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Radiculopathy Vs. Spinal Stenosis: Evocative Electrodiagnosis Identifies the Main Pain Generator

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Radiculopathy Vs. Spinal Stenosis: Evocative Electrodiagnosis Identifies the Main Pain Generator Functional Electromyography Loren M. Fishman · Allen N. Wilkins Functional Electromyography Provocative Maneuvers in Electrodiagnosis 123 Loren M. Fishman, MD Allen N. Wilkins, MD College of Physicians & Surgeons Manhattan Physical Medicine Columbia University and Rehabilitation New York, NY 10028, USA New York, NY 10013, USA [email protected] ISBN 978-1-60761-019-9 e-ISBN 978-1-60761-020-5 DOI 10.1007/978-1-60761-020-5 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010935087 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) To our steadfast families All that is constant is change. – Ancient Chinese proverb Love is not love that alters where it alteration finds. – William Shakespeare This book provides operational definitions for three commonly encountered med- ical conditions that currently lack precise criteria. It accomplishes this task by introducing common sense methods for measuring positional changes in electro- physiological metrics. The authors make an effort to convince the reader of the practical, theoretical and historical fittingness of these further extensions of the physical examination, through anatomical analysis and empirical means, using imaging techniques and series of patients diagnosed and treated according to the methods proposed here. The book’s third and final aim is to suggest guidelines for the electromyographer who wishes to apply these new techniques to novel, and perhaps less frequently seen situations in clinical medicine. Acknowledgment The authors wish to thank Donell Hutson for his deft and decidedly patient treatment of the illustrations, the clear and steady guidance of Richard Lansing, our editor at Springer, Diana Schneider for putting all of us together, our colleagues for their many helpful comments, and our families for everything else. ix Preface In the course of electrodiagnostic examinations over what is, taken together, more than 30 years of practice, we have noticed changes in what were ostensibly immutable parameters. An individual’s nerve conduction velocities or occasionally absolute or interpeak latencies in somatosensory-evoked potentials seemed at times to vary with position. Over the past 10 years, we have tried to study these incon- stancies and to link these changes with their probable cause. In this book we present three of them very much the way we encountered them: in the course of clinical work, as extensions of the physical examination. Our coming across these phenomena is, in a small way, parallel to what has hap- pened in electromyography, and what may happen in science in general. Periods of confusion and disorder were followed by consolidation, standardization, and the drive to achieve a consensus in conceptual approach as well as methods and results. An unorganized, chaotic era of independent inquiry leads, inexorably, toward a uni- fied theory, much as a cooling planet is thrown off to circle a molten sun. Then the subject, in our case electrodiagnosis, like a new planet, gets solid, as it were, and soon able to support practical activity, much as a stable world enables animated pro- cesses such as life itself. And following this, in the science as well as a new world, a second era of disorganized, exploratory activity begins. In this book, we have taken advantage of the broadly accepted and largely stable metrics and parameters of electrodiagnosis in order to present a reasonably novel measure of a type of neuropathology. We have used a method based on unchang- ing techniques to record and interpret exactly the opposite: to document changes. We hope that if these observations are borne out by future work, then the meth- ods described here will eventually join the expanding body of reliable tools of the clinical electromyographer. xi Contents 1 Electricity in Medicine: Philosophy Meets Physiology ........ 1 Electricity and Medicine Grew Up Together .............. 2 Electricity Through History: Minerals ................ 2 The Bible ............................... 2 Electrophysiology Through History: Animals ............ 3 Evidence of Electricity Through History: Beginning to Understand .4 Animal Electricity Controversy .................... 6 Technological Advances in Medicine .................. 10 EMG Specific Advances ....................... 19 References ................................ 21 2 Electrodiagnosis and the Physical Examination: Casting a Fine Net Widely ............................ 23 Summary of the First Chapter and Perspective on the Next ....... 23 Relevance to Our Subject ........................ 24 The Physical Examination Is Not Just Physical ............. 26 “You Can Observe a Lot Just by Looking.”—Yogi Berra ........ 26 It Takes Two ............................... 26 Proposed Provocative Maneuvers in Electrodiagnosis ......... 30 Philosophical Reflection of the Yet Unseen ............... 31 References ................................ 32 3 Dynamic Electrodiagnosis: Provocative/Evocative Maneuvers Define Diagnoses of Exclusion and Refine Dual Diagnoses ................................ 33 The Fallacy Inherent in a “Diagnosis of Exclusion” ........... 33 Thoracic Outlet Syndrome ........................ 37 Piriformis Syndrome ........................... 39 Lumbar Spinal Stenosis Versus Herniated Disc ............. 43 References ................................ 44 4 Neurological Thoracic Outlet Syndrome: Approaching a Pathognomonic Sign ......................... 47 Functional Identification of Thoracic Outlet Syndrome ......... 47 Symptoms ................................ 48 xiii xiv Contents Signs .................................. 48 Standard Test ............................... 53 Treatment ................................ 54 ANewTest................................ 54 In the Clinical Context: Solving the Patient’s Problem ......... 55 Grown Girl with Guitar ......................... 56 References ................................ 62 5 Treating Neurological Thoracic Outlet Syndrome Identified by a Provoked Electromyographic Sign: Analysis of the Data ... 65 Treatment of Thoracic Outlet Syndrome Based on Dynamic Changes in Nerve Conduction ...................... 65 What Is Botulinum Neurotoxin Type B? ................ 66 Injection ................................. 67 Physical Therapy ............................. 68 Scheduled Follow-Up Visits ....................... 69 Analysis of the Data ........................... 69 Results .................................. 69 Results of Scalenus Injections and Physical Therapy .......... 70 References ................................ 75 6 Piriformis Syndrome: Electrophysiology vs. Anatomical Assumption ........................ 77 Can Piriformis Syndrome Be Operationally Defined? .......... 77 Gardenpathogenesis ........................... 82 Some Cadaveric Studies of Anomalous Sciatic-Piriformis Intersection ................................ 83 The Anatomy Close-Up ......................... 83 Symptoms ................................ 84 Signs ................................... 85 Electrophysiological Suggestion of Piriformis Syndrome ........ 85 Mix of Clinical and Electrophysiological Findings ........... 86 Functional Confirmation: Electrophysiological Evidence of Piriformis Syndrome ......................... 86 Technique ................................ 87 Technical Metrics ............................ 88 Measurement of Delay: The H Loop .................. 89 Discrepancy Between Motor and Sensory Nerve Conduction Velocity .......................... 89 Results .................................. 91 References ................................ 93 7 Treating Piriformis Syndrome Identified by a Provoked Electromyographic Sign: Analysis of the Data ............ 95 Treatment of Piriformis Syndrome Patients Identified by Functional EMG ........................... 95 Contents xv Outcome Statistics of the 1,014 Leg Study ............... 97 Treatment ............................... 97 Physical Therapy for Piriformis Syndrome∗ ............... 98 How Does Dual Diagnosis Affect Treatment? .............. 100 Tabulation of Results .......................... 100 Characteristics of Patients with Positive FAIR Tests ......... 100 Results ................................. 101 Surgical Corroboration of the FAIR Test ................ 103 Locating the Piriformis Muscle ..................... 107 Summary ................................. 108 References
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