CRITICAL ANALYSIS OF REFERRALS TO ELECTRODIAGNOSTIC EXAMINATION OF THE PERIPHERAL NERVOUS SYSTEM
Abstract
Background. Clinical neurophysiologists observe a large number of examinees referred to a electromyographic (EMG) laboratory without clinical symptoms or signs of the peripheral nervous system lesion. Such referrals do not improve management of patients, but only unnecessarily burden examinees and laboratory personnel. The aim of the present study was to check appropriateness of referrals to electrodiagnostic examination, look for reasons for problems and suggest possible improvements.
Methods. From the database of the Institute of Clinical Neurophysiology in Ljubljana all examinees evaluated by the author in a »general« EMG laboratory in the first 4 months of 2002 were included. From data about examinees, referral doctors, referral diagnoses, clinical symptoms and signs and electrophysiological findings, predictive values for neurological referral diagnoses and electrodiagnostic abnormalities were calculated using descriptive and multivariate statistical analyses.
Results. Three hundred examinees (42% men) were included. Neurological diagnosis was provided in 55% of referrals. Electrodiagnostic abnormalities were found in 45% of examinees (carpal tunnel syndrome 50%, radiculopathy 25%, other mononeuropathies 15%, polineuropathy 9%). In 9% of examinees only clinical, and in 47% neither clinical nor electrodiagnostic abnormalities were demonstrated. Using a multivariate analysis positive effect of referral with neurological diagnosis, of paraesthesiae and findings of weakness and sensory loss, and negative effect of pain and referral diagnosis cervicobrachialgia or lumboischialgia on pathological electrodiagnostic findings were found. Isolated pain and paraesthesiae (with carpal tunnel syndrome excluded) were particularly poor predictors of abnormal electrodiagnostic findings (9% and 16%, respectively). With exception of 20 patients with carpal tunnel syndrome, none with normal clinical neurological examination had abnormal electrodiagnostic findings.
Conclusions. Our study confirmed inappropriateness of electrodiagnostic examination as a screening tool for the peripheral nervous system lesions. Inappropriate referrals were due to poor evaluation of examinees before referral, and due to use of electrodiagnosis in screening of patients. We propose electrodiagnostic examination only of patients with unequivocal clinical signs of the peripheral nervous system lesion, and of patients with typical symptoms of the carpal tunnel syndrome. Referrals should include neurological diagnostic question and all relevant clinical data. This would reduce waiting time, save money, and improve evaluation of patients with peripheral nervous system lesions.
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References
Anon. Guidelines in electrodiagnostic medicine. American Association of Electrodiagnostic Medicine. Muscle Nerve 1999; 22: Suppl 8: S107–8.
Duncan G, Caird FI. Review of 18 years’ experience of a diagnostic geriatric neurology referral service. Scott Med J 1991; 36: 139–42.
Clarke CE, Shepherd DI, Yuill GM. A critical appraisal of in-patient neurological services in a subregional centre. Br J Clin Pract 1992; 46: 243–8.
Wiles CM, Lindsay M. General practice referrals to a department of neurology. JR Coll Physicians Lond 1996; 30: 426–31.
Robertson NP, Shaunak S, Compston DA. Urgent neurology out-patient referrals from primary health care physicians. QJM 1998; 91: 309–13.
Hogh P, Waldemar G, Knudsen GM et al. A multidisciplinary memory clinic in a neurological setting: diagnostic evaluation of 400 consecutive patients. Eur J Neurol 1999; 6: 279–88.
Porta-Etessam J, Dalmau J. Analysis of the neurologic consultations in an oncologic hospital: contributions of neuro-oncology. Neurologia 1999; 14: 266–74.
Cruz-Velarde JA, Gil de Castro R, Vazquez Allen P, Ochoa Mulas M. Study of inpatient consultation for the neurological services. Neurologia 2000; 15: 199–202.
Wee AS, Cowart MA, Mosley PD. Referral patterns of physicians requesting brain MRI procedures: a community-based study. J Miss State Med Assoc 2000; 41: 439–41.
Morera-Guitart J, Escudero J, Aguilar M et al. Consensus conference on consultation times in neurology. Recommendations on consultation times in neurology outpatients care in Spain. Neurologia 2001; 16: 399–407.
Bekkelund SI, Albretsen C. Evaluation of referrals from general practice to a neurological department. Fam Pract 2002; 19: 297–9.
Vodušek DB, Janko M. Elektromiografska diagnostika – njene možnosti in omejitve. Zdrav Vestn 1983; 52: 189–92.
Danner R. Referral diagnosis versus electroneurophysiological finding. Two years electroneuromyographic consultation in a rehabilitation clinic. Electromyogr Clin Neurophysiol 1990; 30: 153–7.
Johnsen B, Fuglsang-Frederiksen A, Vingtoft S et al. Differences in the handling of the EMG examination at seven European laboratories. Electroencephalogr Clin Neurophysiol 1994; 93: 155–8.
Mondelli M, Giacchi M, Federico A. Requests for electromyography from general practitioners and specialists: critical evaluation. Ital J Neurol Sci 1998; 19: 195–203.
Schon F, Hart P, Fernandez C. Is clinical neurology really so difficult? J Neurol Neurosurg Psychiatry 2002; 72: 557–9.
Zidar J. Bolnik z radikulopatijo – Obravnava na sekundarni ravni. Zdrav Var 2000; 39: 155–9.
Tsao BE, Levin KH, Bodner RA. Comparison of surgical and electrodiagnostic findings in single root lumbosacral radiculopathies. Muscle Nerve 2003; 27: 60–4.
Levin KH, Covington EC, Devereux MW et al. Low back and neck pain. In: Levin KH, Covington EC, Devereux MW eds. Neck and back pain. Continuum 2001; 7: 7–43.
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