1st. International Meeting on Brachial Plexus
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1st. International Meeting on Brachial Plexus Clínica Fausto Viterbo – Cirurgia Plástica FMUNESP. Electrophysiologic evaluation in Brachial Plexus lesion. José A Garbino - ILSL. Botucatu - 2009. Summary. Routine electroneuromiography Motor studies Sensory studies Electromyography

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Electrophysiologic evaluation in Brachial Plexus lesion

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Electrophysiologic evaluation in brachial plexus lesion

1st. International Meeting on Brachial Plexus

Clínica Fausto Viterbo – Cirurgia Plástica FMUNESP

Electrophysiologic evaluation in Brachial Plexuslesion

José A Garbino - ILSL

Botucatu - 2009


Summary

Summary

  • Routine electroneuromiography

    • Motor studies

    • Sensory studies

    • Electromyography

  • Expected results

    • Lesion localization

    • Severity

    • Dennervation and Reinnervation

    • Prognosis


Routine electroneuromyography and its fundamentals

routine electroneuromyography and its fundamentals


Electrophysiologic evaluation in brachial plexus lesion

Nerve conduction – large fibers

1. Motor nerve conduction - parameters

CMAP, Distal Latency, Conduction Velocity (CV m/s= distancy/L2-L1) and F wave (late latencies)

2 MU

CMAP: Compound Motor Action Potential = sum of MU potentials = estimation of motor axons in one nerve


Mnc belly tendon setting

MNC- belly-tendon setting

Active electrode in muscle belly and reference in tendon

Isolated stimulation with hook electrodes and belly-tendon setting using needles

How to do it in animal models?


Muscle fiber diameter x cmap amplitude experimental data

Muscle fiber diameter X CMAP amplitude experimental data

G5

G6

Brambilla, E. J. S. Dupla inervação muscular com neurorrafia término-lateral: estudo em ratos.Tese apresentada à FMB, UNESP, Curso Bases Gerais da Cirurgia, 2009.


Myelination axon fiber diameter x nerve conduction latency

5

2

3B

1

Myelination, axon fiber diameter X nerve conduction (latency)

G5

G6

Brambilla, E. J. S. Dupla inervação muscular com neurorrafia término-lateral: estudo em ratos.Tese apresentada à FMB, UNESP, Curso Bases Gerais da Cirurgia, 2009.

7

Figura 32 – Fibras do músculo tibial cranial direito. Cortes corados pela técnica de HE. (1) grupo G1; (2) grupo G2; (3) grupo G3; (4) grupo G4; (5) grupo G5; (6) grupo G6; (7) grupo G7. Microscopia óptica com aumento de 200 vezes.


Amplitudes cmap m wave side to side comparison crucial in prognosis and graduation

Amplitudes CMAP (M wave) side to side comparison –crucialin prognosis and graduation

≥ 50% reduction

<50% reduction = normal

  • Differences> 50%

  • 50-80%: SLIGHT

  • 80-90%: MODERATE NO RESPONSES: complete lesion

  • > 90%: PRONOUNCED


Electrophysiologic evaluation in brachial plexus lesion

2. sensory CV = distancy/ L1 m/s

Action sensory potential (ASP) = sum of sensory fiber potentials = estimated number of sensory axons in one nerve


Sensory conduction normal and abnormal

Sensory conduction normal and abnormal

normal

amplitude↓

latency↑

velocity ↓


Sc crucial in bp assessment topography pre and post ganglionic lesions

SC: crucialin BP assessment - topographypre and post-ganglionic lesions

pre-ganglionic

post-ganglionic

Garbino

pre-ganglionic

post-ganglionic - myelinic

post-ganglionic - axonal


Mbs male 60 y 27 days after

MBS, male, 60 y, 27 days after

Normal distal CB proximally

complete axonal loss

partial axonal loss

complete axonal loss

partial axonal loss

conduction block - myelinic

post – ganglionic lesions

Complete axonal lesion: terminal reinnervation, 1mm/day

Partial axonal lesion: collateral and terminal sprouting

Myelinic lesion: remyelination/months


Electrophysiologic evaluation in brachial plexus lesion

3. Needle Electromyography

a) resting muscle

voluntary contraction

b) voluntary contraction

Motor unit potential: Shape, polyphasia, amplitude and duration will define the reinnervation patterns: collateral and terminal


Reinnervation patterns collateral and terminal sprouting

Reinnervation patterns: collateral and terminal sprouting

Garbino

terminal

collateral


Electrophysiologic evaluation in brachial plexus lesion

Needle Electromiographyevaluation

  • Muscles mapping

  • spontaneus activities distribution in the target limb

  • Lesion localization: related to root, clavicle position and cords

  • Quantify the amount of spared motor units

  • Look for reinnervation signs

plexus

root


Electrophysiologic evaluation expected results

Electrophysiologicevaluation expected results


Expected results

Expected results

  • NCS: suprascapularis, musculocutaneus, axillary radial superficialis (upper trunk), radial, posterior interosseus (middle trunk), medial cutaneous antebrachialis, median and ulnar nerves (lower trunk)

    • Determine: pre and post-ganglionic lesions,

      underline neuropathology, and severity

  • Electromyography: in the above nerve territories plus paraspinalis muscles

    • Determine: root lesions, supra and infra clavicular or, severity and reinnervation or not


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