Table Of ContentElectrodiagnostic
Medicine
A Practical Approach
Nestor Galvez-Jimenez
Alexandra Soriano
John A. Morren
Editors
123
Electrodiagnostic Medicine
Nestor Galvez-Jimenez
Alexandra Soriano • John A. Morren
Editors
Electrodiagnostic
Medicine
A Practical Approach
Editors
Nestor Galvez-Jimenez Alexandra Soriano
Braathen Neurological Center Braathen Neurological Center
Cleveland Clinic Florida Cleveland Clinic Florida
Weston, FL Weston, FL
USA USA
Cleveland Clinic Lerner College of Cleveland Clinic Lerner College of
Medicine of Case Western Reserve Medicine of Case Western Reserve
University University
Cleveland, OH Cleveland, OH
USA USA
John A. Morren
Neuromuscular Center
Neurological Institute
Cleveland Clinic, and Cleveland Clinic
Lerner College of Medicine of Case
Western Reserve University
Cleveland, OH
USA
ISBN 978-3-030-74996-5 ISBN 978-3-030-74997-2 (eBook)
https://doi.org/10.1007/978-3-030-74997-2
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Dedication to Dr. Virgilio Salanga
We have been privileged to have worked
with some of the best
electrodiagnosticians, neurologists,
residents, and fellows at Cleveland Clinic.
Asa Wilbourn, Maurice Hanson, Kerry
Levin, Robert Shields, Richard Lederman,
Hiroshi Mitsumoto, and many others
come to mind immediately. However, for
most of us Dr. Virgilio Salanga, to whom
this work is dedicated, had a major
influence, and as a consequence made a lasting impact on our
interest and understanding in electrodiagnostic medicine.
Actually, Virgil taught generations of residents and fellows, both
in Ohio and in Florida, many of whom went on to prestigious
academic and practice positions in the USA and internationally.
Upon his retirement he was the holder of the John and Margaret
Krupa distinguished Chair in Neurology at Cleveland Clinic
Florida (CCFla) and Chairman of Neurology at CCFla.
Virgil is a Magna Cum Laude graduate with a Doctor of
Medicine and Surgery degree from the University of Santo
Thomas School of Medicine, in Manila, Philippines. After mixed
surgery and internal medicine internships at Michael Reese
Hospital and Medical Center in Chicago, Virgil went on to do his
residency and neurophysiology training at the Mayo Clinic in
Rochester, Minnesota, where he was a student of Edward
H. Lambert and Jasper Daube. In Rochester, he confided to us on
more than one occasion; he had some of his best formative
years, having worked under Arthur Waltz and interacted with
Thoralf Sundt both from Mayo, when working on his Master of
Science thesis on Regional Cerebral Blood Flow During
Stimulation of the Seventh Cranial Nerve. The resultant degree
was granted by the University of Minnesota. He had the privilege
to study and collaborate with many others who became well-
known electrodiagnosticians in their own right, such as Asa
Wilbourn, H. Royden Jones Jr., Ludwig Gutmann, Ram Ayyar,
and many others. Virgil rose through the ranks at Cleveland
Clinic in Cleveland to Vice-chair of Neurology and subsequently
moved to Florida in 1988 (with Maurice Hanson and
technologist Mary Ronnenberg) to establish the Department of
Neurology and the Neurophysiology Laboratory at the Cleveland
Clinic in Florida. Upon his retirement, the department had
grown to a very busy and academic unit with neurology residents
and fellows, in addition to many rotating medical students. Many
of us who had the privilege to study and work under him at
various times in our academic and professional career,
particularly in electrodiagnostic medicine and neurology, were
the recipients of an unabated commitment to teaching and
excellence. We could not wait to the time of day to be in his office
for review of the procedures performed during the day, especially
those complex studies in which we wanted to hear his
explanation and critical thinking. He was very generous with his
time despite the daily clinical responsibility. He was firm, but
non-judgmental, and he always expected the best from all of us,
never accepting less. In addition, his high-yield lectures were all
well attended by residents, fellows, staff, and technologists.
In spirit, this book is the product of the sum of those interactions
with our mentors in Cleveland, Ohio, but particularly with
Virgilio Salanga to whom this book is dedicated, and to CCFla
in which most of the authors and editors have made their
academic practice and/or formative years.
Foreword
It is with immense pleasure that I write the foreword to this book that is col-
laboratively authored by a former colleague, trainees, and laboratory tech-
nologists at the Cleveland Clinic—Florida, along with other alumni of the
Cleveland Clinic—Ohio. I greatly admire with pride and satisfaction follow-
ing the careers of my former colleague, Dr. Nestor Galvez-Jimenez, and my
former residents and fellows, Drs. Michelle Dompenciel, Raghav
Govindarajan, Ramon Lugo, John A. Morren, and Alexandra Soriano. They
are all astute clinicians and accomplished electrodiagnosticians.
This book is well written and organized, replete with visually enhancing
anatomical and technical illustrations, starting with the underlying principles
and practices, optimal techniques of nerve conduction studies, and electro-
myography. Then specific disorders of the peripheral nervous system are dis-
cussed clinically and how properly performed electrodiagnostic studies will
complement the clinical neurological assessment. This book will be a valu-
able resource in the field of electrodiagnostic medicine that trainees and
existing practitioners will find very helpful. Beginners and experts and men-
tors and mentees will find this book a user-friendly guide in correctly per-
forming and reporting clinically meaningful nerve conduction studies and
electromyography.
Finally, I am deeply humbled and appreciative that this book is dedicated
to me by the editors. It is often said: Teaching is an art that takes time and
patience. And that is certainly true of teaching electrodiagnostic studies. I
remember how I myself was taught this discipline by my mentors, the late Dr.
Jasper Daube and Dr. Edward Lambert, at the Mayo Clinic-Rochester. I am
grateful and pleased to have contributed to the training and mentoring of
several of the coauthors of this book. I wish them even more success in the
future.
Virgilio D. Salanga
Department of Neurology
Cleveland Clinic – Florida
Weston, FL, USA
vii
Preface
Few Antecedent Words of Gratitude from NGJ
When one of us (NGJ) was approached by Springer to work on a book proj-
ect, the decision to work on a book on electrodiagnostic medicine was easy.
The field of electrodiagnostic medicine has grown exponentially with a solid
body of evidence based on careful critical thinking, research, mathematical
thought, and engineering with the appropriate interfacing of neurophysiologi-
cal and neuroanatomical concepts. Hence, electrodiagnostic medicine is a
field with an interdisciplinary nature to the science, study performance, and
approach to patients. Therefore, producing a book of this nature (as has been
wisely said many times) is not done in isolation but is the product of a “vil-
lage.” Having asked Drs. John A. Morren and Alexandra Soriano to join me
on this project was one of the wisest decisions I made when organizing this
project. This is now our work as a team effort. They added editorial expertise,
breath of knowledge, a fresh look, and attention to detail so important in
projects of this type, particularly as it pertains to electrodiagnostic medicine.
My heartfelt thanks go particularly to John A. Morren who added clarity of
thought and made what appears complex to explain easy for the reader to
understand. This work is as much his work as everyone else’s. He read and
editorialized each chapter and attended to my many phone calls no matter
how basic some of those were to make sure we all understood what was con-
veyed in each chapter. It was the best decision to have John provide his insight
and knowledge and Alex adding her expertise in the performance and under-
standing on single fiber EMG, an area in which she excels like no one I know,
and her ability to write electrodiagnostic reports, which is not as easy as many
would make you believe. In addition, I have to give thanks to our technolo-
gists from Cleveland Clinic in Ohio and Florida who gave their time and
expertise and in many instances were willing to be models for the atlas. My
thanks also go to Jessica Galvez, BSc, MEd, PsyD candidate, who, in spite of
a busy doctoral study schedule, managed to participate as model for some of
the laboratory pictures that needed to be replaced on short notice, saving the
day for us. Finally, I will be remiss if I do not acknowledge all the invited
authors, all authorities, and accomplished electrodiagnosticians who took
time from their very busy schedules to participate in this project.
ix
x Preface
Using the Book
One of the critical challenges facing trainees and experienced electrodiagnos-
ticians alike is the attention to detail when performing nerve conduction stud-
ies (NCS) and needle electrode examination (NEE). This is needed for the
coherent interpretation of findings, including when to discard that relatively
unimportant finding, recognize an artifact, and ultimately know how to put all
the pieces together for a cogent EDX diagnosis. Words matter, and sentences
matter in a way that can hardly be more epitomized than with the explana-
tions and conclusions in EDX medicine. Some may argue that an imprecise
word or a superfluous comment may lead to confusion and unnecessary
assessments by the referring physician, or in the worst-case scenario, even an
unnecessary surgical procedure.
The book begins with Chap. 1, which is intended to provide the novice and
expert alike with the neurophysiology and neuroanatomical fundamentals on
the theory and principles for the practice and understanding of EDX studies.
In addition, it provides general concepts on the assessment of common neuro-
muscular complaints and how to use the EDX techniques to approach and
study these patients. More often than not, patients come with symptoms or
complaints, and less so with established neuromuscular diagnoses. Hence, the
hope is to provide enough knowledge to get a handle on EDX thought process
for an appropriate work-up. Chapter 2 describes the most common NCS tech-
niques in great detail using actual individuals in pictures demonstrating the
performance of the studies, detailing the pertinent anatomical localization
within the segment being evaluated, in addition to helpful tips and common
pitfalls. Chapter 3 provides a pictorial survey on the anatomical localization,
and appropriate placement of the needle electrode, with similarly helpful tips
and common pitfalls for each muscle that may be examined. Further, in Chap.
4, a deeper understanding of the electronics and neurophysiology relating to
NEE is facilitated, with explanation of normal and abnormal findings on
NEE. This was provided masterfully by Bryan Tsao, MD, who is a leading
expert in this area, known for his excellent teaching of the topic, particularly
at sessions of the American Association of Neuromuscular and Electrodiagnostic
Medicine (AANEM). This is followed by other excellent chapters written by
experts in their respective fields and/or academic practices with the hope of
providing added insight on the fundamentals of electrodiagnostically assess-
ing patients with neuromuscular conditions. Therefore, these chapters delve
into the major conditions often encountered in a busy neuromuscular medicine
practice. Chapter 5 expands on the mononeuropathies of the upper and lower
extremities with their respective EDX assessments written by Ramon Lugo,
MD, and Alexandra Soriano, MD. Chapter 6 written by Megha Dhamne, MD,
and John A. Morren, MD, deals with the EDX assessment and nuances of
polyneuropathies in a very scholarly fashion. For Chap. 7 on brachial plexopa-
thies, we were extremely lucky to have Mark Ferrante, MD, who is a renowned
national and international expert on the topic. He gives his insight and tremen-
dous knowledge on the EDX assessment of patients with brachial plexus
lesions. One of us (NGJ) had the privilege to be at the EMG laboratory during
residency training when Mark was a fellow at our institution working with Asa
Preface xi
Wilbourn and witnessed how between them, “the book” on the EDX assess-
ment of the brachial plexus and plexopathies was essentially rewritten the way
we know it today. Chapter 8 provides another scholarly discussion by Karen
Karwa, MD, and John A. Morren, MD, on radiculopathies, the work-up for
which is commonly requested in EDX medicine, yet continues to be a source
of spurious interpretations and repeat studies, particularly when coming from
less experienced laboratories. A major source for neuromuscular consultations
and complex EDX assessment is that for patients with disorders of the motor
neuron and mimicker conditions. Michelle Dompenciel, MD, provides a dis-
cussion of the topic in Chap. 9, and more importantly provides the EDX
approach to this complex group of patients. Michelle is an accomplished elec-
trodiagnostician, and we were excited in having her contribute this important
chapter.
Chapter 10 by Elanagan Nagarajan, MD, and Raghav Govindarajan, MD,
well known in the area of neuromuscular medicine, provides an overview of
the pathophysiology and clinical and EDX assessment of patients with neu-
romuscular junction transmission disorders. Dr. Govindarajan is quite active
in the AANEM and one of his main area of interest is that of neuromuscular
junction disorders. Their insight and approach to the work-up of these
patients, with an emphasis on technical proficiency and interpretation accu-
racy of this somewhat complex aspect of electrodiagnostic medicine, is of
great benefit to the reader. Chapter 11 is contributed by Alexandra Soriano,
MD. Alex is an accomplished electrodiagnostician particularly in the assess-
ment, performance, and interpretation of single fiber EMG. She gets referrals
from all over the region and country and has been a source of inspiration and
along with John A. Morren has provided her expertise and meticulous atten-
tion to detail on all matters of EDX medicine. Chapter 12, written by Payam
Soltanzadeh, MD, provides an excellent overview, with discourse on core
concepts and fundamentals pertaining to the assessment and interpretation of
EDX studies in patients with myopathies. The book concludes with Chap. 13
spearheaded by Alex Soriano, MD, and further refined by John A. Morren,
MD, providing a succinct overview on how to write an EDX report, particu-
larly in keeping with the recommendations set forth by the AANEM. Just as
the practice of EDX medicine is both an art and science, so is the ability to
write an EDX report, as this chapter elaborates.
It is the sincere hope of the editors of this work that we have provided a
fresh overview on the subject of electrodiagnostic medicine and that this
book will serve as a primer to many laboratories, as it will be in ours. We
anticipate that it will be very helpful as reference companion, especially to
instructors and lifelong learners in the field (not excluding former and future
residents and fellows). We also hope that our readers have ever-increasing
gratification in the practice of high-quality electrodiagnostic medicine that is
not only a meaningful tribute to their mentors in the field but a great service
to patients who trust us to do the best for them.
Weston, FL Nestor Galvez-Jimenez
Weston, FL Alexandra Soriano
Cleveland, OH John A. Morren
