"Reporting Imaging Findings when you disagree with the Radiologist"
Quickie Consult 1222
Clinical Information 270 CI
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006
"When to Order an EMG-NCV"
Dr. Studin: Hello, please give me the clinical scenario again.
Guest: Patient does a motor vehicle collision, injured was male, early forties. Presents with all of the classics, right. Spasm, reduced range of motion, headaches. The main major thing is ridiculous symptoms down the right arm with difficulty gripping anything. Can't hang onto a fork or a knife. So we ordered an MRI, and it took about a week to get the imaging done, just because of his schedule. We tried to get them in right away. And so within that week, the ridiculous symptoms down the arm has some mostly subsided.
It's hard to tell subjectively, just terrible historian, not a great communicator and that's okay. So just trying to rely on objective tests. Um, you know, can't read what has persistent. Yeah. What's persistent is dysfunction.
Of this right hand? All five fingers.
Guest: No, mostly the fourth and fifth, although it's hard to tell. So I did a tuning fork test, you know, it's one 28 on that fourth metacarpal and he just went through the roof. So, it was fractured. Yeah. So, I x-rayed the hand. I cannot see the fracture, but it was unmistakable, you know, and here's the other weird thing, just trying to release some help him with some palliative, gave him a tens unit, set him up with it was showing him how to put it on the thoracic spine between a T three and T like nine, you know, vertically oriented on the thoracic spine. As soon as I turned that on, his left arm started tingling, numbness. So I take it off right away.
Dr. Studin: So you've got a few diagnostic dilemmas here. You can't close his hand. Is there a fracture? Work suggested x-rays are inconclusive, so you need to rule out a fracture. So that leaves you two choices. Either a cat scan or a bone scan and a bone scan has much less radiation than a cat scan. So, I would consider that to conclusively diagnose that. Does he have any residual radicular stuff even though it's abated or is it a hundred percent God?
Guest: No, there is some residual. And the MRI is inconclusive.
Dr. Studin: Did you interpret the MRI or did you just read the report?
Guest: for the cervical MRI? I read the report. I looked at it myself. I agree.
Dr. Studin: So you looked at the image and you concur with the report that there's nothing going on.
Okay. So, there's two things that I would do in this particular case. Number one, I would order a bone scan only because I don't want to give the guy equivalent of like, you know, like a hundred X rays in the cat scan. That's number one. And number two, I would do an EMG NCV nerve conduction study.
Guest: Okay. I've got that ordered.
Dr. Studin: I just wanted to make sure I was going in the right order and remember this; the symptoms are bathing. There could be a fluid issue cause remember even though the MRI is negative, if there's a fluid imbalance or that area and the CSF when and if the area closes in a little bit of fluid could act as a solid, that's number one. Number two, the nerve could have been contused, and it's just starting to heal for lack of a better word. And some of those symptoms are a bad thing but you still haven't concluded your diagnostics. So again, bone scan, AMG, MCV and VAT should give you a conclusive diagnosis so that you can get the patient in the right direction. And as far as the fracture goes, you need it, you know, you need to get that done. Did you bring your x-rays to a radiologist to look at it also?
Guest: Yeah, I just sent them out today. Um, just to see if I'm missing something on that. I do have the MTV EMG is ordered for the first thing next week.
Dr. Studin: Got it. Okay. Yup. Sounds to me like you're right on. You're right on top of this.
Guest: Thank you.