When is needle examination of thenar muscle necessary in the evaluation of mild and moderate carpal tunnel syndrome?

Objectives: This study aims to evaluate the predictors of standard nerve conduction study (NCS) parameters in determining the presence of axonal loss by means of spontaneous activity in patients with mild and moderate carpal tunnel syndrome (CTS). Patients and methods: Between May 2015 and April 2018, a total of 118 patients (11 males, 107 females; mean age: 52.3±10.6 years; range, 27 to 79 years) who underwent electrophysiological studies and were diagnosed with CTS were included. Demographic data of the patients including age, sex, and symptom duration were recorded. Electrodiagnostic studies were performed in all patients. All the needle electromyography (EMG) findings were recorded, but only the presence or absence of spontaneous EMG activities was used as the indicator of axonal injury. Results: In 37 (31.4%) of the patients, spontaneous activity was detected at the thenar muscle needle EMG. No spontaneous activity was observed in any of 43 (36.4%) patients with normal distal motor latency (DML). There were significant differences in DMLs, compound muscle action potential (CMAP) amplitudes, sensory nerve action potentials amplitudes, and sensory nerve conduction velocities between the groups with and without spontaneous activity (p<0.05). The multiple logistic regression analysis revealed that DML was a significant independent risk variable in determining presence of spontaneous activity. The most optimal cut-off value for median DML was calculated as 4.9 ms. If the median DML was >4.9 ms, the relative risk of finding spontaneous activity on thenar muscle needle EMG was 13.5 (95% CI: 3.6-51.2). Conclusion: Distal motor latency is the main parameter for predicting the presence of spontaneous activity in mild and moderate CTS patients with normal CMAP. Performing needle EMG of the thenar muscle in CTS patients with a DML of >4.9 ms may be beneficial to detect axonal degeneration in early stages.

Relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in patients with obstructed defecation

Background Obstructed defecation is a common pelvic floor medical problem among adult population. Pelvic floor disorders were reported to be associated with sexual dysfunction including erectile dysfunction among male patients. The aim was to determine the relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in male patients with obstructed defecation. Methods This cross-sectional study included 65 married male patients with obstructed defecation and a control group consisted of 15 apparently healthy married males. Assessment of obstructed defecation severity was done by using modified obstructed defecation score, time of toileting and Patient Assessment of Constipation-Quality of Life questionnaire. Assessment of erectile functions was done using erectile function domain of International Index of Erectile Function questionnaire and Erectile Dysfunction-Effect on Quality of Life Questionnaire. Anal manometry and dynamic pelvis magnetic resonance imaging were done. Electrophysiological studies included pudendal nerve motor conduction study and needle electromyography of external anal sphincter, puborectalis and bulbocavernosus muscles. Results There were 32 patients (49.2%) who had erectile dysfunction. The maximum straining anal pressure was significantly higher among patients with erectile dysfunction. Pudendal nerve terminal motor latency was significantly delayed and the percentage of bilateral pudendal neuropathy was significantly higher among patients with erectile dysfunction. The percentage of electromyography evidence of denervation with chronic reinnervation in the external anal sphincter and bulbocavernosus muscles were significantly higher among patients with erectile dysfunction. Regression analysis detected three co-variables to be associated with significantly increasing the likelihood of development of erectile dysfunction. These were maximum straining anal pressure (odd ratio = 1.122), right pudendal nerve terminal motor latency (odd ratio = 3.755) and left pudendal nerve terminal motor latency (odd ratio = 3.770). Conclusions Erectile dysfunction is prevalent among patients with obstructed defecation. It is associated with characteristic pelvic floor electrophysiological abnormalities. Pelvic floor neurophysiological changes vary from minimal to severe neuromuscular abnormalities that usually accompanying erectile dysfunction. Pudendal neuropathy and increased maximum straining anal pressure are essential risk factors for increasing the likelihood of development of erectile dysfunction in patients with obstructed defecation.

Prolonged distal motor latency of median nerve does not improve diagnostic accuracy for CIDP

Compression of the median nerve at the carpal tunnel can give demyelinating features and result in distal motor latency (DML) prolongation fulfilling the EFNS/PNS demyelinating criteria for chronic inflammatory demyelinating polyneuropathy (CIDP). Accordingly, being carpal tunnel syndrome (CTS) common in the general population, the EFNS/PNS guidelines recommend excluding the DML of the median nerve when DML prolongation may be consistent with median neuropathy at the wrist from CTS. The main aims of this study were to verify whether the inclusion of DML of the median nerve (when consistent with CTS) could improve electrophysiological diagnostic accuracy for CIDP and if the median nerve at the carpal tunnel was more prone to demyelination. We analyzed electrophysiological data from 499 patients included consecutively into the Italian CIDP Database. According to the EFNS/PNS criteria, 352 patients had a definite, 10 a probable, and 57 a possible diagnosis of CIDP, while 80 were not fulfilling the diagnostic criteria. The inclusion of DML prolongation of median nerve did not improve significantly the diagnostic accuracy for CIDP; overall diagnostic class changed in 6 out of 499 patients (1.2%) and electrodiagnostic class of CIDP changed from not fulfilling to possible in only 2 patients (2.5% of not-fulfilling patients). In conclusion, we can infer that excluding DML prolongation of median nerve does not increase the risk of missing a diagnosis of CIDP thus corroborating the current EFNS/PNS criteria.

Cervical spondylosis as a possible hidden reason beyond delayed phrenic nerve distal motor latency

Background Cervical spondylosis is a chronic degenerative condition of the cervical spine that can affect the cervical nerve roots. The origin of the phrenic nerve makes it vulnerable to injury. The purpose of this study is to investigate possible subtle phrenic nerve affection in patients with cervical spondylosis using nerve conduction studies (NCS). This study was conducted on 30 patients with cervical spondylosis above C5 and on 30 healthy volunteers. Nerve conduction studies of both phrenic nerves were performed in all cases. Results The patients with cervical spondylosis showed a statistically highly significant prolongation of phrenic nerve distal motor latency (DML) than the control group (P < 0.01). There was no significant difference regarding amplitude (P > 0.05). There was a significant correlation between DML and X-ray score (r < 0.05). Conclusions Cervical spondylosis is an underestimated cause of phrenic nerve delayed DML. There is a correlation between the delay of phrenic nerve DML and the severity of cervical spondylosis.

PENGARUH INJEKSI STEROID LOKAL TERHADAP LATENSI DISTAL SENSORIK DAN MOTORIK PADA SINDROM TEROWONGAN KARPAL

THE EFFECT OF LOCAL STEROID INJECTION ON DISTAL SENSORY AND MOTOR LATENCY IN PATIENTS WITH CARPAL TUNNEL SYNDROMEABSTRACTIntroduction: Carpal tunnel syndrome (CTS) is the most common type of neuropathy found in upper extremities. The syndrome can cause disability and leads to the decrease in productivity. Local steroid injection can help alleviate the symptoms, delay operation, and improve electrophysiologic parameter in a concise period.Aims: To determine the effect of steroid injection on distal sensory and motor latency in patients with CTS.Methods: Clinical trial with non-randomized paralel group design on patients in dr. Wahidin Sudirohusodo Hospi- tal from March to August 2017. Patients were divided into two groups, treatment group who were injected with intracanal steroid (n=20) and control who were treated with oral steroid (n=20). Electroneuromyography (ENMG) evaluation was done on the first day and one week after steroid injection. Statistical analysis was done with Statistical Packages for Social Sciences (SPSS) version 22. Wilcoxon sign-ranked and Mann-Whitney U test were used to analyze the difference between the treatment and control groups.Results: Distal sensory and motor latency improved significantly in both groups. Distal sensory latency after steroid were improved in both groups. But the improvement was more significant in steroid injection group compared to control group in sensory (0,30mSec vs 0,06mSec), and also motor distal latency (0,53mSec vs 0,09mSec).Discussion: Steroid injection improves distal sensory dan motor latency in patients with carpal tunnel syndrome.Keywords: Carpal tunnel syndrome, distal motor latency, distal sensory latency, steroid injectionABSTRAKPendahuluan: Sindrom terowongan karpal (STK) adalah jenis neuropati yang paling sering terjadi pada ekstremi- tas atas. Sindrom ini menyebabkan disabilitas dan menurunkan produktivitas. Injeksi steroid lokal (intrakanal) dapat mer- ingankan gejala, menunda operasi, dan memperbaiki parameter elektrofisiologi dalam jangka pendek.Tujuan: Mengetahui pengaruh injeksi steroid terhadap latensi distal sensorik dan motorik pada pasien dengan STK.Metode: Uji klinis dengan desain grup paralel terhadap pasien dengan STK yang berobat di RSUP Dr. Wahidin Sudirohusodo dari bulan Maret hingga Agustus 2017. Subjek dibagi menjadi kelompok perlakuan yang diberi injeksi ste- roid (lokal) intrakanal (n=20) dan kelompok kontrol yang diberikan steroid oral (n=20). Pemeriksaan elektroneuromiografi (ENMG) dilakukan pada hari pertama subjek datang ke RS dan satu minggu pascaterapi steroid. Analisis statistik dilaku- kan dengan program Statistical Packages for Social Sciences (SPSS) versi 22. Uji Wilcoxon signed-rank dan Mann-Whitney U digunakan untuk meneliti hubungan antar kelompok injeksi steroid lokal dan oral.Hasil: Terdapat pemendekan latensi distal sensorik dan motorik secara signifikan pasca pemberian steroid pada kedua kelompok. Namun pemendekan tersebut terjadi lebih besar dan lebih signifikan pada kelompok injeksi steroid lokal dibandingkan oral, baik pada latensi distal sensorik (0,30mdet vs 0,06mdet), maupun pada latensi distal motorik (0,53mdet vs 0,09mdet).Diskusi: Injeksi steroid intrakanal memperpendek latensi distal sensorik dan motorik pada pasien dengan sindrom terowongan karpal secara bermakna.Kata kunci: Injeksi steroid, latensi distal motorik, latensi distal sensorik, sindrom terowongan karpal