Reappraisal of the F/M amplitude ratio in carpal tunnel syndrome

The F-wave/M-wave amplitude (F/M-amp) ratio has been shown to be increased in peripheral neuropathies, provided the maximum M-wave is relatively preserved. Reduced M-wave amplitudes and central facilitation of antidromically-induced reactivation of the anterior horn cells' axon hillocks (F-wave) are believed to contribute to higher F/M-amp ratios. The present study was undertaken to re-evaluate mechanisms responsible for higher F/M-amp ratios in carpal tunnel syndrome (CTS). We enrolled 232 cases affected by CTS and 108 controls. Fand M-wave amplitudes and F-wave chronodispersion were analyzed for the median and ulnar nerves. The F/M-amp ratio of the median nerve in CTS subjects with moderate-severe nerve damage was significantly higher than that of mild CTS subjects and controls. Chronodispersion of the median nerve F-wave increased with increasing CTS severity. We conclude that the relative preservation of the median nerve F-wave is due to damage to the large diameter muscle afferent fibers responsible for the monosynaptic response. Absence of the monosynaptic response makes the small motoneurons, usually inaccessible to the antidromic volley because of its collision with the orthodromic reflex volley, able to fire in the F-wave.

HCV E1E2-MF59 vaccine in chronic hepatitis C patients treated with PEG-IFNα2a and Ribavirin: a randomized controlled trial

Hepatitis C virus (HCV) vaccines may be able to increase viral clearance in combination with antiviral therapy. We analysed viral dynamics and HCV-specific immune response during retreatment for experienced patients in a phase Ib study with E1E2MF59 vaccine. Seventy-eight genotype 1a/1b patients [relapsers (30), partial responders (16) and nonresponders (32) to interferon-(IFN)/ribavirin-(RBV)] were randomly assigned to vaccine (V:23), Peg-IFNα2a-180-ug/qw and ribavirin 1000-1200-mg/qd for 48 weeks (P/R:25), or their combination (P/R + V:30). Vaccine (100 μg/0.5 mL) was administered intramuscularly at week 0-4-8-12-24-28-32-36. Neutralizing of binding (NOB) antibodies and lymphocyte proliferation assay (LPA) for E1E2-specific-CD4 + T cells were performed at week 0-12-16-48. Viral kinetics were analysed up to week 16. The vaccine was safe, and a sustained virological response (SVR) was achieved in 4 P/R + V and 2 P/R patients. Higher SVR rates were observed in prior relapsers (P/R + V = 27.3%; P/R = 12.5%). Higher NOB titres and LPA indexes were found at week 12 and 16 in P/R + V as compared to P/R patients (P = 0.023 and 0.025, P = 0.019 and <0.001, respectively). Among the 22 patients with the strongest direct antiviral effects of IFN (ε ≥ 0.800), those treated with P/R + V (10) reached lower HCV-RNA levels (P = 0.026) at week 16. HCV E1E2MF59 vaccine in combination with Peg-IFNα2a + RBV was safe and elicited E1E2 neutralizing antibodies and specific CD4 + T cell proliferation. Upon early response to IFN, vaccinations were associated with an enhanced second phase viral load decline. These results prompt phase II trials in combination with new antiviral therapies.

Who is more likely to respond to dual treatment with pegylated-interferon and ribavirin for chronic hepatitis C? A gender-oriented analysis

We assessed, in real-life practice, viral, demographic, genetic and metabolic factors influencing the sustained virologic response (SVR), with a gender-oriented analysis, in patients with chronic hepatitis C virus (HCV) treated with pegylated interferon and ribavirin. Six hundred and seventy naïve patients were treated with dual therapy and evaluated by gender and HCV genotype. Associations between baseline variables and SVR were assessed by multivariate logistic regression analysis. Among 362 genotype 1 patients, SVR was achieved in 158 patients (44%), and SVR was independently associated with age less than 50 years (OR 2.12; 95% CI 1.09-4.30; P=0.039) and C/C genotype rs12979860 SNP (OR 2.83; 1.19-6.74; P=0.002) in 163 females, while absence of visceral obesity (OR 2.491; 1.131-5.487; P=0.023), HCV-RNA lower than 400,000 IU/mL (OR 2.66; 1.273-5.558; P=0.009) and C/C genotype rs12979860 SNP (OR 4.969; 2.401-10.283; P<0.001) were independently associated with SVR in 199 males. Combining favourable baseline variables, the probability of obtaining SVR ranged from 27.6% to 84.2% in females, and from 14.3% to 85.7% in males. The rate of SVR was 81.1% in 175 genotype 2 patients, and 69% in 100 genotype 3 patients. Rapid virologic response was the only valid predictor of SVR regardless of other features. In conclusions, in the setting of HCV genotype 1, chronic hepatitis, combining rapid virologic response and predictive factors, which are different for females and males, allows clinicians to single out a group of patients whose likelihood of SVR exceeds 80%. For these patients, triple therapy with first-generation protease inhibitors may be unwarranted.

Polyneuropathy in cerebrotendinous xanthomatosis and response to treatment with chenodeoxycholic acid

Polyneuropathy has been reported in cerebrotendinous xanthomatosis (CTX), although its nature and possible association with certain genotypes and phenotypes are unclear. The effect of chronic administration of chenodeoxycholic acid (CDCA) on peripheral nerve conduction parameters is still debated. We report clinical, laboratory, and electrophysiological findings in 35 CTX patients. Twenty-six subjects (74.2 %) showed peripheral nerve abnormalities. Polyneuropathy was predominantly axonal (76.9 % of patients) and generally mild. No correlation was found between its presence and clinical or biochemical data. In polyneuropathic patients, CDCA treatment improved electrophysiological conduction parameters, irrespective of the duration of therapy. Improvement mainly concerned nerve conduction velocities, whereas most nerve amplitudes remained unchanged. This means that CDCA treatment did not influence the number of axons activated by maximum electrical stimulation but increased the conduction of the still-excitable fibers. Our findings may suggest that CDCA treatment promotes myelin synthesis in nerve fibers with residual unaffected axons. The effect of therapy may therefore depend largely on the extent of irreversible structural damage to axons.

Distal symmetric polyneuropathy in diabetes. Differences between patients with and without neuropathic pain

AIMS

To demonstrate whether in distal symmetric polyneuropathy (DSPN) in diabetes there are differences between patients with and without neuropathic pain and whether pain is associated with demographic, clinical and electrophysiological variables.

PATIENTS AND METHODS

We prospectively enrolled 154 consecutive patients (mean age 67 years, 64% men) in an electromyography (EMG) lab. The differences were calculated between DSPN patients with (no.78) and without neuropathic pain (no.76) relating to age, sex, BMI, type, duration, treatment and complications of diabetes, HbA1c, type and duration of DSPN symptoms, DSPN clinical severity score (with Diabetic Neuropathic Index-DNI), electrophysiological findings of lower limb muscles and nerves.

RESULTS

The differences between DSPN patients with and without pain included the presence of symptoms (burning and weakness), DNI score and neurographic findings of all nerves and neurogenic EMG. But in the logistic regression models enter only the following variables: DNI score, neurogenic EMG, and among symptoms "burning".

CONCLUSIONS

The presence of pain in DSPN is associated with DSPN clinical severity, neurogenic EMG and presence of "burning- symptom but not with demographic or neurographic findings, or diabetes related variables. Therefore, the neuropathic pain in DSPN does not associate with the degree of involvement of large diameter sensory fibres or diabetes severity.

Prevalent involvement of thenar motor fibres in vineyard workers with carpal tunnel syndrome

OBJECTIVE

Carpal tunnel syndrome (CTS) has a high prevalence in agricultural workers, especially those engaged in vineyards. We postulated that vineyard CTS was electrophysiologically different from CTS of other subjects. We performed a retrospective cross-sectional electrophysiological study of two cohorts of consecutive patients with CTS, the first consisting of vineyard workers and the second, of other unselected types of workers, housewives and pensioners.

METHODS

Thirty-three vineyard workers (mean age 46.8years, 42% women) and 205 patients with other occupations (mean age 53.7years; 66% women) were enrolled. All patients underwent sensory and motor neurography of the median and ulnar nerves. Differences in demographic and electrophysiological findings between groups were calculated and multiple linear regression analysis was performed to eliminate the influence of potential confounding factors (age, sex, BMI, clinical severity of CTS) on the results of univariate difference analysis.

RESULTS

Univariate analysis showed that DML was longer and compound muscle action potential amplitude of the median nerve, recorded from the abductor pollicis brevis muscle, was smaller in vineyard workers than in the other CTS patients. These differences remained significant after adjusting the results for confounding factors.

CONCLUSIONS

The vineyard workers showed a different pattern of CTS than the other patients: thenar motor fibres were more affected, presumably due to chronic compression on the thenar branch. This suggests an association between "common" CTS and thenar mononeuropathy.

SIGNIFICANCE

Occupational physiologists should clarify the mechanisms of neuromuscular engagement in particular jobs and ergonomists design suitable working tools, because many "individual" risk factors are difficult to change, but workplace-related risk factors can be modified.

Ulnar neuropathy at the elbow: how frequent is the idiopathic form? An ultrasonographic study in a cohort of patients

OBJECTIVE

Ulnar neuropathy at the elbow (UNE) is the second most frequent focal neuropathy of the arm. The aim of our study was to establish the frequency of anatomical changes of the cubital tunnel capable of causing UNE.

METHODS

Ninety-one consecutive patients affected by UNE, as established by neurophysiological studies, were enrolled in the study. All patients underwent ultrasonographic examination of the elbow, paying particular attention to the cubital tunnel, which was studied with either static or dynamic scans.

RESULT

Fifty-four of the 91 patients (59.3%) had at least one anatomical alteration of the cubital tunnel. The changes observed in our patients were: subluxation of the ulnar nerve (18.7%), luxation of the ulnar nerve (9.9%), presence of osteophytes (6.6%), presence of accessory muscle (8.8%), articular ganglion (1.1%), post-traumatic lesions (3.3%), presence of osseous fragment (1.1%).

CONCLUSIONS

A possible cause of ulnar nerve entrapment at the elbow was found in more than half of the patients. Joint ultrasonography is indispensable for the identification of such alterations as it allows for both static and dynamic evaluation of the ulnar nerve.

Ultrasonography before and after surgery in carpal tunnel syndrome and relationship with clinical and electrophysiological findings. A new outcome predictor?

OBJECTIVE

To measure the cross-sectional area (CSA) of the median nerve by ultrasonography (US) before and after surgery in subjects with carpal tunnel syndrome (CTS), and to verify whether the normalization of presurgical parameters can be predicted by presurgical CSA values.

PATIENTS AND METHODS

Sixty-seven consecutive cases, mean age 60.5 years, underwent surgical decompression. Before surgery, clinical and electrophysiological severity and self-assessment of symptoms (using the Boston questionnaire, BQ) were recorded. CSAs were measured proximal to the carpal tunnel inlet (CSA-I), at mid-tunnel (CSA-M), and at the tunnel outlet (CSA-O). Follow-ups were performed 1 and 6 months after surgery. Logistic regressions were performed with normalization of CSA, clinical and electrophysiological parameters as independent variables, and presurgical findings as dependent variables.

RESULTS

Before and after surgery there were correlations between CSA-I and clinical and electrophysiological severity scales. After 1 and 6 months, the clinical, electrophysiological, and BQ findings improved. CSA-I reduced at the 1-month follow-up and CSA-O increased between the first and second follow-up. Presurgical values of CSA-I could predict the normalization of its postsurgical value, normalization of the clinical severity scale, BQ, and full patient satisfaction postsurgery.

CONCLUSIONS

CSA-I is the most sensitive US measurement before surgery. The presurgical value of CSA-I is a predictor of postsurgical normalization of clinical parameters and of its own value.

Prominent brain axonal damage and functional reorganization in "pure" adrenomyeloneuropathy

BACKGROUND

Cerebral involvement is usually absent in pure adrenomyeloneuropathy (AMN). Recently, nonconventional MR studies have reported brain abnormalities in patients with pure AMN, providing evidence that occult cerebral involvement may occur in this disease. It remains unclear, however, whether these brain abnormalities reflect centripetal extension of spinal cord long-tract axonopathy or can be the expression of a pathologic process largely involving the brain.

METHODS

Conventional MRI and proton MR spectroscopic imaging (1H-MRSI) data of four patients with pure AMN were compared to those of four men with spinal cord injury (SCI) and 10 age-matched healthy men (HM). Resonance intensity areas of N-acetylaspartate (NAA) and choline were calculated as ratios to creatine (Cr) in voxels located in white matter (WM) regions. Functional MRI (fMRI) data during simple motor task were obtained in a separate session in three patients with AMN and three age-matched HM.

RESULTS

Conventional MRI examinations were normal in all patients. On 1H-MRSI, NAA/Cr values were lower in all WM regions of patients with AMN than in those of patients with SCI (p < 0.05) and HM (p < 0.01). In contrast, patients with SCI showed NAA/Cr values lower than HM only in the periventricular WM (p = 0.04). At fMRI, patients with AMN showed a more pronounced activation than HM in all movement-associated cortical regions contralateral to the hand moved and an exclusive voxel activation of the primary motor, somatosensory, and posterior parietal cortices ipsilateral to the hand moved.

CONCLUSIONS

CNS damage in pure adrenomyeloneuropathy is not confined exclusively to spinal cord and seems to primarily involve the brain.

Long term follow-up of carpal tunnel syndrome during pregnancy: a cohort study and review of the literature

INTRODUCTION

Carpal tunnel syndrome (CTS) occurring during pregnancy is considered to have a short and benign course and very few cases required surgery, however there is no information in literature on long term follow-up. The aim of this study was a systematic review of the literature and to report 3-year follow-up after delivery in a sample of pregnant women with CTS.

PATIENTS AND METHODS

We enrolled 45 consecutive pregnant women with CTS (mean age 32 years). Diagnosis was based on clinical and neurographic findings. Clinical and electrophysiological severity of CTS were scored according to an ordinal scale and the self-administered Boston questionnaires on symptoms (BQ-SYMPT) and functional status (BQ-FUNCT) of the hand during pregnancy and one-year after delivery. Symptoms were evaluated again by BQ over the telephone three years after delivery.

RESULTS

At one-year follow-up BQ-SYMPT and BQ-FUNCT scores improved in 40% of women, did not change in 46.7% and 55.6% and worsened in 13.3% and 4.4%, respectively. Clinical severity was stage 0 (i. e. without symptoms) in 26.7% of women, improved in 6.7%, unchanged in 60% and worse in 6.7%. Electrophysiological severity was stage 0 (i.e. no delay in median nerve conduction) in 17.8%, improved in 20%, unchanged in 57.8% and worse in 4.4%. Only one woman underwent surgery (5 months after delivery), three were treated with local steroid injection before delivery and 18 used a splint, 8 of whom continued to do so periodically after one year. At 3-year follow-up 51% were symptom-free and 49% had anomalous ( > 1) BQ scores, but mean BQ scores improved with respect to those at baseline and one-year follow-up.

CONCLUSION

A Pubmed search identified 20 papers in which therapy and follow-up could be deduced. Almost all reported a short follow-up with disappearance of symptoms. Our study confirms that pregnancy-related CTS has a benign course: improvement of symptoms was evident at one- and 3-year follow-up, but about half the women still complained of symptoms 3 years after delivery. Only one woman underwent surgery and 11% still sometimes wore a splint at night. Despite improvement of symptoms, distal sensory conduction velocity of the median nerve improved but remained delayed in 84% of women one year after delivery.

Body mass index in meralgia paresthetica: a case-control study

OBJECTIVE

This case-control study explored the possibility of an association between body mass index (BMI) and meralgia paresthetica (MP).

PATIENTS AND METHODS

A total of 104 MP cases (33 women and 71 men, mean age 51.7 +/- 15.5 years) were matched for age and sex with 208 neurological and 208 dermatological controls. Differences between cases and controls were analyzed using the Wilcoxon and chi-squared tests. Odds ratio matched K controls (OR(MK)) and 95% confidence intervals (CI) were also calculated.

RESULTS

Mean BMIs were 28.0 +/- 4.9 for cases and 26.0 +/- 4.3 and 25.5 +/- 3.9 for neurological and dermatological controls, respectively. There were significant differences between absolute BMI of cases and neurological (P < 0.01) as well as dermatological controls (P < 0.001), and also significant associations between BMI categories and MP (P = 0.008 vs neurological controls and P = 0.004 vs dermatological controls). There were significant OR(MK) for obesity (BMI >or= 30) [OR(MK) vs neurological controls 2.04 (95% CI 1.13-3.67) and vs dermatological controls 2.5 (95% CI 1.4-4.5)].

CONCLUSION

High BMIs were associated with MP. Obesity doubled the risk of MP. MP may be related to increased pressure due to abdominal protrusion.

A self-administered questionnaire of ulnar neuropathy at the elbow

We report a new self-administered questionnaire for assessment of symptom severity of ulnar neuropathy at the elbow (UNE). The new UNE and Levine's questionnaires were administered to a sample of UNE subjects and for comparison also to a sample of subjects with carpal tunnel syndrome (CTS). We enrolled 89 consecutive patients (32 women, 57 men, mean age 52.3 years) with UNE and 203 consecutive patients (157 women and 46 men, mean age 53.7 years) with CTS. The protocol of the study consisted in self-administration of the new UNE and Levine's questionnaires, as well as scoring of clinical and electrophysiological severity of entrapment syndromes with ordinal scales. The UNE questionnaire (UNEQ) includes nine questions and considers numbness and tingling in the fourth and fifth fingers, elbow pain and modification of pain and paraesthesia with elbow position. A score from 1 (absence of symptom) to 5 (most severe) is assigned for each question. The overall score is calculated as the mean of the nine scores. Test-retest reliability, internal consistency and validity were assessed. Responsiveness was also tested in a sample of patients undergoing conservative treatment. The UNEQ was reproducible. Spearman's correlation coefficient between scores at successive observations (test-retest reliability), assessed in the first 44 patients, was 0.97 and Cohen coefficients kappa for single items were between 0.64 and 0.81. Internal consistency was high: Cronbach's alpha, which summarises interitem correlations among all items of UNEQ, was 0.87. Validity was demonstrated by a direct correlation with UNE clinical and electrophysiological severity scores (0.65 and 0.35). On the contrary, Spearman's correlation coefficients between UNEQ and clinical and electrophysiological CTS severity scores were low (0.11 and 0.02, respectively). Responsiveness was calculated at 6-8 months follow-up in 25 cases. The effect size was 0.46. The Wilcoxon rank-test showed significant improvement between basal and follow-up UNEQ scores (Z=-2.39, p=0.017), but not Boston Questionnaire scores. There was also significant correlation between UNEQ changes and an arbitrary scale of patient satisfaction at follow-up (r=0.85, p<0.001). The UNEQ is reproducible, internally consistent and valid. Although further studies are required to test its responsiveness to clinical changes, UNEQ may be also considered responsive. UNEQ can be used to measure subjective discomfort in UNE patients.

Changes in motor axon recruitment in the median nerve in mild carpal tunnel syndrome

OBJECTIVE

To determine whether patients with mild carpal tunnel syndrome (CTS) and conventional electrodiagnostic evidence of selective involvement of sensory conduction show changes in motor axon recruitment in the median nerve.

METHODS

Wrist-to-abductor pollicis brevis (APB) motor axon conduction was studied by analysing the relationship between the intensity of electrical stimulation and the size of motor response (input-output curve) in 30 CTS patients with conventional electrodiagnostic evidence of selective involvement of sensory conduction. Parameters (threshold, slope and plateau) of input-output curves were compared with those obtained in 30 controls.

RESULTS

The slope of the input-output curve of CTS patients was less steep than that of controls. For stimulus intensity above M-wave threshold (MTh), fewer motor axons were recruited in patients than controls.

CONCLUSIONS

Motor fibres are affected in CTS when conventional electrodiagnostic tests show normal motor conduction. Altered recruitment of motor axons could mainly be due to impairment of energy-dependent processes which affect temporal dispersion of the compound volley or axonal conduction block.

SIGNIFICANCE

In mild CTS, motor fibres are more often affected than was originally thought. The sensitivity of wrist-to-APB motor conduction studies may be increased by using submaximal stimulus intensities.

Carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners

OBJECTIVE

To determine the occurrence of carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow (UNE) in a cohort of floor cleaners and to check differences between workers with and without CTS.

METHODS

All female floor cleaners of three major hospitals in Tuscany (Italy) were contacted. Clinical and electrophysiological severity of CTS and UNE were evaluated with standardized scales and symptoms were assessed with the self-administered Boston Questionnaire (BQ); demographic and non-occupational factors and durations of current and previous occupations were recorded. Univariate analysis of risk factors was performed in workers with and without CTS. Logistic regression was used to evaluate the capacity of independent variables to predict CTS.

RESULTS

Out of a total of 179 cleaners, 145 (81%)-mean age 39.6 years (20-64 years)-were enrolled in the study; 70 (48%) had CTS (diagnosis based on clinical and electrophysiological findings). BQ symptom and hand function scores were anomalous in 108 (74%) and 84 (58%) subjects, respectively. UNE was detected in 7/103 women. Univariate analysis showed that cleaners with CTS were older, had greater BMI and longer exposure to cleaning with previous employers than those without CTS. In the logistic regression, the only predictor of CTS was cleaning with previous employers (O.R. 12.1, 95% CI 3-49.9).

CONCLUSIONS

These results indicate a high occurrence of CTS in floor cleaners; UNE is less frequent than CTS, presumably due to repetitive movements that stress wrists more than elbows. The only predictive factor of CTS was cleaning as an occupation with previous employers. Therefore, the actual risk factor for CTS could not be cleaning per se, but how this job is performed.

Sex differences in carpal tunnel syndrome: comparison of surgical and non-surgical populations

Carpal tunnel syndrome (CTS) patients are known to show gender-related differences in severity. The main aim of this cross-sectional study was to determine whether these differences between women and men may be related to age, education or body mass index (BMI) in two populations, one with idiopathic CTS not treated surgically and the other with idiopathic CTS treated by surgical decompression. A secondary aim was to check differences in surgical results between the genders in the surgical population. The non-surgical population consisted of 172 subjects (126 women and 46 men, mean age 55.1 years) whose data were obtained at electrophysiological examination. The surgical population consisted of 219 patients (177 women and 42 men, mean age 55.1 years) whose data were obtained before surgery. Age, education, BMI, duration of symptoms, electrophysiological and clinical severity of CTS (with ordinal scales), and the self-administered Boston Questionnaire (BQ) of symptoms and functional status of hands were considered. There were no differences in age or clinical and electrophysiological severity between women and men in either group, except for distal motor latency of the median nerve that was more delayed and duration of symptoms that was shorter in men than women in non-surgical sample. Men had a higher BMI than women. Women had higher BQ scores in the surgical and non-surgical samples. These differences remained when the results were analysed matching the men with an identical number of women of the same age, education and BMI. In the surgical population, the results of surgical decompression did not modify the gender-related differences in severity. As in many other syndromes and diseases, for a given clinical severity, women with CTS were more sensitive than men in reporting their symptoms. Risk factors of CTS, such as age, education and BMI, were not responsible for these differences. The results of surgical decompression were similar in men and women.

Multicenter study on carpal tunnel syndrome and pregnancy incidence and natural course

OBJECTIVE

To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS and to assess the course of carpal tunnel syndrome after pregnancy.

METHODS

During 2000-2001, the Italian CTS study group in 7 Italian centers studied the occurrence of CTS in women during the last period of pregnancy. The group enrolled and followed-up (10-15 months) 63 women during and after pregnancy with multiple measurements of CTS. In addition to the physician-centered and neurophysiologic traditional evaluations, a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment was adopted.

RESULTS

CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Comparison of baseline and follow-up data showed a significant spontaneous improvement of patient-oriented and neurophysiologic measurements. Nevertheless, about half of women with CTS during pregnancy still complained of CTS symptoms one year after delivery.

CONCLUSIONS

Our observations confirmed the frequent occurrence of CTS in pregnancy. At follow-up we observed that most CTS cases improve spontaneously without treatment but only in half of women CTS symptoms disappeared one year after delivery.

Italian multicentre study of peroneal mononeuropathy at the fibular head: study design and preliminary results

BACKGROUND

The most common entrapment in the lower extremity is peroneal mononeuropathy (PM) at the fibular head. Several studies of this condition have been published but, until now, no wide multicenter clinical-neurophysiological studies on PM are available. In recent years, multicenter studies have been suggested; moreover it is commonly accepted that a multiperspective approach provides more comprehensive results.

METHOD

The Italian CTS and other entrapments Study Group has designed a strict clinical and neurophysiological protocol to carry out a wide multicentre study on PM at the fibular head. In addition to traditional clinical-neurophysiological evaluation, the group has also adopted validated disability and patient-oriented measurements in order to obtain more comprehensive and reliable data about this entrapment. The study was designed: 1) to identify predisposing factors; 2) to better assess the clinical picture; 3) to evaluate relationships between etiological, clinical and neurophysiological findings; 4) to evaluate the natural evolution of the entrapment. Study design is described.

FINDINGS

During the period from November 2002 to January 2004, 69 patients were enrolled consecutively in eleven Italian centres. Our preliminary data show that PM involves men more frequently than women (M:F = 3.9:1). With regard to the predisposing factors, PM is idiopathic (16%) or due to surgery (21.7%), prolonged posture (23.2%), weight loss (14.5%), external compression (5.8%), arthrogenic cyst at the fibula (1.4%), trauma (10.1%); it also occurred in bedridden patients (7.3%). Unexpectedly, peroneal nerve lesions were due not only to surgical operation close to the peroneal region, but were also associated with thoracic-abdominal surgery. Usually PM involves both terminal branches; patients complain of motor deficit in 99.5% of cases, sensory symptoms in 87.9% and pain in 19.7%.

CONCLUSIONS

Our preliminary results provide some interesting information and confirm the usefulness of multicentre and multiperspective studies to standardise the approach to nerve entrapment.

Evolution of hand dysfunction and symptoms in untreated carpal tunnel syndrome

The Italian Carpal Tunnel Syndrome (CTS) Study Group assessed the evolution of symptoms and hand dysfunction through validated, patient-oriented measures in 264 patients with 354 hands affected by untreated idiopathic CTS (follow-up 10-15 months). The evolution of symptoms and hand dysfunction was positively related. Only in 3% was there discordance between hand dysfunction and symptom evolution. Thus, in patients with CTS, hand dysfunction and symptoms evolve in parallel.

Ulnar neuropathy at the elbow: predictive value of clinical and electrophysiological measurements for surgical outcome

The aim of this study was to identify factors predictive of complete relief of symptoms in subjects with ulnar neuropathy at the elbow (UNE), undergoing surgical release. Clinical and electrophysiological results of 19 consecutive cases of UNE belonging to 18 patients (mean age 50.6 years, range 28-73) undergoing simple decompression were reviewed retrospectively. After surgery, seven cases were free of symptoms, nine showed improvement and three were unchanged. In all cases there was significant postoperative improvement of almost all nerve conduction values. Only preoperative sensory action potential amplitude of the ulnar nerve stimulating the little finger ( U5 SAP) was predictive of postoperative symptom free outcome. The other electrophysiological measures, age of patients, sex, presencelabsence of carpal tunnel syndrome, preoperative clinical stage and duration of symptoms were not predictive of excellent outcome. Preoperative U5 SAP amplitude was found to be a good predictor of disappearance of symptoms after UNE surgery. The probability of normalising electrophysiological values after surgery (U5 SAP amplitude, motor conduction velocity difference between across elbow and below elbow to wrist segments) depended on their preoperative values. Only the moderately anomalous values returned in the normal range.

An electrophysiological severity scale in tarsal tunnel syndrome

OBJECTIVE

To propose a neurophysiological classification of tarsal tunnel syndrome.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of two electromyography laboratories. Case inclusion criteria were based on clinical parameters. Motor conduction velocity, distal motor latency (DML), sensory conduction velocity (SCV) and sensory action potential (SAP) from big toe (T1) and from fifth toe (T5) to medial malleolus were measured in the medial and plantar nerves. When SCVs of T1 and T5 were normal, we considered the difference in T1 SCV between affected and unaffected side and in T1 SCV of the affected side with sural nerve distal SCV. Feet with TTS were classified in six electrophysiological classes: 0, normal SCV and DML; 1, normal absolute SCV with abnormal comparative tests; 2, slowing of T1 and T5 SCV and normal DML; 3, slowing of SCV and DML; 4, absence of T1 and T5 SAPs and abnormal DML; 5, absence of sensory and motor response.

RESULTS

A total of 111 feet belonging to 96 patients (27 men, 69 women; mean age 49.6 years) were diagnosed with TTS. T1 and T5 SCV were abnormal in 82 and 73% of cases, respectively, and comparative tests were abnormal in a further 7% of cases. DML was abnormal in 82 feet (73.9%). Eight feet (7%) were without neurographic abnormalities. The distribution of feet in neurophysiological classes was: stage 0, 7%; stage 1, 9%; stage 2, 10%; stage 3, 39%; stage 4, 32%; stage 5, 3%. Higher clinical scores coincided with higher neurographic classes.

CONCLUSION

The progression of neurographic abnormalities in TTS reflects the relation between SCV and DML, and between neurographic values and clinical severity. The scale assigns severity classes in a reliable and non-arbitrary way. This classification can easily be used by electrophysiological laboratories with their own electrophysiological techniques and normal values.

Mitochondrial alterations in muscle biopsies of patients on statin therapy

Clinical and biopsy study of nine patients on statin therapy suffering from various myopathic syndromes is reported. Biopsy findings showed non specific myopathic signs and mitochondrial changes, such as subsarcolemmal accumulation, morphological alterations, lipid increase and Cox-negative fibers. These findings confirm that statins may cause muscle damage and impair oxidative metabolism.

Carpal tunnel syndrome in pregnancy: multiperspective follow-up of untreated cases

In a follow-up of carpal tunnel syndrome (CTS) after pregnancy, the Italian CTS Study Group prospectively studied 63 pregnant women with multiple measurements of CTS symptoms. Fifty-four percent of women with CTS symptoms during pregnancy had symptoms 1 year later. Patients with onset of CTS symptoms early during pregnancy are less likely to improve after delivery.

Inter-observer reproducibility and responsiveness of a clinical severity scale in surgically treated carpal tunnel syndrome

OBJECTIVES

To test a recently proposed carpal tunnel syndrome (CTS) clinical severity scale for reproducibility between two observers (neurosurgeon and neurophysiologist) before surgery, for responsiveness to changes in clinical status 6 months after surgery, and for correlations with the electrophysiological findings and 'Boston Carpal Tunnel Syndrome Questionnaire' (BQ).

MATERIAL AND METHODS

The tests were applied prospectively to a consecutive series of 254 hands with idiopathic CTS, referred for surgical decompression. The hands belonged to 219 subjects (177 women and 42 men, mean age 55.6).

RESULTS

Percentage agreement between the two observers in assigning severity to the same class was 78% and Cohen coefficient kappa was 0.69 (P < 0.001). The scale was found to be responsive to changes in clinical status after surgery. Direct correlations were also found between the scale and patient age, duration of symptoms, BQ scores and the neurophysiological severity scale. The significance of these associations was maintained for 6 months after the operation.

CONCLUSION

This clinical severity scale is simple, reproducible and sensitive for evaluating severity of CTS in patients undergoing surgery.

Nemaline myopathy: description of an adult onset case

Nemaline myopathy is a rare congenital muscle disease, with neonatal or adult onset. We report clinical and ultrastructural study of a 73-year-old woman whose symptoms manifested at age 40 years with proximal muscle weakness, nocturnal cramps, muscle pain and walking impairment. Muscle biopsy showed rods and other typical findings suggesting nemaline myopathy. This myopathy should be taken into account in the differential diagnosis of adult onset myopathies. Only ultrastructural examination allows an exact diagnosis.

A new clinical scale of carpal tunnel syndrome: validation of the measurement and clinical-neurophysiological assessment

OBJECTIVE

To validate a new clinical scale of carpal tunnel syndrome (CTS). The scale is based on clinical history and physical examination findings and includes two figures. The first is a score determined by clinical history and objective findings. The second evaluates the presence/absence of pain as a dichotomous categorical score.

METHODS

One hundred and sixty-eight consecutive idiopathic CTS hands were studied in two centers (Rome, Siena). We compare the results of the historical-objective scale (Hi-Ob scale) with the results of other validated measurements of CTS severity: (1) the Italian version of the Boston Carpal Tunnel Questionnaire, (2) the neurophysiological classification adopted by the Italian CTS study group. Furthermore, for the Hi-Ob scale the intra-observer and inter-observer evaluations were assessed.

RESULTS

The main Hi-Ob parameter was positively related to the conventional validated measurements. Conversely, the category 'PAIN' of the Hi-Ob scale appeared unrelated to the other clinical and electrophysiological parameters. Intra- and inter-observer evaluation showed the reproducibility of the Hi-Ob assessment.

CONCLUSIONS

Our data show that the Hi-Ob scale is a reliable measurement which may be useful in CTS evaluation either for clinical or for scientific purposes.

Provocative tests in different stages of carpal tunnel syndrome

The frequency of positive results of four conventional provocative tests (Phalen sign, Tinel sign, wrist extension and pressure provocation test) was evaluated in 179 patients with clinical and electrophysiological findings consistent with idiopathic carpal tunnel syndrome (CTS), 147 control subjects and 39 patients with polyneuropathy. The diagnostic accuracy was evaluated for each test alone and in combination and the sensitivity correlated with the clinical and electrophysiological severity of CTS. For comparison of the CTS group with the control group, none of the tests reached sufficient diagnostic accuracy. The same was found for comparison of the CTS group with the polyneuropathy group, the Tinel sign being the least accurate. The combination of signs was not found to be more useful than single signs. The sensitivity of all signs was much less in severe clinical stages of CTS, especially for tests that increase the intra-carpal canal pressure. Traditional provocative tests, such as those tested here, have limited or no value for distinguishing patients with and without CTS, one reason being that their sensitivity depends largely on the clinical and electrophysiological severity of CTS. This correlation may also explain the contradictory results in the literature.

Symptoms and neurophysiological picture of carpal tunnel syndrome in pregnancy

OBJECTIVE

To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS.

METHODS

During 2000, the Italian CTS study group focussed on the occurrence of CTS in women during the final stages of pregnancy, enrolled in 7 Italian centers. In addition to the physician-centered and neurophysiologic traditional evaluations, we used a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment.

RESULTS

In our study, CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Our study provides evidence, reported here for the first time, of a correlation between edema and neurophysiological picture. Similarly, our study provides a correlation between validated patient-oriented measurement and edema. Moreover, a significant correlation between a negative trend (subjectively assessed) and smoking and alcohol consumption was observed.

CONCLUSIONS

Our observations confirm that the edema of the tissues in the carpal tunnel could induce a mechanical compression of the nerve. Moreover, our data suggest that smoking and alcohol consumption have a negative role in the evolution of the syndrome probably due to impairment of the microcirculation.

Cerebrotendinous xanthomatosis: 11-year treatment with chenodeoxycholic acid in five patients. An electrophysiological study

We report the electrophysiological follow-up of five cerebrotendinous xanthomatosis patients treated for 11 years with chenodeoxycholic acid (CDCA). Nerve conduction velocity (NCV) was reduced in three cases. P100 latency of visual evoked potentials was delayed in four cases, interpeaks I-III and I-V of brainstem auditory evoked potentials (BAEPs) was increased in two and interpeak N13-20 of upper limb somatosensory evoked potentials (SEPs) was slowed in one. After 4 months of therapy with CDCA, NCV was normal and did not show any significant change during the 11 years of observation. Central motor conduction time of motor evoked potentials (MEPs) and N24-P40 interpeak latency of lower limb SEPs were increased in five and four cases, respectively, in spite of 2/3-year treatment with CDCA. Improvement of evoked potentials, especially of MEPs and SEPs, was slower and continued over the whole 11-year period. The size of xanthomas slightly decreased in some patients during treatment and the clinical manifestations stabilized, avoiding progressive worsening, but there was no significant improvement in neurological deficit. Two sisters of patients who never took CDCA showed progressive worsening of clinical manifestations, upper limb SEPs and BAEPs.

Clinical and neurophysiological outcome of surgery in extreme carpal tunnel syndrome

INTRODUCTION

Surgical release is the most effective therapy for the symptoms of carpal tunnel syndrome (CTS). It is widely considered that surgery may be ineffective in 'extreme' cases (those with atrophy of the thenar eminence muscles and no sensory and motor response of the median nerve).

OBJECTIVE

To report clinical and electrophysiological outcome of 10 subjects with 'extreme' CTS surgically treated.

METHODS

Ten hands belonging to 10 patients (9 women and one man, mean age 65 years) underwent surgical release by the mini-incision of the palm technique. All showed atrophy of thenar eminence and absence of motor and sensory responses of the median nerve. The protocol consisted of clinical and electrophysiological evaluation, with the patient completing the self-administered Boston questionnaire (BQ) before the operation and one and 6 months after it.

RESULTS

After surgical release, all patients reported an absence of pain and disappearance or reduction of paraesthesia. Six months after the operation, motor and sensory responses of the median nerve returned in 8 and 5 hands, respectively. The BQ showed a significant improvement in symptom and functional scores, although muscle atrophy remained unchanged. No correlation was found between the degree of clinical and electrical improvement and the age of the patients.

CONCLUSION

It is possible to obtain good clinical and electrophysiological results even in extreme cases of CTS.

Nerve conduction velocity study of the upper limb in Raynaud's phenomenon

A prospective study of upper limb nerve conduction velocity was performed in 39 subjects (9 males, 30 females, mean age 46.8 years) with idiopathic Raynaud's phenomenon (RP) and 18 patients (3 males, 15 females, mean age 49.9 years) with RP secondary to systemic sclerosis (SS). Five subjects with idiopathic RP (13%) showed slowing of sensory conduction velocity (SCV) of the distal median nerve, associated with delayed distal motor latency (DML) of the same nerve in three patients, without clinical signs or symptoms of carpal tunnel syndrome (CTS). Three patients with secondary RP (17%) had reduction of SCV of the distal median nerve, associated with increased DML of the same nerve in one and with clinically silent slowing of SCV of the ulnar nerve in two (11%). Mean distal SCVs of the median nerve were significantly lower and mean DMLs were significantly higher in both groups with respect to a control group. Mean distal conduction of the ulnar nerve was significantly slower only in the group with secondary RP. No slowing was observed in the proximal part of any nerve. It seems likely that patients with idiopathic RP have slowing of conduction in the distal part of the median nerve, along the carpal tunnel. Since slowing does not occur in all parts of the nerves of the hand, it cannot be related to acral vasomotor disturbances, but to local or systemic factors. In contrast, patients with secondary RP had slowing of median and ulnar nerve conduction velocity, presumably related to subclinical distal peripheral neuropathy. A nerve conduction study of the hand could be useful in cases of suspected secondary origin of RP. In idiopathic RP, slowing of conduction may only affect the median nerve, whereas in secondary RP it may affect other nerves of the hand.

Sympathetic skin response before and after surgical release of carpal tunnel syndrome

Sympathetic skin response (SSR) was performed before and 1 year after surgical release of the median nerve in 20 subjects (mean age 52.8 years) with unilateral idiopathic carpal tunnel syndrome (CTS). SSR was evoked by stimulation of the ulnar nerve at the wrist contralateral to the side with CTS, recording from the palm, third (M3) and fifth fingers, and from the third finger contralateral to the side of CTS (M3c). Before surgery, anomalies of M3 SSR were found in 8 hands (40%): M3 SSR was absent in 1 hand; and the M3c/M3 SSR largest area ratio was abnormal in 7 hands, 3 of which also had abnormal mean differences between M3 and M3c SSR latencies. M3 SSRs were not significantly modified after surgery. The absence of postsurgical improvement may be due to the poor reinnervation capacity of sympathetic fibers.

Occult hepatitis B virus infection

Many studies have shown that hepatitis B virus infection may also occur in hepatitis B surface antigen-negative patients. This occult infection has been identified both in patients with cryptogenic liver disease and in patients with hepatitis C virus-related chronic hepatitis, and much evidence suggests that it may be a risk factor of hepatocellular carcinoma development. However several aspects of this occult infection remain unclear such as its prevalence and the factor(s) involved in the lack of circulating hepatitis B surface antigen. Moreover, it is uncertain whether the occult hepatitis B virus infection may contribute to chronic liver damage, considering that it is usually associated with a suppressed viral replication. Evidence and hypotheses concerning this fascinating field of bio-medical research are reviewed.

Hepatitis C is more severe in drug users with human immunodeficiency virus infection

Drug users with chronic hepatitis C virus (HCV) infection are frequently co-infected with human immunodeficiency virus-1 (HIV-1), but it is still not clear whether HIV-1 worsens the natural history of hepatitis C. To investigate this, we conducted a multicentre observational study in 163 drug addicts with histologically documented hepatitis C, 92 of whom were also infected with HIV-1: 25 (27%) were CDC stage II, 53 (58%) were CDC stage III and 14 (15%) were CDC stage IV. Eighty-eight (54%) patients had chronic hepatitis (CH) with minimal activity, 28 (17%) had CH with moderate activity, 40 (25%) had CH with severe activity and seven (4%) had active cirrhosis. Twenty-one HIV-negative patients and 15 HIV-positive patients admitted to alcohol abuse (29% vs 16%, P=0.0665). Liver disease was more severe in HIV-positive patients than in HIV-negative ones (P=0.0198): 34 HIV-positive patients and 13 HIV negatives had severe CH and cirrhosis. These two severe liver diseases were seen more often in HIV-positive patients with a history of alcohol abuse than in HIV-negative patients (10 out of 16 vs seven out of 21). Age, alcohol abuse and distribution of the histological categories of liver disease were statistically different in HIV-infected and HIV-uninfected patients. Multivariate analysis showed that age, alcohol abuse and serum antibodies to HIV were independently associated with severe CH or cirrhosis. Thus, HIV may enhance the risk of severe liver disease in drug users with hepatitis C, independently of the degree of immune dysfunction. Alcohol abuse may contribute independently, aggravating the cause of HCV-dependent liver disease.

Relationship between the self-administered Boston questionnaire and electrophysiological findings in follow-up of surgically-treated carpal tunnel syndrome

A prospective study of electrophysiological examination and the Boston self-administered questionnaire (BQ) was carried out in patients with surgically-treated carpal tunnel syndrome. There were 104 hands in 93 patients (13 men and 80 women, mean age 56 years). The BQ was used to assess the severity of symptoms and function, and nerve conduction studies were done before surgical release by short incision at the palm, and at follow-ups 1 and 6 months after surgery. The BQ severity score improved or became normal in 98% of hands. The mean BQ scores and distal sensory and motor conduction velocities in the median nerve showed significant improvement at the 1 month follow-up. Further significant improvement was found at 6 months. There was no relationship between the improvements in BQ scores and the distal conduction in the median nerve. The degree of improvement in sensory and motor distal conduction velocities could be forecast from presurgical values, whereas the degree of improvement in the symptoms and the functional status after release could not be predicted from the presurgical BQ scores.

Detection of genomic- and minus-strand of hepatitis C virus RNA in the liver of chronic hepatitis C patients by strand-specific semiquantitative reverse-transcriptase polymerase chain reaction

Studies aimed at correlating the intrahepatic hepatitis C virus (HCV)-RNA level and anatomo-clinical features have been difficult because of sensitivity and specificity shortcomings of available techniques. We titered the genomic- and minus-strand HCV RNAs by a strand-specific, semiquantitative, genotype-independent reverse-transcriptase polymerase chain reaction (RT-PCR) in the liver tissue of 61 patients with chronic hepatitis C. Findings were correlated with the levels of HCV RNA in the serum, the HCV genotype, the expression of intrahepatic HCV antigens, the histological activity (using separate scores for the lobular and the portal/periportal necroinflammatory activity and for the fibrosis), and the response to interferon alfa (IFN-alpha) treatment. Genomic- and minus-strand HCV RNA were detected in 59 and 57 liver specimens, respectively. The HCV-RNA level in the serum correlated with the genomic-strand, but not with the minus-strand, HCV-RNA titer in the liver. No correlations were found between either strand of the intrahepatic HCV RNA and the level of expression of HCV antigens in the liver, or with the grading/staging of the underlying liver disease. The response to IFN-alpha treatment could be predicted by the serum HCV-RNA level and genotype, but not by the intrahepatic level of genomic- or minus-strand HCV RNA. These results suggest that, although the detection of the minus-strand HCV RNA reliably identifies the presence of replicating HCV in its target organ, the quantitative measurement of viremia remains the clinically meaningful "golden standard" for assessing the level of HCV replication.

Electrophysiological evidence of a relationship between idiopathic carpal and tarsal tunnel syndromes

Electrophysiological findings are reported suggesting a relationship between idiopathic tarsal (TTS) and carpal tunnel syndromes (CTS) to explain that the coexistence of both entrapment syndromes in the same patients is not coincidental. Sixty-five patients with idiopathic CTS and 15 with idiopathic TTS were selected. None of the patients with CTS reported any symptoms, nor did they have any signs of TTS, and vice versa. Distal sensory conduction velocity (SCV) of the tibial nerve was reduced in ten of 65 patients with CTS; in five of these ten patients, tibial distal motor latency (DML) was also delayed. Reduced SCV and increased DML were evident in the median nerve of two patients with TTS. The mean of DML and SCV of the tibial nerve in the CTS group and of the median nerve in the TTS group were significantly reduced with respect to the control group without differences in the conduction of the ulnar, deep peroneal and sural nerves. This indicates that there was subclinical involvement of the median and tibial nerves in these patients. Besides having a narrow carpal tunnel, patients with CTS presumably also have a narrow tarsal tunnel and vice versa, and are therefore prone to develop both nerve entrapment syndromes. The different incidence of the two syndromes is explained on the basis of anatomical and functional differences between the two nerves.

Clinical and electrophysiological findings and follow-up in tarsal tunnel syndrome

The authors report clinical and electrophysiological findings in 59 patients with tarsal tunnel syndrome (TTS) and follow-up in 23 of them. The entrapment was prevalent in females; was bilateral in 6 patients and involved medial plantar in 7 and lateral plantar nerves in two cases. Eleven presented with other nerve entrapment syndromes or focal mononeuropathies, due to hereditary neuropathy with liability to pressure palsy or systemic diseases. The other 48 subjects had TTS without any other related entrapment syndromes: 23 were idiopathic cases, 13 had a history of local trauma, 3 had systemic diseases and the others had external or intrinsic compressions. The most frequent symptoms were paraesthesia or dysaesthesia (86% of feet) and pain (55%). Hypoaesthesia of the sole and weakness of toe flexion were evident in 74% and 22% of feet, respectively. Absence of sensory action potential or slowing of sensory conduction velocity (SCV) of the plantar nerves were present in 77% of feet; significant differences of SCV between affected and unaffected plantar nerves and/or between distal sural and plantar nerves were evident in 14%. Abnormalities of plantar SCV were therefore absent in only 9% of feet. Distal motor latency was delayed in 55% and electromyography showed neurogenic changes in 45% of sole muscles. Five cases (6 feet) underwent surgery with excellent or good results in 5, 4 of them also showing improvement in distal conduction of the plantar nerves. Nine were treated with local steroid injections, with good results shown in 6 patients. Nine other patients who did not receive any therapy showed a disappearance of symptoms or good outcome in 6 cases. The subjects with poor therapeutic results had S1 radiculopathy or systemic diseases. The authors underline that patients with connective tissue diseases should not be treated by surgical decompression because they may have subclinical neuropathy. Some subjects with idiopathic or trauma-induced TTS recover spontaneously. Surgical release should be limited to cases with space-occupying lesions and when conservative treatments fail.

Requests for electromyography from general practitioners and specialists: critical evaluation

In order to improve the quality of service and limit costs of a local electromyographic service, the requests for electromyographic (EMG) examination issued by general practitioners and specialists were critically evaluated. The diagnoses suspected by referring doctors were compared with medical history and clinical data to analyze (1) the utility of EMG for the final diagnosis and (2) the concordance with that of the neurophysiologist and with the EMG results. In 1994 and 1995, there were 3482 patients referred to the EMG service. Only patients undergoing EMG for the first time (2706 subjects) were considered. In 76.6% of cases, the referring doctor had indicated the suspected diagnosis in the request. This diagnosis was compatible with medical history, symptoms and the results of neurological examination in 57.6% of cases. In 77.2%, the neurophysiologist considered the EMG useful in confirming the clinical diagnosis. The suspected diagnosis was confirmed by the clinical diagnosis of the neurophysiologist and by the EMG results in 54.2% and 45.4% of cases, respectively. When the request was issued by neurosurgeons, neurologists, orthopedists, rheumatologists and physiatrists, the suspected diagnosis was more accurate; as a consequence the EMG was more correctly oriented than when the request was issued by other specialists or by general practitioners. It is recommended that neurological examination be a prerequisite for EMG requests issued by general practitioners.