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Dr. Frank
Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 7201
Experience:  Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
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Hi, I have bilateral leg pain, tingling in toes and calf fasiculations.

Customer Question

Hi, I have bilateral leg pain, tingling in toes and calf fasiculations. Lumbar MRIs suggest only mild bilateral foraminal stenosis at L4/L5 and very mild disc bulge. Neuros I have seen have therefore discounted this as a cause for my symptoms. Could it be S-Joint or Piriformis if it is bilateral?
Submitted: 1 year ago.
Category: Neurology
Expert:  Dr. Frank replied 1 year ago.

neuromd2012 :

Welcome to Just Answer. I am an Adult Neurologist and was contacted to answer your question.

neuromd2012 :

Hello. yes you can have bilateral SI joint problems, or piriformis syndrome, but you should have weakness, EMG changes, and exam changes to suggest a severe problem

neuromd2012 :

as you are offline, please get back to me to discuss this further. Dr Frank T

Expert:  Dr. Frank replied 1 year ago.
Our chat has ended, but you can still continue to ask me questions here until you are satisfied with your answer. Come back to this page to view our conversation and any other new information.

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If you haven’t already done so, please rate your answer above. Or, you can reply to me using the box below.
Customer: replied 1 year ago.

Hi, I am avaiable now. How do I get online?


 


What do you suggest given all that I have trie? I have heard of a MR Neurography scan. Would this be helpful?

Expert:  Dr. Frank replied 1 year ago.
Hi. there are special surface coils that you can place in an MRI scanner, and do a "piriformis" study, that looks at the inflammation of the muscle itself, and you can get some cross-sectional information about the sciatic nerve as well. You can also do a MR Neurogram, but the question is what difference does it make? The treatment is all symptomatic regardless of the cause. I would suggest an EMG study looking at if your H responses (tibial nerve) are prolonged, and also the tibial F waves. Did the Neurologist do an EMG?

There is one "alternative" treatment, if you have tried everything, which is perispinal etanerocept, as prescribed by Dr. Tobinick in his clinics around the US. I have no experience with this treatment, and he has not published his data.

please get back to me if I can help Dr Frank T
Customer: replied 1 year ago.


I have had a nerve conduction study and I was only told that it was normal. They only check the nerve response in my feet where I was feeling the tingling at that moment. Nothing was done in that test to chec the fasiculations in my calves though.


If there is entrapment, wouldn't knowing where the entrapment is assist in the treatment of the condition?


Do you suggest another EMG requesting those specific things you mentioned?

Expert:  Dr. Frank replied 1 year ago.
Hello. so that nerve conduction study was probably only a sensory nerve conduction study to exclude polyneuropathy (?). I would suggest a conduction study to look at what I had mentioned, if not previously done. the needle EMG examination of your calf muscles to look if there is active denervation as a cause for the fasciculations, or if they are "benign fasciculations" is warranted as well. So you may need another EMG, or if you have the report, paste it in here, and I can tell you what was or was not done. You are correct about the entrapment issue, and that is the reason for the piriformis study. The MR neurography does not give you specific localized information, only the amount of signal down the nerve, consistent with an axonal or demyelinating injury to the nerve. There are surgeries for piriformis syndrome if you can show inflammation/scar in the muscles itself.
Customer: replied 1 year ago.

Ok, I will return to the last Neurologist I saw then. I didn't go back for the EMG he suggested because he seemed a bit disingenous as he listened very little to what I had to say and said he could not see the very obvious calf fasiculations with his naked eye (although all the referring doctors saw them). He was onluy insistent that I only come back to do an EMG with him (which of course he would get more money for) as that was the only way to tell for sure.


Seems a bit crazy that I would have all these symptoms and no problem!


I also maybe should have mentioned that I have a Syrinx in the Thoracic region. It is long and narrow and the Neuros have told me the symptoms I am getting are not from my thoracic spine so it is just asymptomatic. Would you agree with that?

Expert:  Dr. Frank replied 1 year ago.
syringomyelia can give you symptoms of a "man in a barrel" syndrome, as it effects the central crossing fibers in the spinal cord , so only things outside the barrel, are effected, which could be your calves in this case, it would depend on the size of the syrinx. Ask your neurologist about this issue, and if he isn't listening walk out. If it is long and narrow, yes, you could be asymptomatic. You need some testing with a pin for sensation. The needle EMG should be done especially with this syrinx issue, to look at your fasciculations, and your recruitment patterns in those muscles.

I hope I could help, please get back to me if you get results that need an explanation, or anything else. Dr Frank T
Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 7201
Experience: Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
Dr. Frank and other Neurology Specialists are ready to help you
Customer: replied 1 year ago.


Thanks a lot, Doc. I will get back to you when I have the results.

Expert:  Dr. Frank replied 1 year ago.
you are welcome, ask him if your calf muscles are hyper-recruiting during the needle exam, and do they have a full interference pattern.
Customer: replied 1 year ago.


Ok, will do! Thanks again.

Expert:  Dr. Frank replied 1 year ago.
good luck
Customer: replied 1 year ago.


Hi doc, I had the EMG and Nerve Conduction Study done today. The Neuro synopsis was:


"NCS are Normal. Muscle sampling shows occassional fasiculations but no giant potentials"


Results:


 


Sensory:


Rt Sural - Amp (uV): 6.3


Rt Sural - Lat (MS) - 5.3


 


Motor:


Rt Lateral Popiteal Nerve (SE on EDB):


DML - 4 - ms


CMAP (ankle) - 7 - mV


CMAP (knee) - 7 mV


F-wave latency - 56 ms


NCV - 48 - Ms (to the negaive one power)


 


Rt Posterior Tibial Nerve (SE on AH):


DML - 7 ms


CMAP (ankle) mV


 


 


EMG:


Rt/Lt Medial Gastrocnemius - 0 Fibs, + Fasics, I/P normal.


 


 

Expert:  Dr. Frank replied 1 year ago.
Hello. Well all of these parameters are normal, You have no evidence or motor or sensory neuropathy, no findings to suggest chronic denervation from a sciatic nerve pathology at the sciatic notch over piriformis or from your lumbar spine. This study excludes the need to consider some surgical intervention.

I hope that helps guide in your decision on treatment for your pain. Dr Frank T
Customer: replied 1 year ago.


The pain and tingling still exist though. Does it just mean that I have nerve irritation but not nerve damage?

Expert:  Dr. Frank replied 1 year ago.
Hi. the way we explain it, is that the pain fibers are the thinnest, unmyelinated fibers in the nerve, so they are preferentially effected over motor and sensory fibers. So yes, the nerve is irritated but not damaged to the point of having an electrical disturbance on testing. The key is that you do not need surgical correction if the severity of injury is below the threshold for detection on the test.

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