Eric, let’s back up and see what we actually know…
UMN: The clinical exam performed by Neuro 1 found: “Neuro exam pertinent for tendon hyperreflexia and increased tone in the lower extremities.” These may be a sign of UMN lesions, but I believe there are dozens of potential causes of this finding. A lot (like a severed spinal cord) can be ruled out, but I don’t know that others like spinal cord tumor or stenosis have been.
By the way, Wikipedia says, “The most common cause of hyperreflexia is spinal cord injury…. But hyperreflexia can be developed via many other causes, including medication and stimulant side
effects, hyperthyroidism, electrolyte imbalance, serotonin syndrome and severe brain trauma.”
You said his MRI came back fine. What was this an MRI of? Lumbar, thoracic, cervical? In other words, has his whole spinal cord been examined for a possible cause of the hyperreflexia?
LMN: Next, “EMG/NCS: The electrophysiologic findings are suggestive of a widespread disorder of lower motor neurons with active axonal loss (fibrillations, positive waves) and motor unit irritability (fasciculations, cramps), evident more in bi lateral lumbar, and less in cervical myotomes. These findings can be seen in disorders of anterior horn cells or extensive polyridiculopathies. No evidence of myopathy.” Anterior horn cells are cells in the spinal cord. Polyradiculopathies are many radiculopathies, which are basically pinched nerves at the root (“radix”) which is at the spinal cord. And note that polyradiculopathies are not ALS. Could some other spinal condition, or two simultaneous conditions, be causing the apparent UMN and LMN signs? I don’t know, but have all spinal cord conditions been ruled out? (Can’t be ALS until everything else is ruled out.)
WEAKNESS: I believe you have indicated he has no perceived weakness and was 5/5 on all strength tests. This makes it not sound like ALS to my non-doctor mind, but we have to be careful. Nerves lose about 70% of their fibers before weakness is generally noted by the patient. So, yes I guess it’s possible to perceive no weakness and still have a dirty EMG.
Based on what you have stated, it seems to me the answer is a big INCONCLUSIVE. (Which in the world of ALS means--Not ALS… at least not yet.) So, I’d say don’t give up hope, don’t get depressed, don’t get anxious. Just move on to the next step… UofM or a similar institution. The diagnosis of ALS or discovery of the other neurological cause is a long journey. Journey on!