Dr. Seyedaidin Sajedi
Neurology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
I have some questions in regards to some symptoms I have had recently. Two years back, I had a twitching feeling around my body, such as my forearm, face (cheeks), eyebrows, and fingers. Occasionally in my biceps and shoulders. The twitching was very random and could be two days in my forearm only to stop and begin in my fingers for three days, and it goes on. It is very spontaneous and random. The twitching completely went away a few months later. Last year, the twitching started again, and the same as the year prior, it was sporadic and random. This lasted for a month. At that time, I decided to visit the doctor. The doctor did a comprehensive physical examination which comprised walking, doing squats, testing my shoulder strength, arm strength, eye movement, and much more. The results turned out to be completely normal. The doctor suggested two other tests. One was magnetic resonance imaging (MRI) of the cervical spine (results were normal) and an electromyography (EMG) test in which electrical shocks were sent to my muscles to test muscle activity. This was the response from the EMG test. EMG test has been conducted, and no significant deviations were found. However, slight deviations were found in the right arm ulnar nerve of unclear clinical significance. The investigation has now ended, and the patient is informed to return if symptoms come again or new symptoms emerge. They were interpreted as benign fasciculations that spontaneously stopped. I would like to have your opinion, doctor. Should I be worried about my symptoms? Is the slight deviation of my right arm ulnar nerve anything to worry about?
Hello,
Welcome to icliniq.com.
I can understand your concern.
A comprehensive clinical examination is critical because fasciculation would be a grave sign only when it is accompanied by weakness, atrophy, or clinical signs of upper motor neuron involvement. The results of your electromyography (EMG) reports are normal and confirm the good result of clinical examination that your fasciculations are benign. I need to see your electromyography (EMG) figures and tables to give you an exact opinion about the ulnar nerve. If you have a copy of the reports, share it with me.
Thank you.
Patient's Query
Hi doctor,
Thanks for your response. Unfortunately, I do not have a copy of the electromyography (EMG) result figures in hand right now, but I will try to get a copy of it next week and update you. I have two follow up questions; as in regards to my electromyography (EMG) results, is it safe to say that given that the results of that test were normal (apart from the slight deviation of ulnar nerve), one can exclude potential malignant causes for the symptoms such as amyotrophic lateral sclerosis (ALS)? When asked about the right side ulnar nerve deviation, my doctor suggested it is of no clinical significance, and some people have natural differentiations. What is your opinion on this exactly? What complications (if any) can the deviations of the ulnar nerve signify?
Thank you.
Hello,
Welcome back to icliniq.com.
I understand your concern. In general, there are four main reasons for fasciculation, including poly-neuropathy, motor-neuron diseases, metabolic causes (like electrolyte disturbance), and idiopathic (benign fasciculation syndrome). In all of them, except benign fasciculation syndrome, there would be abnormal results in clinical examination or electromyography (EMG) or laboratory tests. So, with regular examination and normal test results, you have no essential evidence in favor of amyotrophic lateral sclerosis (ALS) or poly-neuropathy. The ulnar nerve is a very long nerve that some areas of its route are very superficial and prone to chronic injury. As I said before, to give an opinion about your ulnar nerve, I need the details of your electromyography reports.
Thank you.
Patient's Query
Hello doctor,
I have some additional follow-up questions about fasciculations. I can see that benign fasciculation is one of your expertise, so I would like to ask some other things. First, regarding the nature of fasciculations, what is the main differentiator of fasciculations coming from BFS compared to motor neuron diseases like ALS? For instance, if the fasciculations are sporadic and random, i.e., appearing almost across all of the body (forearms, face, cheeks, or fingers), etc., and appearing random in duration (anywhere from one day to one week in each body part) only then to suddenly disappear for 12 months after reappearing, would that signify ample confirmation that its BFS? Could you elaborate more on the nature of fasciculations in the case of ALS? Can it also be random or sporadic, or is it more persisting and never-ending? I would love it if you could elaborate more to increase my knowledge.
Hi,
Welcome back to icliniq.com.
I understand your concern. To your knowledge, fasciculation is not a specific sign of a specific disease. Any cause that disrupt neuron signalling to muscles, can cause fasciculation. It may be a neuropathic disorder, motor neuron disease, or a electrolyte disturbance. In any of above cases, there are accompanying features that help to distinguish them. For example, in neuropathy, usually there are mixed motor and sensory symptoms. The affected region or limb may be weak with decreased tone. In the motor neuron disease, there is no sensory symptoms. The limb or affected region would be weak but spastic (and sometimes flacid and atrophic). More importantly, there would be signs of central nervous system involvement in the physical examination. In BFS (benign fasciculation syndrome), there is no sign of neuropathy or central nervous system involvement, no evidence of atrophy or spasticity. And yes, random fasciculations without the mentioned signs which come and then disappear for long time or forever, are BFS.
Thank you.
Patient's Query
Hello doctor,
I have some additional questions about EMG. As mentioned above, I took an EMG test around two months ago. It was comprised of two parts-electrical shocks were sent to different parts of my body. Then, around ten to 20 pulses were sent to each muscle and analyzed on the computer. Then, fine needles were inserted into different muscles in my body again, and I was asked to contract the specific muscle during the insertion. Muscle activity was logged and saved on the computer. These tests turned out to be expected as per the physician's response. My question is whether a benign or positive EMG result yields enough evidence to rule out potential malignancies such as ALS? In other words, had there been underlying malignancies such as ALS, would that have manifested itself in the EMG results?
Hi,
Welcome back to icliniq.com.
I understand your concern.
Yes, a normal electrodiagnostic study like electromyography (EMG) and nerve conduction study (NCS) study along with normal physical examination, rule out the amyotrophic lateral sclerosis (ALS).
Thank you.
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