns are normal. Some increased insertional activity her and ther to complement the PSWs and fibs.
So I get a little more creative and do NCV of proximal muscles - stim Erb's and pickup from Delt, Bic, Tric and Supraspinatus - all amplitudes and latecies normal and similar bilaterally. Cervical paraspinals were normal.
At this point I had to stop, or I was going to give the poor guy an MI - he was having a lot of pain at the end. He took it like a trooper but it was a lot for him.
I'm ordering MRI brain and bilateral brachial plexuses (plexi?). What do you think? Prolonged, slowly developing Parsonage-Turner? Proximal variant of
GBS? MS vs ALS? TOS? Any recs for further W/U. He had some labs by his PCP a few months ago - normal CBC, CMP, TSH.