Tarsal Tunnel Syndrome [TTS] is the most common lower limb focal neuropathy but it has a poor pick up rate in most Electrodiagnostic (EXD) Laboratories. There is no gold standard for assessing TTS. The tibial nerve ha...Tarsal Tunnel Syndrome [TTS] is the most common lower limb focal neuropathy but it has a poor pick up rate in most Electrodiagnostic (EXD) Laboratories. There is no gold standard for assessing TTS. The tibial nerve has a complex branching system with 4 main branches and 9 different patterns of division. This study evaluated potential TTS with a similar and extensive assessment of the tibial nerve. The protocol involved 2 tibial motor studies to the Adductor Hallucis Longus (AH) and Adductor Digiti Quinti (ADQ) muscles, assessing amplitudes and distal latencies;medial plantar, lateral plantar and calcaneal sensory studies assessing amplitudes and distal latencies. A needle EMG to the tibial innervated AH and ADQ muscles was also performed. This protocol evaluated 12 different parameters which significantly increased the diagnostic yield. TTS has a low pick up rate using current standard assessment methods accounting for between 0.5% and 0.6% of positive cases referred to electrodiagnostic laboratories. This study had a pick up rate of 3.3% with 40 positive cases identified out of a population of 1210 patients referred to an electrodiagnostic laboratory in a calendar year. A combination of positive findings was observed. There were on average 4.3 positive parameters. The calcaneal sensory study and the needle EMG to the distal AH and ADQ muscles were the most sensitive tests. These 3 tests are not routinely performed in most labs. Of the 40 cases of TTS over 80% had a history of either prior injury or surgery to affected lower limb. This study suggests that this 12 parameter assessment will increase diagnostic sensitivity.展开更多
A 62-year-old woman presented with an 8-year history of chronic persisting pelvic pain. She described constant throbbing, stabbing vaginal pain. A pelvic floor neurophysiological assessment of the pudendal nerve was p...A 62-year-old woman presented with an 8-year history of chronic persisting pelvic pain. She described constant throbbing, stabbing vaginal pain. A pelvic floor neurophysiological assessment of the pudendal nerve was performed by performing a needle EMG to the left and right external anal sphincter assessing for insertional activity and recruitment pattern. A quantitative assessment of the motor unit action potentials [MUAPs] was also performed. Tests confirmed a left pudendal neuropathy with chronic denervation in the left external anal sphincter, with reasonable muscle function, with a recruitment pattern of 65% - 70% of normal. The CAR showed an elevated sensory threshold with a normal distal latency. All other conventional pudendal nerve treatments including oral antiepileptic medication, neuromodulation and pudendal nerve blocking injections had failed, and the patient was exacerbated by the persisting pain and discomfort. In this case, 30 international units (iu) of botulinum toxin type A in 10 divided doses of 3 iu were injected along the nerve. Four days later the patient reported a significant improvement in the pain symptoms. She was reviewed 3 weeks later and for the first time in 8 years had made the 70 mile journey to the clinic as a passenger in her husband’s car. This case highlights a new therapeutic option of botulinum toxin type A injection, along the nerve length, for this common painful condition. It seems to have clinical veracity as unlike other therapeutic option the affect lasts for 3 or 4 months.展开更多
文摘Tarsal Tunnel Syndrome [TTS] is the most common lower limb focal neuropathy but it has a poor pick up rate in most Electrodiagnostic (EXD) Laboratories. There is no gold standard for assessing TTS. The tibial nerve has a complex branching system with 4 main branches and 9 different patterns of division. This study evaluated potential TTS with a similar and extensive assessment of the tibial nerve. The protocol involved 2 tibial motor studies to the Adductor Hallucis Longus (AH) and Adductor Digiti Quinti (ADQ) muscles, assessing amplitudes and distal latencies;medial plantar, lateral plantar and calcaneal sensory studies assessing amplitudes and distal latencies. A needle EMG to the tibial innervated AH and ADQ muscles was also performed. This protocol evaluated 12 different parameters which significantly increased the diagnostic yield. TTS has a low pick up rate using current standard assessment methods accounting for between 0.5% and 0.6% of positive cases referred to electrodiagnostic laboratories. This study had a pick up rate of 3.3% with 40 positive cases identified out of a population of 1210 patients referred to an electrodiagnostic laboratory in a calendar year. A combination of positive findings was observed. There were on average 4.3 positive parameters. The calcaneal sensory study and the needle EMG to the distal AH and ADQ muscles were the most sensitive tests. These 3 tests are not routinely performed in most labs. Of the 40 cases of TTS over 80% had a history of either prior injury or surgery to affected lower limb. This study suggests that this 12 parameter assessment will increase diagnostic sensitivity.
文摘A 62-year-old woman presented with an 8-year history of chronic persisting pelvic pain. She described constant throbbing, stabbing vaginal pain. A pelvic floor neurophysiological assessment of the pudendal nerve was performed by performing a needle EMG to the left and right external anal sphincter assessing for insertional activity and recruitment pattern. A quantitative assessment of the motor unit action potentials [MUAPs] was also performed. Tests confirmed a left pudendal neuropathy with chronic denervation in the left external anal sphincter, with reasonable muscle function, with a recruitment pattern of 65% - 70% of normal. The CAR showed an elevated sensory threshold with a normal distal latency. All other conventional pudendal nerve treatments including oral antiepileptic medication, neuromodulation and pudendal nerve blocking injections had failed, and the patient was exacerbated by the persisting pain and discomfort. In this case, 30 international units (iu) of botulinum toxin type A in 10 divided doses of 3 iu were injected along the nerve. Four days later the patient reported a significant improvement in the pain symptoms. She was reviewed 3 weeks later and for the first time in 8 years had made the 70 mile journey to the clinic as a passenger in her husband’s car. This case highlights a new therapeutic option of botulinum toxin type A injection, along the nerve length, for this common painful condition. It seems to have clinical veracity as unlike other therapeutic option the affect lasts for 3 or 4 months.
