How does EMG/NCV fit in a Tertiary Care Shoulder Practice?
Vivek Agrawal, MDThe Shoulder Center
Carmel, Indiana
The Shoulder
• Present cases to help highlight the importance of detailed shoulder girdle/cervical EMG/NCV for our shoulder patients.
Case #1
• 84 y/o retired business owner referred with persistent shoulder pain/ debility.
• RIGHT TSA 10/2006 • RIGHT TSA revision and RCR
2007 • RIGHT shoulder arthroscopy
debridement and RCR 2007• Peripheral Neuropathy• TIAs
Case #1• Right shoulder:
Neurovascular Exam: Anterior Interosseous intact, Posterior Interosseous Nerve Intact, Radial Nerve Intact, Ulnar Nerve intact, Median Nerve Intact, Radial pulse present, Ulnar pulse present. Inspection: infraspinatous atrophy ;PREVIOUS DELTOPECTORAL INCISIONS. Sensation to Light Touch Normal. Active ROM: Active FF/ER/IR (90)=30/20/10. Active External Rotation Severely Limited. Active Internal Rotation Dorsum of hand to buttock. Passive ROM: Passive FF/ER/IR(90)=60/50/20. Strength testing: Deltoid: +3/5. Infraspinatus: +4/5. Subscapularis (Belly Press): Positive. Palpation: RENT Test Positive for Full Thickness Tear.
• Cervical Spine C3-4 Spondylolisthesis GRADE I; C4-5 C5-6 C6-7 Advanced DJD Multilevel Arthrosis
• EMG/NCV
• Supraspinatus: 2.3ms latency and 0.5mV amplitude
• Infraspinatus: 2.7ms and 0.2mV and Temporal Dispersion
• Normal Axillary Nerve
• No evidence of Radiculopathy, Plexopathy.
Case #1• Based on Severe Suprascapular
Nerve Pathology but Intact Deltoid performed:
• Right Reverse Total Shoulder with Removal of Failed TSA in September 2008
• Examination April 2010:
• Excellent Pain Relief and Overhead Function Right shoulder: Inspection: all surgical wounds healed. Active ROM: Active AB=155. Strength testing: Deltoid: -5/5. Infraspinatus: -5/5. Subscapularis (Belly Press): +3/5.
Case #2• 57y/o with persistent pain/debility
following hemiarthroplasty performed Dec. 2007 complicated by intraoperative spiral fracture
• Left shoulder: Neurovascular Exam: Anterior Interosseous intact, Posterior Interosseous Nerve Intact, Radial Nerve Intact, Ulnar Nerve intact, Median Nerve Intact, Radial pulse present, Ulnar pulse present. Inspection: infraspinatous atrophy// left deltoid atrophy present// all surgical wounds healed// no scapular winging. Sensation to Light Touch Diminished. Active ROM: Active FF/ER/IR (90)=70/10/25. Active External Rotation Hand behind head with elbow held forward. Active Internal Rotation Dorsum of hand to L3. Passive ROM: Passive FF/ER/IR(90)=, ACTIVE=PASSIVE. Strength testing: Deltoid: +3/5. Supraspinatus: +3/5. Infraspinatus: +4/5. Subscapularis (Belly Press): -5/5 (Break Away).
Case #2
• EMG/NCV-
• Posterior Deltoid 1+ fibrillation potentials, 1+ positive sharp waves, increased polyphasic motor units with prolonged axillary latency 6.6-7.8ms with amplitudes 5.8-7.7mV. Demyelinative Axillary Neuropathy without Conduction Block
• SSN-prolonged latency to SSN 7.0ms with low amplitudes 1.1-2.6mV and temporal dispersion
• Cervical Radiculitis/Radiculopathy at C6 and/or C7
Case #2
• Referred for primary evaluation and treatment of radiculopathy
• Had C6 and C7 selective blocks and good neurogenic symptom control with multimodal regimen
• Left shoulder arthroscopic global capsulotomy and extensive debridement, acromioplasty, distal clavicle resection, suprascapular nerve decompression (bony suprascapular notch) and axillary nerve decompression
Patient #2
• Visit 15 months postop:• Excellent Pain Relief
and below shoulder level function with ROM: FF/ER/IR(90)=125/70/70.
Case #3• 25 year old male presents with c/o pain Hx of
garage door falling and crushing cervical vertebrae approx 1 yr ago had A&P cervical fusion , Location: anterior and posterior radiates down arm to elbow , numbness and tingling, c/o weakness and atrophy. , Nature: dull in cervical area, sharp in shoulder ,, reports popping with some movements that is painful., Aggravated by: reaching overhead for short periods of time, reaching across chest, twisting, driving, lifting over # 5
• Right Shoulder Exam: Dynamic Scapular Winging
• Strength testing: Deltoid:, +5/5. Supraspinatus: +4/5 improved to -5 with scapula stabilized. Infraspinatus: +5/5. Teres Minor (Hornblower's): Intact. Subscapularis (Belly Press): +5/5. Subscapularis (Lift Off): +5/5. Palpation: ACJ non-tender SLAP test positive RENT Test is negative. Tests: POSITIVE O'BRIEN positive Yergason's. Stability tests: post. apprehension positive.
Case #3• EMG/NCV:
• SSN: Normal latency with severely low amplitudes to both Supra and Infra with significant conduction block
• Chronic C6 and C7 radiculopathy
• Normal Axillary Nerve Function
• Normal Long Thoracic and Dorsal Scapular and Thoracodorsal Nerve Studies
• Referred for Diagnostic SSN block which did not provide much relief (? Severe conduction block)
• Mechanical Symptoms severe enough at shoulder that wanted to proceed with Arthroscopic Management.
• RIGHT shoulder arthroscopic capsular shift with extensive labrum repair, type II SLAP lesion repair, and suprascapular nerve decompression
Suprascapular Nerve
Suprascapular Nerve
Neuralgic AmyotrophyNeuritis (Mono or Multifocal)
• Significant number of these patients have concurrent shoulder pathology/pain
• Frozen Shoulder– Axillary and SSN
• Rotator Cuff Tear• Unstable Shoulder
EMG/NCV
• Important to include detailed objective criteria for SSN and Axillary Nerve
• Large differential for parascapular and shoulder pain with significant Neurogenic Contribution.
