Health Matters - London Bridge Hospital

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EMG/NCS UseDr Alistair PurvesConsultant ClinicalNeurophysiologistEMG/NCS Usein Primary Careby Dr Alistair PurvesMost GPs will be aware of the existence of departments of ClinicalNeurophysiology in their local hospitals, but historically not many have had directaccess. In my NHS practice at King’s College Hospital I have had open access toGPs for some years – currently about 15-25% of my referrals are direct. I findthat the patients coming to us directly are essentially the same as those comingfrom orthopaedics etc, and the rising proportion of GP referrals suggests thatthose who refer are finding it a valuable diagnostic tool.Electromyogram and Nerve Conduction Studies (EMG/NCS) are concernedwith techniques looking directly at peripheral nerve and muscle function viatheir electrical properties. We can characterise nerve damage or compressionproblems, and can indicate the site of this as well as the severity. This is wellestablished for many of the common entrapment neuropathies such as CTS orulnar compression.A new and important area exists in EMG/NCS where patients who present withsymptoms that appear to be neurological like tingling, numbness, pain, clumsinessor weakness in an arm or leg, but where the distribution does not conform toa standard pattern. A typical patient might have pins and needles throughout anarm, weakness or unreliability of grip and poorly localised proximal pain. Spinalimaging often fails to show any abnormality beyond some degenerative changeappropriate to occupation and age.Due to the very neurological flavour of the symptoms there often remainsconcern that there is nerve damage somewhere, and it is very helpful clinicallyto demonstrate that there is no nerve compression or damage either in theperipheral nerves, or in the brachial plexus or in the cervical roots. We oftenfind that patients who have neck and shoulder pain and who have some othercoexisting condition such as carpal tunnel syndrome (CTS), display atypicalsymptoms, e.g. the sensory symptoms are often in the entire hand or even in the‘ulnar’ fingers. We can show the separate components of a mixed picture that canbe clinically very confusing.Dr Purves qualified at Cambridgein 1981, and trained atAddenbrookes Hospital andthe National Hospital forNeurology and Neurosurgery.He is a Consultant at King’sCollege Hospital and providesan extensive service in EMGand conduction studies thereand in Kent. He has a particularinterest in the neurophysiologyof pain syndromes.For more information on EMGand NCS or to contact DrPurves’ secretary, please phone:T: 01622 620910Some patients with what wouldotherwise be called a pure painsyndrome, such as fibromyalgia, doalso have neurological symptoms,and neurophysiology is veryuseful for reassuring patientsand doctors that there is nounderlying nerve damage. If thereis an abnormality, this then allowsan appropriate further referral tobe made – to rheumatology or apain specialist, or to orthopaedicsif there is a peripheral lesion suchas a CTS, or to neurosurgery, ifthere is evidence of cervical orlumbar root lesions.TENEMG/NCS Use
Keyhole Surgery forFractures Aroundthe ShoulderFractures around the shoulder are usuallydue to high energy impacts like thoseoften seen in contact sporting injuries.These usually result in either a fracture ofthe proximal humerus or of the glenoidprocess of the scapula. Such fractures arenotorious for poor outcomes and longperiods of rehabilitation and often requirelarge open operations to fix the fractures.The latest techniques involve usingkeyhole surgery (shoulder arthroscopy)to assist in debriding the fracturefragments and under direct visualisation,accurately reduce the fracture back toan anatomical position. The advantagesof these techniques are that mostprocedures can be performed viaminimally invasive techniques with areduced risk of infection, a faster recoveryrate and a better long-term outcome.By remaining at the forefront of thelatest techniques and ensuring bestpractice, Mr Kochhar has developed ahigh quality and efficient shoulder servicefor sports injuries and fractures, as well asdegenerative conditions of the shoulderand upper limb.Case study 1A 38-year-old gentleman fell over ontohis right shoulder whilst skiing. Thepre-operative CT scan demonstratesa fracture of the anterior part of theglenoid:by Tony KochharFig. 1 – Pre-op CTFig. 2 – Pre-fixation viewVia arthroscopy of his shoulder, the fracturefragment was debrided and reducedaccurately and then via a mini open incisionfrom the front of the shoulder, a screw wasplaced retrograde (from front to back),securely fixing the fragment back onto therest of the glenoid fossa.Fig. 3 – Retrograde screwThe fixation was solid and there wasan accurate reduction. The patientwas mobilised almost immediately. Hereturned to a pre-operative level offunction within eight weeks. He hasreturned to full sporting activities.Case study 2Fig. 4A 44-year-old man was rugby-tackled andsustained a minimally displaced impactionfracture of the greater tuberosity.Fig. 5He underwent an arthroscopy of hisshoulder and under direct arthroscopicvisualisation the fracture was debrided.Fig. 6The fracture was securely fixed using twosuture anchors. These sutures were passedthrough the fragments to result in a solidsuture repair of this fracture.Tony KochharConsultant Shoulder &Upper Limb SurgeonTony Kochhar is a ConsultantOrthopaedic Surgeon here atLondon Bridge Hospital. Heis an expert in surgery of theshoulder, elbow, wrist and hand.He completed his training atthe Royal National OrthopaedicHospital in London. He hasfurthered his shoulder and upperlimb training by working withsome of the best surgeons in theworld, having completed specialistfellowships at worldwide centresof excellence in New York andthe world-renowned Alps SurgeryInstitute in Annecy, France.By remaining at the forefrontof the latest techniques andensuring best practice, MrKochhar has developed a highquality and efficient shoulderservice for sports injuries andfractures as well as degenerativeconditions of the shoulder andupper limb. Mr Kochhar regularlylectures on shoulder and upperlimb surgery at national andinternational conferences andtraining courses.Keyhole SurgeryFig. 1Fig. 2Fig. 3He has regular outpatient clinicsessions here at London BridgeHospital on Tuesdays and Fridays(both daytimes and evenings).To make an appointment to seeMr Kochhar, please contact theGP liaison department at LondonBridge Hospital, or his secretaryon:T: 020 3301 3750Fig. 4Fig. 5Fig. 6Further information is availableon Mr Kochhar’s website:www.shoulderdoctor.co.ukKeyhole SurgeryELEVEN
Page 1 and 2: Health MattersWinter 2010 • Issue
Page 3: FeaturesFeaturesp4 Oncoplastic Brea
Page 6 and 7: Extracorporeal Shock Wave TherapyEx
Page 8 and 9: 10 Minutes With...10 minuteswith...
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Page 14 and 15: 31 Old Broad StreetHEALTHCAREEXCELL
Page 16 and 17: NewsCorventis MobileCardiac Telemet
Page 18 and 19: UpdatesLondon Bridge HospitalRefurb
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