Kerry H. Levin

Cervical radiculopathies: Comparison of surgical and EMG localization of single-root lesions

To identify the various electrodiagnostic (EDX) patterns of C-5, C-6, C-7, and C-8 cervical radiculopathy, we compared 50 cases of surgically proven solitary-root lesions with their preoperative EDX patterns. We excluded patients with polyradiculopathy, myelopathy, and previous surgery. We classified EDX studies as abnormal only by the needle electrode examination, and only by the demonstration of fibrillation potentials (either the positive sharp wave or the biphasic spike form). Seven patients (14%) had C-5 radiculopathy, nine (18%) had C-6, 28 (56%) C-7, and six (12%) C-8. With C-5, C-7, and C-8 radiculopathies, changes were relatively stereotyped, with involvement of the spinati, deltoid, biceps, and brachioradialis with C-5; the pronator teres, flexor carpi radialis, triceps, and anconeus with C-7; and the first dorsal interosseous, abductor digiti minimi, abductor pollicis brevis, flexor pollicis longus, and extensor indicis proprius with C-8. The root lesion with the most variable presentation was C-6--in half the patients, the findings were similar to C-5 radiculopathies, except that the pronator teres tended to be involved, whereas in the other half, the findings were identical to those with C-7 radiculopathies. NEUROLOGY 1996;46: 1022-1025

Acute Infection with the Human Immunodeficiency Virus (HIV) Associated with Acute Brachial Neuritis and Exanthematous Rash

Clinical descriptions of acute or primary infection with the human immunodeficiency virus (HIV) are rare. Among cases previously reported, most describe an acute illness resembling infectious mononucleosis. We describe the case of a 32-year-old homosexual man with an acute illness associated with strong serologic evidence of a primary infection with HIV. This case illustrates two new clinical features: an acute, bilateral brachial neuritis, and a vesicular, pustular exanthematous and enanthematous rash. Studies of HIV-related serologic results show differential sensitivities for enzyme-linked immunosorbent assay, Western blot, immunofluorescence, and viral antigen techniques in the acute phase of HIV infection. There appears to be significant clinical heterogeneity of the acute phase of HIV infection.

L5 radiculopathy with reduced superficial peroneal sensory responses : Intraspinal and extraspinal causes

Thirteen patients were retrospectively identified with the electrodiagnostic pattern of combined L5 radiculopathy by needle electrode examination, and abnormality of the superficial peroneal nerve (SPN) sensory nerve action potential (SNAP) amplitude. To have combined L5‐derived sensory and motor axon loss, lesions must be localized at or distal to the L5 dorsal root ganglion (DRG), but also proximal to the sacral plexus. Six patients had evidence of an active intraspinal canal (ISC) lesion, 3 had diabetes, and 4 had nonspecific causes. The ISC localization in at least 6 of our cases is counter to the commonly held electrodiagnostic dogma that L5 radiculopathy spares the SPN SNAP, but recent anatomic studies confirm the ISC location of up to 40% of L5 DRG. Thus loss of the SPN SNAP does not exclude ISC lesions. Published by John Wiley & Sons, Inc.

Utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy: An evidence-based review.

This is an evidence‐based review of electrodiagnostic (EDX) testing of patients with suspected lumbosacral radiculopathy to determine its utility in diagnosis and prognosis. Literature searches were performed to identify articles applying EDX techniques to patients with suspected lumbosacral radiculopathy. From the 355 articles initially discovered, 119 articles describing nerve conduction studies, electromyography (EMG), or evoked potentials in adequate detail were reviewed further. Fifty‐three studies met inclusion criteria and were graded using predetermined criteria for classification of evidence for diagnostic studies. Two class II, 7 class III, and 34 class IV studies described the diagnostic use of EDX. One class II and three class III articles described H‐reflexes with acceptable statistical significance for use in the diagnosis and confirmation of suspected S1 lumbosacral radiculopathy. Two class II and two class III studies demonstrated a range of sensitivities for use of muscle paraspinal mapping. Two class II studies demonstrated the utility of peripheral myotomal limb electromyography in radiculopathies. Muscle Nerve 42:276–282, 2010

Electrodiagnostic approach to the patient with suspected radiculopathy

Cervical and lumbosacral radiculopathies are among the most common causes of referral to the electromyographic (EMG) laboratory. Among all the other electrodiagnostic studies (nerve conduction studies, late responses, somatosensory evoked potentials, root electrical and magnetic stimulation studies), the needle electrode (needle EMG) examination is the most specific and sensitive. A good grasp of the anatomic, clinical and electromyographic myotomal charts is essential to localize radiculopathies to single (or more) root lesions.

Cervical rib and median sternotomy-related brachial plexopathies A reassessment

Objective: The objective of this study was to identify electrodiagnostic and anatomic distinctions between true neurogenic thoracic outlet syndrome and median sternotomy-related brachial plexopathy, in reference to the pattern of abnormality of the medial antebrachial cutaneous sensory nerve conduction study (NCS) response. Background: Neurogenic thoracic outlet syndrome and sternotomy-related brachial plexopathy are both lower trunk brachial plexopathies, but their clinical and electrodiagnostic presentations are distinct. The anatomic differences distinguishing these disorders from each other, and from other lower trunk brachial plexopathies, have not been defined. Methods: We compared the medial antebrachial cutaneous sensory nerve action potential amplitude with the median motor, ulnar motor, and ulnar sensory NCS amplitudes in 10 patients with neurogenic thoracic outlet syndrome and in 14 patients with sternotomy-related brachial plexopathy. Results: In the 10 patients with neurogenic thoracic outlet syndrome, the medial antebrachial cutaneous amplitude was most affected, followed in decreasing order of involvement by the median motor, ulnar sensory, and ulnar motor amplitudes. Conversely, in the 14 patients with sternotomy-related brachial plexopathy, the ulnar sensory and motor amplitudes were the most affected responses. Medial antebrachial cutaneous NCS changes closely paralleled median motor response changes. Conclusions: The medial antebrachial cutaneous sensory response is sensitive in the diagnosis of neurogenic thoracic outlet syndrome. Our data suggest that medial antebrachial cutaneous nerve fibers are closely associated anatomically at the T1 root level with median motor fibers innervating the thenar muscles. Neurogenic thoracic outlet syndrome shows predominant damage in the T1 distribution, whereas sternotomy-related brachial plexopathy shows predominant damage in the C8 distribution, suggesting that these lesions are localized at the level of the anterior primary rami of the cervical roots, and not in the lower trunk of the brachial plexus.

Angiotropic large-cell lymphoma with peripheral nerve and skeletal muscle involvement Early diagnosis and treatment

Angiotropic large-cell lymphoma is a disorder characterized by an intravascular proliferation of malignant lymphoid cells. We present a patient with polyradiculoneuropathy, myelopathy, and myopathy diagnosed by peripheral nerve and muscle biopsy, who was treated and remains in stable neurologic condition. NEUROLOGY 1996;47: 1009-1011

Burnout, career satisfaction, and well-being among US neurologists in 2016

Objective: To study prevalence of and factors that contribute to burnout, career satisfaction, and well-being in US neurologists. Methods: A total of 4,127 US American Academy of Neurology member neurologists who had finished training were surveyed using validated measures of burnout, career satisfaction, and well-being from January 19 to March 21, 2016. Results: Response rate was 40.5% (1,671 of 4,127). Average age of participants was 51 years, with 65.3% male and nearly equal representation across US geographic regions. Approximately 60% of respondents had at least one symptom of burnout. Hours worked/week, nights on call/week, number of outpatients seen/week, and amount of clerical work were associated with greater burnout risk. Effective support staff, job autonomy, meaningful work, age, and subspecializing in epilepsy were associated with lower risk. Academic practice (AP) neurologists had a lower burnout rate and higher rates of career satisfaction and quality of life than clinical practice (CP) neurologists. Some factors contributing to burnout were shared between AP and CP, but some risks were unique to practice setting. Factors independently associated with profession satisfaction included meaningfulness of work, job autonomy, effectiveness of support staff, age, practicing sleep medicine (inverse relationship), and percent time in clinical practice (inverse relationship). Burnout was strongly associated with decreased career satisfaction. Conclusions: Burnout is common in all neurology practice settings and subspecialties. The largest driver of career satisfaction is the meaning neurologists find in their work. The results from this survey will inform approaches needed to reduce burnout and promote career satisfaction and well-being in US neurologists.

Comparison of surgical and electrodiagnostic findings in single root lumbosacral radiculopathies.

To identify the segmental innervation of L‐2–S‐1 muscles, we compared the preoperative electrodiagnostic examinations of 45 patients with single‐level lumbosacral radiculopathies confirmed radiologically and surgically. The electrodiagnostic findings were classified as abnormal only by the needle examination and only if muscles demonstrated active denervation or a marked neurogenic motor unit potential firing pattern. In comparison to other surgical, intraoperative root stimulation, and clinical studies, we found several differences. Overall, there was little overlap among L‐2–4, L‐5, and S‐1 radiculopathies. The tibialis anterior was predominantly L‐5 innervated, the gastrocnemius (medial and lateral head) predominantly S‐1 innervated, and the biceps femoris (short and long head) exclusively S‐1 innervated. The two heads of biceps femoris were not affected in any patients with L‐5 radiculopathy in whom they were examined. These findings help guide both the clinician and surgeon in the diagnosis and treatment of lumbosacral radiculopathies. Muscle Nerve 27: 60–64, 2003

Obturator mononeuropathy caused by pelvic cancer: six cases.

Objective: To report the clinical and pelvic CT findings in six patients with obturator mononeuropathy caused by cancer. Design: A clinical case series of six patients followed for 2 months to 10 years (one patient lost to follow-up). Setting: Three referral centers. Patients: Three men and three women, ages 52 to 81 years. Three patients had transitional cell carcinoma of the bladder, and one patient each had pelvic papillary carcinoma, carcinoma of unknown origin, and lymphoma. Main results: In each patient, symptoms of obturator mononeuropathy were the sole presenting sign of new or recurrent pelvic cancer. Three patients had ipsilateral leg edema in addition to the typical sensory and motor findings of obturator mononeuropathy. Tumor sites detected on pelvic CT that correlated with obturator nerve compression or infiltration, singly or in combination, included the posterolateral wall of the upper pelvis or midpelvis, the anterior wall of the lower pelvis, and the external obturator and pectineus muscles extrinsic to the bony pelvis. Antineoplastic treatment provided symptomatic relief in four patients. Conclusions: Pelvic CT or MRI should be performed to exclude pelvic tumor in patients with obturator mononeuropathy if there is no temporal association with pelvic trauma or intra-abdominal, pelvic, or hip surgery.