Worried about possibility of ALS

[ncoetzee]

Hi everyone,

This thread is related to my husband, 30 years of age.

He developed a limp in September 2018, which worsened and he was diagnosed with left foot drop in January 2019. We went to see a neurologist to determine the cause; however, he was unable to provide definitive answers and we were told to keep an eye on any progression. The neurologist conducted an MRI of the lumbar area to rule out any disc/foraminal stenosis issues. He also conducted a list of blood tests which indicated low Vit B12 and Vit D (my husband was put on supplements). He conducted a nerve conduction test as well as an EMG. Kindly see results attached (the neurologist told us that the results are abnormal but he is not able to diagnose any specific problems).

Since then my husband attended physiotherapy sessions in order to improve his walking. His left upper leg has atrophied to almost half the side of his right upper leg. In the last month he has showed a reduction in his ability to do a calf raise on his right side (which was not a problem before) as well as range of movement and strength in dorsiflexion. He has muscle twitches all over his body and severe cramps in several muscles, sometimes strange muscles such as the abdominal muscles or intercostal muscles. I have also noticed that when he lies on his back and is busy on his phone, his hands become tingly. We are currently awaiting drs appointments as we recently moved to a new country and it was a bit of a mission to get appointments with the corona situation.

So my question is, from the old data as well as newly developed symptoms, is there a possibility that this might be early stage ALS?

Thank you.

 

[Nikki J]

the table you posted is the ncs not the emg. Ncs abnormalities point away from ALS. Was the emg normal? There should also have been a summary page. Tingly is sensory which also points away from ALS. He needs to see a doctor for reevaluation of course

 

[ncoetzee]

I believe the table contains both NCS and motor summary information. EMG was abnormal. This is the summary form the dr:

"What concerns me currently is the positive sharp waves on the left ant tibialis muscle, together with
polyphasic units during action innervated by mostly L4, where there is no real stenosis at the L4 level, and
the fact that there are abnormal wave patterns also present more proximally in the left (mostly) but also
some on the right vastus lateralis muscle.
At this stage I haven't done any further LP, but the blood tests only indicate a low Vit B12, and a low Vit D
level. This patient has signs of a motor neuropathy involving the left posterior tibialis and peroneal nerve,
with minimal signs present on the right side, but mild EMG changes on the right side."

With regard to tingling is his hands, I am not sure whether this might be due to the position he is in, but I mentioned this because it did not occur in the past.

 

[Nikki J]

What is displaying for me in the second attachment is the ncs which includes motor nerves. Are you seeing a table that lists tested muscles in a downward column and then categories like fibs, psws, fascics, recruit, mup in the across? That is what the emg looks like If it is there but not displaying to everyone can you post it separately?

it sounds like he needs follow up but the summary sounds non specific. They may want to repeat the emg at 3-6 months. I hope you are seeing a neuromuscular specialist

 

[Nikki J]

This is an example of the chart ( taken from an internet teaching site) I mentioned that should be part of your report

 

[ncoetzee]

Hi Nikki,

This is the only report we received from this dr. Yes we are going to see a dr hopefully within this month and will probably redo all of these tests. I was just hoping someone will be able to definitively point me away from ALS based on the EMG results as the neurologist was a bit vague (in the opinion of his physiotherapist as well). As we just moved to a new country we need a GP's referral to see a neurologist. So that is what we are waiting for now.

With regard to your second response - no we did not receive a table like this. Thank you. We currently have a lock down in the country where these were conducted so I will reach out t the dr to find out whether he did indeed obtain that info.

Thank you

 

[Nikki J]

There definitely should be a table even if he didn’t do as many muscles as my example ( it was from a teaching site- in real life they do only what is clinically indicated). your new neurologist will want it so worth pursuing. Probably just got left out of your copy by mistake

 

[ncoetzee]

Thank you, I will definitely request that table then. I did not even know the info was missing. Apologies, he provided the following regarding the EMG and NCV that I failed to post in my previous response:

"NCV & EMG Findings:
Sensory conductions in the feet are normal.
There is reduced amplitudes of the left peroneal nerve conduction using the EBD muscle, but no conduction block over the fibular head is noted. Using the Tib ant muscle no overt conduction block is noted either over the head of the fibular. The conduction velocity is within normal limits.
The left post tibialis nerve also shows decreased amplitude, with normal conduction velocities.
On the right the peroneal nerve shows a lower amplitude with normal conduction velocities.
The post tibial nerve appears to be normal on the right side.
Based on these findings it appears to be an axonal problem present.
EMG done of the left tib anterior: Polyphasic, smallish to medium amplitude present. Positive sharp waves were noted at rest which were very rhythmic (1/second)
Left Vastus Lateralis: Spontaneous fasciculations were noted, some polyphasic. During activity some large polyphasic units were noted.
Right Tib Anterior: During rest:No abnormal units noted; During activity: mildly polyphasic units.
Right Vastus Lateralis: Polyphasic fasciculation noted during rest, with activity mostly normal looking, but at times 1+polyphasic large units."

Thank you for your time. I appreciate it.

 

[ncoetzee]

Thank you, I will definitely request that table then. I did not even know the info was missing. Apologies, he provided the following regarding the EMG and NCV that I failed to post in my previous response:

"NCV & EMG Findings:
Sensory conductions in the feet are normal.
There is reduced amplitudes of the left peroneal nerve conduction using the EBD muscle, but no conduction block over the fibular head is noted. Using the Tib ant muscle no overt conduction block is noted either over the head of the fibular. The conduction velocity is within normal limits.
The left post tibialis nerve also shows decreased amplitude, with normal conduction velocities.
On the right the peroneal nerve shows a lower amplitude with normal conduction velocities.
The post tibial nerve appears to be normal on the right side.
Based on these findings it appears to be an axonal problem present.
EMG done of the left tib anterior: Polyphasic, smallish to medium amplitude present. Positive sharp waves were noted at rest which were very rhythmic (1/second)
Left Vastus Lateralis: Spontaneous fasciculations were noted, some polyphasic. During activity some large polyphasic units were noted.
Right Tib Anterior: During rest:No abnormal units noted; During activity: mildly polyphasic units.
Right Vastus Lateralis: Polyphasic fasciculation noted during rest, with activity mostly normal looking, but at times 1+polyphasic large units."

Thank you for your time. I appreciate it.

Please note that these tests were also performed January of 2019.

 

[KarenNWendyn]

This is an example of the chart I mentioned

Nikki, I assume you provided that illustration as an example of EMG data, not as the actual results for ncoetzee’s husband (I was initially confused by it and wanted to clarify in case anyone else is confused).

EMG done of the left tib anterior: Polyphasic, smallish to medium amplitude present. Positive sharp waves were noted at rest which were very rhythmic (1/second)
Left Vastus Lateralis: Spontaneous fasciculations were noted, some polyphasic. During activity some large polyphasic units were noted.
Right Tib Anterior: During rest:No abnormal units noted; During activity: mildly polyphasic units.
Right Vastus Lateralis: Polyphasic fasciculation noted during rest, with activity mostly normal looking, but at times 1+polyphasic large units."

This would be good to see in chart form which is what I think Nikki was requesting.

Ncoetzee, your husband’s presentation is concerning, but at this point could still be any number of things. If that EMG was done in January 2019, then it’s definitely time for a new assessment and a new EMG. Best of luck and please keep us updated.

 

[ncoetzee]

Hi Both,

Thank you very much, I will try to obtain the emg tables from the old neurologist. And try to press for a closer appointment with the new dr then.