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Chen HB, Huang YL, Chen M, Wu HB. Reducing decompression levels by diffusion tensor imaging and conventional magnetic resonance imaging in degenerative lumbar spinal stenosis. Br J Neurosurg 2024; 38:265-271. [PMID: 33538210 DOI: 10.1080/02688697.2020.1861432] [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: 02/10/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The selection of a correct level in lumbar spinal stenosis (LSS) remains a common problem and is critically important to the effectiveness of this surgical treatment. Surgery is invasive, and extended laminectomy may lead to secondary surgical complications. The application of diffuse tensor imagining (DTI) and paraspinal mapping (PM) in addition to conventional magnetic resonance imaging (cMRI) may be helpful in this respect. However, the superiority of cMRI + DTI over cMRI+ (DTI or PM) in reducing decompression has not yet been established. METHODS We compared the surgical levels, determined by cMRI + DTI and cMRI+ (DTI or PM) (self-control). Treatment outcome measurements were performed at two weeks, three months, six months, and twelve months postoperatively. RESULTS The surgical levels determined by cMRI ± DTI showed less than that determined by cMRI± (DTI or PM) with statistically significant differences (p value = 0.0199) and cMRI ± PM with no statistically significant differences (p value = 0.5503). CONCLUSIONS The effectiveness of cMRI ± DTI in the reduction of the surgical levels in degenerative lumbar spinal stenosis is superior than that of cMRI± (DTI or PM).
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Affiliation(s)
- Hua-Biao Chen
- Departments of Orthopaedic Surgery, Affiliated Huizhou Central People Hospital, Sun Yat-Sen University and Guangdong Medical University, People's Republic of China
| | - Yu-Liang Huang
- Departments of Orthopaedic Surgery, Affiliated Huizhou Central People Hospital, Sun Yat-Sen University and Guangdong Medical University, People's Republic of China
| | - Min Chen
- Departments of Orthopaedic Surgery, Affiliated Huizhou Central People Hospital, Sun Yat-Sen University and Guangdong Medical University, People's Republic of China
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Montaner-Cuello A, Bueno-Gracia E, Rodríguez-Mena D, Estébanez-de-Miguel E, Malo-Urriés M, Ciuffreda G, Caudevilla-Polo S. Is the Straight Leg Raise Suitable for the Diagnosis of Radiculopathy? Analysis of Diagnostic Accuracy in a Phase III Study. Healthcare (Basel) 2023; 11:3138. [PMID: 38132028 PMCID: PMC10742430 DOI: 10.3390/healthcare11243138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023] Open
Abstract
The straight leg raise test (SLR) has been proposed to detect increased nerve mechanosensitivity of the lower limbs in individuals with low back pain. However, its validity in the diagnosis of lumbosacral radiculopathy shows very variable results. The aim of this study was to analyse the diagnostic validity of the SLR including well-defined diagnostic criteria (a change in symptoms with the structural differentiation manoeuvre and the reproduction of the patient's symptoms during the test or the asymmetries in the range of motion or symptoms location between limbs) in a sample of participants in phase III with suspicion of lumbar radiculopathy using the electrodiagnostic studies (EDX) as the reference standard. A phase III diagnostic accuracy study was designed. In total, 142 individuals with suspected lumbosacral radiculopathy referred for EDX participated in the study. Each participant was tested with EDX and SLR. SLR was considered positive using three diagnostic criteria. The sensitivity of the SLR for Criterion 3 was 89.02% (CI 81.65-96.40), the specificity was 25.00% (CI 13.21-36.79), and the positive and negative likelihood ratios were 1.19 (CI 1.01-1.40) and 0.44 (0.21-0.94), respectively. SLR showed limited validity in the diagnosis of lumbosacral radiculopathy. The incorporation of more objective diagnostic criteria (asymmetry in range of motion or localisation of symptoms) improved the diagnostic validity but the imprecision of the confidence intervals limited the interpretation of the results.
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Affiliation(s)
| | - Elena Bueno-Gracia
- Physiatry and Nursery Department, Health Sciences Faculty, University of Zaragoza, 50009 Zaragoza, Spain; (A.M.-C.); (D.R.-M.); (E.E.-d.-M.); (M.M.-U.); (G.C.); (S.C.-P.)
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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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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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Seliverstova EG, Sinkin MV, Kordonsky AY, Aleinikova IB, Tikhomirov IV, Grin AA. [Electrodiagnostic evaluation in differential diagnosis and neurosurgical treatment of radiculopathies caused by spine disorders. Diagnostic value and methodology]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:109-118. [PMID: 35412720 DOI: 10.17116/neiro202286021109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
UNLABELLED One of the most common causes of radiculopathy requiring neurosurgical treatment is a herniated disc. Magnetic resonance imaging (MRI) is still the main diagnostic approach for this lesion. However, MRI does not allow assessing the functional state of the root. Neurophysiological examination assesses the function of peripheral nervous system. These methods are used for differential diagnosis of causes of neurological symptoms and determine the level of the nerve root injury. OBJECTIVE To assess the role of electromyography including paraspinal muscle mapping in diagnosis of radiculopathies following spine diseases. MATERIAL AND METHODS We have analyzed literature data in the Scopus, Pubmed, and RSCI databases and selected 93 references for primary reviewing. Final analysis enrolled the manuscripts with a detailed description of neurophysiological examinations and data on sensitivity/specificity of these methods. RESULTS Needle electromyography (EMG) is the most informative neurophysiological method for diagnosis of radicular damage. Sensitivity of EMG is up to 90% for lumbosacral radiculopathy. Electromyography of the paraspinal muscles can be used in case of of cervical, thoracic and lumbar radiculopathy in addition to EMG of limb muscles. Therefore sensitivity increases to 100%. Diagnostic value of nerve conduction study (NCS) is low, and performing NCS without EMG is not useful. CONCLUSION In neurosurgical practice electrodiagnostic (EDX) should be performed for differential diagnosis of radiculopathy and peripheral nervous system lesions, to determine the level of radicular compression, and when physical examination does not correspond with neuroimaging or MRI is not possible to perform.
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Affiliation(s)
- E G Seliverstova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - M V Sinkin
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A Yu Kordonsky
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - I B Aleinikova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - I V Tikhomirov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - A A Grin
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Park CH, Lee SH. The Outcome of Pulsed Radiofrequency Treatment According to Electodiagnosis in Patients with Intractable Lumbosacral Radicular Pain. PAIN MEDICINE 2020; 20:1697-1701. [PMID: 30848820 DOI: 10.1093/pm/pnz028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Radicular pain is related to lesions that either directly compromise the dorsal root ganglion (DRG) or indirectly compromise the spinal nerve and its roots by causing ischemia or inflammation of the axons. OBJECTIVE Our study aimed to assess the outcomes of pulsed readiofrequency treatment (PRF) according to electrodiagnosis results in patients with chronic intractable lumbosacral radicular pain. METHODS A total of 82 failed back surgery syndrome (FBSS) patients were included in this study. All of them underwent electromyography/nerve conduction studies before pulsed radiofrequency (PRF) treatment at the DRG, and they were classified according to the electrodiagnostic results as: group 1, no definite finding (normal); group 2, radiculopathy; and group 3, neuropathy. Pain intensity was assessed according to a numeric rating scale score and the Oswestry Disability Index (ODI) before treatment and at one, three, six, and 12 months after treatment, and successful treatment was defined as a pain score reduction of ≥50% at 12 months, as compared with the pretreatment score. RESULTS Pretreatment electrodiagnosis identified 28 patients with no definite findings, 31 patients with radiculopathy, and 23 patients with neuropathy. The patients with neuropathy had less pain relief after treatment than those with no definite findings and those with radiculopathy. The prevalence of pain reduction of at least 50% was lower in the neuropathy group than in the other groups. There was no statistically significant difference in ODI between group. CONCLUSION Outcomes after PRF at the DRG did not show strong differences according to electrodiagnostic findings in FBSS patients with chronic intractable lumbosacral radicular pain.
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Affiliation(s)
- Chan Hong Park
- Department of Anesthesiology and Pain Medicine, Daegu Wooridul Spine Hospital, Daegu, South Korea
| | - Sang Ho Lee
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, South Korea
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Munjupong S, Kumnerddee W. Effect of supraneural transforaminal epidural steroid injection combined with caudal epidural steroid injection with catheter in chronic radicular pain management: Double blinded randomized controlled trial. F1000Res 2020; 9:634. [PMID: 32695314 PMCID: PMC7344176 DOI: 10.12688/f1000research.23188.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Epidural steroid injection (ESI) has been used in managing chronic radicular pain. Regarding various techniques of ESI, the synergistic effect of caudal ESI (CESI) on transforaminal ESI (TFESI) in chronic lumbosacral radicular pain in prospective randomized controlled trial has not been determined.
Methods: A total of 54 eligible patients with lumbosacral radicular pain were randomly allocated to undergo TFESI plus CESI (TC group) or TFESI alone (T group). The effective response to treatment was predefined by at least a 30% reduced verbal numerical rating scale (VNRS) from baseline between group comparison and the functional outcomes as measured by improved Oswestry Disability Index by least 15 points from baseline. All participants were evaluated using a single blinded outcome assessor before the procedure and at 1, 3 and 6 months after the procedure. P <0.05 was considered as statistically significant.
Results: Average VNRS reduced significantly from baseline after receiving procedure at 1, 3 and 6 months in both groups (P-value <0.05). The TC group exhibited more effective and showed significant pain relief compared with the T group at 3 months (P=0.01). However, no statistical difference was observed between sub group analysis in pain relief and insignificant difference between group comparisons of functional outcomes. Conclusions: A treatment combining TFESI and CESI showed significant pain relief over TFESI alone at 3 months. No effect was found concerning functional evaluation. Registration: Thai Clinical Trials Registry ID TCTR20171101002 01/11/2017F
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Affiliation(s)
- Sithapan Munjupong
- Department of Anaesthesiology, Phramongkutklao Hospital and College of Medicine, Bangkok, Bangkok, 10400, Thailand
| | - Wipoo Kumnerddee
- Department of Rehabilitation Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Bangkok, 10400, Thailand
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Ali SS, Khan AY, Michael SG, Tankha P, Tokuno H. Use of Digital Infrared Thermal Imaging in the Electromyography Clinic: A Case Series. Cureus 2019; 11:e4087. [PMID: 31032148 PMCID: PMC6472870 DOI: 10.7759/cureus.4087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction: Foot drop often results from denervation of the dorsiflexor muscles in the leg. Neurological evaluation begins with lower extremity motor testing followed by electromyography needle electrode examination (EMG-NEE). We explored digital infrared thermography (IRT) as a complementary tool in diagnosing peripheral nerve disorders. Methods: Using a digital IRT camera, we recorded differences in skin surface temperatures from affected and unaffected limbs in three patients with unilateral foot drop. Denervation in the affected limb was confirmed with EMG-NEE. Results: IRT imaging revealed lower relative skin surface temperatures in regions of the leg corresponding to denervated dorsiflexor muscles for all three consecutive patients who presented to the EMG Clinic with foot drop. Conclusions: Denervation appears to cause a decrease in thermal energy output from affected muscle groups. Alongside the EMG and magnetic resonance imaging (MRI), IRT may have an important role in assessing the severity and prognosis of a nerve injury. This observation may have implications for chronic pain syndromes, such as complex regional pain syndrome (CRPS), in which thermal change is a diagnostic criterion.
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Affiliation(s)
- Sameer S Ali
- Neurology, Veterans Affairs Hospital - Connecticut Healthcare System, West Haven, USA
| | - Arjumond Y Khan
- Neurology, Veterans Affairs Hospital - Connecticut Healthcare System, West Haven, USA
| | | | - Pavan Tankha
- Pain Management, Veterans Affairs Hospital - Connecticut Healthcare System, West Haven, USA
| | - Hajime Tokuno
- Neurology, Veterans Affairs Hospital - Connecticut Healthcare System, West Haven, USA
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McNeish B, Hearn S, Craig A, Laidlaw A, Ziadeh M, Richardson JK. Motor amplitudes may predict electromyography-confirmed radiculopathy in patients referred for radiating limb pain. Muscle Nerve 2019; 59:561-566. [PMID: 30734323 DOI: 10.1002/mus.26442] [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] [Accepted: 02/05/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Radiculopathy is diagnosed by needle electromyography, with nerve conduction studies excluding alternative diagnoses. METHODS In patients referred for electrodiagnostic evaluation of radiating limb pain, we compared ulnar motor amplitudes between those with and without electromyographically confirmed C8 radiculopathy, as well as fibular motor amplitudes between those with and without electromyographically confirmed L5 radiculopathy. RESULTS Patients with electromyographically confirmed C8 or L5 radiculopathy demonstrated decreased ulnar or fibular motor amplitudes, respectively, as compared to patients without radiculopathy. Receiver operating characteristic curves demonstrated good diagnostic accuracy, with areas under the curve of 0.85 and 0.82, respectively. Optimal cut-offs for electromyographically confirmed C8 and L5 radiculopathies were 10.2 mV and 3.6 mV, respectively, with associated sensitivities/specificities of 0.86/0.74 and 0.92/0.60. DISCUSSION Ulnar and fibular motor amplitudes may have clinical utility in assessing the likelihood of patients demonstrating electromyographically confirmed C8 and L5 radiculopathies with active denervation. The findings may be particularly useful in patients intolerant of needle electromyography. Muscle Nerve 59:561-561, 2019.
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Affiliation(s)
- Brendan McNeish
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Sandra Hearn
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Anita Craig
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Ann Laidlaw
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark Ziadeh
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - James K Richardson
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
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Chen HB, Chen M, Peng HH, Xu QF, Li XC, Bai B. Relationship between the benefits of paraspinal mapping and diffusion tensor imaging and the increase of decompression levels determined by conventional magnetic resonance imaging in degenerative lumbar spinal stenosis. J Orthop Surg Res 2019; 14:23. [PMID: 30670090 PMCID: PMC6341682 DOI: 10.1186/s13018-019-1065-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In lumbar spinal stenosis (LSS), at most times, several levels are impaired and selecting the correct level remains a common problem for surgeons, as surgery remains invasive, and extended laminectomy may lead to secondary surgical complications. Therefore, helping to select the correct level may be useful for surgeons. The use of diffuse tensor imaging (DTI) and paraspinal mapping (PM) in addition to conventional magnetic resonance imaging (MRI) may be helpful (Chen et al., J Orthop Surg Res 11:47, 2016). However, with decompression levels determined by conventional magnetic resonance imaging (MRI) increasing, whether the benefits of reducing decompression level of conventional MRI + (DTI or PM) will be more obvious is unknown. METHODS Reduced surgical levels that were different between levels determined by conventional MRI + (DTI or PM) and conventional MRI + neurogenic examination (NE) between groups were compared. Treatment outcome measures were performed at 2 weeks, 3 months, 6 months, and 12 months postoperatively. RESULTS The reduced levels of three groups showed no statistically significant differences between each other except for two levels and four levels (two levels/three levels, p = 0.085; two levels/four levels, p = 0.039; three levels/ four levels, p = 0.506, respectively). CONCLUSIONS With surgical levels determined by conventional MRI increasing, the benefits of DTI and PM will be uncertainly more obvious.
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Affiliation(s)
- Hua-Biao Chen
- Departments of Spine Surgery, Affiliated Huizhou Central People Hospital, Sun Yat-Sen University and Guangdong Medical University, 41Goose Ridge North Road, 516001, Huizhou City, Guangdong Province, People's Republic of China.
| | - Min Chen
- Departments of Spine Surgery, Affiliated Huizhou Central People Hospital, Sun Yat-Sen University and Guangdong Medical University, 41Goose Ridge North Road, 516001, Huizhou City, Guangdong Province, People's Republic of China
| | - Hong-Hui Peng
- Departments of Spine Surgery, Affiliated Huizhou Central People Hospital, Sun Yat-Sen University and Guangdong Medical University, 41Goose Ridge North Road, 516001, Huizhou City, Guangdong Province, People's Republic of China
| | - Qi-Feng Xu
- Department of Electromyography, First Affiliated Hospital, Guangzhou Medical University, 151Yanjiang Road, 510120, Guangzhou, People's Republic of China
| | - Xin-Chun Li
- Department of Radiology, First Affiliated Hospital, Guangzhou Medical University, 151Yanjiang Road, 510120, Guangzhou, People's Republic of China
| | - Bo Bai
- Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, First Affiliated Hospital, Guangzhou Medical University, 151Yanjiang Road, 510120, Guangzhou, People's Republic of China.,Department of Orthopaedic, First Affiliated Hospital, Guangzhou Medical University, 151Yanjiang Road, 510120, Guangzhou, People's Republic of China
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Hooten WM, Cohen SP. Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists. Mayo Clin Proc 2015; 90:1699-718. [PMID: 26653300 DOI: 10.1016/j.mayocp.2015.10.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 10/10/2015] [Accepted: 10/15/2015] [Indexed: 01/15/2023]
Abstract
Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis. The accuracy of historical and physical examination findings has been established for sacroiliac joint pain, radiculopathy, and lumbar spinal stenosis. However, the accuracy of similar data, so-called red flags, for identifying the underlying medical sources of LBP has been overstated. Diagnostic imaging studies can be useful, and adherence to established guidelines can protect against overuse. Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related indications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence.
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Affiliation(s)
- W Michael Hooten
- Mayo Clinic College of Medicine and Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN.
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD; Department of Anesthesiology, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD
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Cohen SP, Furman MB, Weber NH, Singh JR. Single Versus Two-Level Transforaminal Epidural Steroid Injection for Treating Lumbosacral Radicular Pain: What is the Evidence? PM R 2015; 7:883-888. [DOI: 10.1016/j.pmrj.2015.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/01/2015] [Indexed: 12/31/2022]
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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: 21] [Impact Index Per Article: 1.9] [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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Al Nezari NH, Schneiders AG, Hendrick PA. Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review and meta-analysis. Spine J 2013; 13:657-74. [PMID: 23499340 DOI: 10.1016/j.spinee.2013.02.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 05/09/2012] [Accepted: 02/08/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Disc herniation is a common low back pain (LBP) disorder, and several clinical test procedures are routinely employed in its diagnosis. The neurological examination that assesses sensory neuron and motor responses has historically played a role in the differential diagnosis of disc herniation, particularly when radiculopathy is suspected; however, the diagnostic ability of this examination has not been explicitly investigated. PURPOSE To review the scientific literature to evaluate the diagnostic accuracy of the neurological examination to detect lumbar disc herniation with suspected radiculopathy. STUDY DESIGN A systematic review and meta-analysis of the literature. METHODS Six major electronic databases were searched with no date or language restrictions for relevant articles up until March 2011. All diagnostic studies investigating neurological impairments in LBP patients because of lumbar disc herniation were assessed for possible inclusion. Retrieved studies were individually evaluated and assessed for quality using the Quality Assessment of Diagnostic Accuracy Studies tool, and where appropriate, a meta-analysis was performed. RESULTS A total of 14 studies that investigated three standard neurological examination components, sensory, motor, and reflexes, met the study criteria and were included. Eight distinct meta-analyses were performed that compared the findings of the neurological examination with the reference standard results from surgery, radiology (magnetic resonance imaging, computed tomography, and myelography), and radiological findings at specific lumbar levels of disc herniation. Pooled data for sensory testing demonstrated low diagnostic sensitivity for surgically (0.40) and radiologically (0.32) confirmed disc herniation, and identification of a specific level of disc herniation (0.35), with moderate specificity achieved for all the three reference standards (0.59, 0.72, and 0.64, respectively). Motor testing for paresis demonstrated similarly low pooled diagnostic sensitivities (0.22 and 0.40) and moderate specificity values (0.79 and 0.62) for surgically and radiologically determined disc herniation, whereas motor testing for muscle atrophy resulted in a pooled sensitivity of 0.31 and the specificity was 0.76 for surgically determined disc herniation. For reflex testing, the pooled sensitivities for surgically and radiologically confirmed levels of disc herniation were 0.29 and 0.25, whereas the specificity values were 0.78 and 0.75, respectively. The pooled positive likelihood ratios for all neurological examination components ranged between 1.02 and 1.26. CONCLUSIONS This systematic review and meta-analysis demonstrate that neurological testing procedures have limited overall diagnostic accuracy in detecting disc herniation with suspected radiculopathy. Pooled diagnostic accuracy values of the tests were poor, whereby all tests demonstrated low sensitivity, moderate specificity, and limited diagnostic accuracy independent of the disc herniation reference standard or the specific level of herniation. The lack of a standardized classification criterion for disc herniation, the variable psychometric properties of the testing procedures, and the complex pathoetiology of lumbar disc herniation with radiculopathy are suggested as possible reasons for these findings.
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Affiliation(s)
- Nezar H Al Nezari
- Centre for Physiotherapy Research, University of Otago, Dunedin, 9016, New Zealand
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