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Results from my EMG/Nerve Velocity test :) (:
I thought I would bug the forum since they get so many questions. I got my EMG report and basically there was no large fiber peripheral neuropathy but can't rule out small fiber neuropathy. But I was more interested in his assessment, he is a Physical Medicine and rehab doctor who specializes in mini torture rooms. lol. No seriously he was the first who seemed to do a very accurate and time consuming physical exam. and he found me to be hypereflexic in both the upper and lower extremities 3+ reflexes. Her Hoffan's sign is present bilaterally in the upper extremities, and a positive Babinski sign is present in right foot. She has 4-5 beats of clonus with ankle jerks on the left and about 3 on the right. She has a negative Romberg sign.
Ok that is it, I knew in past when they tested my knee reflexes they were very brisk ,but now I am seeing a lot of other reflexes are abnormal. What do you think those mean. Do they point in direction of MS, Sarcoidosis or just inflammation?
In his final note area he said due to hx of brain lesions found in periventricular, subcortical and frontal lobe white matter and positive spinal tap with 4 oligoclonal bands found in CSF and not in serum as well as elevated IgG index. He feels results are more likely associated with a "central nervous process" which ones is he talking about? . Ok let me know what you think. I did try reading some health pages on babinski but it just said problems in spinal cortical tract.
Two more new symptoms over last couple of weeks I get this stabbing pain behind my right eye off on on most days. It is not painful just a little blurriness that resolves; I also have been getting these hard to describe severe muscle spams on the right rib area, it sometimes radiates to back, sometimes down right arm or sometimes into middle of sternum. It does make you want to breathe through it like you would a labor pain,a few I can just relax through but others are much stronger. So does any thing jump out at you all. Any input would be great...
Thanks Amers
Then saw ENT to see why bilateral tinnitus developed suddenly after Christmas and has stayed. He says no hearing loss no treatment, no damage to ears everything looks good so still no answer, but he definitely feels it is connected to all these autoimnmune problems, facial parasesthias, TN, bilateral toes numb and tingling, tinnitus. weak right hand coordination.
Thank you for explaining the space and time thing. It sounds like I definitely qualify if that is the term you would use. My question how would I present this to my MS specialist without him getting ticked or feeling intimidated or second guessed. Should I bring copies of your explanations or supporting data?
I am becoming convinced in my mind I have narrowed it down to MS or Neuro Sarc. I have so much upper torso pain right now, I feel like I am not going to be able to lift and use my right arm much, it just causes so many spasms in that sternoclido muscle and trapezius. fingers on right hand get clumsy so easily . The grip is strong when tested but it is the dropping of things and clummsiness that worries me. Could be myofascial pain from stress to I guess, holding ice pack to face all day long.
I don't know what else that is not MS or neuro sarc that would cause the hyperreflexia, clonus, hoffman and babinki on just r. foot. I am hoping to get some good support this Wednesday from my rheumy and see what other tests may help. I will let you know how that appointment goes.
Stay well, and know you are special and let us know how we can help you as well anytime.
Amers
I am becoming convinced in my mind I have narrowed it down to MS or Neuro Sarc. I have so much upper torso pain right now, I feel like I am not going to be able to lift and use my right arm much, it just causes so many spasms in that sternoclido muscle and trapezius. fingers on right hand get clumsy so easily . The grip is strong when tested but it is the dropping of things and clummsiness that worries me. Could be myofascial pain from stress to I guess, holding ice pack to face all day long.
I don't know what else that is not MS or neuro sarc that would cause the hyperreflexia, clonus, hoffman and babinki on just r. foot. I am hoping to get some good support this Wednesday from my rheumy and see what other tests may help. I will let you know how that appointment goes.
Stay well, and know you are special and let us know how we can help you as well anytime.
Amers
Amers, if the MS specialist you mean is the one I think you do, he's known for not taking "hard" cases and for wanting only the most straightforward, by-the-book MS cases...and these are the ones that he will dx. That's what I hear, anyway.
Bio
Bio
The main way to determine Dissemination in Time is to evaluate the behavior of the patient's symptoms. If you have had two or more distinct attacks (episodes of symptoms) then you have Dissemination in Time.
The only time you need to look at the McDonald Criteria is if you don't have enough clinical (symptoms and neuro exam abnormalities) data to prove dissemination in time or space THEN you can use MRI data for the evidence. That is the main usefulness for the McDonald Criteria. The group that formulated the McDonald Criteria (both the intitial and the revised) themselves stated this. You can use info from the MC to substitute if the patient is missing a second attack or if there is only evidence of one lesion - that is only evidence of one spot of damage in the CNS.
Your neuro should be paying more attention to the findings on the neuro exam. Here are the distinct "lesions" that I find from what you have told us:
1) Trigeminal Neuralgia - bilateral - This can only arrise from a lesion on the brainstem or along the Trigeminal nerve as it runs to the face. Since it is bilateral that probably means that you have two lesions on the brainstem or the nerve. Since it is in the same area, a neurologist would probably count this as "one location" of damage.
2) Clonus - This is the maximum amount of hyperreflexia. By definition, hyperreflexia is caused by a spinal cord lesion. So this is a separate area of damage from the brainstem.
3) Positive Hoffman's and assymetrical Babinski - This might be a separate lesion from the one(s) causing the hyper reflexes - I don't know. The fact that the Babinski is present only on one side is highly suggestive of MS.
4) If the tinnitus is related to MS then it is another separate lesion involving the brainstem, but the Cranial Nerve VIII - the Accoustic Nerve.
You fulfill Dissemination in Spave by virtue of #'s 1 and 2. Now, if you have had more than one attack, you fulfill Dissemination in Time. Period.
Remember, our neuro's should only be looking to the MRI for evidence for spread in time or space IF the evidence is lacking from our history (two or more attacks) or our neuro exam (abnormalities on exam or testing).
Also, remember that testing can provide evidence of lesions in other locations. The best example is a positive VEP showing damage to the optic nerve.
MS is STILL best assessed by LISTENING to the patient (noting all the features of attacks and symptoms), LOOKING at the patient with a very thorough neuro exam (noting the abnormalities and realizing that these abnormailties indicate areas of damage in the central nervous system) and THINKING!
If the patient has 2 or more attacks and 2 or more areas of damage, then the ONLY thing they need to look at the MRI for is consistent lesions. One or more consistent lesions is enough to nail the diagnosis.
So much of the time the McDonal Criteria are NEVER needed.
The two Health Pages that describe this best are the very long, but useful:
http://www.medhelp.org/health_pages/Multiple-Sclerosis/History-of-the-Diagnosis-of-MS/show/158?cid=36
http://www.medhelp.org/health_pages/Multiple-Sclerosis/Diagnosing-MS---The-McDonald-Criteria-revised-2005/show/370?cid=36
I hope this takes care of the confusion.
Quix
The only time you need to look at the McDonald Criteria is if you don't have enough clinical (symptoms and neuro exam abnormalities) data to prove dissemination in time or space THEN you can use MRI data for the evidence. That is the main usefulness for the McDonald Criteria. The group that formulated the McDonald Criteria (both the intitial and the revised) themselves stated this. You can use info from the MC to substitute if the patient is missing a second attack or if there is only evidence of one lesion - that is only evidence of one spot of damage in the CNS.
Your neuro should be paying more attention to the findings on the neuro exam. Here are the distinct "lesions" that I find from what you have told us:
1) Trigeminal Neuralgia - bilateral - This can only arrise from a lesion on the brainstem or along the Trigeminal nerve as it runs to the face. Since it is bilateral that probably means that you have two lesions on the brainstem or the nerve. Since it is in the same area, a neurologist would probably count this as "one location" of damage.
2) Clonus - This is the maximum amount of hyperreflexia. By definition, hyperreflexia is caused by a spinal cord lesion. So this is a separate area of damage from the brainstem.
3) Positive Hoffman's and assymetrical Babinski - This might be a separate lesion from the one(s) causing the hyper reflexes - I don't know. The fact that the Babinski is present only on one side is highly suggestive of MS.
4) If the tinnitus is related to MS then it is another separate lesion involving the brainstem, but the Cranial Nerve VIII - the Accoustic Nerve.
You fulfill Dissemination in Spave by virtue of #'s 1 and 2. Now, if you have had more than one attack, you fulfill Dissemination in Time. Period.
Remember, our neuro's should only be looking to the MRI for evidence for spread in time or space IF the evidence is lacking from our history (two or more attacks) or our neuro exam (abnormalities on exam or testing).
Also, remember that testing can provide evidence of lesions in other locations. The best example is a positive VEP showing damage to the optic nerve.
MS is STILL best assessed by LISTENING to the patient (noting all the features of attacks and symptoms), LOOKING at the patient with a very thorough neuro exam (noting the abnormalities and realizing that these abnormailties indicate areas of damage in the central nervous system) and THINKING!
If the patient has 2 or more attacks and 2 or more areas of damage, then the ONLY thing they need to look at the MRI for is consistent lesions. One or more consistent lesions is enough to nail the diagnosis.
So much of the time the McDonal Criteria are NEVER needed.
The two Health Pages that describe this best are the very long, but useful:
http://www.medhelp.org/health_pages/Multiple-Sclerosis/History-of-the-Diagnosis-of-MS/show/158?cid=36
http://www.medhelp.org/health_pages/Multiple-Sclerosis/Diagnosing-MS---The-McDonald-Criteria-revised-2005/show/370?cid=36
I hope this takes care of the confusion.
Quix
Hi Again Quix,
Thanks for your response , you crack me up...I know I am being extremely patient but one problem is my current neuro is the MS specialist well known in this area of Texas. My second opinion neuro I just did not connect with at all, and he just gave up once all my blood tests came back normal. He was the one who originially told me back in Dec 07 that it was probably MS but when I went back to see him last month, he knew I got the 2nd opinion from the MS specialist and he seemed to retract all, and agree with specialist. Maybe because he is a "weenie" lol or maybe because he also feels it could be a combination of other CNS problems but not MS.
I still get confused with dissemination in time versus space. But I did look at health pages, so for space since I have both TN and then a couple months ago the toes parasthesias and tinnitus. Maybe they don't feel they are related so it would not count towards the "space" Although I never was told I had + babinski, hoffman or clonus so does that count?
As for dissemination in "time" Well I don't have any visible lesions anywhere else except the brain and those have not changed for two years. I am trying but this still seems so confusing. I like how both neuro's say not MS but then they can't tell me what it is. That doesn't make sense. They must have some idea.
As for neuro sarc, I know my rheumatologist thought about it but have never been worked up for it, not sure what that involves but when I see her this week I will find out. I think I should get a CT of my chest since I have been having so much chest pain. But thanks Quix, I will keep reading and trying to understand. Any other tests you all think I should get?
Have a great and blessed Easter...Thanks for always helping Quix and all of you, you are so generous with your "time"
Just a little joke when I was having my EMG I told my doctor well if I ever decide to commit First degree murder I will make sure it is in a state where they DON'T use an electric chair...he chuckled ... Amers
Thanks for your response , you crack me up...I know I am being extremely patient but one problem is my current neuro is the MS specialist well known in this area of Texas. My second opinion neuro I just did not connect with at all, and he just gave up once all my blood tests came back normal. He was the one who originially told me back in Dec 07 that it was probably MS but when I went back to see him last month, he knew I got the 2nd opinion from the MS specialist and he seemed to retract all, and agree with specialist. Maybe because he is a "weenie" lol or maybe because he also feels it could be a combination of other CNS problems but not MS.
I still get confused with dissemination in time versus space. But I did look at health pages, so for space since I have both TN and then a couple months ago the toes parasthesias and tinnitus. Maybe they don't feel they are related so it would not count towards the "space" Although I never was told I had + babinski, hoffman or clonus so does that count?
As for dissemination in "time" Well I don't have any visible lesions anywhere else except the brain and those have not changed for two years. I am trying but this still seems so confusing. I like how both neuro's say not MS but then they can't tell me what it is. That doesn't make sense. They must have some idea.
As for neuro sarc, I know my rheumatologist thought about it but have never been worked up for it, not sure what that involves but when I see her this week I will find out. I think I should get a CT of my chest since I have been having so much chest pain. But thanks Quix, I will keep reading and trying to understand. Any other tests you all think I should get?
Have a great and blessed Easter...Thanks for always helping Quix and all of you, you are so generous with your "time"
Just a little joke when I was having my EMG I told my doctor well if I ever decide to commit First degree murder I will make sure it is in a state where they DON'T use an electric chair...he chuckled ... Amers
Oh, Amers, your neuro is a total weenie! He cannot see the forest because he doesn't want to deal with it. He must have run headlong into one of the trees (TN - bilateral no less) and been brained by it. I think I see the poor bugger scurrying off into the brush. Sheesh! I wouldn't want anything further to do with him either. You have OBVIOUS dissemination in Space!! Whether there has been dissemination in Time depends on whether any of these symptoms have occurred in separate "attacks" separated from from the previous one by at least 30 days of improvement or stabilization of existing symptoms.
Is this a duck? Let me count the ways.
Bilateral Trigeminal Neuralgia - Brainstem lesion. Some would say MS until PROVEN not.
Diffuse hyperreflexia with clonus - Can we all say "Spinal Lesion" in unison?
Positive Hoffman's and Babinksi - also usually a corticospinal tract lesion
Very Positive LP with Oligoclonal Bands and elevated IgG Index - We are screaming CNS inflammation here.
The eye pain is lasting a little long to be called optic neuritis, but it really needs to be considered here. Other causes can be dry eye. Need Eye Eval and probably VEP.
Chest pain suggestive of an MS Hug that only goes part way around (assymmetrical)
The Physical Medicine doctor really did do a careful neuro exam. It's amazing when you see what a really thorough exam is, isn't it? But, he was totally vague and non-committal about the cause, other than it was clear Central.
I don't remember. Has Sarcoidosis been raised as a possibility for you? It would have to be NeuroSarcoid and you don't seem sick enough for that.
Again, there is no rule that new lesions have to appear in a certain length of time. MRIs can be static for years - I don't have info on how many years the MRI can be unchanging before one can "rule out" MS.
New neuro. New neuro. New Neuro. New Neuro.
Quix
Is this a duck? Let me count the ways.
Bilateral Trigeminal Neuralgia - Brainstem lesion. Some would say MS until PROVEN not.
Diffuse hyperreflexia with clonus - Can we all say "Spinal Lesion" in unison?
Positive Hoffman's and Babinksi - also usually a corticospinal tract lesion
Very Positive LP with Oligoclonal Bands and elevated IgG Index - We are screaming CNS inflammation here.
The eye pain is lasting a little long to be called optic neuritis, but it really needs to be considered here. Other causes can be dry eye. Need Eye Eval and probably VEP.
Chest pain suggestive of an MS Hug that only goes part way around (assymmetrical)
The Physical Medicine doctor really did do a careful neuro exam. It's amazing when you see what a really thorough exam is, isn't it? But, he was totally vague and non-committal about the cause, other than it was clear Central.
I don't remember. Has Sarcoidosis been raised as a possibility for you? It would have to be NeuroSarcoid and you don't seem sick enough for that.
Again, there is no rule that new lesions have to appear in a certain length of time. MRIs can be static for years - I don't have info on how many years the MRI can be unchanging before one can "rule out" MS.
New neuro. New neuro. New Neuro. New Neuro.
Quix
Thanks for your input. My MS specialist is still sticking with the diagnosis of TN. I guess he feels since many of the symptoms are bilateral which is unusual in MS and per him I have no dissemination in time or space. All of my Brain MRI's showed the lesions to be the same each time and no "new" lesions.
I don't know, I have different CNS sites I think, TN started on r side and 6 months later went bilateral. Now parasthesia of toes but no lesion see on spine, except for a cord syrinx in thoracic area. I don't know, I am seeing my rheumatologist this coming Wednesday, she will go over tests and may draw some more blood. Will keep you guys posted...Thanks for your support:) Amers
I don't know, I have different CNS sites I think, TN started on r side and 6 months later went bilateral. Now parasthesia of toes but no lesion see on spine, except for a cord syrinx in thoracic area. I don't know, I am seeing my rheumatologist this coming Wednesday, she will go over tests and may draw some more blood. Will keep you guys posted...Thanks for your support:) Amers
I'm in agreement with ess, as is almost always the case. Everything you wrote screams MS to me , but I'm not an expert. Keep pushing for answers - you really need to know what you are facing here.
Your mini-torture room made me smile- do you ever wonder what type of person goes into this area of medicine? What personality type would want to zap people with electrical currents? :-)
stay in touch,
Lulu
Your mini-torture room made me smile- do you ever wonder what type of person goes into this area of medicine? What personality type would want to zap people with electrical currents? :-)
stay in touch,
Lulu
My goodness, you're sure going through the wringer. To me, what you describe sounds like classic MS, including the hyper-reflexia. This doctor isn't even a neuro?
If you are waiting for a diagnosis and are hearing CNS disorder, then I'd be very surprised if it could be anything other than MS, considering your brain MRI and LP. You should see an ophthalmologist about your eye issue, to cover all the bases. As to tinnitus, that happens to so many people, and it's often of unknown cause, so it's not much use in diagnosis.
Small fiber neuropathy can't be ruled out by EMG/NCS. If that is really suspected, a skin biopsy can be done, but I haven't heard of that happening often.
I'm sorry, but I don't recall what your neuro is saying. If he or she is on the fence, time for a trade-in.
ess
If you are waiting for a diagnosis and are hearing CNS disorder, then I'd be very surprised if it could be anything other than MS, considering your brain MRI and LP. You should see an ophthalmologist about your eye issue, to cover all the bases. As to tinnitus, that happens to so many people, and it's often of unknown cause, so it's not much use in diagnosis.
Small fiber neuropathy can't be ruled out by EMG/NCS. If that is really suspected, a skin biopsy can be done, but I haven't heard of that happening often.
I'm sorry, but I don't recall what your neuro is saying. If he or she is on the fence, time for a trade-in.
ess
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