Dr. Drasko Simovic, MD

Research & Development Labs, Medical Clinics

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EMG Laboratory

Theodore Gavrilescu, MD

Gavrilescu, Ted

Gavrilescu, Ted, Md - Emg Laboratory

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Phone: (978) 687-2586

Address: 50 Prospect St, Lawrence, MA 01841

Website: http://www.emglaboratory.com

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Dr. Drasko Simovic, MD

General Practitioners

Arthritis
Diabetes mellitus, rheumatoid arthritis, gout, amyloidosis, myxedema, multiple myeloma, pregnancy, hemodialysis, SLE, sceroderma, acromegaly, repetitive wrist motion stress injury, hypothyroidism, ganglion, sarcoid, and previous radius fracture. Most cases are idiopathic.
Plantar Fasciitis

Pregnancy

Neurology
Castle Connolly Medical Ltd., America's trusted source for identifying Top Doctors, has selected Boston's Neurology specialist Dr. Drasko Simovic for inclusion in its highly selective list of Castle Connolly Top Doctors this year. All told, more than 44,000 physicians - approximately 5% of the nation's licensed physicians - have been selected as Castle Connolly Top Doctors in their regions for their specialties... more
Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is the most frequently encountered mononeuropathy in the clinical practice. Although now a well recognized entity, it took almost 100 years from the initial observations until the pathophysiology of the disorder was finally accepted as a median nerve compression at the wrist. Sir James Paget (1854) was the first to describe the clinical features of CTS.
Neurolysis
- Peroneal Nerve Palsy: - peroneal palsy following TKR - nerve injury - discussion: - peroneal nerve palsy may lead to severe disability w/ foot drop and paresthesias; - note that in contrast to other types of nerve palsies, peroneal palsy may demonstrate a greater motor deficit (than sensory deficit) because the deep motor brach is subject to tethering a two points: the fibular neck and the intermuscular septum; - traumatic peroneal palsy: may result from supracondylar frx, knee dislocation, and proximal tibial frx; - atraumatic peroneal nerve palsy: - may result from a large fabella which impinges on peroneal nerve behind the knee or may result from a proximal tibiofibular synovial cyst (which is identifed by MRI); - these patients will often have a history of lumber disc disease, ETOH use, and diabetes. - references: - Unusual manifestations of proximal tibiofibular joint synovial cysts. TA Damron, MG Rock. Orthopedics. Vol 20, 1997. p 225-230. - exam: - always consider lumbar radiculopathy during the examination; - there may be an obvious foot drop; - sensory loss may be difficult to determine because of variable & small autonomous zone of sensation; - Tinel's sign over the fibular neck, helps localize the site of nerve compression; - always check for a fabella and check to see if direct compression reproduces nerve symptoms; - in cases of knee dislocation it is important to test for function of the tibial branch of the sciatic nerve as well; - in some cases of peroneal nerve avulsion, there will also be a sciatic nerve traction injury; - EMG: - useful to objectively document the conduction block; - if possible should be performed w/ in one month of injury; - amplitude of the sensory potential and decreases in nerve conduction velocities are used to confirm sensory and motor deficits, respectively; - prognosis; - w/ partial nerve palsy, > 80% will recover completely; - w/ complete palsy, < 40% will have complete recovery; - peroneal nerve in continuity which arises from a well defined etiology will tend to do better than nerve palsies arising from idiopathic causes; - treatment: - if there is no neurologic improvement after 2-3 months, then operative decompression is indicated; - nerve in continuity: - operative treatment invovles external neurolysis of peroneal nerve at the level of the fibular head; - the nerve and its branches need to be freed from its adherence to the proximal fibula, particularly at its most proximal 4 cm as well as a 2nd region of adherence which may lie between 7 and 15 cm from the fibular head; - the nerve may be entrapped by thick fibrous bands which arch over the nerve as it crosses the fibular neck; - the arch has a superficial band and a deep band; - nerve not in continuity: ( neurotomesis ) - see nerve repair - one of the problems encountered in peroneal nerve repair following knee dislocations (or other injuries) is that the location of the nerve injury may be well above the knee joint; - in the case of knee dis
Multiple Sclerosis
The diagnosis of ALS is a "rule-out" procedure. There is no simple blood test for the disease. People who are suspected of having ALS are generally put through a series of tests to rule out other neurological conditions like multiple sclerosis, strokes or even carpal tunnel syndrome, said Dr. Simovic...

Depression
Psychiatry
Acar D, Simovic D, Weinberg DH, Ropper AH: Mononeuritis multiplex mimicking acute demyelinating polyneuropathy; Presented at the Annual Stanley Cobb Assembly - Boston Society of Neurology and Psychiatry Meeting, Boston; April 1997

Endocrinologist

Diabetes Care
Hypothyroidism

MRI

Orthopedics
Pinched Nerve
Simply put, the problem is a pinched nerve, which people often don't realize. "They're always surprised that it's the nerve that is pinched" Dr. Simovic said. "For whatever reason, there's a misconception."...
Hand Surgery
- See: - Posterior Interosseous Nerve Syndrome: - Radial Nerve Palsy Associated w/ Humeral Shaft Frx: - Radial Nerve Block - Tendon Transfers for Radial Nerve Palsy: - Anatomy: - three posterior divsions of brachial plexus form posterior cord: ( C5, C6, C7, C8, T1 ) - radial nerve ( C5, C6, C7, C8, and T1 ) is largest of & most frequently injured branch of both the posterior cord (as well as the brachial plexus ); - in axilla, it gives off: - posterior cutaneous nerve of arm; - branch to long & medial heads of triceps; - between axilla & spiral groove of humerus: - it distributes a branch to the lateral head of the triceps; - nerve may or may not travel in spiral groove and is often separated by the humerus by 1 to 5 cm of muscle; - course of nerve through the intermuscular septum; - nerve travels from deep to the lateral head of the triceps, piercing the intermuscular septum; - after piercing lateral intermuscular septum, the nerve comes to lie between the brachialis and brachioradialis, and goes on to pass in front of elbow: - radial nerve emanates from the spiral groove approximately 10 cm proximal to the lateral epicondyle; - branch to brachioradialis & ECRL; - nerve remains anterior relative to the humerus, and passes along the lateral column of the distal humerus; - reference: One-third, two-thirds: relationship of the radial nerve to the lateral intermuscular septum in the arm. - each of motor branches, arising from radial nerve & passing to lateral head of triceps, is accompanied closely by a branch of profunda brachi artery and vein; - as noted by Gerwin et al (JBJS Am. 1996 Nov;78(11):1690-5. ), the nerve crosses the posterior aspect of the humerus at 20-21 cm proximal to the medial epicondyle and 14-15 cm proximal to the lateral epicondyle; - posterior interosseous nerve: - it divides in front of radial head, w/ deep branch ( PIN ) passing backward thru supinator (arcade of Froshe) to supply 9 muscles on extensor aspect of forearm; - because of the numerous branches into which the deep radial nerve breaks up at the lower border of the supinator, surgical repair of the nerve here is difficult; - remaining part PIN, runs downward parallel to posterior interosseous artery to supply all of deeper lying extensor muscles & ends as a twig to wrist joint; - in this course, it passes superficial to long abductor & EPB of thumb, but its terminal branch to wrist joint passes deep to EPL & EIP; - Sensory Branch: - superficial branch of radial nerve passes into forearm deep to brachioradialis muscle; - approx 8 cm from tip of radial styloid, nerve emerges from under tendon of BR between tendon of BR & tendon of ECRL; - sensory branch passes downward emerging dorsally from beneath BR tendon about 5 cm proximal to radial styloid; - it lies just deep to the superficial veins; - distally, it provides sensation to dorsum of thumb, excluding subungual region which is supplied by branches of median; - superficial branch innervates dorsal aspect of first w

Cyst
Lesions
The EMG in ulnar nerve lesions can establish the location of the pathological process, document the severity and evaluate for common differential diagnosis which includes lower trunk brachial plexopathy and C8 radiculopathy.

Physical Therapists

Tennis Elbow
- Inciting causes: - radiocapitellar joint ganglions and synovitis - congenital tightness of ligamentous arcade of Frohse; - include poorly placed screws for fracture fixation - PIN is vulnerable during ORIF of proximal radius; - in 25% of pts, PIN lies in direct contact w/ periosteum of radius just dorsal to the biciptial tuberosity; - fixation device applied to radius, which might have its proximal screw at level of the bicipital tuberosity, could cause PIN syndrome by entrapment beneath the plate; - to avoid this complication, the nerve should be directly exposed; - idiopathic compression syndrome: - sites of compression: - fibrous bands anterior to the radial head at the entrance of radial tunnel (uncommon cause of compression); - radial recurrent vessels (leash of Henry); - tendinous origin of ECRB: the ECRL is more superficial and is not a source of compression; - arcade of Froshe: - this is the most common location of nerve compression in radial tunnel syndrome; - lies deep to the extensor carpi radialis brevis - tendinous proximal border of supinator (arcade of Frohse): - distal edge of the supinator at exit: this is the least common site of compression; - reference: - Radial nerve entrapment at the elbow: surgical anatomy. - Peripheral nerve compression. RH Gelberman et al. JBJS. Vol 75-A. 1993. p 1854-1878. - Diff Dx: of Post Interosseous Nerve Syndrome: - C7 radiculopathy: - unlike PIN, there will be weakness of triceps and wrist flexors; - lateral epicondylitis ( ECRB ) - it is often misdiagnosed as resistant tennis elbow or PIN Syndrome; - unlike tennis elbow, there is tenderness about 4 cm distal to the lateral humeral epicondyle; - distal PIN syndrome: - pts w/ distal posterior interosseous nerve syndrome have pain with repetitive dorsiflexion & tenderness centered over the 4th extensor compartment; - trigger finger (no passive movement possible); - extensor tendon rupture: - may be differentiated by tenodesis effect of passive flexion of wrist: if the tendons are intact, the digits will extend (ie., tenodesis effect is lost); - failure of digit extension from chronic dislocation of MCP (see MP joint in RA ) - pt can maintain extension achieved passively - Bouvier's Test
Flatfoot Correction
Heel Pain
Neck Pain
Back Pain

Flat Feet
- Complications: - iatrogenic nerve compression: - as noted by JTC Lau and TR Daniels, a tarsal tunnel release w/ a concomitant pes planus may have the effect of increasing posterior tibial nerve tension, which may explain the high rate of poor surgical results; - in the same study, distraction calcaneo-cuboid arthrodesis reduced nerve tension;
Heel Spurs
- Distal Tibial Tarsal Tunnel Syndrome: - a cause of heel pain arising from compression of the distal branches of the posterior tibial nerve by the deep fascia along the medial border of the abductor hallucis; - this can be exacerbated by by hyperpronation, thickening of the plantar fascia, thickening of the deep fascia of the abductor hallucis; - first branch lateral plantar nerve: - this nerve supplies the abductor digiti quinti (and possibly it innervates the quatratus plantae and FDB) as well as deep sensory innervation; - nerve runs deep to the deep fascia of the abductor hallucis and then runs laterally and transversely superficial to the quadratus (and deep to the FHB ) on its way to innervate the abductor digiti quinti; - nerve may be compressed by the superior-deep edge of abductor hallucis fascia & most medial edge of the plantar fascia, and in addition the nerve may be compressed by medial edge of quadratus; - the nerve is best exposed by superior retraction of the abductor hallucis, or in some cases, the abductor must be mobilized or divided inorder to adequately expose (and decompress) the nerve; - entrapment of the first branch occurs as the nerve changes from vertical to a horizontal direction around the medial plantar aspect of the heel; - the calcaneal heel spur lies just plantar to the course of the nerve and may be contributing to nerve compression or irritation; - pts w/ flat feet are thought to be at risk for this compression; - the nerve is decompressed by elevating the abductor hallucis and then releasing the deep fascia beneath the abductor and the contiguous medial plantar fascia; - medial calcaneal nerve: - nerve branches that innervate the plantar medial aspect of the heel pass medial (superficial) to the abductor hallucis muscle and are usually not involved with the entrapment of the first banch; - some have theorized that a valgus hindfoot predisposes joggers to compression of this nerve branch; - terminal latencies of abductor hallucis (which is innervated by the medial plantar nerve) more than 6.2 msec is abnormal;
Heel Pain
Plantar Fasciitis
- Tarsal Tunnel Syndrome: - compression syndrome of the tibial nerve in the tarsal tunnel; - tarsal tunnel is formed by the flexor retinaculum behind and distal to the medial malleolus; - inciting causes: - lipoma, ganglia, or neoplasms within the tarsal tunnel; - an accessory flexor digitorum longus muscle is a common cause; - exostosis within the tarsal tunnel; - hindfoot valgus deformity will potentiate the deformity; - in the study by Daniels et al 1998, tibial nerve tension was increased by erversion and dorsiflexion of the foot; - diff dx: - stress fractures (identified on 45 deg medial oblique view) - inflammatory arthritides ( RA or Reiter's Syndrome ) - plantar fasciitis - herniated disk - peripheral neuropathy - disc herniation; - clinical findings: - patients may note pain when the ankle is placed in extremes of dorsiflexion (from nerve tension); - patients note pain, paresthesias, foot numbness, and in somes cases atropy of foot intrinsics; - pain will radiate along the plantar side of the foot, sometimes up into the calf; - positive Tinel sign behind medial malleolus; - manual compression for 30 sec. may reproduce symptoms; - consider performing 2 point discrimination test both on medial and lateral sides of the foot (and opposite foot); - if the 2 point discrimination is increased on one side of the foot, it may indicate which branch of the plantar nerve is compressed; - in most cases, symptoms will be improved w/ rest; - EMG - can be useful when the operator has experience w/ this condition; - prolonged distal motor latency; - terminal latencies of the ADQ (lateral plantar nerve) more than 7.0 msec are abnormal; - terminal latencies of abductor hallucis (which is innervated by the medial plantar nerve) more than 6.2 msec is abnormal; - fibrillations in the abductor hallucis; - in the series by DS Bailie MD and AS Kelikian 1998, 81% of patients had abnormal EMG studies; - MRI: may be used to identify ganglia or extrinsic masses and the specific site of compression; - operative decompression: - is considered for patients w/ space occupying lesions (there are numerous case reports of neurolemoma involving the tibial nerve within the tarsal tunnel); - concerns have been raised about tarsal tunnel decompressions, noting that the decompression would not alter stretch forces on the nerve (rather this would have to be managed by stabilization of the foot in a corrected position; - the nerve is decompressed from the posterior tibial nerve from its flexor retinaculum to a point past the bifurcation; - if an anomalous muscle if found with in the tunnel and is thought to be the cause of nerve compression then the muscle should be resected; - cautions: nerve decompression of the tarsal tunnel may not produce the favorable long term results seen in other nerve decrompression procedures;

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