Welcome to a new episode of AANEM's Lessons from the Lab. I'm Devin Rubin. I'm a neurologist at Mayo Clinic in Jacksonville, Florida, and I'll be hosting this next episode. I'm really excited for this episode. We have a great guy, a great physiologist and physiatrist who I'm going to be interviewing and presenting a case. He's actually a neighbor to me down in South Florida. And I have a challenging case, one that we saw in the lab. It's kind of an interesting case, and I'm looking forward to picking his brain, seeing how he would approach this patient, learn a bit from him, and hopefully will teach the viewers something about an approach to a unique situation. So sit back and enjoy, and welcome to Lessons from the Lab. It's a pleasure to introduce the next expert and guest on Lessons from the Lab. That's Dr. Robert Irwin. Dr. Irwin is a professor of physical medicine and rehabilitation at University of Miami, and he is the current president of the AANEM. So welcome, Bob. It's great to have you here. Well, hey, Devin. Thanks for inviting me. I'm excited about this. I'm really honored to be here. So I'm excited to see how this goes. Well, I'm honored to speak with you and a neighbor Floridian. I was just down in Miami in the airport last week. I thought I was going to have to call you because my plane kept getting delayed, and I needed a place to sleep, but it eventually went. So I made it home to Jacksonville. Yes, Miami can be a little tough with that airport. Yeah, yeah, but at least I can drive home if I got stuck. I almost got off the plane and rented a car, but I'm home. So have you had a good week? It's been a busy week. I've been on call, so covering lots of extra patients. And there was a little lull in June, but it's July now, and everybody's back and trying to get in before school starts. Who knows what August is going to bring when school starts, so we'll see. And you never know when the hurricanes are going to hit and then totally shut everything down. That's right. The water's warm this year, so we'll see. Exactly. But then soon there'll be the annual meeting in Phoenix, right? Yeah, we don't have to worry about any hurricanes there. I think it's going to be a great meeting. It's going to be a little different this year. I'm kind of focusing more on some physical medicine and rehab topic type stuff, looking at disability in neuromuscular disease and kind of a different view than what we may normally get looking at cures for things. And we've got a bunch of people out there who aren't candidates for the cures and still have issues. And so we kind of need to know what's going on and how to address those. So I think it's going to be really interesting. Yeah. Yeah. I've looked at the program. I'm going to be there the whole time, so I'm excited about it. And how has it been? Let me ask you, what has been your favorite thing of being president of AANEM? My favorite thing about being president, actually, the favorite thing was choosing the plenary, like choosing who the speakers were, talking with them, talking about my vision of what I wanted to put together. You know, when you put together six different speakers, you kind of have to coordinate instead of just giving them, here, talk about this, so that it sort of looks like a big pie as opposed to a bunch of pieces of pie together. So that was really fun, getting to talk to these people. They're so smart. They're so good at what they do. It's just kind of amazing that these people aren't recognized more for what they do. So you know, I think it's really good. It was a good learning experience for me as well, because it also allowed me to see what are the things that are going on in their specialty areas that I didn't know about. Yeah, well, I'm excited to hear them. So again, you've done a fantastic job in putting this together, so kudos to you. Thank you. And speaking of learning experience, I'm excited to learn from you a little bit. And as you know, I think that these lessons from the lab, the goal of this is for us to just discuss a case, so the viewers, we can teach the viewers and learn from each other about how we might approach a certain case that comes to us in clinic or in the EMG lab. So I'd like to present an interesting patient to you and pick your brain and see what you might do to evaluate this patient. So does that sound okay? That sounds good. Let's hope I got enough brain left that I can give you some information from it. All right. Well, so the case is pretty simple or pretty straightforward. And it was a guy who was, I think, about 50 years old, so a young man. I just had a birthday, so 50 seems really young to me, but happy birthday. Thank you. Thank you. So he was a 50-year-old man, and he developed this pretty sudden onset of pain involving kind of his left shoulder. And it came on over the course of a few days. He had a little bit of paresthesias in his left arm, and at the same time, he developed a rash around his shoulder and a little bit up on his neck. And he was found to have some fluid-filled vesicles, and he was diagnosed with shingles and treated for shingles. And he was doing well, and about six weeks later, he was picking up a cup of coffee, and he felt that poking sensation on his right, like his scapula was kind of poking his shirt. He kind of felt it felt sort of weird. And then he noticed over the next couple of weeks that when he would do any type of activity overhead or like pushups, that he felt kind of weaker on the right side, and he felt like his scapula was kind of pushing outward. He didn't have any other symptoms in his arm. He still had a little bit of pain in the left neck, but that was improving with the treatment. And he didn't have any neck pain on the right side or arm pain on the right side or any sensory symptoms on the right. So you say that he was getting treatment, we're six weeks out. So in someone who I'm presuming had shingles, that they got antivirals, and by that time that would be out. So what sort of treatment was he getting at six weeks out? Well, he had gotten the course of antiviral and I think they had put him on gabapentin for some of the pain and paresthesias. That was it. So he was not finished. Of course. Yeah. OK. He was not getting any physical therapy. He wasn't doing any home exercises or anything like that, I'm assuming. Right. Right. And he hadn't on the left neck, the left shoulder, he didn't have any weakness. It was just pain. And he had a bit of paresthesias and he didn't have any symptoms on the right at the time. And he had shingles, which was kind of interesting. So let me just get this straight. So his rash was on the left side or on the right side? It was on the left side. So everything's on the left side, nothing on the right side. OK. And, you know, this kind of when it first starts, we kind of think of all the things it could be. And just because he had shingles doesn't mean he can't have something else on top of it. So we kind of have to think about that. I generally think about somebody who comes in and I might see them before the rash, in which case then all these things run through my head, whether he's got a C5 or C6 radiculopathy, whether he has an idiopathic brachial plexopathy, you know, so you have to kind of look at that. The other thing you'll think about is maybe myopathies if it's weakness, but with pain, I don't think so much myopathies. So, you know, weakness, definitely you're six weeks out. But since we have something that looks like a trigger, we're going to kind of focus in on that. So it sort of looks like he's got a viral plexopathy at this point. But it doesn't mean he can't also on top of that have a C5 radiculopathy that's giving him weakness of his rhomboids and levator scapula. And that makes his, you know, medial portion of the scapula a little bit weaker. And that may stick out when he tries to do things. The other thing is depending on how the scapula moves, you know, it could be the serratus anterior like we see a lot and that you get winging with that. So those are the kind of things that run through my head. So now he's six weeks out from his shingles and got weakness. This also goes along the same sort of timeline that you see with someone with a idiopathic brachial plexopathy that we used to call Parsonage-Turner to sort of see the same timing that you get weakness afterwards. So what happened next after he started complaining of this? So let me ask you a question. So if this guy, if that was the story, you got the history, what would be your next step in the evaluation? So there are a couple of things you could do. One, if you're really not sure of the diagnosis or you're not sure what's being involved, we might move to nerve conduction studies and EMG. I would do that before I would do an MRI of the neck because I think that that gives us a better look at a radiculopathy as well as a plexopathy, as well as if it's just an isolated nerve injury. So that's a good thing to move on. It also is nice because you're six weeks out, you might be able to get some good information on return of function, whether he's got return of the nerve, what do the motor units look like? And so that's what I would go with. I would order that. I would also get him into some physical therapy to kind of start working on things right away. There's no reason to delay that at any point in time. If he's not having pain, the use of gabapentin at this point may be able to be stopped because that's really for pain. It's not going to help anything for weakness. So those are the things I would look at. I wouldn't stop it if he has any pain at all because it may be keeping it down. And if you stop it, suddenly he may have terrible pain. And that can happen post-herpetic infection that you can get bad pain afterwards. This is why we try to get them under control quickly. Right. Yeah. So you're answering all my questions right away, but I'm going to back up for a second. No, this is great. This is a great. So I know this was an obvious oversight. Not an oversight, but you assume that we would have examined the patient, which is always a good thing to do first, right? And so I want to ask you a question because he had this sort of protruded scapula that he felt. And I know we want to try on our clinical exam to try to determine what the problem might be. Right. So I don't have, I'm going to show you, I'm going to just share a slide here on my screen and see if I can pull this up real quick here. And I... So while you're doing that, I want to talk to people. It depends on who's reading or listening to this. But one of the things in my clinic is if it's a new patient coming in or a patient coming in with a new complaint, they need to be in a gown. Okay. You actually need to see their skin. All right. You need to know if there's a rash. You need to know if there's other things going on. And when you're looking at things like scapular dyskinesis, which may not be viral, you got to see how the scapula moves. So in my clinic, everybody gets in a gown if they're a new patient. So that's a real key point for the young learners that they can't do this through their shirt or through whatever, no matter how shy the person is. Yeah. You might be able to feel the scapula poking like the patient did, but you got to examine them and look at it, right? And see how it moves. I mean, that's the important thing because if it doesn't move at all, then you got a different issue. Right? Yeah. So I don't have pictures of the actual patient, but I'm showing you what he kind of looked like here. You can see this slide? Yep. I can see. So I'll just tell you, his exam in his arm, his motor exam was normal. So biceps, triceps, supinator, hand, that was all normal. His reflexes were normal. His sensation was normal. But he did have some changes in his scapula. And when he, just like this picture, when he pushed forward, this is really what his scapula looked like. So a question for you is what would you be thinking if you saw this and would you do any other maneuvers on the exam? So the pushing on a plinth or whatever you want to call it, pushing forward and having this pop out is sort of classic for a serratus anterior, right? And so that's certainly something that you got to think about. When you have an issue like that, then you want to see how the rest of the muscles are moving. So you're going to want to do range of motion, looking at abduction, all right? You also want to see if this isn't resulting in some sort of rotator cuff impingement on top of what's going on, because if you don't get stabilization of the scapula, it doesn't function right when you're abducting your shoulder. So I want to make sure that he's got good range of motion without any impingement. So supraspinatus test, a Hawkins sign for impingement would be important. I'd want to see if he can retract his shoulders. That's an important thing to know, to whether he's got medial support as well. And then shoulder shrugs, okay? So you want to check to make sure he doesn't have some sort of trapezius involvement. You know, shingles can get anywhere and it can get in multiple places. I don't know exactly where his rash was. That might have given us an idea, but it notoriously doesn't, unless you're doing it in the trunk, in which case you get a dermatomal fashion. But you know, when you're getting up into the shoulder, the head and neck, it doesn't really match where the rash is and what's going on. Yeah. Okay. So you would, so in other words, you know, this would make you think, be concerned about serratus anterior or long thoracic nerve involvement or something like that. But I'm going to show you another just picture. So I think you alluded to this. These are other muscles that, like the trapezius, that can also potentially cause some protrusion of the scapula and the rhomboids you've mentioned too. Right. Right. So you want to check all those just to make sure that all the other muscles are functioning. It depends on where in the brachial plexus things are being affected, right? Because the rhomboids are C5, but it's also one of the first individual nerves that come off of the plexus and the upper trunk. And if you're looking at serratus anterior, that may also be involved. It may be too proximal to be involved. So you have to kind of look at that together. Okay. So then after you've done your thorough exam, you mentioned a moment ago of doing electrodiagnostic testing. And so I'm curious in your lab or in your approach to someone like this, what would you do? Like, how extensive of nerve conductions or needle do you do in this situation? Well, first off, you want to check to make sure that the other muscles that could be involved are not. So anything from the upper trunk. So you're going to do your normal motor conduction, maybe in your median nerve, check an ulnar to make sure for comparison. If you have to go to the other side, you would go to the other side if you look at and see anything, right? Because C5 through the upper trunk and C6 then eventually comes down. The C6 is something that you see in the sensation from the nerve. So you want to do a sensory there and see if that's affected at all. So that's something to look at. We also would routinely get a medial antibrachial cutaneous study just to make sure that there's not any more diffuse involvement of the brachial plexus. F waves would be important in this case. So if you're doing motor studies, you'd want to do F waves to see what's going on more proximally. So that's kind of where I would start. But really for me, the money is in the EMG portion, okay? And the EMG portion around the shoulder is the most important thing. The more distal muscles are not so exciting, unless once you start doing things, you see this could be a radiculopathy too, because you can get a polyradicular neuropathy from shingles or from other things as well, if they're diabetic. And then you might see things more from the nerve roots. So that's got to be something I would do. Yeah. And I would agree. I think in this situation, the clinical suspicion of a more diffused plexopathy wasn't very high because he had no symptoms from his shoulder down, but we did do the basic conductions. I don't think we did the antibrachials in him, but we did a median and ulnar motor and sensory to screen for a patchy subclinical plexopathy. Those were all normal. But what about nerve conduction of the long thoracic, do you ever do that? So I don't do that because I put more, because you're going to want to do both sides, right? So you're going to have to stick on, do your stimulation on both sides. It's not a real comfortable study. And I find that the needle exam gives me the information that I want. In something like this, you're not going to have a conduction block, okay? You're going to have an axonal injury. And that's why I don't do it. I don't know how, in your lab, do you do that fairly often? No, I'm similar to you. I think I've tried it a few times. I think that there's some nice papers describing the technique, but I think there are a lot of pitfalls with that because, as you know, the latissimus is overlying the serratus and I think the two techniques, if I recall, you can stimulate way up in the axilla up here, or you can actually stimulate up at the supraclavicular area. But I always worry about getting volume conduction or direct stimulation of the latissimus. And then I'm not sure if I'm getting a true serratus response. And again, you got to think about the comfort of the patient, right? How much does that add to our particular study at this time? The EMG, I tolerate the needle better than I do the nerve conduction. So an Erb's point or up in the axilla would be really torture for me. So you think about those things when you're doing it. We want to do what we need to, but we don't need to do things that don't add that much to our study. It's funny. I'm the opposite of you. I'll shock myself at Erb's point just for fun, just because I like the sensation, but I won't poke a needle in my muscle. So we're all different, right? Yeah. I remember Gerald Herbison just sticking a needle in his arm saying, look, here it is. And it's like, OK, so he's OK with the needles. He doesn't feel that. Yeah. Yeah. It's what we can do to ourselves. You know, it's interesting. So. So, OK. So, yeah, I agree with you. Yeah. We would I would focus predominantly on the needle exam. And so just out of curiosity, how do you needle the serratus when you when you stick that muscle? So I've tried a couple of different ways. The one that I seem to like best is when you're hitting at the just lateral to the inferior border of the scapula where the triangle is down at the bottom there. Yeah. That you can get a good where you can see actually on your other picture where it says anterior group, where it all connects right there at the inferior border. You can get into those muscles and get good recruitment. It also decreases your risk of pneumothorax, which is there. It's not high in good hands. And we like to think we're good hands. The other way we did it is over the ribs, as you can see on your other anterior picture there that, you know, right over the ribs, actually down in the bottom here where it says anterior. Yeah. So you can go right over each of the ribs and try and get those. And that works pretty well. It's more of a problem in people who are a little heavier because you're you're palpating for the bone, trying to go right over the bone, and the soft tissue may not allow you to get in there. Thin people, it's a lot easier. You're more comfortable with where you are, not going between the bones. So I end up going really at the angle of the scapula, just because it's more consistent for me. Yeah, that's interesting. I, yeah, there's both. I agree, there's both ways. I usually go more down, like your second suggestion, more anterior. I try to retract the latissimus, feel the border of the latissimus, try to pull it back with my fingers, and then kind of go in this area. But I think from, you know, when there's protrusion of the scapula, like in this picture, it's probably easier to go this way as well, just because that, you know, that scapula is away from the ribs, so not as worried about getting into the intercostal space. Yeah, and I agree, they both work. And so it's whatever you're comfortable with and how you set it up. It also is how comfortable the patient is. Yeah, exactly. So, okay, so you would examine the serratus, and then would you, do you examine the rhomboids here? So, yeah, I would do several others. I would do rhomboids. I would probably do a supraspinatus, just to make sure, okay? So you gotta remember, you gotta go through your trapezius to get there. And supraspinatus is nice because it's got a nice little fossa. You don't have to worry about going through things, but it's easy to activate once you're there. So I would make sure I get that. Again, I would make sure I do paraspinals just in case there's something more proximal than what I'm thinking. You know, every once in a while, we miss something that we feel like we should have caught. And so, just to be thorough, as long as I'm there, I would go ahead and get that done. I don't think I would do an infraspinatus, you know? And you'd, of course, do a deltoid too, because that certainly is gonna be affected if you've got C6, even though it's a posterior cord muscle. We do wanna make sure that we check on that. So those would be the major ones that I look at. I wouldn't do much more distal in the arm. Some people might be able to convince me that I should do, you know, the biceps, because it's also C5-6, but I don't see that it's as helpful. Yeah. Yeah, interesting. So I'll just show you, I don't think this table's all inclusive, because I did a few other muscles as well, but these are the muscles that I focused on, and I did do the rhomboids as well. And you can just see our table. I forgot to share my sound, but this was, I'll play it anyway, even though we need to hear the waveforms, but this was in the serratus, and you're not gonna be able to hear it, but I think you can. But you can see it. Yeah, so. You know, you gotta be able to see and hear what's going on. So it's clear that you can see those fibs, and it looks like some positive waves on an earlier sweep through, and maybe right there. Yeah. But yeah, yep. And you could see on the grading table. So he had profuse fibrillations, and couldn't activate the serratus at all. I could not record any motor units, but the other muscles, including the rhomboid, were fine. And I only did the two you mentioned, deltoid and infraspinatus. I didn't do, because those were all normal, I didn't extend that into the arm. I felt pretty comfortable based on this, that this was really long thoracic. Well, you bring up a good point here, and that's that doing your EMG is not a static plan, okay? So as you start to get your information, you change what muscles you may or may not want to do. So given what you see here, or what I see that you've done, I wouldn't be as excited about doing paraspinals, because it seems like the other muscles that would be innervated by C5 and C6 do not appear to be affected, okay? So, again, it saves him a little bit of poking and prodding, if he's one of those people who doesn't care for the needle portion, that you have to change it as you go, okay? And I think that that's an important point, that we watch each one and then change our approach based on that. Right, right, and as you've said, based on level of suspicion too. So just because two muscles that are C5, C6, two other muscles were normal, I think if there was this higher suspicion that this is a more diffused or patchy plexopathy, then I think the inclination would be to do more muscles and search for other involvement outside of that nerve. Can I stop you there for a second? Sure. My lights just went off, and so I'm gonna go turn them back on. Okay. I will be right back and they'll have to edit this portion out. Okay. All right, so let's see, I was right here. There we go. We might not edit it. We can just talk about gait assessment for a second too. You have a good gait. Thank you, thank you. So do you do in the EMG lab, do you do any other techniques? Do you use like ultrasound in a case like this? Are you using that? I do use ultrasound. I don't know how much it would add in a case like this. Certainly you would be able to see some atrophy, but the nerve itself, you're probably not gonna get a good look at. I'm not good at looking at the plexus with ultrasound. So some people are pretty facile with that, and they could be able to take a look and see, and if there's nerve swelling or actually loss of size, if you've got contraction from axonal loss, depending on when you actually do it. So I don't for a brachial plexus because I'm just not good at it. Yeah. Yeah, we're evolving in our clinic and using it for the brachial plexus, but I did look at the muscle. I think sometimes it's useful to look at the actual muscle, particularly in muscles that might be challenging to needle for some people or might be at a high risk. And I'm just gonna show you this, and I don't know how much you look at the serratus muscle on ultrasound, but this is the affected side, and then this is the unaffected side. So it's interesting, you can see on the affected side that there's a change in echogenicity, okay? So it seems to be more dense. I also noticed on the side here that you've got that the width is 4.2 for the affected side and 6.5 for the unaffected side. And so that gives you a clue as well that there's something going on that it's not working as well. But the fact that you've got loss of, or you're more hyperechoic suggests that you're getting maybe some more infiltration of fibrinous stuff because it's not being innervated and you're getting more atrophy. One would actually be interested in following, say every two months, the same area. So if you can do this in a standardized fashion, you can see as it starts to come back, if it gains any size. The problem with that is if you're not exactly in the same spot, you may be just getting another section and not seeing it. Right, right. Yeah, and I think also in these cases with ultrasound, it can help for two other reasons. One is it can help identify a safe space to place the needle. So, you know, it can see the rib shadow and I know we can still palpate between in the intercostal spaces, but at least I know this is a safe space if I'm gonna put the needle right underneath that transducer. And then the other thing that I like to do is have them contract and see, does that muscle actually thicken when they're contracting to see, you know, if it's thickening, but I have the needle in and I'm not getting motor units, I'm probably not in the right muscle. So I think that can be helpful sometimes too. So do you routinely, if you're doing a serratus anterior, use the ultrasound to guide your EMG needle? I do, but I don't needle with the transducer on. So I find the right space, especially in larger people that I can't easily palpate. I find the space, then I take the transducer off and I keep my fingers in the intercostal space, but I make a little mark so I know where a safe space is. Oh, good. I think for experienced, I mean, you're experienced and those who are very experienced may not need the ultrasound to do that, but I think especially for learners or people who don't do the serratus and have the accessibility to an ultrasound, it can be very helpful. And that's the nice thing about what's going on now is we're getting now more machines that have a complimentary ultrasound built in so that these pictures can feed into your report. I remember when I started doing this, what, 20 years ago, that we had a separate ultrasound machine and then that had to go into a separate database that the radiologist would be looking at. It's like, we want this all together and it's just starting to come around to that now, which is really nice. It tells a lot too when you're looking at other issues, say carpal tunnel or something, that you can send a picture saying, look, it's in the proximal tunnel that we got the problem to the surgeon and they can say, oh, that's great. Or you can give them a heads up, say, hey, look right here, you've got an anomalous artery. So a recurrent median artery and that you wanna maybe consider missing that when you're doing your surgery, if you're doing it arthroscopically. Yeah, absolutely. And now we don't have to unplug the machine and bring a new machine in. Like you said, it's a lot easier in a busy practice. Exactly. And there's more and more literature. I'm not gonna go through literature, but there is one paper you may be familiar with that Mike Cartwright was involved in a neuromuscular ultrasound for scapular weighing. So it's a really nice paper describing how you would look at different muscles. So, yeah. Yeah, and that group has been really good. That's actually where I learned how to do ultrasound at the Wake Forest group. And I think Michael Cartwright at the time was a medical student. And so we were all kind of learning together and Francis Walker was our fearless leader in that. Right, we've come a long way and we've got a long way to go still, but it's exciting to incorporate this. So, okay. So I think we would agree. I'll ask you, would you agree this looks like it's a long thoracic neuropathy? I do agree on the left side, exactly. On the right side. That was the right side. Oh, on the right side, right. Okay. So the big question is why, you know, and I don't know that there's an answer to this, but you alluded to this earlier, is this, why is this, do you think it's related to the shingles? You know, I think that's the highest likelihood in my thoughts. It would be rare that you would have a second viral issue, right? Because we think a lot of the idiopathic plexopathies are viral issues, but they usually come with severe pain that then lets up and then you get the weakness later. Well, if he got the severe pain and the shingles together, you kind of have to say that's probably it. And it really depends on if you're one who sees the forest or the trees. Okay. So are you going to say that they had shingles and an idiopathic brachial plexopathy at the same time, or is it all one issue? So I would go with the one issue. I'm a forest person in general, but it really isn't going to make a big difference in your recovery for this patient. It's still a viral plexopathy. It's still had the pain. It's still, you got treated. And so we just need to try and re-trigger the nerve to sprout and get the nerve reinnervating that muscle. Yeah. And I think you mentioned this early on that, so with shingles, can you get, have you seen motor involvement with zoster? I don't see a lot of motor involvement because most of it is in the trunk muscles, which there aren't a lot of things. I mean, yeah, you might get a little weakness of some of your intercostals or something, but there's so many others there that make up the difference. It doesn't affect your breathing or your abdominals. You can see sometimes weakness in the abdominals after a shingles flare up. So yeah, maybe we do get some. It's hard to say whether that's just an inhibition because of the pain and that the body's just not wanting to contract. I haven't seen anything permanent from shingles. Yeah. And there is, you know, it is rare, but there is, I'm going to show two more quick slides just for all of our education, but there was a study up at Mayo and Rochester a number of years ago with limb paresis associated with zoster, and so it can affect the motor nerves. And what's interesting is something you said earlier that, and I'm not going to go through this in detail, people can read the paper, but there was weakness outside of the distribution predicted by the rash in 18% of individuals. So, you know, most of those were more in the hand and not, I don't think any of these people had long thoracic involvement, but this to me makes it seem like what you said, that this could certainly be related and outside the distribution. So it's kind of interesting that that happens. Yeah. Whether it's a part, like a inflammatory remote effect, like you said, or, I mean, I suppose that's the mechanism. Yeah. And, you know, the whole thing about zoster is there's probably even more things out there that we don't know that it does. And so it is important, you know, we do have some treatments or prevention for this, you know, with our vaccines. And so we need to make sure that people get this, but, you know, younger people can get this just as easily. I think the first time I ever had a zoster outbreak was when I was 18 during finals in my first year of college. And so it was, you know, it's like, what is this? And it's in the middle of my back, so I couldn't hardly reach it. And when the nurse said, oh, look, you've got herpes, you know, as an 18 year old, I'm like, what? But yeah, she was just playing with me. But, you know, people can get it young under any kind of stress situation. Yeah. There are better ways to try to get out of an exam than getting shingles, you know. I didn't get out of the exam. That was the problem. Oh. Yeah. The dog ate my paper is an old way, right? Yeah. Now it's the dog ate my computer. Right. So, okay. Well, and then one last question, since you're a rehabilitation specialist and someone like this, or someone who has, let's say a long thoracic neuropathy and scapular winging, what do you do? I know therapy, but is there anything specific besides physical therapy that you recommend? Yeah. So in the physical therapy realm, you can do different things. And one is you can try and get them to activate, but you can do also muscle and nerve stimulation to try and get things going again. We see that a lot in stroke. Okay. So trying to get, you know, muscles to reactivate. And there is some evidence that it may promote sprouting and therefore you can get return of function. And what we would expect with this person is that they would get some return of function. You don't know how much you would get. I don't know, and you may know this, whether there's any good follow-ups on long-term EMG changes after an idiopathic brachial plexopathy and whether you are getting large motor units or not. Do you know of anything? Yeah, I think, you know, with typical idiopathic plexopathy, and of course the answer is always it depends and it depends on severity, but, you know, many of those parsonage turners will improve. And, you know, some of the older evidence is that they'll have a pretty good recovery after two or three years. I think follow-up evidence suggests it's not always the case and some people don't make a full recovery as we all see. But I think in this patient, I'm a little more concerned because he didn't have any motor units at all and he had really dense fibrillations. And I think the EMG was done, you know, maybe a month or so after this had occurred. So I worry that it's that bad that I'm not sure how much functional reinnervation he'll get, but I think it was too early to really prognosticate. Yeah, so I think I remember reading one article that there was around 90% that ended up with a really good outcome, maybe just slight weakness, but almost nothing that they could recognize. So there are those 10% of people who end up without getting, you know, as good a recovery as they may want. And we don't know exactly whether it's the severity at onset or whether there's some other underlying genetic issue. Because remember, there are those people who have a genetic predisposition and if they have it on one side, they may get it on the other side as well. So there's, you know, some things out there that we don't quite know. And that's why I thought it'd be interesting to see them in a year later and see what their serratus anterior looks like on EMG and ultrasound. Right, yeah, yeah. And I don't think, this patient, I don't think I got follow-up on, but yeah, I think that's important to just kind of see how they evolve. So, well, this has been great. This is enlightening. I love hearing your insight into this case and these type of patients. Any last words of advice to the viewers who are assessing or dealing with patients with a situation like this? Well, first off, I'm gonna put in a shameless plug for the AANEM meeting, because, you know, this is where you can go and talk to people and say, look, I had this patient and this, and this is what I did. Should I have done something else? And everybody's happy to share. So I think that's a really good thing. When you're treating someone like this, clearly, you know, if you're the treating physician, you wanna make sure that you get activation of the muscles as soon as possible. The longer you let this go, I think the poorer the outcome will be. So catching it early, finding out exactly what the diagnosis is, and then getting treatments going in, whether you have to control pain while you're doing that, that's another thing. I am not aware of anything that says you cannot use gabapentin because it decreases the return. So I would say if they've got pain, gabapentin is a great choice. Great. Well, thank you so much for taking the time. This is great. I can't wait to see you in Phoenix at AANEM, and you've done a great job, and keep up the great work. All right, well, thanks for inviting me. Again, I'm honored to do this, and I hope it's helpful to some of our listeners. Great, it's been great seeing you. All right, you take care, Devin. Bye-bye. Well, what a great discussion on an unusual situation. That was really fantastic. I certainly learned from Dr. Irwin. I think there were some important teaching points in this case. The first is to consider the different muscles and nerves that impact the scapula, and that could be involved in patients that have scapular winging, particularly the serratus anterior, the trapezius, and the rhomboid. I think we learned that the needle examination is probably more useful than nerve conduction studies in patients with isolated or pure scapular winging, but it's also important to screen for a more diffuse process such as a plexopathy. We did touch on the fact that neuromuscular ultrasound can be very useful and complement the nerve conduction studies and needle examination in assessing patients with scapular winging, and I think the last thing that we learned is the importance of going to the AANEM annual meeting. Dr. Irwin's put on a terrific program. I can't wait to hear the speakers, and as he said, it's a great opportunity to interact with each other, learn from each other, and have a great time together. So I hope you enjoyed this episode of Lessons from the Lab, and have a wonderful day. Thank you.

scapular winging

brachial plexopathy

viral plexopathy

physical therapy

muscle activation

nerve stimulation

neuromuscular ultrasound

AANEM annual meeting