1. Wang FC, Tinant F, Tomasella M CHU de Liège, Belgique

3.  29-year-old woman, without specific antecedent  Delivery in february  + 14 Kg during pregnancy  Numbness in the hands (L > R), worsening at night and at rest, since month 7 of pregnancy  The numbness was less pronounced after delivery; but, the patient reported left finger stiffness (residual oedema ?) and a sensation of weakness in the left intrinsic hand muscles (thumb abduction for instance)  Since one month (april), the patient experienced pain in the left wrist over the ulnar or radial side; the numbness has disappeared

4. Nerve (MCV)SegmentAMPL (mV)DLAT (ms)CV (m/s)F-LAT (ms) Median R Forearm9.9 4.3 5321.8 Median L Forearm 0.17.74825.5 Ulnar L Forearm9.82.56322.0 Elbow48 Radial L Forearm 2.4 3.568 Nerve (SCV)SegmentAMPL (µV)CV (m/s) Median R palm/wrist54 43 Median L palm/wrist40 38 Ulnar R palm/wrist4158 Ulnar L palm/wrist2964 Radial R distal forearm3260 Radial L distal forearm3566 Cutaneous ante. lateral R forearm1666 Cutaneous ante. lateral L forearm2160 Cutaneous ante. medial R forearm 8.4 66 Cutaneous ante. medial L forearm 8.1 65 Normal needle EMG in : interosseus dorsalis I L ext dig communis L pronator quadratus L biceps L abd pollicis brevis R Needle EMG : reduced recruitment in : triceps L flex carpi rad L subacute denervation in : abd pollicis brevis L

5. Examination was normal on right upper limb and both lower limbs On the left upper limb :  No reflex change  Phalen’s sign : +, Tinel’s sign : - Carpal compression test : pain without paresthesia  Decrased pin-prick sensation over the thumb and the ulnar aspect of the hand No loss of touch sensation  Adson’s test : + Chandelier : pain in the thumb No tender spot or Tinel’s sign on supraclavicular area  Muscle weakness : abductor and extensor pollicis and flexor carpi (C8D1)

6. X-ray of the cervical spine : normal, no cervical rib X-ray of wrists and hands : normal Biological findings :  No inflammatory syndrome  Blood cytology and ions : normal  Immunology: - no gammopathy - no antibodies against the peripheral nervous system - normal C3, C4 complement components - rhumatoid factor : 43 UI/ml (0-11) - ANA : + (speckled) HEP.2 cell titer : 1/160 -anti-DNA : - - ANCA : -

7. Nerve (MCV)SegmentAMPL (mV)DLAT (ms)CV (m/s)F-LAT (ms) Median R Forearm12.4 (9.9) 4.5 (4.3) (53)(21.8) Median L Forearm 0.8 (0.1)15.2 (7.7)(48)(25.5) Ulnar L Forearm11 (9.8)2.7 (2.5)59 (63)22.0 (22.0) Elbow53 (48) Radial L Forearm 7 (2.4) 2.6 (3.5)(68) Nerve (SCV)SegmentAMPL (µV)CV (m/s) Median R palm/wrist63 (54) 45 (43 ) Median L palm/wrist46 (40) 40 (38 ) Ulnar R palm/wrist36 (41)61 (58) Ulnar L palm/wrist30 (29)63 (64 ) Radial R distal forearm(32)(60) Radial L distal forearm(35)(66) Cutaneous ante. lateral R forearm(16)(66) Cutaneous ante. lateral L forearm(21)(60) Cutaneous ante. medial R forearm 11 (8.4) 68 (66) Cutaneous ante. medial L forearm 13 (8.1) 67 (65) Needle EMG : subacute denervation in : abd pollicis brevis L 22 ms wrist palm

8. 22 ms wrist palm Surgery (6/14/04) wrist elbow palm After surgery (9/8/04)

9. Normal branching of the median nerve : 46%

10. Subligamentous origin and course of the muscular (thenar) branch in the carpal tunnel : 31%

11. Transligamentous course of the muscular (thenar) branch : 23%

12. Origin of the muscular (thenar) branch from the ulnar aspect of the median nerve

13. Muscular (thenar) branch courses around the distal margin of the retinaculum

14. Double branching of the muscular (thenar) branch

15. Radial : 60% At the margin of the radial third : 18% Central position : 22%

19. Patient hospitalized and sent to the ENMG lab. for evaluation of an asymmetrical CIDP (Lewis-Sumner syndrome) including CV slowings and CB. Ulnar nerve stimulation M wave recorded over the ADM Stimulation site AMPL (mV) AREA DECAY DISPERSIONDLAT (ms) CV (m/s) Wrist 5.63.2 76 Below elbow 4.1 -34%32% 5.5 53 Above elbow 3.0 -36% -29%7

20. Ulnar nerve stimulation M wave recorded over the ADM Stimulation site AMPL (mV) AREA DECAY DISPERSIONDLAT (ms) CV (m/s) Wrist 4.5 5.2 44 Elbow 5.0 +25% 11%9.5 Ulnar F-LAT : 24.3 ms Median nerve stimulation M wave recorded over the APB

21. Stimulation site AMPL (mV) AREA DECAY DISPERSIONDLAT (ms) CV (m/s) Wrist 6.83.0 42 Below elbow 2.9 -37%28%7.3 7 Above elbow 0.7 -69% 16% 19 Wrist 0.1 Elbow 3.2 Ulnar nerve/ADM Median nerve/ADM

22. Ulnar nerve stimulation M wave recorded over the ADM Ulnar F-LAT : 24.3 msUlnar F-LAT : 52 ms

23. Ulnar nerve stimulation M wave recorded over the ADM Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus

24. Ulnar nerve stimulation M wave recorded over the ADM Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus 100 mA 1 ms

25. Ulnar nerve stimulation M wave recorded over the ADM Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus 60 mA 1 ms

26. Ulnar nerve/ADM Median nerve/ADM Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus

27. Ulnar nerve/ADM Median nerve/ADM Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus 100 mA 0.2 ms

28. Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus 12 mA 0.2 ms Ulnar nerve/ADM Median nerve/ADM

29. Ulnar nerve/ADM Median nerve/ADM Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus

30. Median nerve stimulation M wave recorded over the APB Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus

31. Median nerve stimulation M wave recorded over the APB Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus

32. Abductor pollicis brevis Median nerve Ulnar nerve Abductor digiti minimi First dorsal interosseus