u/Affectionate-Fact-34

The power light would turn on and it would make noise, but the screen wouldn’t come on. They fully refunded thanks to the manufacturer warranty, but it was such a hassle. But it seems like it is generally a recommended TV here? We just want something reliable - doesn’t have to be best of the best. Should we try the same one again or is there something less likely to fail?

Curious to get others’ opinions on this case.

Young healthy guy comes for EMG to evaluate paresthesias on palm/thumb side of both hands. No other symptoms.

Exam is normal.

LEFT:
Median motor seems to demonstrate a conduction block in the forearm, so I switch to ultrasound to confirm placement and eval appearance. Median is quite large at the wrist with enlarged fascicles (around 0.2 cm^2 CSA), normal mid forearm 0.09 cm^2, enlarges again at elbow 0.24 cm^2.

Repeat nerve conduction at lower stim and get a normal appearing wave now (amp and latency/CV) without conduction block but with a proximal site positive deflection. Assume volume conduction previously made distal higher amp and being off the nerve lowered proximal site, giving false initial appearance of block.

NCS of ulnar 42m/s across the elbow with normal amp, but ultrasound balloons just proximal to the elbow (0.21 cm^2 with large fascicles) and remains big to the plexus. Confirmed MGA.

Normal radial, median, and ulnar sensories. Did a radial thumb comparison, which was normal. Normal median F wave (didn’t do others).

RIGHT:
Median appears large at the wrist on ultrasound (0.19 cm^2) and normal proximally to mid biceps (0.10 cm^2).

All NCS normal (median/ulnar motor, radial/median/ulnar sensory, transcarpal comparison).

Needle is normal in bilateral cervical paraspinals, deltoid, biceps, triceps, FCR, FDI.

Ran out of time to do legs, but no symptoms in the legs. Will bring him back.

So now I’m left with a clear ulnar at the elbow by NCS with bilateral median distribution symptoms. That alone wouldn’t bug me. What bugs me is:

1. A proximal site initial positive deflection is usually seen in a CTS + MGA. I found the MGA and the ultrasound suggests median at wrist, but the NCS do not support median at wrist.
2. The ultrasound suggests nerve injury at multiple sites, including compressive and non compressive, though the EMG/NCS does not agree.
3. I wonder if I falsely “fixed” a true median conduction block in the forearm.

I’ve built a differential for what this could be and have a plan for next steps, but I’m curious to hear from other neuromuscular / neurophys folks if you have thoughts. Happy to clarify anything.