Abnormal EMG and Hyperreflexia

[wisewhisk]

Hi all,

This all started in July 2024 with some patchy numbness (fingertips on both hands, a small area on my back, and both knees). I have cervical stenosis at C4-C5 and thought it could be related but the neurosurgeon suggested to refer to neurology just in case. I saw neuro and they noted that I had hyperreflexia in both knees but no weakness. So they did a complete blood workup (all normal except mildly elevated autoimmune disease markers) and a brain/spine MRI (normal except some degeneration of the L5-S1 spine).

EMG was done yesterday and below are the results which showed active and chronic changes in muscles L5-S1 on both legs and near the spine. The neurologist who did the exam was surprised I didn't have sensory findings and noted that there was still no weakness. However, in the past few weeks I noticed I had knee and ankle pain possibly due to non-observable gait changes as well as twitching all over my body throughout the day (for a few seconds in each location but not long). The EMG didn't show any fasciculations however. The neurologist didn't provide any potential reasons for the abnormal EMG in his conclusion as he mentioned that it was up to my referring neurologist to determine the reason.

This could be due to the L5-S1 degeneration that was found on the MRI but it noted that there wasn't any severe stenosis or narrowing. However, I have had lower back pain, mainly on my right side, for ~2 years. The neurologist who did the EMG didn't test my arms at all, which surprised me since I had fingertip numbness (which as improved) so I don't know if other muscles, besides my legs are affected.

I haven't talked to my neurologist yet but I've gone into the Google/Reddit black hole and convinced myself I have early ALS. The hyperreflexia first started me down the ALS path and with the negative MRI and abnormal EMG, it's made it more possible. The EMG is a bit confusing to interpret but based on my research, it could fit both radiculopathy or early ALS. Thoughts are appreciated.

 

[lgelb]

My advice is to stop reading about ALS and EMGs. It does no good. For an EMG to be valid, does not require that they test all the muscles that you see issues in. The hallmark of ALS is motor neuron damage affecting a variety of muscles that you don't have a motor problem with, and late-breaking pain does not count at all.

Why not talk with the neurologist who can reassure you based not only on the EMG but their exam and your history? As they have said, this is not an EMG that can be interpreted either way. It does not support ALS. "Consistent with radicular involvement" means the damage in your spine, which is likely also responsible for the back pain, previous numbness, etc. can be seen on the EMG. And that points to a possible role for PT, which I would ask the neuro about.

 

[wisewhisk]

Thanks for the feedback. Spoke with the neurologist who at first said that he still didn't think ALS was a likely diagnosis. He asked me to send him a video of my twitching. Then I got a phone call today from the clinic saying that I should come in to see a neuromuscular specialist. I'm not sure what changed the neurologist's mind (maybe the video or maybe he spoke with another neurologist about my case).

Now my anxiety is through the roof.

Question (not sure if anyone can answer) - from my EMG, my gastrocnemius muscles have both active and chronic denervation while both of my tibialis anterior muscles have only chronic denervation. Because the tibialis anterior muscles only have chronic changes, would that make ALS a less likely diagnosis?

 

[lgelb]

Yes.
But there's a total clinical picture and history + tests to consider as well.