REFERRING PHYSICIAN: John Doe , MD
STUDY: Bilateral lower extremity EMG/nerve conduction study.
INDICATION: Right hip/thigh pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed male who complains of right thigh pain. The patient had a right total hip arthroplasty and notes inability walking on that leg secondary to pain. The patient notes that with standing, he has a lot of pain in the anterior and lateral aspect of the right thigh; it does not go down below the knee. He said that he has had fairly extensive workup including multiple x-rays and even a second opinion. There is no evident fracture or dislocation of the hardware. He does describe weakness in his right lower extremity. The patient went to physical therapy for 8 weeks and really has not gotten much better. He has no symptoms in his left lower extremity. The patient reports that in the remote past he did have a right L5-S1 herniated disk and had a discectomy. At that time, he did have some weakness in the right lower extremity. He feels that has subsequently improved. He has no upper extremity symptoms. He has had no other trauma that he can identify.
On examination, the patient has 2+ knee jerks, 1+ ankle jerks bilaterally. Motor strength in the lower extremities, knee extensors, dorsiflexors, and plantar flexors appear essentially without functional limitation. Light touch is grossly preserved. The patient identifies an area over the distal lateral right thigh, which is hyperpathic.
NERVE CONDUCTION STUDIES:
Right Lower Extremity: Sural, sensory, and tibial motor studies are essentially within normal limits. The standard right peroneal motor study was not reliably recorded; however, with stimulation to the right tibialis anterior muscle, the study is considered normal. A right tibial F-wave was also within normal limits.
Left Lower Extremity: The peroneal sensory study is within normal limits. The left tibial motor study is within normal limits. The left peroneal motor study also has similar findings with difficulty in picking up the peroneal study to the extensor digitorum brevis muscle (EDB). However, with pickup over the left tibialis anterior, the peroneal motor study is normal around the fibular head. Attention was placed to the left lateral femoral cutaneous nerve (LFCN). This study is considered easily obtainable and reproducible with a distal latency of 1.8 milliseconds and an amplitude of 21 microvolts (normal being less than 2.5 and greater than 4 microvolts respectively). Again, the left LFCN is well within normal limits and easily obtainable.
The right lateral femoral cutaneous nerve study is simply not recordable despite exhaustive attempts. A side-to-side comparison using the same anatomic landmarks was obtained as compared with left and the study is not recordable.
EMG of the right lower extremity including multiple femoral innervated muscles demonstrated no acute abnormalities. Mechanical insertional activity is within normal limits. There was no abnormal spontaneous activity appreciated. The right vastus medialis and rectus femoris muscles are considered normal with no evidence of active and no evidence of acute denervation/reinnervation. Interestingly, multiple right lower extremity muscles did demonstrate abnormally large amplitude motor units without active denervation. Corresponding right lower extremity paraspinal muscles are within normal limits.
IMPRESSION:
1. Abnormal study.
2. There is electrodiagnostic evidence suggestive of a right lateral femoral cutaneous nerve palsy. This was a technically challenging study. On the left (normal) side, it was easily obtainable. The response is absent on the right side. Of note, the patient did state that approximately 24 hours earlier, he had a block with local anesthetic. This could alter the study, but since most local anesthetics only last for several hours, this would seem less likely to be the reason for this abnormality.
3. Most importantly, there is no electrodiagnostic evidence of a right lower extremity mononeuropathy otherwise. In particular, there is no active femoral nerve palsy, no active peroneal nerve palsy, and no evidence of tibial nerve/sciatic nerve injury. There is no evidence of a superior gluteal nerve acute injury either. Again, there is no evident active denervation and no active reinnervation in any muscles in the right lower extremity.
4. There is electrodiagnostic evidence of a chronic inactive process, which appears to be involving the right lower extremity. In particular, the right tibialis anterior and right medial gastrocnemius muscles demonstrate abnormally large motor units suggestive of chronic reinnervation. This would seem unrelated to the patient's current symptoms.
5. There is no electrodiagnostic evidence to suggest a peripheral polyneuropathy.
6. There is no electrodiagnostic evidence to suggest a myopathic process.
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Medical Transcription Word Seeker - Google Search for MTs - Searches just Medical Websites5. There is no electrodiagnostic evidence to suggest a peripheral polyneuropathy.
6. There is no electrodiagnostic evidence to suggest a myopathic process.
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