肌电图在临床诊断中的应用现状和价值分析
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摘要
背景近年国内神经电生理的临床诊断和研究水平不断进步,但各地区电生理技术发展不平衡。当前,神经电生理检测在我国临床诊断中是否真正发挥了其应有的作用?又有何不足之处?明确肌电图临床应用现状,获得基线资料,对于进一步促进肌电图规范化应用具有重要意义。北京协和医院作为国内电生理领域的核心单位之一,可以作为国内肌电图技术应用较好的代表,对其应用现状进行分析,具有一定的意义。
目的通过对北京协和医院肌电图患者临床与电生理资料的回顾性分析,获得肌电图应用现状的基线资料,分析我院目前电生理对临床诊断的价值,并对临床症状、体征和电生理之间的相关性进行探讨。
方法回顾性收集我院2008-2010年所有行常规肌电图(routine electromyography, rtEMG)、神经传导测定(nerve conduction study, NCS)、重复神经电刺激(repetitive nerve stimulation, RNS)患者的临床和电生理资料,建立数据库,并与1993-2003年资料进行比较。调查内容包括一般情况、临床情况、相关既往史、相关辅助检查、诊断结果、电生理结果、临床与电生理关系,对肌电图检测的现状进行描述性统计,并就临床和电生理的相关性以及应用价值进行统计分析。
结果1)不同年度行肌电图检查例数及阳性率分别为：1993-1995年3097例,阳性率62.8%；2001-2003年6455例,阳性率60.7%；2008-2010年10161例,阳性率48.9%。2)2008-2010年间,具有不同首发症状的患者EMG阳性率不同,分别为：运动功能障碍68.1%,同时具有运动和感觉障碍67.2%,单纯感觉症状49%,其他难以归类的症状31.9%,无症状30.7%；同时合并感觉症状与客观查体感觉障碍者肌电图阳性率(69.3%)与仅存在感觉症状者的阳性率(38.5%)存在明显差异(P<0.05)。3)在所有行针电极EMG的患者中,39.5%为神经源性损害,7.9%为肌源性损害,1.5%同时合并神经源性和肌源性损害。肌电图表现为广泛神经源性损害者546例(占神经源性损害的14.7%),包括运动神经元病/肌萎缩侧索硬化400例(73.3%)、脊肌萎缩症10例、肯尼迪病7例、平山病9例、神经根神经病19例、腓骨肌萎缩症9例、多灶性运动神经病3例、其他疾病7例、不能确诊者82例。肌电图表现为上下肢周围神经源性损害者704例,包括糖尿病周围神经病246例、急性炎症性脱髓鞘性多发性神经病43例、腓骨肌萎缩症43例、结缔组织病相关周围神经病36例、POEMS综合征22例,慢性炎性脱髓鞘性多发神经病16例,副肿瘤综合征7例,其他29例,不能确诊者262例。4)4688例肌电图与临床初步诊断一致,其中1339例(28.5%)肌电图无异常。2822例肌电图与初步诊断不一致,其中2010例(71.2%)肌电图无异常；在肌电图阳性的812例患者中,250例可解释原有临床症状并改变了原有诊断,411例肌电图虽阳性,但与临床所诊治疾病无关,151例预期肌电图阴性,却得到了可以解释病情的阳性结果。
结论：1)近年来肌电图检测的病例总数明显增加,但阳性率下降。2)不同首发症状、体征对应肌电图检测的阳性率不同,其中感觉症状阳性率最低,对仅有感觉障碍主诉者进行肌电图检测、筛查,是造成肌电图阳性率下降的原因之一。3)尽管肌电图检测对临床诊断起到了重要的支持作用,但存在过度使用现象。4)同一肌电图结果,可对应于多种临床疾病,同一疾病也可有多种电生理表现,37.6%的病例临床诊断和肌电图诊断无关,因此肌电图结果的解释必须结合临床。
Background:The diagnostic ability and research in neuroelectrophysiology in China have progressed a lot in recent years; the academic standard has reached global level. Have electrodiagnostic tests played its role in clinic? How to make it work more efficiently? Figuring out the application status of neuroelectrophysiological tests in China and collecting the baseline data plays an important role on the further work and the standardized application of EMG. The analysis of the application status and diagnostic value of electromyography is blank in China. As one of the famous EMG laboratory in China, PUMCH accumulates huge amount of neurophysiologic and clinical data, which is the foundation of this large sample retrospective experiment.
Objectives:Through the retrospective analysis of clinical and neurophysiological data of PUMCH to establish the baseline information of EMG application, analyze the diagnostic value of EMG and the correlation between clinical symptoms, signs, and electrophysiology.
Methods:Select all the patients who underwent needle EMG, nerve conduction study, repetitive nerve stimulation and skin sympathetic response test in PUMCH from2008to2010to retrospective analyze the clinical and neurophysiological information, establish the database, and compare with that from1993to2003. The survey includes general situation, the clinical situation, the relevant previous histories, related auxiliary tests, diagnosis, electrophysiological results, and the relationship between clinical and electrophysiology.
Results:1) The number of patients examined and positive rate in different years were3097(62.8%) from1993to1995,6455(60.7%) from2001to2003,10161(48.9%) from2008to2010.2) The positive rates in EMG results of different first symptoms were68.1%for motor symptom,67.2%for concomitant motor and sensory symptom,49%for sensory symptom,31.9%for unclassified symptom,30.7%for no symptom and sign. The positive rate of EMG were38.5%for those with sensory symptom only and69.3%for those with both sensory symptoms and signs (P<0.05).3) In all patients performed needle EMG,39.5%was neurogenic lesion,7.9%was myogenic lesion, and1.5%was concomitant neurogenic and myogenic lesion.546patients showed diffuse neurogenic changes on EMG, including400(73.3%) patients with MND/ALS,19with cervical spondylosis combined with lumbar spondylosis,10with spinal muscular atrophy,9with Charcot-Marie-Tooth disease,9with Hirayama disease,7with Kennedy's disease,3with multiple motor neuropathy and7with other diseases,82patients with no definite diagnosis.704patients showed multiple peripheral neuropathy changes on EMG, including246patients with diabetic polyneuropathy,43with CMT/HMSN,36with connective tissue disease,43with AIDP,22with POEMS syndrome,16with CIDP,7with paraneoplastic syndrome and29with other diseases,262with no definite diagnosis.4) EMG results of4688patients were consistent with the initial clinical diagnosis, of which28.5%(1339/4688) showed normal EMG. EMG results of2822patients were different from initial clinical diagnosis, of which71.2%(2010/4688) showed normal EMG results. In those with abnormal EMG results, EMG results of250patients were consistent with the symptoms, but they were different from the initial diagnosis, EMG results of411patients had no relevant to the initial diagnosis and symptoms, while only151patients had unexpected positive results who were misdiagnosed to functional disorders.
Conclusions:1) The number of patients performed EMG has been increasing during the past years; however the positive rate of EMG is decreasing.2) The positive rate of EMG changes with different symptoms and signs at onset. Performing EMG test on those who only have sensory symptoms and screening for the potential neuromuscular diseases are the reasons for decreasing positive rate.3) EMG plays an important role in clinical diagnosis, but the excessive use of it should be concerned.4) Different diseases can show the same EMG results and different EMG results can be detected in the same disease.37.6%of EMG results are irrelevant with clinical situation. EMG result should be explained with clinic and other auxiliary tests together to get a proper diagnosis.
目的通过对北京协和医院肌电图患者临床与电生理资料的回顾性分析,获得肌电图应用现状的基线资料,分析我院目前电生理对临床诊断的价值,并对临床症状、体征和电生理之间的相关性进行探讨。
方法回顾性收集我院2008-2010年所有行常规肌电图(routine electromyography, rtEMG)、神经传导测定(nerve conduction study, NCS)、重复神经电刺激(repetitive nerve stimulation, RNS)患者的临床和电生理资料,建立数据库,并与1993-2003年资料进行比较。调查内容包括一般情况、临床情况、相关既往史、相关辅助检查、诊断结果、电生理结果、临床与电生理关系,对肌电图检测的现状进行描述性统计,并就临床和电生理的相关性以及应用价值进行统计分析。
结果1)不同年度行肌电图检查例数及阳性率分别为：1993-1995年3097例,阳性率62.8%；2001-2003年6455例,阳性率60.7%；2008-2010年10161例,阳性率48.9%。2)2008-2010年间,具有不同首发症状的患者EMG阳性率不同,分别为：运动功能障碍68.1%,同时具有运动和感觉障碍67.2%,单纯感觉症状49%,其他难以归类的症状31.9%,无症状30.7%；同时合并感觉症状与客观查体感觉障碍者肌电图阳性率(69.3%)与仅存在感觉症状者的阳性率(38.5%)存在明显差异(P<0.05)。3)在所有行针电极EMG的患者中,39.5%为神经源性损害,7.9%为肌源性损害,1.5%同时合并神经源性和肌源性损害。肌电图表现为广泛神经源性损害者546例(占神经源性损害的14.7%),包括运动神经元病/肌萎缩侧索硬化400例(73.3%)、脊肌萎缩症10例、肯尼迪病7例、平山病9例、神经根神经病19例、腓骨肌萎缩症9例、多灶性运动神经病3例、其他疾病7例、不能确诊者82例。肌电图表现为上下肢周围神经源性损害者704例,包括糖尿病周围神经病246例、急性炎症性脱髓鞘性多发性神经病43例、腓骨肌萎缩症43例、结缔组织病相关周围神经病36例、POEMS综合征22例,慢性炎性脱髓鞘性多发神经病16例,副肿瘤综合征7例,其他29例,不能确诊者262例。4)4688例肌电图与临床初步诊断一致,其中1339例(28.5%)肌电图无异常。2822例肌电图与初步诊断不一致,其中2010例(71.2%)肌电图无异常；在肌电图阳性的812例患者中,250例可解释原有临床症状并改变了原有诊断,411例肌电图虽阳性,但与临床所诊治疾病无关,151例预期肌电图阴性,却得到了可以解释病情的阳性结果。
结论：1)近年来肌电图检测的病例总数明显增加,但阳性率下降。2)不同首发症状、体征对应肌电图检测的阳性率不同,其中感觉症状阳性率最低,对仅有感觉障碍主诉者进行肌电图检测、筛查,是造成肌电图阳性率下降的原因之一。3)尽管肌电图检测对临床诊断起到了重要的支持作用,但存在过度使用现象。4)同一肌电图结果,可对应于多种临床疾病,同一疾病也可有多种电生理表现,37.6%的病例临床诊断和肌电图诊断无关,因此肌电图结果的解释必须结合临床。
Background:The diagnostic ability and research in neuroelectrophysiology in China have progressed a lot in recent years; the academic standard has reached global level. Have electrodiagnostic tests played its role in clinic? How to make it work more efficiently? Figuring out the application status of neuroelectrophysiological tests in China and collecting the baseline data plays an important role on the further work and the standardized application of EMG. The analysis of the application status and diagnostic value of electromyography is blank in China. As one of the famous EMG laboratory in China, PUMCH accumulates huge amount of neurophysiologic and clinical data, which is the foundation of this large sample retrospective experiment.
Objectives:Through the retrospective analysis of clinical and neurophysiological data of PUMCH to establish the baseline information of EMG application, analyze the diagnostic value of EMG and the correlation between clinical symptoms, signs, and electrophysiology.
Methods:Select all the patients who underwent needle EMG, nerve conduction study, repetitive nerve stimulation and skin sympathetic response test in PUMCH from2008to2010to retrospective analyze the clinical and neurophysiological information, establish the database, and compare with that from1993to2003. The survey includes general situation, the clinical situation, the relevant previous histories, related auxiliary tests, diagnosis, electrophysiological results, and the relationship between clinical and electrophysiology.
Results:1) The number of patients examined and positive rate in different years were3097(62.8%) from1993to1995,6455(60.7%) from2001to2003,10161(48.9%) from2008to2010.2) The positive rates in EMG results of different first symptoms were68.1%for motor symptom,67.2%for concomitant motor and sensory symptom,49%for sensory symptom,31.9%for unclassified symptom,30.7%for no symptom and sign. The positive rate of EMG were38.5%for those with sensory symptom only and69.3%for those with both sensory symptoms and signs (P<0.05).3) In all patients performed needle EMG,39.5%was neurogenic lesion,7.9%was myogenic lesion, and1.5%was concomitant neurogenic and myogenic lesion.546patients showed diffuse neurogenic changes on EMG, including400(73.3%) patients with MND/ALS,19with cervical spondylosis combined with lumbar spondylosis,10with spinal muscular atrophy,9with Charcot-Marie-Tooth disease,9with Hirayama disease,7with Kennedy's disease,3with multiple motor neuropathy and7with other diseases,82patients with no definite diagnosis.704patients showed multiple peripheral neuropathy changes on EMG, including246patients with diabetic polyneuropathy,43with CMT/HMSN,36with connective tissue disease,43with AIDP,22with POEMS syndrome,16with CIDP,7with paraneoplastic syndrome and29with other diseases,262with no definite diagnosis.4) EMG results of4688patients were consistent with the initial clinical diagnosis, of which28.5%(1339/4688) showed normal EMG. EMG results of2822patients were different from initial clinical diagnosis, of which71.2%(2010/4688) showed normal EMG results. In those with abnormal EMG results, EMG results of250patients were consistent with the symptoms, but they were different from the initial diagnosis, EMG results of411patients had no relevant to the initial diagnosis and symptoms, while only151patients had unexpected positive results who were misdiagnosed to functional disorders.
Conclusions:1) The number of patients performed EMG has been increasing during the past years; however the positive rate of EMG is decreasing.2) The positive rate of EMG changes with different symptoms and signs at onset. Performing EMG test on those who only have sensory symptoms and screening for the potential neuromuscular diseases are the reasons for decreasing positive rate.3) EMG plays an important role in clinical diagnosis, but the excessive use of it should be concerned.4) Different diseases can show the same EMG results and different EMG results can be detected in the same disease.37.6%of EMG results are irrelevant with clinical situation. EMG result should be explained with clinic and other auxiliary tests together to get a proper diagnosis.
引文
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