This document discusses a case of a 45-year-old female bank officer presenting with weakness and clumsiness in her right hand over the past 3-4 weeks. On examination, she showed wasting of the thenar muscle and weakness of thumb and finger movements. Nerve conduction studies showed reduced motor responses in the median and ulnar nerves without slowing. Electromyography revealed generalized reduction of motor units. The patient was diagnosed with amyotrophic lateral sclerosis based on meeting diagnostic criteria. The document then provides background information on ALS and discusses differential diagnoses considered for the patient's symptoms.

1. Clumsy Hand
Neurophysiological Evaluation
DMW Dharmakeerthi

2. • Brief case discussion bit uncommon case
• Common clinical problem
• Spectrum of clinical neurophysiology

3. • 45 years lady, bank officer, weakness, clumsiness
and paresthesia of right hand for 3 - 4 weeks.
• Insidious onset over a month
• No neck or hand pain
• Inconsistent numb sensation along the medial
aspect of forearm and hand
• No nocturnal symptoms or diurnal variation
• Not increased with a particular manure
• PMHx- nill
• Referral: ? R / Ulnar neuropathy

4. • Any thoughts ?
• Ulnar neuropathy
• CTS
• Cx Radiculopathy
• MNM (combined median and ulnar)
• Lower Brachial Plexus
• Cervical syrinx
• Is it a generalized process

5. Examination
• Wasting of thenar muscle
• Mild dorsal guttering
• Weak thumb abduction, adduction, flexion
• Weak finger abduction, adduction
• Phalen’s and Tinel’s negative

7. • DD?
• CTS
• Ulnar neuropathy
• Cx Radiculopathy
• MNM (combined median and ulnar)
• Lower Brachial Plexus
• Cervical syrinx
• Is it a generalized process

8. • Anything else in examination ???

10. • Biceps
• Triceps
• Supinator
• Deltoid
• KJ
• AJ
• Jaw jerk
• Plantar equivocal

11. • DD?
• CTS
• Cx myelo-Radiculopathy
• Ulnar neuropathy
• MNM (combined median and ulnar)
• Lower Brachial Plexus
• Cervical syrinx (should have prominent sensory)
• Is it a generalized process

12. What is the generalized pathology ?
• Further questioning ?
• Leg cramps
• Worms creeping in arms and legs
• More throat clearing than earlier
• Frequent food stuck in throat
• No bladder or bowel problems

13. Could it be a ??
• Cx myelo Radiculopathy (brisk Jaw jerk)
• Syrinx(no prominent sensory symptoms)
• AHCD

14. Nerve conductions

17. Results
• Normal median and ulnar sensory responses
• Reduced ulnar CMAP, but no slowing at the
wrist or elbow
• Reduced median CMAP, but no slowing at the
wrist or forearm
• Normal sensory in LL
• Reduced CMAPs with normal CV in LL

18. • Normal sensory system with abnormal motor
system which shows generalized reduction of
motor units.

21. Electromyography (EMG)

24. EMG results
FDIO B/L
APB
EIP
FPL
EDC
TR
Biceps
Deltoid
Tongue
Sternomastoid
Rectus abdominis
VM
TA

25. Diagnosis
• Fulfills Avaji lower motor criteria for a
diagnosis of probable ALS type AHCD.

26. AHCD/MND/Lou Gehrig's disease
• Prevalence 2/100000
• Many types – spectrum
• ALS – Amyotrophic Lateral Sclerosis
• PLS – Primary Lateral Sclerosis
• PBP – Progressive Bulbar Palsy
• SMA – Spinal Muscular Atrophy
• HSP – Hereditary Spastic Para paresis
• Kennedy
• PPS – Post Polio Syndrome

27. • Commonest – ALS (5-10 % familial)
• Survival – 50% < 3 years 20% >5-10< years
• Conservative Mx
• No drugs to halt the disease
• Riluzole (Max 3months)

32. Carpal Tunnel Syndrome
• Carpal tunnel syndrome, the most common
focal peripheral focal neuropathy, results from
compression of the median nerve at the wrist.

33. Carpal Tunnel Syndrome

35. Clinical Features
• Numbness
• Tingling
• Pain
• Symptoms are usually worse at night and can
awaken patients from sleep.
• To relieve the symptoms, patients often “flick”
their wrist as if shaking down a thermometer
(flick sign).

37. Atrophy

38. Physical examination
• Phalen’s maneuver
• Tinel’s sign
• weak thumb abduction.
• two-point discrimination

39. Phalen’s maneuver

40. Tinel’s sign

41. Diagnostic
• History
• Physical examination
• Nerve Conduction Study

44. The Canterbury NCS Severity Scale for CTS
• Normal (grade 0)
• Very mild (grade 1), CTS demonstrable only with most sensitive
tests
• Mild (grade 2), sensory nerve conduction velocity slow on
finger/wrist measurement, normal terminal motor latency
• Moderate (grade 3), sensory potential preserved with motor
slowing, distal motor latency to abductor pollicis brevis (APB)
>4.5- < 5.5 ms
• Severe (grade 4), sensory potentials absent but motor response
preserved, distal motor latency to APB >5.5 < 6. 5 ms
• Very severe (grade 5), terminal latency to APB > 6.5 ms
• Extremely severe (grade 6), sensory and motor potentials
effectively un recordable (surface motor potential from APB < 0.2
mV amplitude)

45. Differential Diagnostics
• Tendonitis
• Tenosynovitis
• Diabetic and other neuropathies
• Kienbock's disease
• Compression of the Median nerve at the
elbow
• If acute onset, could be a more serious ??GBS

46. Treatment
• CONSERVATIVE TREATMENTS
– General measures
– WRIST SPLINTS
– ORAL MEDICATIONS
– LOCAL INJECTION
– ULTRASOUND THERAPY
– Predicting the Outcome of Conservative
Treatment
• SURGERY

47. GENERAL MEASURES
• Avoid repetitive wrist and hand motions that
may exacerbate symptoms or make symptom
relief difficult to achieve.
• Not use vibratory tools
• Ergonomic measures to relieve symptoms
depending on the motion that needs to be
minimized

49. WRIST SPLINTS
• Probably most
effective when it is
applied within
three months of the
onset of symptoms
• Optimal splinting
regimen ?

50. WRIST SPLINTS

51. ORAL MEDICATIONS
• Diuretics
• Nonsteroidal anti-inflammatory drugs
(NSAIDs)
• pyridoxine (vitamin B6)
• Orally administered corticosteroids
– Prednisolone
– 20 mg per day for two weeks
– followed by 10 mg per day for two weeks

52. LOCAL INJECTION
• A mixture of 10 to 20 mg of lidocaine
(Xylocaine) without epinephrine and 20 to 40
mg of methylprednisolone acetate (Depo-
Medrol) or similar corticosteroid preparation
is injected with a 25-gauge needle at the distal
wrist crease (or 1 cm proximal to it).

53. LOCAL INJECTION

54. LOCAL INJECTION
• Splinting is generally recommended after local
corticosteroid injection.
• If the first injection is successful, a repeat
injection can be considered after a few
months
• Surgery should be considered if a patient
needs more than two injections

55. ULTRASOUND THERAPY
•May be beneficial in the
long term management
•More studies are needed
to confirm it’s usefulness

56. SURGERY
• Should be considered in patients with
symptoms that do not respond to
conservative measures and in patients with
significant nerve entrapment (Grade 3-6) as
evidenced by nerve conduction studies.

57. SURGERY
Complications of surgery
• Injury to the palmar cutaneous or recurrent motor
branch of the median nerve
• Hypertrophic scarring
• Tendon adhesion
• Postoperative infection
• Hematoma
• Arterial injury
• Stiffness
• RSDS

58. SURGERY FAQ
• How long does it take ?
• One or both hands ?
• When can I go to work?
• Under LA/GA?
• Can it get worse ?? Of course it can

60. PREGNANCY
• Alterations in fluid balance may
predispose some pregnant women to
develop carpal tunnel syndrome.
• Symptoms are typically bilateral and
first noted during the third trimester.
• Conservative measures are
appropriate, because symptoms
resolve after delivery in most women
with pregnancy-related carpal tunnel
syndrome.

61. Conclusion
• Neurophysiology is an extension of
neurological examination
• Always follow basic rules of medicine
• History and psycho-physical examination
• No machine can replace your thinking process,
clinical skills and common sense
• Questioning is highly appreciated

64. NCS

65. NCS
• Motor Nerve Conduction
• Sensory Nerve Conduction
• Mixed Nerve conduction
• Late Responses

66. • Generalized neuropathies (Acquired / Heredit)
• Sub Classification
• Decide treatment and prognosis
• Radiculopathies, plexopathies and focal
Neuropathies (Traumatic / immune/MNM)
• Assessment of progression

67. Motor NCS

69. Sensory NCS

71. Late responses
• F Wave
• H reflex
• Blink Reflex

72. F Wave

73. H Reflex

74. Cranial nerves by NCS

75. Small Fiber Analysis
• SSR
• Cutaneous Silent Period
• Thermal Threshold Testing
• Micro Neurography

76. Needle EMG

77. • Diagnosis of lower motor pathologies (MND)
• Sub classification of generalized pathologies
• Localization of focal pathologies (traumatic)
• Pattern recognition (CIDP / Diabetic neuropa)
• Assessment of recovery (Brachial plexopathy)
• Myopathies
• Neuromyotonias (Dystrophic/ Non dystrophic)

78. Sphincter EMG
• Sacral plexus analysis
• Internal urethral sphincter dysfunction
• Time consuming and invasive
• Peri-urethral aproach
• If really necessary

79. NMJ

80. NMJ / SFEMG

81. SFEMG

82. MG

83. Movement disorder analysis
EMG / MDA

84. • Myoclonus (cortical/sub cortical)
• Tremor analysis
• Functional disorders

85. Cranial Nerves by EP
• ERG
• VEP
• BAEP

88. BAEP

89. SSEP

90. Magnetic Brain Stimulation
CMCT / SSEP

92. TMS

93. EEG / ECoG

94. • Epilepsy (important for syndromic diagnosis)
• Encephalopathy (Less specific)
• Encephalitis
• Structural abnormalities (Not specific)
• Ambulatory monitoring
• Video telemetry
• Brain mapping

95. • Localization during epilepsy surgeries

96. IOM / ECoG

97. EEG Brain Mapping

98. IOM / Spinal surgeries

99. IOM

100. • Help and guide the surgeon
• Retrospective analysis
• Research

101. Therapeutics
• Deep brain stimulation
• EMG guided Botox
• Advanced epilepsy management (vagal
stimulation)
• Sphincter management (sacral nerve
stimulation)

102. Thank You for your patience