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The Value of Electromyography in Neurology

A. A. MARINACCI, M.D., Los Angeles

GALVANI IN 1791 observed from studies of neuro- * By detection of muscular fibrillation, a sign
muscular sections of frogs' legs two fundamental of motor nerve impairment, through e/ectro-
principles: that muscle contracts when stimulated, myography, diseases of the motor nervous sys-
and that an electrical current is generated during tem can be distinguished from muscular dis-
such contraction. orders, malingering, and psychoneurotic states.
In the light of today's knowledge it is proper to The site of lesion can be determined and the
assume from Galvani's observations that the current degree of impairment and progress of recov-
produced during the contraction of muscle is the ery can be estimated. The method has been
electrical counterpart of the motor unit action poten- used successfully in amyotrophic lateral sc/ero-
tial that is generated during voluntary contraction. sis, poliomyelitis, peripheral neuritis and neuro-
Schiff in 1851 dissected the hypoglossal nerve of nitis, and root compression syndrome, as also
the tongue of a dog and observed fibrillation of the for indirect evidence in muscular dystrophy and
affected muscle five days later. He further demon- other myopathic conditions.
strated that fibrillation is the result of nerve degen-
eration and ceases as the nerve regenerates.
From Schiffs discovery it is concluded that de- The degree of fibrillation indicates whether the lesion
nervated muscle fibrillates because it has been dis- is minimal, slight, moderate, severe or complete.
connected from its nerve supply, and that fibrillation Nerve Regeneration
ceases either when the nerve is regenerated or when
the muscle has undergone fibrosis. The electromyogram has proved to be of great
Denny-Brown and Pennybackerl reported observ- diagnostic and prognostic value in determining the
ing the fibrillation of denervation both in experi- rate of nerve regeneration not only after repair but
mental animals and in human beings with amyo- also in lesions regenerating without repair. Regen-
trophic lateral sclerosis. They observed that the eration of the nerve after serum plexitis, neuronitis,
denervated fibers fibrillate independently. neuritis and other reversible conditions of the lower
Weddell, Feinstein and Pattle,10 the first to apply motor neuron also can be followed electromyograph.
electromyography in clinical neurology, were able ically. In many cases nerve regeneration can be de-
to localize the lesion and follow the course of nerve tected from four weeks to four months before de-
regeneration in a number of neurological conditions. tectable clinical recovery.
Jasper and co-workers5 also applied electromyog- Degenerative Diseases of the Spinal Cord
raphy in studies of peripheral nerve regeneration
and in studies of poliomyelitis and other diseases In early amyotrophic lateral sclerosis, when there
of the lower motor neurons. Huddleston and Gol- may be no other clinical symptoms than, for exam-
seth4 in 1948 reported upon the value of electro- ple, wasting of the hand, an electromyogram may
myography in poliomyelitis, and Kugelberg and co- indicate not only fibrillation in both upper extremi-
workers6 found the method useful in the diagnosis ties but also the beginning of axon interruption in
of muscular dystrophy. The author7' 8 has reviewed both lower extremities signifying diffuse progressive
the clinical use of electromyography in 2,500 cases. degeneration of the lower motor neurons.
The electromyographic finding in multiple sclero-
Nerve Injuries sis is usually diffuse spotty fibrillation of denervation.
Electromyography in nerve lesions indicates the In some cases other effects may be suspected; for
degree of involvement. If the nerve is completely example, although only the muscles of the hand are
cut only fibrillation is recorded; no motor unit po- affected, lower motor neuron disease may be sus-
tentials are generated. In partial lesions, portions pected, but the electromyogram may indicate only
of the muscle show fibrillation while in other por- peripheral nerve involvement.
tions motor units are generated by voluntary efforts. By revealing progressive degenerative disease of
From the Department of Electromyography, Hospital of the Good the spinal cord in the earliest stage, the electromyo-
Samaritan, the University of Southern California School of Medicine, gram often makes it possible to relate to the organic
and the Los Angeles County General Hospital, Los Angeles.
Presented before the Section on Psychiatry and Neurology at the
82nd Annual -Session of the California Medical Association, Los
changes symptoms that otherwise might be attrib-
Angeles, May 24-28, 1953. uted to hysteria or psychoneurosis.
Infectious Disease of the Lower Motor Neuron when the patient is completely relaxed there is no
In anterior poliomyelitis it can be definitely deter- fibrillation of denervation.
mined from the electromyogram what specific group In neurogenic disability the interruption of the
of muscles is affected and the extent of denervation. axon puts the entire unit out of action, whereas in
This information is important in planning physical myopathosis the muscle fibers separately cease to
therapy, which is advisable in partial denervation. function. The motor impulses remaining in neuro-
The same is true in peripheral neuritis or neuronitis. genic disability, therefore, are usually of higher
Root Compression Syndrome voltage, of longer duration and less frequent than in
It should be emphasized that root compression myopathy, and it may even be difficult to detect
syndrome cannot be diagnosed by electromyography them, while in myopathy they are clearly discernible
unless fibrillation is present throughout a group of by electromyography and numerous in relation to
muscles innervated by one myotome, or root. For the degree of muscle atrophy.
example, in involvement of the fifth cervical root In myotonia the burst of impulses may continue
the fibrillation would be present not only in the for 30 to 50 seconds, but there is no fibrillation. In
anterior primary division but also in the posterior myasthenia gravis there is first a burst of impulses
primary division-in the sacrospinalis between the activated by voluntary efforts diminishing in size,
fourth and fifth cervical vertebrae, in the rhomboid, amplitude and frequency in a short period because
the supra-infraspinatus, the deltoid, the biceps and the patient cannot maintain them. In myasthenia
the brachioradialis. A few fibrillations and poly- gravis, Prostigmineg causes a temporary reversion
phasic motor impulses observed only in the brachio- toward normal motor impulses.
radialis and the deltoid would not justify the diag- Electromyograms may be accepted as conclusive
nosis of root involvement. evidence of poliomyelitis in persons desiring to
In localizing root involvement of the lumbosacral qualify for assistance from a poliomyelitis aid fund.
region it is necessary to test the entire myotome. If Also, muscular dystrophy is sometimes distinguished
the first sacral root were involved, fibrillation and from either poliomyelitis or upper or lower motor
abnormal motor units would be detectable in the neuron disease by electromyography. Other distinc-
gastrocnemius, the hamstrings, the gluteus maximus tions possible are those of primary muscle atrophy
and the erector spinalis between the first and second from progressive spinal muscular atrophy; late dis-
sacral vertebrae. As in the example above, a few indi- tal myopathy from peroneal spinal muscle atrophy
cations of fibrillation in the gastrocnemius and the (Charcot-Marie-Tooth type), and proximal myop-
hamstrings would not be diagnostic. Electromyo- athy from proximal spinal muscular atrophy. In
graphic abnormalities are most pronounced in cases conditions in which muscular dystrophy is combined
of definite insult to the root that causes relatively with disease of the lower motor neuron the relative
definite and-prolonged disability; only slight changes importance of each can be determined.
or none at all may be shown in cases of temporary 1. Denny-Brown, D., and Pennybacker, J. B.: Fibrilla-
attacks causing little disability. tion and fasciculation in voluntary muscle, Brain, 61:311-
334, Mar. 1938.
Shea, Woods and Werden9 found electromyog- 2. Galvani, L.: De viribus electricitatis in motu muscu-
raphy of great help in root compression syndrome lari commentarius, Memoirs of the Institute of Sciences,
7:1791, Bologna, Italy.
in conjunction with neurological examination and 3. Golseth, J. G.: Diagnostic contributions of the electro-
myelography with Pantopaque.® The method may myogram, Calif. Med., 73:355-357, Oct. 1950.
also be useful when studies with Pantopaque indi- 4. Huddleston, 0. L., and Golseth, J. G.:. Electromyo-
graphic studies of paralyzed and paretic muscles in ante-
cate doubtful abnormality or none. The electromyo- rior poliomyelitis, Arch. Phys. Med., 29:92-98, Feb. 1948.
gram identifies the site in about 90 per cent of cases 5. Jasper, H. H., and Ballem, G.: Unipolar electromyo-
grams of normal and denervated human muscles, J. Neuro-
when the fifth lumbar disc is involved and only physiol., 12:231-244, Oct. 1949.
slightly less when the fourth disc is the site. It has 6. Kugelberg, E.: Electromyography in muscular dystro-
been found that the diagnosis of root compression phies, J. Neurol., Neurosurg. and Psychiat., 12:129-136,
syndrome is much more frequently confirmed when 7. Marinacci, A. A.: Electromyography as an adjunct in
both electromyography and Pantopaque myelog- neurological diagnosis: A review, Bull. Los Angeles Neurol.
raphy are used than when either is used alone. Soc., 18:25-39, Mar. 1953.
8. Marinacci, A. A.: Clinical Electromyography, San
Myopathic Conditions Lucas Press, Los Angeles (in press).
9. Shea, P. A., Woods, W. W., and Werden, D. R.: Elec-
In muscular dystrophy the recorded impulses are tromyography in diagnosis of nerve root compression syn-
not only more faint but also shorter, varying from drome, Arch. Neurol. & Psychiat., 64:93-104, July 1950.
1 to 2 milliseconds and up to 150 microvolts; but 10. Weddell, G., Feinstein, B., and Pattle, R. E.: The
electrical activity of voluntary muscle in man under normal
they do not diminish in proportion to the degree of and pathological conditions, Brain, 67:178-257, Sept. 1944.
atrophy, because gradual destruction of the individ- 11. Woods, W. W., and Shea, P. A.: The value of electro-
myography in neurology and neurosurgery, J. Neurosurg.,
ual muscle fibers reduces the size of the motor unit; 8:595-607, May 1951.
VOL. 80, NO. 4 * APRIL 1954 315