A false chord?

[neglect]

34 yo with wasted left > right hand. Onset 4 years ago. Lots of pain and tingling. Nl. mentation, CN's, 5/5 and good bulk in delts, bis, tris, but 5-/5 in left wrist flex/ext, 4/5 in all hand intrinsics and thumb ext with marked atrophy on the left. On the right, presevation of bulk with 5-/5 hand intrinsics, all else 5/5. Sensation decreased in all nerve distributions of the hand, L>R. Has reduced reflexes on the left, and only 1+ on the right. Legs normal. MRI C-spine: small disc.

Sensories:
Left Median Anti Sensory
amp: 63.1 uV velocity: 46.7
Right Median Anti Sensory
33.0 46.9
Left Radial Anti Sensory
25.7 50.0
Right Radial Anti Sensory
36.1 52.2
Left Ulnar Anti Sensory
15.1 50.0
Right Ulnar Anti Sensory
40.5 48.1

Motor is normal, except for an ulnar amplitude of 2 mV with proportionate slowing.

EMG shows old chronic neurogenic changes in most muscles with huge, bizzare motor units. (Pronator, ExtDigCom, 1stDorInt, Triceps) No spontaneous activity. Delt/bi normal though. paraspinals normal.

So although 'normal,' the sensory side to side tell a story of an asymetric process distal to the root. The ulnar loss of amplitude is consistent with the exam. And the EMG shows

Another case of brachial plexopathy? Imaging is pending. I worry that the sensory stuff isn't 'real' enough and may warrant ALS. Perhaps I should have EMG'd the legs, suprascapular, but I can't do it all.

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[PMR 4 MSK]

Were those sensory velocities forearm or distal? I use latecies for distal evals rather than CV.

Sounds like an old Guillain-Barre

Bring him back in for the legs - inquiring minds want to know!

Also Med and lat antebrachial sensories might be revealing.

Not likely brachial plexus as it is all so distal.

I sometimes see cases like this wih profound muscle wasing way out of proportion to the EMG findings. Good case!

 

[neglect]

Were those sensory velocities forearm or distal? I use latecies for distal evals rather than CV.

Sounds like an old Guillain-Barre

Bring him back in for the legs - inquiring minds want to know!

Also Med and lat antebrachial sensories might be revealing.

Not likely brachial plexus as it is all so distal.

I sometimes see cases like this wih profound muscle wasing way out of proportion to the EMG findings. Good case!

All sensories are distal conduction velocites (I shock first, measure second). Of course he was warm, and you're right, the slight decreases in sensory velocites are not fully explained by a proximal source, but I found GBS difficult to invoke here. How would you explain the R/L differences in amplitude (although some are within range of interobserver, the ulnar is very low in comparison). You're right: should have done the med/lat antebrachial, but I went overtime with him as it was. The legs are clinically normal, but perhaps a routine screen... As it is now, we'll see what the plexus anatomy shows BL.

Nothing new on the EMG, and nothing suggesting CIDP, but distant GBS... Interesting. Thanks for your thoughts.