Pitfalls in Using Electrophysiological Studies to Diagnose Neuromuscular Disorders

Electrodiagnostic testing is used widely for the full characterization of neuromuscular disorders and for providing unique information on the processes underlying the pathology of peripheral nerves and muscles. However, such testing should be considered as an extension of anamnesis and physical examination, not as pathognomonic of a specific disease entity. There are many pitfalls that could lead to erroneous interpretation of electrophysiological study results when the studies are not performed properly or if they are performed in the presence of anatomical aberrations. The diagnostic reliability of electrodiagnostic studies can be improved and the associated pitfalls overcome if the physician is familiar with all of those possible pitfalls. In this article we discuss the most common and important pitfalls associated with electrodiagnostic medicine.

[1]  O. Takahashi,et al.  What is the origin of the premotor potential recorded from the second lumbrical? , 2006, Muscle & nerve.

[2]  G. Midroni,et al.  Proximal Martin–Gruber anastomosis mimicking ulnar neuropathy at the elbow , 1999, Muscle & nerve.

[3]  I. Štětkářová,et al.  Martin–Gruber anastomosis with anomalous superficial radial innervation to ulnar dorsum of hand: A pitfall when common variants coexist , 2010, Muscle & nerve.

[4]  L Kiers,et al.  Facilitatory effect of thinking about movement on magnetic motor-evoked potentials. , 1997, Electroencephalography and clinical neurophysiology.

[5]  J Kimura,et al.  Collision technique , 1976, Neurology.

[6]  I. Chung,et al.  An anatomic study of the Martin–Gruber anastomosis: Electrodiagnostic implications , 2005, Muscle & nerve.

[7]  A. Haig,et al.  Specificity of Needle Electromyography for Lumbar Radiculopathy and Plexopathy in 55- to 79-Year-Old Asymptomatic Subjects , 2006, American journal of physical medicine & rehabilitation.

[8]  Pietro Cortelli,et al.  Sympathetic skin response: basic mechanisms and clinical applications. , 2003, Clinical autonomic research : official journal of the Clinical Autonomic Research Society.

[9]  C. Hayes,et al.  Ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography--report of three cases. , 2001, Radiology.

[10]  S. Henry,et al.  A technique for needle localization in paraspinal muscles with cadaveric confirmation , 1991, Muscle & nerve.

[11]  M. Zwarts,et al.  Special Nerve Conduction Techniques , 2004 .

[12]  K. Stappaerts,et al.  Effect of size and pressure of surface recording electrodes on amplitude of sensory nerve action potentials , 2004, Muscle & nerve.

[13]  S. Koh,et al.  Pearls & Oy-sters: False positives in short-segment nerve conduction studies due to ulnar nerve dislocation , 2008, Neurology.

[14]  D. Tavy,et al.  Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy , 2010, Journal of Neurology.

[15]  G. Somjen,et al.  Excitability and inhibitability of motoneurons of different sizes. , 1965, Journal of neurophysiology.

[16]  Alfred Franzblau,et al.  Effect of aging on sensory nerve conduction study parameters , 2004, Muscle & nerve.

[17]  Hereditary aspects of accessory deep peroneal nerve , 1973, Journal of neurology, neurosurgery, and psychiatry.

[18]  D. Burke,et al.  The optimal recording electrode configuration for compound sensory action potentials. , 1988, Journal of neurology, neurosurgery, and psychiatry.

[19]  A. Brashear,et al.  The influence of the reference electrode on CMAP configuration: Leg nerve observations and an alternative reference site , 1996, Muscle & nerve.

[20]  Median–ulnar nerve communications and anomalous innervation of the intrinsic hand muscles: An electrophysiological study , 1992, Muscle & nerve.

[21]  Shin J. Oh Clinical Electromyography: Nerve Conduction Studies , 1984 .

[22]  J. Blok,et al.  Limb Temperature and Nerve Conduction Velocity During Warming With Hot Water Blankets , 2008, Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society.

[23]  L. Schöls,et al.  Fact and fallacy in clinical and electrophysiological studies of anomalous innervation of the intrinsic foot muscles. , 1996, Muscle & nerve.

[24]  D. Simons,et al.  Stimulus artifact reduction in nerve conduction. , 1985, Archives of physical medicine and rehabilitation.

[25]  Sanjeev D Nandedkar,et al.  Contribution of reference electrode to the compound muscle action potential , 2007, Muscle & nerve.

[26]  T. Dillingham,et al.  Cervical radiculopathies: Relationship between symptom duration and spontaneous EMG activity , 1999, Muscle & nerve.

[27]  J. Sañudo,et al.  Martin‐Gruber anastomosis revisited , 2002, Clinical anatomy.

[28]  R. Seiberth,et al.  The accessory deep peroneal nerve , 1975, Journal of Neurology.

[29]  정인혁 An anatomic study of the Martin-Gruber anastomosis: Electrodiagnostic implications , 2005 .

[30]  Sang-Heon Lee,et al.  Distance measure error induced by displacement of the ulnar nerve when the elbow is flexed. , 2005, Archives of physical medicine and rehabilitation.

[31]  S. Chokroverty,et al.  Accessory deep peroneal neuropathy: Collision technique diagnosis , 1998, Muscle & nerve.

[32]  B. Park,et al.  Physiologic changes of compound muscle action potentials related to voluntary contraction and muscle length in carpal tunnel syndrome. , 2005, Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology.

[33]  S. Meenakshi-Sundaram,et al.  Marinacci communication: an electrophysiological study , 2003, Clinical Neurophysiology.

[34]  D. J. Hunter,et al.  The Accuracy of the Physical Examination for the Diagnosis of Midlumbar and Low Lumbar Nerve Root Impingement , 2011, Spine.

[35]  T. Dillingham,et al.  Cervical paraspinal muscle abnormalities and symptom duration: A multivariate analysis , 1998, Muscle & nerve.

[36]  M. Kiernan,et al.  Riche-Cannieu anastomosis as an inherited trait , 2007, Clinical Neurophysiology.

[37]  J. Rhodes,et al.  The median-ulnar anastomosis (Martin-Gruber) in normal and congenitally abnormal fetuses. , 1981, Archives of neurology.

[38]  M. Floeter Cutaneous silent periods , 2003, Muscle & nerve.

[39]  J. Knottnerus,et al.  Consistency of History Taking and Physical Examination in Patients With Suspected Lumbar Nerve Root Involvement , 2000, Spine.

[40]  K. Kitano,et al.  Shortening of distal motor latency in anode distal stimulation , 2005, Clinical Neurophysiology.

[41]  Allison Brashear,et al.  The influence of the reference electrode on CMAP configuration , 1993, Muscle & nerve.

[42]  G. Pozzessere,et al.  A simple method for estimating conduction velocity of the spinothalamic tract in healthy humans , 2000, Clinical Neurophysiology.

[43]  Emmanuel Simons,et al.  Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. , 2010, The Cochrane database of systematic reviews.

[44]  E. Lambert The accessory deep peroneal nerve , 1969, Neurology.

[45]  N. Walsh,et al.  Practical Instrumentation and Common Sources of Error , 1988, American Journal of Physical Medicine & Rehabilitation.

[46]  J. Jabre,et al.  Effect of Gender on Orthodromic Sensory Nerve Action Potential Amplitude , 2001, American journal of physical medicine & rehabilitation.

[47]  S. Kuwabara,et al.  The effects of age, gender, and body mass index on amplitude of sensory nerve action potentials: Multivariate analyses , 2009, Clinical Neurophysiology.

[48]  M. Horiguchi,et al.  The consistent presence of the human accessory deep peroneal nerve , 1999, Journal of anatomy.

[49]  Maria Knikou,et al.  The H-reflex as a probe: Pathways and pitfalls , 2008, Journal of Neuroscience Methods.

[50]  M. Giuliani,et al.  Comparison of different modalities for detection of small fiber neuropathy , 1999, Clinical Neurophysiology.

[51]  E Henneman,et al.  Responses of motoneurons of different sizes to graded stimulation of supraspinal centers of the brain. , 1965, Journal of neurophysiology.

[52]  Double peak sensory responses: effects of capsaicin , 2007, Neurological Sciences.

[53]  P. Zehr Considerations for use of the Hoffmann reflex in exercise studies , 2002, European Journal of Applied Physiology.

[54]  H. M. Childress Recurrent ulnar-nerve dislocation at the elbow. , 1956, The Journal of bone and joint surgery. American volume.

[55]  Byung Jo Kim,et al.  Chapter 28 Cervical and thoracic radiculopathies , 2006 .

[56]  J. Teraoka,et al.  The prevalence of lumbar paraspinal spontaneous activity in asymptomatic subjects , 1996, Muscle & nerve.

[57]  M. Wilcox,et al.  The influence of the reference electrode on CMAP configuration: leg nerve observations and an alternative reference site. , 1996, Muscle & nerve.

[58]  Z M Pine,et al.  Medial paraspinal muscle electromyography: techniques of examination. , 1993, Archives of physical medicine and rehabilitation.

[59]  T. Dillingham,et al.  Symptom duration and spontaneous activity in lumbosacral radiculopathy. , 2000, American journal of physical medicine & rehabilitation.

[60]  J. Engstrom Electrodiagnostic medicine, 2nd edition , 2003 .

[61]  D. Dumitru,et al.  ANODAL BLOCK V ANODAL STIMULATION , 1993 .

[62]  Byung-Jo Kim,et al.  PDMS- and Silver-Ball-Based Flexible Multichannel Surface Electrode: Fabrication and Application in Nerve Conduction Study on Patients With Diabetic Polyneuropathy , 2009, IEEE Sensors Journal.

[63]  Carlos A Díaz,et al.  Prevalence of Denervation in Paraspinal and Foot Intrinsic Musculature , 2001, American journal of physical medicine & rehabilitation.

[64]  R. Buschbacher,et al.  Optimal interelectrode distance in sensory and mixed compound nerve action potentials: 3- versus 4-centimeter bar electrodes. , 2004, Archives of physical medicine and rehabilitation.

[65]  I. Vlachonikolis,et al.  Verification of the median-to-ulnar and ulnar-to-median nerve motor fiber anastomosis in the forearm: an electrophysiological study , 2003, Clinical Neurophysiology.

[66]  岡本 雅雄 Morphology and dynamics of the ulnar nerve in the cubital tunnel : observation by ultrasonography , 2001 .

[67]  Bashar Katirji,et al.  Total innervation of the extensor digitorum brevis by the accessory deep peroneal nerve , 1999, European journal of neurology.

[68]  D. Dumitru,et al.  Physiologic basis of potentials recorded in electromyography , 2000, Muscle & nerve.

[69]  B.H. Tracey,et al.  Automated Removal of Stimulus Artifact in Nerve Conduction Studies , 2006, 2006 International Conference of the IEEE Engineering in Medicine and Biology Society.

[70]  Y. So,et al.  Utility of the cutaneous silent period in patients with diabetes mellitus , 2010, Journal of the Neurological Sciences.

[71]  J. Raglin,et al.  Effect of mental imagery of a motor task on the Hoffmann reflex , 2003, Behavioural Brain Research.

[72]  M. Kiernan,et al.  Nerve conduction studies. , 2011, Australian family physician.

[73]  H. Hastings,et al.  Martin-Gruber revisited. , 1992, Journal of Hand Surgery-American Volume.

[74]  A. Haig,et al.  Paraspinal denervation and the spinal degenerative cascade. , 2002, The spine journal : official journal of the North American Spine Society.

[75]  S. Grevsten,et al.  Recurrent ulnar nerve dislocation at the elbow. Report of a non-traumatic case with ulnar entrapment neuropathy. , 1978, Acta orthopaedica Scandinavica.

[76]  W. van der Kamp,et al.  CMAP variability as a function of electrode site and size , 1995, Muscle & nerve.

[77]  S. Rutkove,et al.  Fibrillations in lumbosacral paraspinal muscles of normal subjects , 1998, Muscle & nerve.

[78]  D Dumitru,et al.  Anodal block V anodal stimulation. Fact or fiction. , 1993, American journal of physical medicine & rehabilitation.

[79]  Charles H. Whitaker,et al.  Apparent conduction block in patients with ulnar neuropathy at the elbow and proximal Martin–Gruber anastomosis , 2004, Muscle & nerve.

[80]  R. VetrugnoMD,et al.  Sympathetic skin response , 2003 .

[81]  Byung Jo Kim,et al.  Electromyographic technique for lumbar multifidus examination: comparison of previous techniques used to localize the multifidus. , 2005, Archives of physical medicine and rehabilitation.

[82]  J. Knottnerus,et al.  Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review , 1999, Journal of Neurology.

[83]  J. Yoon,et al.  Cervical paraspinal spontaneous activity in asymptomatic subjects , 2006, Muscle & nerve.

[84]  Sang-Heon Lee,et al.  Unilateral all ulnar hand including sensory without forearm communication. , 2004, American journal of physical medicine & rehabilitation.

[85]  W. J. Hennessey,et al.  Needle electromyography. , 1995, Archives of physical medicine and rehabilitation.

[86]  E. Sekeles,et al.  The double anastomotic innervation of thenar muscles. , 1971, Journal of anatomy.

[87]  R. Freeman,et al.  Testing the autonomic nervous system. , 2013, Handbook of clinical neurology.

[88]  F. Awiszus,et al.  The relationship between estimates of Ia-EPSP amplitude and conduction velocity in human soleus motoneurons , 2004, Experimental Brain Research.

[89]  A. Fuglsang-Frederiksen,et al.  Amplitude, area and duration of the compound muscle action potential change in different ways over the length of the ulnar nerve , 2006, Clinical Neurophysiology.