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Coker C, Park J, Jacobson RD. Neurologic Approach to Radiculopathy, Back Pain, and Neck Pain. Prim Care 2024; 51:345-358. [PMID: 38692779 DOI: 10.1016/j.pop.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Back pain and neck pain are common in clinical practice, but significant challenges and pitfalls exist in their diagnosis, treatment, and management. From the neurologic standpoint, cervical radiculopathy and lumbosacral radiculopathy are characterized by neck pain or back pain accompanied by sensory and motor symptoms in an arm or leg. The basic neurologic examination is vital, but testing like electromyography and MRI is often needed especially in cases that fail conservative management. Oral medications, injection-based therapies, physical therapy, and surgical evaluation all have a place in the comprehensive neurologic management of back and neck pain and associated radiculopathy.
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Affiliation(s)
- Canaan Coker
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Jade Park
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Ryan D Jacobson
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA.
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2
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McGuire T, Haig AJ. A review of electromyography techniques of the cervical paraspinal muscles. PM R 2024; 16:287-294. [PMID: 37528546 DOI: 10.1002/pmrj.13047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/28/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023]
Abstract
Electrodiagnosis for cervical radiculopathy often involves exploration of the cervical paraspinal muscles. Accurate and reproducible results require a technique with specific anatomic localization, direction of insertion, extent of insertion, scoring system for insertion, and criteria for determining abnormality. We sought to understand if a published technique met these criteria. A Medline search found 39 articles with original research and 10 review articles involving the cervical paraspinals. A library search found 19 textbooks since 2000, but 9 were not available. Only two studies were specific to the question. Neither had reproducible techniques and they contradicted each other. Studies in which the paraspinals were used for comparison or inclusion did not provide any specific technique. The review articles and textbooks typically met none of our criteria and the few that discussed technique at all provided no reproducible methods. Despite 80 years of electrodiagnostic testing, there is no useful, reproducible technique for exploring the cervical paraspinal muscles. Yet such a paraspinal mapping technique has proven invaluable in the lumbar region. For cervical electromyography to be of value, the next step is to understand the anatomy and propose a reproducible technique. Subsequent research will determine whether the neck muscles are helpful in the diagnosis of cervical radiculopathy. The absence of a valid reproducible cervical paraspinal technique impedes clinical and scientific understanding of cervical radiculopathy.
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Affiliation(s)
| | - Andrew J Haig
- Haig Physical Medicine PLC, The University of Michigan, Ann Arbor, Michigan, USA
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Joaquim AF, Martins CR, Riew KD. How Knowledgeable Are Spine Surgeons Regarding EMG-NCS for Cervical Spine Conditions? An International Aospine Survey. Global Spine J 2023; 13:2033-2046. [PMID: 35044872 PMCID: PMC10556916 DOI: 10.1177/21925682211068795] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Cross-sectional, international survey. OBJECTIVES To evaluate the knowledge of spine surgeons regarding the use of electromyography (EMG) and nerve conduction studies (NCS) for degenerative cervical spine conditions (DCC). METHODS All members of AO Spine International were emailed an anonymous survey to evaluate their clinical knowledge about the use of EMG and nerve conduction studies for DCC. Descriptive statistics were used to analyze the results, as well as to compare the answers among different groups of surgeons and assess demographic characteristics. RESULTS A total of 402 participants answered the survey, 91.79% were men from the 5 continents. There were 221 orthopedic surgeons (55.39%) and 171 neurosurgeons (42.86%), more than a half of them with a complete spinal fellowship (56.44%). The most common reasons that surgeons obtain the test is to differentiate a radiculopathy from a peripheral nerve compression (88.06%). As a group, the responding surgeons' knowledge regarding EMG-NCS was poor. Only 53.46% of surgeons correctly answered that EMG-NCS is unable to differentiate a C5 from a C6 radiculopathy. Only 23.47% of the surgeons knew that EMG-NCS are not able to diagnose a pre vs a post-fixed brachial plexus. Only 25% of the surgeons correctly answered a question regarding the test's ability to diagnose other neurological diseases. CONCLUSIONS We found that our respondents' knowledge regarding EMG-NCS for DCC was poor. Identifying the weak points of knowledge about EMG-NCS may help to educate surgeons on the indications for the test and the proper way to interpret the results.
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Affiliation(s)
- Andrei Fernandes Joaquim
- Professor of Neurosurgery, Department of Neurology, Discipline of Neurosurgery, University of Campinas (UNICAMP), Campinas-SP, Brazil
| | - Carlos Roberto Martins
- Neurophysiologist, Department of Neurology, Discipline of Neurology, University of Campinas (UNICAMP), Campinas-SP, Brazil
| | - K. Daniel Riew
- Professor of Orthopedic Surgery, Department of Orthopaedics, Department of Neurological Surgery, Weill-Cornell Medical Center, The Och Spine Hospital at New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
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Shen P, Chi-Chung Tsang R, Liang Y, Chen X. Diagnostic accuracy of the upper limb neurodynamic test with median bias (ULNT1) for cervical radiculopathy: a systematic review and meta-analysis. Physiotherapy 2023; 120:17-25. [PMID: 37356367 DOI: 10.1016/j.physio.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 05/06/2023] [Accepted: 06/03/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The upper limb neurodynamic test for median nerve (ULNT1) is commonly applied for assessment of cervical radiculopathy (CR). However, the diagnostic accuracy of ULNT1 in diagnosing CR remains unclear. OBJECTIVE This study aimed to examine the diagnostic accuracy of the ULNT1 for the CR. DATA SOURCES Four databases were searched for relevant studies published up to April 30, 2023. STUDY SELECTION Cross-sectional or cohort studies that assessed the diagnostic accuracy of ULNT1 for CR were included. DATA SYNTHESIS The methodological quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist. A bivariate random-effects regression model was used for the data synthesis. The overall quality of evidence was evaluated using the GRADE approach. RESULTS A total of 592 references were identified, and five studies with 465 patients met the inclusion criteria. The overall quality of the body of evidence was very low across studies. Heterogeneity of studies was high. The pooled sensitivity and specificity of the ULNT1 were 0.69 (95% CI 0.50-0.83) and 0.54 (95% CI 0.36-0.71), respectively. The summary receiver operating characteristic curve area was 0.65 (95% CI 0.61-0.69). CONCLUSION There is low certainty of evidence that the ULNT1 has only fair accuracy in diagnosing CR. The ULNT1 was recommended as an add-on test after the existing diagnostic pathway to enhance diagnostic accuracy further. High-quality studies which follow the Standards for Reporting of Diagnostic Accuracy and the QUADAS-2; a revised tool for the quality assessment of diagnostic accuracy, are needed. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO: CRD42021255686 CONTRIBUTION OF THE PAPER.
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Affiliation(s)
- Peng Shen
- The First Affiliated Hospital of Nanchang University, NO.17, Yong Wai Zheng Jie, 330006 Nanchang, Jiangxi, China
| | | | - Ying Liang
- The First Affiliated Hospital of Nanchang University, NO.17, Yong Wai Zheng Jie, 330006 Nanchang, Jiangxi, China
| | - Xiwen Chen
- The First Affiliated Hospital of Nanchang University, NO.17, Yong Wai Zheng Jie, 330006 Nanchang, Jiangxi, China.
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Sonoo M. Recent advances in neuroanatomy: the myotome update. J Neurol Neurosurg Psychiatry 2023; 94:643-648. [PMID: 36653172 DOI: 10.1136/jnnp-2022-329696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023]
Abstract
The myotome of a muscle is the basis for diagnosing spinal and peripheral nerve disorders. Despite its critical importance in clinical neurology, myotome charts presented in many textbooks, surprisingly, show non-negligible discordances with each other. Many authors do not even clearly state the bases of their charts. Studies that have presented with raw data regarding myotome identification are rather rare. A classic study in the 19th century that pursued the nerve course in cadavers still has a substantial influence on existing charts, despite its definite limitations. Other scarce studies in humans include identification by root stimulation during surgery, clinical observations in root avulsion or spinal cord injury and clinical and electromyographical investigations in patients with single radiculopathies or certain plexopathies. A few recent studies have proposed new theories regarding the myotomes of some muscles. T1 innervation of the median intrinsic hand muscles is a typical example. We have added a number of new findings, such as T1 innervation of the forearm flexor muscles innervated by the median nerve except the pronator teres and flexor carpi radialis, C5 innervation of the brachioradialis, and two C6 indicator muscles, pronator teres and extensor carpi radialis brevis. Increased accuracy of the myotome charts will improve the localisation in neurology.
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Affiliation(s)
- Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
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KARAZİNCİR S, TURHANOĞLU AD, OKUYUCU E, BURAKGAZİ G. Brakial Pleksopatide Klinik, EMG ve MR Nörografi Bulgularının Değerlendirilmesi. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2022. [DOI: 10.17944/mkutfd.971518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Amaç: Çalışmanın amacı brakial pleksopatide MR nörografi sonuçlarını elektrodiagnostik test ile birlikte değerlendirmek ve MR nörografinin yararlığını saptamaktır.
Yöntem: Brakial pleksopati şüphesi bulunan ve elektrodiagnostik test yapılan 50 hasta çalışmaya dahil edildi. MR nörografide Brakiyal pleksusun kök, gövde ve kord seviyesinde seyri, kalibrasyonu, sinyal yoğunluğu ve devamlılığı 2 bağımsız radyolog tarafından değerlendirildi.
Bulgular: Elektrodiagnostik test altın standart tanı testi kabul edilerek yapılan analizde MR nörografinin tanısal doğruluk, duyarlılık, özgüllüğü; 1. okuyucu için sırasıyla %64, %45.16, %94.73; 2. okuyucu için sırasıyla %74, %67.74, % 84.21. Okuyucular arası tutarlılık %78 idi.
Sonuç: Brakial pleksopati klinik şüphesi bulunan hastalarda MR’ın duyarlılığı ve okuyucular arasındaki uyum orta derecede bulundu. MR nörografi brakial pleksopatiyi gösterebilir ancak pleksusun normal görünümü pleksopati tanısını dışlamamalıdır.
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Chiou-Tan FY. Musculoskeletal mimics of cervical radiculopathy. Muscle Nerve 2022; 66:6-14. [PMID: 35466429 DOI: 10.1002/mus.27553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 11/10/2022]
Abstract
Musculoskeletal mimics of cervical radiculopathy will be explored in this AANEM monograph. A review of the literature and textbooks was conducted. Musculoskeletal cervical radiculopathy mimics include: (1) head/neck pain, such as neck tension, cervicogenic headache, and temporomandibular disorder; (2) referred pain from shoulder pathology, such as rotator cuff tears/impingement; (3) elbow region abnormalities, including medial/lateral epicondylitis; (4) wrist/hand conditions, such as DeQuervain's tenosynovitis and intersection syndrome; (5) muscle connective tissue disorders, including myofascial trigger points; (6) conditions that have decreased range of motion, including frozen shoulder and rounded shoulders with tight pectoral/scalene muscles; (7) conditions with joint hyperlaxity and instability, as seen in post-stroke shoulder subluxation; (8) vascular conditions, such as thoracic outlet syndrome; and (9) autonomic controlled soft tissue changes associated with complex regional pain syndrome. Formulating a differential diagnosis and recognizing mimics of cervical radiculopathy can decrease the time between symptom onset and diagnosis/treatment plan.
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Affiliation(s)
- Faye Y Chiou-Tan
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA.,Harris Health System, Electrodiagnostic Laboratory, Smith Clinic/Ben Taub Hospital, Houston, Texas, USA
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Ercan M, Kuruoglu H. Significance of pure sensory manifestations in estimating electromyography results in cervical radiculopathy. NEUROL SCI NEUROPHYS 2022. [DOI: 10.4103/nsn.nsn_10_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Static Body Balance in Children and Expert Adults Ballroom Dancers: Insights from Spectral Analysis of Shifts. BIOLOGY 2021; 10:biology10121291. [PMID: 34943206 PMCID: PMC8698350 DOI: 10.3390/biology10121291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the differences in maintaining body balance (influence of different sensorial sub-systems) in a representative sample of active Dance Sport competitors (children and adults). METHODS Overall, 13 children and 15 high-level adults sport dancers underwent a static equilibrium test on a force platform, in which 17 different parameters were examined, including a spectral analysis of shifts using an FFT algorithm that can assess the contribution of different somatic-sensory systems on maintaining body balance. RESULTS Younger subjects rely on their somatic-sensory reactions to maintain their balance, while adults rely more on the vestibular system, according to shifts' spectral analysis. No differences were noted between the male and female participants. CONCLUSIONS Children predominantly use the somatic-sensory system in body balance, while adults make more use of the vestibular system. According to these results and due to the trainability phases, exercises that challenge the somato-sensorial system are recommended to train balance in young dancers, while exercises that challenge the vestibular system are recommended in adult dancers which who have not developed exceptional somato-sensory balance abilities during their growth and training history.
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Chang PJ, Asher A, Smith SR. A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment. Cancers (Basel) 2021; 13:5191. [PMID: 34680339 PMCID: PMC8534110 DOI: 10.3390/cancers13205191] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/09/2021] [Accepted: 10/14/2021] [Indexed: 01/10/2023] Open
Abstract
Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.
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Affiliation(s)
- Philip J. Chang
- Department of Physical Medicine and Rehabilitation, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | - Arash Asher
- Department of Physical Medicine and Rehabilitation, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | - Sean R. Smith
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48108, USA;
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Correlation of Electrodiagnostic Findings in C8 Radiculopathies With Radiographic Data: A Retrospective Chart Review. Am J Phys Med Rehabil 2021; 100:721-724. [PMID: 34131095 DOI: 10.1097/phm.0000000000001722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Signs and symptoms of a C8 radiculopathy could mimic common comorbidities such as entrapment and peripheral neuropathies. These conditions and a C8 radiculopathy both can result in abnormal findings on needle examination of intrinsic hand muscles. It was hypothesized that needle examination of C8-innervated muscles in the forearm might improve concordance with magnetic resonance imaging (MRI) in the presence of underlying comorbidities. A retrospective analysis of electromyogram and C-spine MRI data in 80 patients with negative MRI of C-spine for C8-T1 neuroforaminal stenosis was performed. The percentage of false-positive results in the MRI-negative group undergoing electromyogram testing for hand and forearm muscles (MRI-NH + F) was 3% compared with 18% (P = 0.06) in the group with electromyogram of the hand intrinsic muscles only (MRI-NH). The false-positive result tends to be lower in the MRI-NH + F group in comparison with the MRI-NH group especially in the presence of underlying peripheral and entrapment neuropathies.
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Furukawa Y, Miyaji Y, Kadoya A, Kamiya H, Chiba T, Hokkoku KI, Hatanaka Y, Imafuku I, Miyoshi K, Sonoo M. Determining C5, C6 and C7 myotomes through comparative analyses of clinical, MRI and EMG findings in cervical radiculopathy. Clin Neurophysiol Pract 2021; 6:88-92. [PMID: 33748550 PMCID: PMC7966958 DOI: 10.1016/j.cnp.2021.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 01/02/2021] [Accepted: 02/08/2021] [Indexed: 11/18/2022] Open
Abstract
Objective There are many myotome charts in the literature, but few studies have presented actual data to support their identification. We aimed to determine C5/C6/C7 myotomes based on clinical and EMG data of patients with cervical spondylotic radiculopathy (CSR) having a single-root lesion confirmed by MRI. Methods Medical Research Council (MRC) scores and EMG findings were retrospectively reviewed for patients enrolled from our EMG database. Results Enrolled were 25 patients (10 C5, 6 C6, and 9 C7 CSR). In C5 CSR, weakness or denervation potentials in EMG, or both, were observed in the deltoid (Del) and infraspinatus (Isp) muscles for all patients, and in the biceps brachii (BB) and brachioradialis (BR) muscles for 9/10 and 8/9 patients, respectively. In C6 CSR, weakness of the wrist extensor and/or denervation of the extensor carpi radialis longus (ECRL)/extensor carpi radialis brevis (ECRB), and those of the pronator teres (PT) were observed for all patients. Weakness was not observed for any other muscle in C6 CSR. Denervation potentials of ECRL were found in 5/8 and 3/5 patients with C5 and C6 CSR, respectively, whereas those of ECRB were found in 1/5, 6/6, and 2/5 patients with C5, C6 and C7 CSR, respectively. In C7 CSR, weakness/denervation of the triceps brachii (TB) and denervation potentials of the flexor carpi radialis (FCR) were observed for all patients. Denervation potentials in PT and weakness/denervation of the extensor digitorum (ED) were observed in 2/9 and 4/9 patients, respectively. Conclusion Suggested dominant myotomes are: C5 for the Del, Isp, BB, and BR, C5/6 for the ECRL, C6 > C7 for the ECRB and PT, and C7 for the TB and FCR. Significance The current study identified dominant myotomes that differ from the existing literature.
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Affiliation(s)
- Yuichi Furukawa
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo, Japan
| | - Yosuke Miyaji
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo, Japan
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, Kanagawa, Japan
| | - Akiko Kadoya
- Department of Neurology, Anti-aging and Vascular Medicine, National Defense Medical College, Namiki 3-2, Tokorozawa-shi, Saitama, Japan
| | - Hisao Kamiya
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo, Japan
| | - Takashi Chiba
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo, Japan
| | - Kei-ichi Hokkoku
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo, Japan
| | - Yuki Hatanaka
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo, Japan
| | - Ichiro Imafuku
- Department of Neurology, Yokohama Rosai Hospital, Kozukue 3211, Kohoku-ku, Yokohaya-shi, Kanagawa, Japan
| | - Kota Miyoshi
- Department of Orthopedics, Yokohama Rosai Hospital, Kozukue 3211, Kohoku-ku, Yokohaya-shi, Kanagawa, Japan
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo, Japan
- Corresponding author.
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Kang KC, Lee HS, Lee JH. Cervical Radiculopathy Focus on Characteristics and Differential Diagnosis. Asian Spine J 2020; 14:921-930. [PMID: 33373515 PMCID: PMC7788378 DOI: 10.31616/asj.2020.0647] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/14/2020] [Indexed: 12/14/2022] Open
Abstract
Cervical radiculopathy is characterized by neurological dysfunction caused by compression and inflammation of the spinal nerves or nerve roots of the cervical spine. It mainly presents with neck and arm pain, sensory loss, motor dysfunction, and reflex changes according to the dermatomal distribution. The most common causes of cervical radiculopathy are cervical disc herniation and cervical spondylosis. It is important to find the exact symptomatic segment and distinguish between conditions that may mimic certain cervical radicular compression syndromes through meticulous physical examinations and precise reading of radiographs. Non-surgical treatments are recommended as an initial management. Surgery is applicable to patients with intractable or persistent pain despite sufficient conservative management or with severe or progressive neurological deficits. Cervical radiculopathy is treated surgically by anterior and/or posterior approaches. The appropriate choice of surgical treatment should be individualized, considering the patient’s main pathophysiology, specific clinical symptoms and radiographic findings thoroughly.
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Affiliation(s)
- Kyung-Chung Kang
- Department of Orthopedic Surgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hee Sung Lee
- Department of Orthopedic Surgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung-Hee Lee
- Department of Orthopedic Surgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
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Mansfield M, Smith T, Spahr N, Thacker M. Cervical spine radiculopathy epidemiology: A systematic review. Musculoskeletal Care 2020; 18:555-567. [PMID: 32710604 DOI: 10.1002/msc.1498] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND OBJECTIVE Cervical spine radiculopathy (CSR) is a disabling condition that has significant negative impacts on a person's mental health, physical functioning and social participation. Research has reported variable CSR incidence and prevalence among different populations. To date, no systematic review has been completed investigating the prevalence or incidence of CSR; therefore, our objective was to determine the incidence and/or prevalence of CSR in adults. DESIGN AND METHOD A systematic review was conducted including searches of PubMed (MEDLINE), EMBASE and CINAHL from inception to February 25, 2020. Studies including data on incidence and/or prevalence of CSR were included. Methodological quality was assessed using a modified Hayden, Cote and Bombardier appraisal checklist. Data were analysed narratively. RESULTS Nine low- to high-quality studies were included in the final review. Incidence ranged between 0.832 and 1.79 per 1,000 person-years from two high-quality and one low-quality study. Prevalence values ranged from 1.21 to 5.8 per 1,000 from four medium- to high-quality studies. Prevalence values of 1.14% [95% confidence interval (CI): 0.45-1.82] and 1.31% (95% CI: 0.66-1.96) for males and females, respectively, were reported from one medium-quality study. One medium-quality study reported an unadjusted prevalence value of 6.3% for males and females. CONCLUSIONS This is the first systematic review investigating the epidemiology of CSR in an adult population. This review reports a variable incidence rate and prevalence of CSR among specific populations; however, this was based on nine studies. There is a priority to investigate CSR epidemiology across other populations globally and standardising CSR diagnostic criteria.
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Affiliation(s)
- Michael Mansfield
- School of Health and Social Care, Department of Allied Health Sciences. Pain Research Cluster; Ageing, Acute and Long Term Conditions Research Group., London South Bank University, London, UK
| | - Toby Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, , Botnar Research Centre, University of Oxford, Oxford, UK
| | - Nicolas Spahr
- Physiotherapy Department, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
- Pain Section, Neuroimaging, Institute of Psychiatry, King's College London, London, UK
| | - Mick Thacker
- School of Health and Social Care, Department of Allied Health Sciences. Pain Research Cluster; Ageing, Acute and Long Term Conditions Research Group., London South Bank University, London, UK
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Diffusion tensor imaging of the roots of the brachial plexus: a systematic review and meta-analysis of normative values. Clin Transl Imaging 2020; 8:419-431. [PMID: 33282795 PMCID: PMC7708343 DOI: 10.1007/s40336-020-00393-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023]
Abstract
Purpose Diffusion tensor magnetic resonance imaging (DTI) characterises tissue microstructure and provides proxy measures of myelination, axon diameter, fibre density and organisation. This may be valuable in the assessment of the roots of the brachial plexus in health and disease. Therefore, there is a need to define the normal DTI values. Methods The literature was systematically searched for studies of asymptomatic adults who underwent DTI of the brachial plexus. Participant characteristics, scanning protocols, and measurements of the fractional anisotropy (FA) and mean diffusivity (MD) of each spinal root were extracted by two independent review authors. Generalised linear modelling was used to estimate the effect of experimental conditions on the FA and MD. Meta-analysis of root-level estimates was performed using Cohen's method with random effects. Results Nine articles, describing 316 adults (1:1 male:female) of mean age 35 years (SD 6) were included. Increments of ten diffusion sensitising gradient directions reduced the mean FA by 0.01 (95% CI 0.01, 0.03). Each year of life reduced the mean MD by 0.03 × 10-3 mm2/s (95% CI 0.01, 0.04). At 3-T, the pooled mean FA of the roots was 0.36 (95% CI 0.34, 0.38; I 2 98%). The pooled mean MD of the roots was 1.51 × 10-3 mm2/s (95% CI 1.45, 1.56; I 2 99%). Conclusions The FA and MD of the roots of the brachial plexus vary according to experimental conditions and participant factors. We provide summary estimates of the normative values in different conditions which may be valuable to researchers and clinicians alike.
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Dillingham TR, Annaswamy TM, Plastaras CT. Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part II). Muscle Nerve 2020; 62:474-484. [PMID: 32564381 DOI: 10.1002/mus.27008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/06/2022]
Abstract
The electrodiagnostic (EDX) examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and complements imaging of the spine. In this second of a two-part review, the implications of electrodiagnostic findings for diagnosis and clinical management of persons with radiculopathy are reviewed. An EMG confirmed lumbosacral radiculopathy is associated with better clinical outcomes for persons undergoing aggressive conservative management. A positive EMG test portends a better clinical response to epidural corticosteroid injections. If a person undergoes spine surgery, a positive pre-operative EMG for radiculopathy is also associated with better outcomes.
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Affiliation(s)
- Timothy R Dillingham
- Department of Physical Medicine and Rehabilitation, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thiru M Annaswamy
- Electrodiagnostic and Spine Sections, VA North Texas Health Care System, Dallas VA Medical Center, Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher T Plastaras
- Musculoskeletal Spine & Sports Rehabilitation Medicine, MossRehab, Einstein Spine Institute, Co-Chair, Albert Einstein Healthcare Network, Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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17
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Dillingham TR, Annaswamy TM, Plastaras CT. Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part I). Muscle Nerve 2020; 62:462-473. [PMID: 32557709 DOI: 10.1002/mus.26997] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 11/11/2022]
Abstract
Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed.
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Affiliation(s)
- Timothy R Dillingham
- Department of Physical Medicine and Rehabilitation, the Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thiru M Annaswamy
- Department of Physical Medicine & Rehabilitation, Electrodiagnostic and Spine Sections, VA North Texas Health Care System, Dallas VA Medical Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher T Plastaras
- Musculoskeletal Spine & Sports Rehabilitation Medicine, MossRehab, Einstein Spine Institute, Einstein Healthcare Network, Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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18
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Kim KH, Leem MJ, Yi TI, Kim JS, Yoon SY. Balance Ability in Low Back Pain Patients With Lumbosacral Radiculopathy Evaluated With Tetrax: A Matched Case-Control Study. Ann Rehabil Med 2020; 44:195-202. [PMID: 32475097 PMCID: PMC7349042 DOI: 10.5535/arm.19101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 12/03/2022] Open
Abstract
Objective To compare postural balance ability in patients with low back pain between groups with and without lumbosacral radiculopathy. Methods Patients who were referred for electromyography because of low back pain during the period from April 2017 through June 2018 were chosen as subjects. They were divided into groups with and without lumbosacral radiculopathy based on the results of electromyography. We used Tetrax (Sunlight Medical Ltd., Ramat Gan, Israel) to objectively evaluate postural balance ability, and to measure the fall risk, stability index, weight distribution index, and Fourier index. Results Patients in the lumbosacral radiculopathy group showed significantly higher fall risk (73.25 vs. 38.00; p<0.05), weight distribution index (8.57 vs. 5.00; p<0.05), and stability index (21.19 vs. 13.16; p<0.05) than those in the group without lumbosacral radiculopathy. The Fourier index at high-medium frequency was significantly increased in the lumbosacral radiculopathy group (8.27 vs. 5.56; p<0.05), whereas weight-bearing on the side of radiculopathy was significantly decreased. Conclusion Patients with lumbosacral radiculopathy have decreased postural balance compared with patients without this condition. Somatosensory disturbances in lumbosacral radiculopathy might cause postural balance impairment. Assessment and treatment plan not only for pain reduction but also for postural balance improvement should be considered in the management of patients with lumbosacral radiculopathy.
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Affiliation(s)
- Kee Hoon Kim
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Min Jeong Leem
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Tae Im Yi
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Joo Sup Kim
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Seo Yeon Yoon
- Department of Rehabilitation Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea
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19
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Correlation between Findings in Physical Examination, Magnetic Resonance Imaging, and Nerve Conduction Studies in Lumbosacral Radiculopathy Caused by Lumbar Intervertebral Disc Herniation. Adv Orthop 2020; 2020:9719813. [PMID: 32082626 PMCID: PMC7008266 DOI: 10.1155/2020/9719813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/31/2019] [Accepted: 12/03/2019] [Indexed: 11/20/2022] Open
Abstract
Purpose The aim of this study was to find out the correlation between magnetic resonance imaging (MRI) and nerve conduction studies' (NCS) findings in patients with lumbosacral radiculopathy caused by lumbar intervertebral disc herniation. In addition, the study aimed at finding the correlation between the clinical manifestations of lumbosacral radiculopathy and both MRI and NCS. Patients and Methods. The study was a cross-sectional analytic study which included thirty patients with a history suggestive of lumbosacral radiculopathy. Inclusion criteria were as follows: patients who had an MRI confirmed L4/5 and/or L5/S1 intervertebral disc prolapse in addition to one or more of the following (dermatomal distribution of symptoms appropriate with MRI level, presence of motor weakness, sensory impairment, absent ankle jerk, or positive straight leg raising test). All patients underwent clinical assessment and NCS, and their MRI examination was reviewed. The Chi-Squared/Fisher's exact test was used to test the correlation. Results There was a statistically significant correlation between abnormal physical findings and nerve root compression in MRI. Statistically significant correlation was neither found between abnormal physical examination findings and abnormal NCS nor between nerve root compression in MRI and abnormal NCS findings. Conclusion Abnormal neurological examination findings can be used to predict nerve root compression in MRI examination. On the contrary, positive findings of physical examination do not predict abnormal NCS, as well as negative findings do not exclude abnormal NCS; therefore, it is useful to add NCS when MRI findings do not match clinical examination findings or when no neuroimaging abnormalities can be identified.
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20
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Markman JD, Czerniecka-Foxx K, Khalsa PS, Hayek SM, Asher AL, Loeser JD, Chou R. AAPT Diagnostic Criteria for Chronic Low Back Pain. THE JOURNAL OF PAIN 2020; 21:1138-1148. [PMID: 32036046 DOI: 10.1016/j.jpain.2020.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
Abstract
Chronic low back pain (CLBP) conditions are highly prevalent and constitute the leading cause of disability worldwide. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS), have combined to create the ACTTION-APS Pain Taxonomy (AAPT). The AAPT initiative convened a working group to develop diagnostic criteria for CLBP. The working group identified 3 distinct low back pain conditions which result in a vast public health burden across the lifespan. This article focuses on: 1) the axial predominant syndrome of chronic musculoskeletal low back pain, 2) the lateralized, distally-radiating syndrome of chronic lumbosacral radicular pain 3) and neurogenic claudication associated with lumbar spinal stenosis. This classification of CLBP is organized according to the AAPT multidimensional framework, specifically 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. PERSPECTIVE: An evidence-based classification of CLBP conditions was constructed for the AAPT initiative. This multidimensional diagnostic framework includes: 1) core diagnostic criteria; 2) common features; 3) medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.
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Affiliation(s)
- John D Markman
- Translational Pain Research Program, Department of Neurosurgery, University of Rochester, Rochester, New York.
| | | | - Partap S Khalsa
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
| | - Salim Michel Hayek
- Division of Pain Medicine, Department of Anesthesiology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Anthony L Asher
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Atrium Health, Charlotte, North Carolina
| | - John D Loeser
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
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21
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Tonsbeek AM, Groen JL, Vleggeert-Lankamp CLAM. Surgical Interventions for Cervical Radiculopathy Caused by a Vertebral Artery Loop: A Case Report and Review of the Literature. World Neurosurg 2019; 135:28-34. [PMID: 31809894 DOI: 10.1016/j.wneu.2019.11.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Aberrant vertebral artery loops are a rare clinical condition, with sparse data regarding the optimal treatment guidelines for individual patients. The heterogeneity of treatment options in the literature creates a problem when tailoring treatments to individual patients. In this review of the literature, multiple surgical treatments for cervical vertebral artery loops were analyzed and compared. In addition, this article provides a clinical case of a patient with a vertebral artery loop. METHODS A literature review was conducted to identify studies investigating surgical treatments for a vertebral artery loop. Different surgical techniques were examined and the involved techniques and approaches described. The outcomes were assessed for each study and the effectiveness of the treatment determined. RESULTS Twelve articles met the inclusion criteria for this review. Six types of surgical interventions were found in the literature. Each intervention had similar postoperative results, leading to either a significant improvement or a complete resolution of symptoms. CONCLUSIONS Multiple successful surgical interventions have been described in the medical literature. However, because of the lack of evidence-based studies, no surgical intervention protocol could be determined. Treatment should therefore be tailored to individual patients' characteristics. Because not every radiologically detected vertebral artery loop is the main reason for a patient's symptoms, a thorough multidisciplinary approach is justified and advocated in patients with an atypical presentation, before a neurosurgical intervention takes place. More deliberate clinical decisions can be made once the understanding of the pathogenesis of this rare disease entity has been established and treatment protocols formulated.
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Affiliation(s)
- Anthony M Tonsbeek
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Justus L Groen
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
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22
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Wade RG, Takwoingi Y, Wormald JCR, Ridgway JP, Tanner S, Rankine JJ, Bourke G. MRI for Detecting Root Avulsions in Traumatic Adult Brachial Plexus Injuries: A Systematic Review and Meta-Analysis of Diagnostic Accuracy. Radiology 2019; 293:125-133. [DOI: 10.1148/radiol.2019190218] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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23
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Degree of Agreement between Electrodiagnostic Testing and Magnetic Resonance Imaging in the Evaluation of Brachial Plexopathy. Am J Phys Med Rehabil 2019; 98:545-548. [PMID: 30664530 DOI: 10.1097/phm.0000000000001139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Electrodiagnostic study (EDX) and magnetic resonance imaging (MRI) are commonly used in the diagnosis of brachial plexopathy, but the agreement between these 2 studies is unknown. The aim of this study was to evaluate the agreement of EDX and MRI in patients with brachial plexopathy. DESIGN The records of 69 patients with symptoms of brachial plexopathy who underwent EDX and MRI were reviewed. Based on the degree of agreement of EDX and MRI results, patients were classified as a "complete match," "partial match," or "mismatch." RESULTS Both studies yielded similar results for the majority of patients (63.2%). Among the enrolled patients, 26.4% were classified as a "complete match," 36.8% as "partial match," and 36.8% as "mismatch." However, only 1 test, either EDX or MRI, revealed abnormal findings in 21.1% of patients. CONCLUSIONS The agreement between EDX and MRI was high in patients with brachial plexopathy. However, only one of these tests, not both, revealed abnormal findings in several cases. Although both EDX and MRI were in accord with the diagnosis of brachial plexopathy in majority of cases, these 2 studies remain complementary diagnostic modalities for evaluating brachial plexopathies.
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24
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Wade RG, Takwoingi Y, Wormald JCR, Ridgway JP, Tanner S, Rankine JJ, Bourke G. Magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries: protocol for a systematic review of diagnostic accuracy. Syst Rev 2018; 7:76. [PMID: 29778092 PMCID: PMC5960500 DOI: 10.1186/s13643-018-0737-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 05/01/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Adult brachial plexus injuries (BPI) are becoming more common. The reconstruction and prognosis of pre-ganglionic injuries (root avulsions) are different to other types of BPI injury. Preoperative magnetic resonance imaging (MRI) is being used to identify root avulsions, but the evidence from studies of its diagnostic accuracy are conflicting. Therefore, a systematic review is needed to address uncertainty about the accuracy of MRI and to guide future research. METHODS We will conduct a systematic search of electronic databases alongside reference tracking. We will include studies of adults with traumatic BPI which report the accuracy of preoperative MRI (index test) against surgical exploration of the roots of the brachial plexus (reference standard) for detecting either of the two target conditions (any root avulsion or any pseudomeningocoele as a surrogate marker of root avulsion). We will exclude case reports, articles considering bilateral injuries and studies where the number of true positives, false positives, false negatives and true negatives cannot be derived. The methodological quality of the included studies will be assessed using a tailored version of the QUADAS-2 tool. Where possible, a bivariate model will be used for meta-analysis to obtain summary sensitivities and specificities for both target conditions. We will investigate heterogeneity in the performance of MRI according to field strength and the risk of bias if data permits. DISCUSSION This review will summarise the current diagnostic accuracy of MRI for adult BPI, identify shortcomings and gaps in the literature and so help to guide future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016049702 .
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Affiliation(s)
- Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK. .,Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK.
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Justin C R Wormald
- Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - John P Ridgway
- Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Steven Tanner
- Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - James J Rankine
- Department of Radiology, Leeds Teaching Hospitals Trust, Leeds, UK.,Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Grainne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK.,Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
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25
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Batistaki C, Angelopoulou A, Smyrnioti ME, Kitsou MC, Kostopanagiotou G. Electromyographic Findings After Epidural Steroid Injections in Patients with Radicular Low Back Pain: A Prospective Open-Label Study. Anesth Pain Med 2018; 7:e62556. [PMID: 29696128 PMCID: PMC5903381 DOI: 10.5812/aapm.62556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/21/2017] [Accepted: 12/15/2017] [Indexed: 12/14/2022] Open
Abstract
Epidural steroid injections (ESIs) are commonly used in the management of chronic lower back and leg pain. The aim of this study was to investigate the short- and long-term electromyographic and clinical outcome of patients with chronic radicular pain after ESIs. This prospective, open-label study, included patients with chronic radicular pain due to disc herniation or spinal stenosis, who underwent interlaminar, fluoroscopy-guided ESIs. Patients were assessed before ESIs, as well as after 6 and 12 months, clinically (VAS 0-10, BPI, DN4, Rolland Morris, DASS, STAI) and electromyographically for the improvement of spontaneous activity (SA) and of motor unit recruitment/interference pattern (IP/MUR). A total of 39 patients were studied, 20 (51.3%) who had a significant improvement in VAS, RM, DN4 and BPI were revealed, mainly during the first 6 months (P < 0.05). Statistically significant improvement was revealed in MUR/SA for almost all nerve roots studied. Patients with disc herniation showed a greater improvement in mean difference of MUR/SA (P < 0.05) (with a prognostic value of radicular LBP versus spinal stenosis in short- [VAS P = 0.042] and long-term improvement of pain [VAS P = 0.009]. The independent variables “MUR” and “SA” had a significant prognostic value for improvement of pain (VAS: R2 = 0.287, P = 0.032 and VAS: R2 = 0.277, P = 0.036 respectively). Electromyographic and clinical findings indicated a benefit from epidural steroid injections. Patients with disc herniation exhibited a better outcome, especially during the first 6 months post-treatment.
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Affiliation(s)
- Chrysanthi Batistaki
- 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
- Corresponding author: Chrysanthi Batistaki, Assistant Professor of Anesthesiology, 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, 1 Rimini str, 12462, Athens, Greece. Tel: +30-2105832371, E-mail:
| | - Athina Angelopoulou
- 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
| | - Maria-Eleni Smyrnioti
- 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
| | - Maria-Chrysanthi Kitsou
- 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
| | - Georgia Kostopanagiotou
- 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
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26
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Baima JA, Silver JK, Most M. Neuromuscular dysfunction in the cancer patient: Evaluation and treatment. Muscle Nerve 2018; 58:335-343. [PMID: 29461633 DOI: 10.1002/mus.26103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 02/12/2018] [Accepted: 02/17/2018] [Indexed: 11/07/2022]
Abstract
Cancer is a common diagnosis. In conjunction with various anti-neoplastic therapies delivered sequentially or concurrently, it makes oncology patients among the most complex to treat. This review uses a series of case studies to discuss the diagnosis and treatment of cancer-related nerve and muscle disorders. Oncologic treatment interventions such as surgery, chemotherapy, radiation therapy, and hormonal therapy, often have predictable side-effects, and sometimes their associated disability can be mitigated, especially if recognized early. Disease progression can mimic other diagnoses. The case studies provide a lens through which to study the presenting symptoms, differential diagnoses, diagnostic evaluation, and treatment interventions. These are all considered within the context of the patient's prognosis and health-related quality of life. Muscle Nerve 58: 335-343, 2018.
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Affiliation(s)
- Jennifer A Baima
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, 119 Belmont Street, Worcester, Massachusetts, 01605, USA
| | - Julie K Silver
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mathew Most
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, 119 Belmont Street, Worcester, Massachusetts, 01605, USA
- Division of Orthopedic Oncology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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27
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Li W, Liu YC, Zheng CF, Miao J, Chen H, Quan HY, Yan SH, Zhang K. Diagnosis of Compressed Nerve Root in Lumbar Disc Herniation Patients by Surface Electromyography. Orthop Surg 2018; 10:47-55. [PMID: 29424098 DOI: 10.1111/os.12362] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/20/2017] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To establish a logistic regression model using surface electromyography (SEMG) parameters for diagnosing the compressed nerve root at L5 or S1 level in patients with lumbar disc herniation (LDH). METHODS This study recruited 24 patients with L5 nerve root compression and 23 patients with S1 nerve root compression caused by LDH from May 2014 to May 2016. SEMG signals from the bilateral tibialis anterior and lateral gastrocnemius were measured. The root mean square (RMS), the RMS peak time, the mean power frequency (MPF), and the median frequency (MF) were analyzed. The accuracy, sensitivity, and specificity values were calculated separately. The areas under the curve (AUC) of the receiver-operating characteristic (ROC) curve and the kappa value were used to evaluate the accuracy of the SEMG diagnostic model. RESULTS The accuracy of the SEMG model ranged from 85.71% to 100%, with an average of 93.57%. The sensitivity, specificity, AUC, and kappa value of the logistic regression model were 0.98 ± 0.05, 0.92 ± 0.09, 0.95 ± 0.04 (P = 0.006), and 0.87 ± 0.11, respectively (P = 0.001). The final diagnostic model was: P=1-11+ey; y = 10.76 - (5.95 × TA_RMS Ratio) - (0.38 × TA_RMS Peak Time Ratio) - (5.44 × 44 × LG_RMS Peak Time Ratio). L5 nerve root compression is diagnosed when P < 0.5 and S1 nerve root compression when P ≥ 0.5. CONCLUSIONS The logistic regression model developed in this study showed high diagnostic accuracy in detecting the compressed nerve root (L5 and S1 ) in these patients with LDH.
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Affiliation(s)
- Wei Li
- School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Yan-Cheng Liu
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, China
| | - Chen-Fan Zheng
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China
| | - Jun Miao
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Hai-Ying Quan
- School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Song-Hua Yan
- School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Kuan Zhang
- School of Biomedical Engineering, Capital Medical University, Beijing, China
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Singh R, Yadav SK, Sood S, Yadav RK, Rohilla R. Evaluation of the Correlation of Magnetic Resonance Imaging and Electrodiagnostic Findings in Chronic Low Backache Patients. Asian J Neurosurg 2018; 13:1078-1083. [PMID: 30459872 PMCID: PMC6208195 DOI: 10.4103/ajns.ajns_169_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Low back pain (LBP) is one of the most common medical complaints and leading cause of workforce loss in many countries. Magnetic resonance imaging (MRI) is a highly sensitive method for the detection of lesions in the spine because of its excellent imaging of anatomical detail. However, MRI does not provide information about physiological nerve function and has relatively low specificity. Electrodiagnostic (EDX) study, including needle electromyography (EMG), is a specific test to assess the physiological functions of nerve roots or peripheral nerves. The aim of the present study was to correlate the electrophysiological and MRI findings in chronic low backache patients. Materials and Methods Fifty patients (26 males and 24 females) with mean age 33.54 ± 8.33 years with a history of LBP of minimum 3 consecutive months were evaluated with MRI and EDX (bilateral nerve conduction study of three nerves [tibial, peroneal, and sural nerve] and bilateral EMG of three muscles [paraspinal, tibialis anterior, vastus medialis]) studies. Results Twenty-seven patients showed disc involvement on MRI and 23 MRI were normal. Mean conduction velocity was mildly decreased in tibial and sural nerves in all the patients either with normal MRI or disc involvement on MRI. In disc involvement conduction velocity, decrease was more as compared to normal MRI. About 39% patients with normal MRI and 78% patients with disc involvement showed abnormal EMG. This data represented statistically significant association of EDX study with MRI (P < 0.05). Conclusions In patients with LBP, EDX studies are significantly more correlated with clinical data than MRI. Therefore, EMG may be a useful diagnostic tool to establish management protocols and prevent unnecessary interventions. EDX gives a better representation of physiological status of nerve and muscle, a supra added benefit which MRI lacks. However, MRI gives better visualization of anatomic parameters and structural details which may or may not be associated with chronic LBP.
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Affiliation(s)
- Roop Singh
- Department of Orthopaedic Surgery, Paraplegia and Rehabilitation, Government Medical College and Hospital, Chandigarh, India
| | - Sushil Kumar Yadav
- Department of Orthopaedic Surgery, Paraplegia and Rehabilitation, Government Medical College and Hospital, Chandigarh, India
| | - Sushma Sood
- Department of Physiology, Government Medical College and Hospital, Chandigarh, India
| | - Rohtas Kumar Yadav
- Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India
| | - Ravi Rohilla
- Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
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Evaluation of proximal and distal motor nerve conduction using the electrical root stimulation technique in the femoral and obturator nerves. Vet Comp Orthop Traumatol 2017; 30:111-117. [DOI: 10.3415/vcot-16-02-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 10/21/2016] [Indexed: 11/17/2022]
Abstract
SummaryObjectives: This study aimed to investigate the adaptability of the electrical root stimulation technique by achieving normative data from the obturator and femoral nerves of healthy dogs.Methods: For this purpose, two stimulations and recordings were performed on both the obturator and femoral nerves in 40 dogs (22 males and 18 females). Electrical root stimulation was applied via monopolar needle electrodes between the sixth to seventh and fifth to sixth lumbar inter arcuate spaces to the obturator and femoral nerves, respectively. Muscle waves were recorded from the gracilis and sartorius muscles of the left and right pelvic limb.Results: The proximal motor nerve conduction velocity was 60.89 ± 3.93 m/s and 59.87 ± 4.83 m/s in the obturator and femoral nerves, respectively.Clinical significance: Our results showed that electrical root stimulation could be a useful method to test the integrity of the roots of obturator and femoral nerves and their proximal parts.
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Abstract
STUDY DESIGN Case series. OBJECTIVE This study compared the locations of arm pain, sensory symptoms, and subjective complaints of arm weakness in patients with cervical radiculopathy from MRI confirmed C6 and C7 nerve root compression. SUMMARY OF BACKGROUND DATA Cervical radiculopathy is defined as arm pain, sensory and motor symptoms caused by irritation of a cervical nerve root. The C6 and C7 roots are most commonly involved, and differentiating symptoms associated with each root has proven difficult. Cervical MRI allows accurate identification of nerve root compression and therefore makes it possible to explore symptom patterns that may differentiate C6 from C7 radiculopathy. METHODS A total of 122 patients with symptoms suggestive of cervical radiculopathy were recruited. Of these, 30 patients had MRI confirmed C6 and 39 patients C7 nerve root compression. By completing a study questionnaire, patients reported specific arm weakness, and marked the location of arm pain and tingling/numbness on graphic representations of the arm. Marked areas were interpreted by superimposing a grid that divided the arm into 54 distinct areas. The frequencies of reported symptoms with C6 and C7 were totaled and then compared with likelihood rations. Power analysis calculated that 27 patients would be needed in each group based on the assumption that a 30 percentage point difference in frequency of specific symptom would be clinically useful for differentiating C6 from C7 radiculopathy. RESULTS Arm pain and sensory symptoms were diffuse, and were not distinctly different for C6 or C7 radiculopathy. Some weakness was reported by 41 percent of patients, with specific descriptions of weakness having limited value for differentiating between radiculopathies. CONCLUSION The location of pain and sensory symptoms, and specific weakness complaints associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting root involvement based on symptoms. LEVEL OF EVIDENCE 3.
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Narayanaswami P, Geisbush T, Jones L, Weiss M, Mozaffar T, Gronseth G, Rutkove SB. Critically re-evaluating a common technique: Accuracy, reliability, and confirmation bias of EMG. Neurology 2015; 86:218-23. [PMID: 26701380 DOI: 10.1212/wnl.0000000000002292] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/16/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES (1) To assess the diagnostic accuracy of EMG in radiculopathy. (2) To evaluate the intrarater reliability and interrater reliability of EMG in radiculopathy. (3) To assess the presence of confirmation bias in EMG. METHODS Three experienced academic electromyographers interpreted 3 compact discs with 20 EMG videos (10 normal, 10 radiculopathy) in a blinded, standardized fashion without information regarding the nature of the study. The EMGs were interpreted 3 times (discs A, B, C) 1 month apart. Clinical information was provided only with disc C. Intrarater reliability was calculated by comparing interpretations in discs A and B, interrater reliability by comparing interpretation between reviewers. Confirmation bias was estimated by the difference in correct interpretations when clinical information was provided. RESULTS Sensitivity was similar to previous reports (77%, confidence interval [CI] 63%-90%); specificity was 71%, CI 56%-85%. Intrarater reliability was good (κ 0.61, 95% CI 0.41-0.81); interrater reliability was lower (κ 0.53, CI 0.35-0.71). There was no substantial confirmation bias when clinical information was provided (absolute difference in correct responses 2.2%, CI -13.3% to 17.7%); the study lacked precision to exclude moderate confirmation bias. CONCLUSIONS This study supports that (1) serial EMG studies should be performed by the same electromyographer since intrarater reliability is better than interrater reliability; (2) knowledge of clinical information does not bias EMG interpretation substantially; (3) EMG has moderate diagnostic accuracy for radiculopathy with modest specificity and electromyographers should exercise caution interpreting mild abnormalities. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that EMG has moderate diagnostic accuracy and specificity for radiculopathy.
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Affiliation(s)
- Pushpa Narayanaswami
- From the Department of Neurology (P.N., T.G., S.B.R.), Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; the Department of Neurology (L.J.), Mayo Clinic, Rochester, MN; the Department of Neurology (M.W.), University of Washington, Seattle; the Department of Neurology (T.M.), University of California, Irvine; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City.
| | - Thomas Geisbush
- From the Department of Neurology (P.N., T.G., S.B.R.), Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; the Department of Neurology (L.J.), Mayo Clinic, Rochester, MN; the Department of Neurology (M.W.), University of Washington, Seattle; the Department of Neurology (T.M.), University of California, Irvine; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City
| | - Lyell Jones
- From the Department of Neurology (P.N., T.G., S.B.R.), Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; the Department of Neurology (L.J.), Mayo Clinic, Rochester, MN; the Department of Neurology (M.W.), University of Washington, Seattle; the Department of Neurology (T.M.), University of California, Irvine; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City
| | - Michael Weiss
- From the Department of Neurology (P.N., T.G., S.B.R.), Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; the Department of Neurology (L.J.), Mayo Clinic, Rochester, MN; the Department of Neurology (M.W.), University of Washington, Seattle; the Department of Neurology (T.M.), University of California, Irvine; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City
| | - Tahseen Mozaffar
- From the Department of Neurology (P.N., T.G., S.B.R.), Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; the Department of Neurology (L.J.), Mayo Clinic, Rochester, MN; the Department of Neurology (M.W.), University of Washington, Seattle; the Department of Neurology (T.M.), University of California, Irvine; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City
| | - Gary Gronseth
- From the Department of Neurology (P.N., T.G., S.B.R.), Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; the Department of Neurology (L.J.), Mayo Clinic, Rochester, MN; the Department of Neurology (M.W.), University of Washington, Seattle; the Department of Neurology (T.M.), University of California, Irvine; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City
| | - Seward B Rutkove
- From the Department of Neurology (P.N., T.G., S.B.R.), Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; the Department of Neurology (L.J.), Mayo Clinic, Rochester, MN; the Department of Neurology (M.W.), University of Washington, Seattle; the Department of Neurology (T.M.), University of California, Irvine; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City
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Intradural communication between dorsal rootlets of spinal nerves: their clinical significance. Acta Neurochir (Wien) 2015; 157:1069-76; discussion 1076. [PMID: 25911298 DOI: 10.1007/s00701-015-2425-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anatomical and surgical textbooks give almost no attention to the intradural communications between dorsal rootlets of adjacent spinal nerves. These communications can be of significance in various neurosurgical procedures and clinical conditions of the region. METHODS The spinal cord of six formaldehyde-fixed cadavers was dissected from C1-S5. The dorsal rootlets of the spinal nerves were exposed via a posterior approach and communications between adjacent spinal nerves were documented. RESULTS The frequency of communication between adjacent dorsal rootlets of the spinal nerves showed variations among spinal levels. Thirty-eight dorsal rootlet communications were observed in six cadavers (12 sides) and 20 (52.6%) were at cervical levels, 14 (36.8%) at thoracic levels, and four (10.5%) at lumbar levels. The majority of communications were observed on the left side (65.8%). Communications were most frequently observed at cervical (C4-C5, C5-C6) and upper thoracic (T1-T2) levels and seen least frequently at lower thoracic and lumbar levels. No communications were observed at sacral levels. Five types of communication were observed: I. oblique ascending, II. oblique descending III. short Y, IV. long Y and V shaped. None of the communication extended beyond one segment at any spinal level. The occurrence of such dorsal rootlet communications ranged from 3 to 7 for each cadaver and the mean was 4.8 ± 1.3. Histological sections from various levels of the dorsal rootlet communications showed that all consisted of myelinated fibers of varying diameters. CONCLUSIONS Such communications may lead to misinterpretation of the pathology on the basis of clinical signs and symptoms and also should be considered in rhizotomy.
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Abstract
Background:Electromyography (EMG) for suspected cervical or lumbosacral root compression is often negative, producing expense and physical discomfort that could have been avoided. To improve patient selection for testing, we sought to identify clinical features that would accurately predict presence of radiculopathy on EMG.Methods:Adult patients consecutively evaluated for suspected cervical or lumbosacral root compression at an academic clinical neurophysiology laboratory were prospectively enrolled. Presence of clinical features suggesting root disease (neck or back pain, dermatomal pain or numbness, myotomal weakness, segmental reflex loss, and straight leg-raising) was recorded prior to testing. EMG examination to confirm root compression was conducted per standard protocols. Analysis was based on computation of sensitivity, specificity, predictive values, and accuracy.Results:A total of 200 patients (55% male; mean age 46.4 years; 38% suspected of cervical and 62% of lumbosacral disease) were included. EMG evidence of root disease was detected in 31% of cervical and 62% of lumbosacral referrals. Dermatomal pain was the most sensitive, and segmental reflex loss and myotomal weakness the most specific individual predictors of root disease. Combined presence of dermatomal pain or numbness with segmental reflex loss and myotomal weakness approached specificities of 78% (lumbosacral disease) and 99% (cervical disease). In all cases, myotomal weakness was the most accurate predictor of root disease.Conclusion:The diverse symptoms and signs of cervical and lumbosacral root compression predict a positive electrodiagnosis of radiculopathy with varying degrees of accuracy, and may be used to guide patient selection for EMG testing.
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Botez SA, Zynda-Weiss AM, Logigian EL. Diffuse age-related lumbar mri changes confound diagnosis of single (L5) root lesions. Muscle Nerve 2014; 50:135-7. [DOI: 10.1002/mus.24170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Stephan A. Botez
- Department of Neurology and Neuroradiology; University of Rochester Medical Center; 601 Elmwood Avenue, Box 673 Rochester New York 14642 USA
| | - Andrea M. Zynda-Weiss
- Department of Neurology and Neuroradiology; University of Rochester Medical Center; 601 Elmwood Avenue, Box 673 Rochester New York 14642 USA
| | - Eric L. Logigian
- Department of Neurology and Neuroradiology; University of Rochester Medical Center; 601 Elmwood Avenue, Box 673 Rochester New York 14642 USA
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Reza Soltani Z, Sajadi S, Tavana B. A comparison of magnetic resonance imaging with electrodiagnostic findings in the evaluation of clinical radiculopathy: a cross-sectional study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:916-21. [PMID: 24413775 DOI: 10.1007/s00586-013-3164-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 12/31/2013] [Accepted: 12/31/2013] [Indexed: 01/07/2023]
Abstract
PURPOSE The aim of this study was to evaluate the agreement of magnetic resonance imaging and electrodiagnostic studies by comparing their findings in patients with clinically suspected radiculopathy. The agreements between these two procedures and clinical findings were also examined. METHODS In a 2-year cross-sectional study, a total of 114 patients with clinically suspected cervical or lumbosacral radiculopathy were included. RESULTS The total agreements between clinical with MRI and EDX findings were 72 and 52%, respectively while their agreements were similar in group definite (89 vs. 82%). The agreement between EDX and MRI was 59.6 in total and 49% with respect to clinical findings. CONCLUSION This study further supports that these two methods are complementary in general. It is reasonable to add EDX when there is discrepancy between MRI and clinical findings or when MRI neurologic findings are not visible.
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Affiliation(s)
- Zahra Reza Soltani
- Department of Physical Medicine and Rehabilitation, School of Medicine, Islamic Republic of Iran Army University of Medical Sciences, Tehran, Islamic Republic of Iran
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Spieker AJ, Narayanaswami P, Fleming L, Keel JC, Muzin SC, Rutkove SB. Electrical impedance myography in the diagnosis of radiculopathy. Muscle Nerve 2013; 48:800-5. [PMID: 23483460 DOI: 10.1002/mus.23833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2013] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We sought to determine whether electrical impedance myography (EIM) could serve as a diagnostic procedure for evaluation of radiculopathy. METHODS Twenty-seven patients with clinically and radiologically diagnosed cervical or lumbosacral radiculopathy who met a "gold standard" definition underwent EIM and standard needle electromyography (EMG) of multiple upper or lower extremity muscles. RESULTS EIM reactance values revealed consistent reductions in the radiculopathy-affected myotomal muscles as compared with those on the unaffected side; the degree of asymmetry was associated strongly with the degree of EMG abnormality (P < 0.001). EIM had a sensitivity of 64.5% and a specificity of 77.0%; in comparison, EMG had a sensitivity of 79.7% but a specificity of 69.7%. CONCLUSIONS These findings support the potential for EIM to serve as a new non-invasive tool to assist in diagnosis of radiculopathy; however, further refinement of the technique is needed for this specific application.
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Affiliation(s)
- Andrew J Spieker
- Department of Neurology, Beth Israel Deaconness Medical Center, 330 Brookline Avenue, Boston, Massachusetts, 02215, USA
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Clinical findings and electrodiagnostic testing in 108 consecutive cases of lumbosacral radiculopathy due to herniated disc. Neurophysiol Clin 2013; 43:205-15. [PMID: 24094906 DOI: 10.1016/j.neucli.2013.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 05/29/2013] [Accepted: 05/29/2013] [Indexed: 12/19/2022] Open
Abstract
STUDY AIM This prospective study aim to examine whether clinical findings and electrodiagnostic testing (EDX) in patients with lumbosacral monoradiculopathy due to herniated disc (HD) differ as a function of root involvement level (L5 vs. S1) and HD zone (paramedian vs. intraforaminal). PATIENTS AND METHODS All patients with L4, L5 or S1 monoradiculopathy were prospectively enrolled at four electromyography (EMG) labs over a 2-year period. The diagnosis was based on a congruence between patient history and MRI evidence of HD. We compared the sensitivities of clinical findings and EDX with respect to both root involvement level and HD zone. Multivariate logistic regression was performed in order to verify the association between abnormal EMG, clinical, and neuroradiological findings. RESULTS One hundred and eight patients (mean age 47.7 years, 55% men) were consecutively enrolled. Sensory loss in the painful dermatome was the most frequent finding at physical examination (56% of cases). EMG was abnormal in at least one muscle supplied by femoral and sciatic nerves in 45 cases (42%). Inclusion of paraspinal muscles increased sensitivity to only 49% and that of proximal muscles was useless. Motor and sensory neurography was seldom abnormal. The most frequent motor neurographic abnormalities were a delay of F-wave minimum latency and decrease in the compound muscle action potential amplitude from extensor digitorum brevis and abductor hallucis in L5 and S1 radiculopathies, respectively. Sensory neurography was usually normal, the amplitude of sensory nerve action potential was seldom reduced when HD injured dorsal root ganglion or postganglionic root fibres. Multivariate logistic regression analysis showed that EMG abnormalities could be predicted by myotomal muscular weakness, abnormal deep reflexes, and paraesthesiae. The only clinical and electrophysiological differences with respect to root involvement level concerned deep reflexes and motor neurography of deep peroneal and tibial nerves. CONCLUSIONS Only some EDX parameters are helpful for the diagnosis of lumbosacral radiculopathy. EMG was abnormal in less than 50% of cases and its abnormalities could be predicted by some clinical findings. However, neurography is useful as a tool for differential diagnosis between radiculopathy and more diffuse disorders of the peripheral nervous system (polyneuropathy, plexopathy).
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Bartlett RJV, Rigby AS, Joseph J, Raman A, Kunnacherry A, Hill CAR. Extension MRI is clinically useful in cervical myelopathy. Neuroradiology 2013; 55:1081-8. [PMID: 23740097 DOI: 10.1007/s00234-013-1208-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Cervical spine MRI with the neck in extension has been well described over the last 10 years, but its clinical value remains unknown. METHODS We performed extension imaging in 60 patients in whom the initial neutral study showed borderline cord compression. Images were assessed using a previously validated grading system for cord compression. Multiple linear and area measurements were also obtained. Images were scored blindly and randomly. Inter- and intra-rater variability were determined in a subset of 20 cases. Independent clinical assessment utilised the Ranwat criteria. RESULTS For most parameters inter/intra-observer variance of kappa/ICC > 0.6 was highly satisfactory. Standard MR was poor at discriminating between patients with and without myelopathy (ROC analysis, area under the curve (AUC), 0.52). This was considerably improved with extension imaging (AUC, 0.60), or by using the change in compression score between neutral and extension studies. Most measurements were not helpful; however, the ratio of cord area/CSF area at the level of maximum compression on extended images was the best discriminator (AUC, 0.71), as well as the presence of T2 change in cord substance (AUC, 0.68). CONCLUSION This is the first study to demonstrate added clinical value utilising extension MRI. In this cohort of difficult patients, when there was no T2 signal change in the cord, the presence of clinical myelopathy could only be predicted by utilising the data from extension imaging.
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Annaswamy TM, Bierner SM, Avraham R. Role of electrodiagnosis in patients being considered for epidural steroid injections. PM R 2013; 5:S96-9. [PMID: 23524071 DOI: 10.1016/j.pmrj.2013.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 03/15/2013] [Indexed: 11/30/2022]
Abstract
Electrodiagnostic (EDX) evaluation, and, more specifically, electromyography (EMG), has a well-established role in the diagnostic confirmation of cervical and lumbar radiculopathy. The role of EMG in prognostication, however, is less established and remains a topic of debate. The purpose of this article is to evaluate the diagnostic and prognosticating role of EMG in cervical and lumbar radiculopathies, and to assess the utility of EMG in predicting outcomes after epidural steroid injections (ESI). A review of the existing literature strongly supports a prognosticating role for EDX in predicting outcomes after lumbar ESI in lumbosacral radiculopathies (LSR). Although limited research regarding outcome prediction after cervical ESI in cervical radiculopathies has been performed, no study has specifically evaluated the utility of EMG in predicting outcomes for cervical ESI, and this topic requires further investigation. An EDX evaluation can provide clinicians with accurate and reliable diagnostic information (level I or level II evidence) in the evaluation of patients with lumbosacral radiculopathies, and can provide more valid prognostic information (level I evidence) regarding potential benefits of lumbar ESI. An EDX evaluation, therefore, can enhance a clinician's ability to advise patients on the most appropriate and efficacious evaluation and management plan for the treatment of painful radiculopathies.
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Affiliation(s)
- Thiru M Annaswamy
- Electrodiagnostic and Spine Sections, Physical Medicine and Rehabilitation Service, Dallas VA Medical Center, Dallas, TX, USA.
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Dillingham TR. Evaluating the patient with suspected radiculopathy. PM R 2013; 5:S41-9. [PMID: 23524070 DOI: 10.1016/j.pmrj.2013.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 03/15/2013] [Indexed: 10/27/2022]
Abstract
Persons with back, neck, and limb symptoms are commonly seen by health care providers. They constitute a major referral population to specialists in electrodiagnostic medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The electrodiagnostic examination with needle electromyography is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity. It complements imaging of the spine. Electromyography in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy, conditions that frequently mimic radicular symptoms. A streamlined examination with 6 muscles, 1 of which is the paraspinal, has a high diagnostic yield, yet minimizes patient discomfort and examiner time. This article presents an overview of the electrodiagnostic evaluation for patients with suspected radiculopathy.
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Affiliation(s)
- Timothy R Dillingham
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard Street, 1st floor, Philadelphia, PA 19146, USA.
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Kara M, Özçakar L, Tiftik T, Kaymak B, Özel S, Akkuş S, Akıncı A. Sonographic Evaluation of Sciatic Nerves in Patients With Unilateral Sciatica. Arch Phys Med Rehabil 2012; 93:1598-602. [DOI: 10.1016/j.apmr.2012.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 02/26/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
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Adebajo A, Fabule J. Management of radicular pain in rheumatic disease: insight for the physician. Ther Adv Musculoskelet Dis 2012; 4:137-47. [PMID: 22850677 DOI: 10.1177/1759720x12437180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rheumatologists are still relatively unaware of the causes, presentation, diagnosis and management of radicular pain. This is against a background of increasing evidence of the presence and importance of radicular problems in patients with rheumatological disorders. When they coexist in patients, differentiating between nociceptive and neuropathic pain is clinically important because these components require different pain management strategies. Consequently, it is essential that rheumatologists become skilled in identifying as well as managing both forms of pain. This review will serve to further increase awareness among rheumatologists of this important issue as well as discuss the practical aspects of managing these conditions. The evaluation of patients requires very careful history taking and full thorough neurological examination. Diagnostic testing is suggested mainly to confirm the diagnosis and aetiology in patients with persistent symptoms despite conservative treatment. Neuroimaging is recommended for patients with acute radicular pain with progressive neurological deficits or those with high suspicion of neoplasm or epidural abscess. If neuroimaging does not confirm diagnosis, electrophysiology studies may be helpful. The management of this condition is multifaceted and involves physicians and allied healthcare professionals as well as the patients who should be encouraged to participate in self-management programmes. Nociceptive and neuropathic pain often coexists in patients with rheumatic disease. There are challenges to making the diagnosis of radicular pain in these patients. The diagnosis is primarily clinical but pathophysiological issues, diversity in symptoms, the multiple mechanisms of action and difficulties in communication between patients and their doctors as well as variable response to therapy pose challenges to the effective management of these patients. Despite these difficulties and challenges, it is essential that rheumatologists familiarize themselves with the management of radicular pain in rheumatic diseases. The evaluation of patients requires very careful history taking, aided by the use of an appropriate screening tool and full, thorough neurological examination. In addition, investigations such as the use of imaging or electrophysiology studies when required may help to differentiate between the pain phenotypes.
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Affiliation(s)
- Ade Adebajo
- Academic Rheumatology Group, Faculty of Medicine, University of Sheffield and Barnsley Hospital NHS Foundation Trust, Gawber Road, Barnsley S75 2EP, UK
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Hehir MK, Figueroa JJ, Zynda-Weiss AM, Stanton M, Logigian EL. Unexpected neuroimaging abnormalities in patients with apparent C8 radiculopathy: broadening the clinical spectrum. Muscle Nerve 2012; 45:859-65. [PMID: 22581540 DOI: 10.1002/mus.23319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION C8-root impingement by C7/T1 lesions on neuroimaging studies is not consistently observed in C8 radiculopathy. We hypothesized that C7 or T1 root lesions (with a pre- or postfixed plexus) or cervical myelopathy might explain some "C8 radiculopathies" without C8 root compression. METHODS Retrospective analysis of cervical neuroimaging in 31 consecutive patients with EMG-confirmed C8 radiculopathy. RESULTS Five patients (16%) had C8-root compression at C7/T1. Of those without C8-root compression, 5 (16%) had C7-root compression at C6/7, one (3%) had T1-root compression at T1/T2, 7 (23%) had cervical cord compression at or above the C6/7 level, 4 (13%) had intramedullary cervical lesions, and 9 (29%) had mild or nonspecific findings. CONCLUSIONS C8 radiculopathy without C8-root compression may be due to C7-root compression in the setting of a "prefixed" brachial plexus, upper cervical cord compression with vascular compromise of the distal cervical spinal cord ("myelopathic hand"), or intramedullary cervical cord lesions.
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Affiliation(s)
- Michael K Hehir
- University of Vermont, Department of Neurology, Burlington, Vermont, USA
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Electrodiagnostic Testing Before Epidural Steroid Injections. PM R 2012; 4:223-9. [DOI: 10.1016/j.pmrj.2012.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/02/2012] [Indexed: 11/18/2022]
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Annaswamy TM, Bierner SM, Chouteau W, Elliott AC. Needle electromyography predicts outcome after lumbar epidural steroid injection. Muscle Nerve 2012; 45:346-55. [DOI: 10.1002/mus.22320] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bartlett RJV, Hill CAR, Rigby AS, Chandrasekaran S, Narayanamurthy H. MRI of the cervical spine with neck extension: is it useful? Br J Radiol 2012; 85:1044-51. [PMID: 22215879 DOI: 10.1259/bjr/94315429] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Standard MRI of the cervical spine is performed in a different anatomical position to that utilised for traditional contrast myelography. Those well practised in myelography are familiar with the considerable changes in configuration of the bony and soft tissues of the cervical spine that may occur with changes in the degree of neck flexion and extension. We set out to compare the findings in a select group of patients with myeloradiculopathy who had undergone myelography and MRI in both standard and neck-extended positions. These findings were correlated with the clinical status. METHODS 29 patients underwent myelography with CT (CTM) and MRI in neutral and neck-extended positions. The imaging was assessed for the degree of cord compression and neural foraminal narrowing, quantified using a simple grading scheme suitable for routine clinical practice. The degree of neck extension was assessed using an angular measurement. RESULTS For both CTM and MRI, scanning with the neck extended significantly increases the severity of cord compression compared with the standard supine position, to a degree similar to that shown during conventional prone myelography. The degree of perceived cord compression is related to the degree of neck extension achieved. Correlation of standard MRI findings and the clinical level of radiculopathy is poor. This correlation improves when the neck is extended. CONCLUSIONS The most appropriate position for routine MRI of the cervical spine in degenerative disease remains unknown, but in selected patients imaging with the neck extended may provide important additional information.
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Diagnostic accuracy of MRI in adults with suspect brachial plexus lesions: a multicentre retrospective study with surgical findings and clinical follow-up as reference standard. Eur J Radiol 2011; 81:2666-72. [PMID: 22071340 DOI: 10.1016/j.ejrad.2011.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 10/12/2011] [Accepted: 10/14/2011] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate brachial plexus MRI accuracy with surgical findings and clinical follow-up as reference standard in a large multicentre study. MATERIALS AND METHODS The research was approved by the Institutional Review Boards, and all patients provided their written informed consent. A multicentre retrospective trial that included three centres was performed between March 2006 and April 2011. A total of 157 patients (men/women: 81/76; age range, 18-84 years) were evaluated: surgical findings and clinical follow-up of at least 12 months were used as the reference standard. MR imaging was performed with different equipment at 1.5 T and 3.0 T. The patient group was divided in five subgroups: mass lesion, traumatic injury, entrapment syndromes, post-treatment evaluation, and other. Sensitivity, specificity with 95% confidence intervals (CIs), positive predictive value (PPV), pre-test-probability (the prevalence), negative predictive value (NPV), pre- and post-test odds (OR), likelihood ratio for positive results (LH+), likelihood ratio for negative results (LH-), accuracy and post-test probability (post-P) were reported on a per-patient basis. RESULTS The overall sensitivity and specificity with 95% CIs were: 0.810/0.914; (0.697-0.904). Overall PPV, pre-test probability, NPV, LH+, LH-, and accuracy: 0.823, 0.331, 0.905, 9.432, 0.210, 0.878. CONCLUSIONS The overall diagnostic accuracy of brachial plexus MRI calculated on a per-patient base is relatively high. The specificity of brachial plexus MRI in patients suspected of having a space-occupying mass is very high. The sensitivity is also high, but there are false-positive interpretations as well.
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Abstract
BACKGROUND Cervical radiculopathy is defined as a syndrome of pain and/or sensorimotor deficits due to compression of a cervical nerve root. Understanding of this disease is vital for rapid diagnosis and treatment of patients with this condition, facilitating their recovery and return to regular activity. PURPOSE This review is designed to clarify (1) the pathophysiology that leads to nerve root compression; (2) the diagnosis of the disease guided by history, physical exam, imaging, and electrophysiology; and (3) operative and non-operative options for treatment and how these should be applied. METHODS The PubMed database was searched for relevant articles and these articles were reviewed by independent authors. The conclusions are presented in this manuscript. RESULTS Facet joint spondylosis and herniation of the intervertebral disc are the most common causes of nerve root compression. The clinical consequence of radiculopathy is arm pain or paresthesias in the dermatomal distribution of the affected nerve and may or may not be associated with neck pain and motor weakness. Patient history and clinical examination are important for diagnosis. Further imaging modalities, such as x-ray, computed tomography, magnetic resonance imaging, and electrophysiologic testing, are of importance. Most patients will significantly improve from non-surgical active and passive therapies. Indicated for surgery are patients with clinically significant motor deficits, debilitating pain that is resistant to conservative modalities and/or time, or instability in the setting of disabling radiculopathy. Surgical treatment options include anterior cervical decompression with fusion and posterior cervical laminoforaminotomy. CONCLUSION Understanding the pathophysiology, diagnosis, treatment indications, and treatment techniques is essential for rapid diagnosis and care of patients with cervical radiculopathy.
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Affiliation(s)
- John M. Caridi
- Hospital for Special Surgery, 535 East 70th Street,
New York, NY 10021 USA
| | - Matthias Pumberger
- Hospital for Special Surgery, 535 East 70th Street,
New York, NY 10021 USA
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