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To determine whether patients with lumbosacral (LS) radiculopathy and peripheral polyneuropathy (PPNP) exhibit sudomotor abnormalities and whether SUDOSCAN (Impeto Medical, Paris, France) can complement nerve conduction study (NCS) and electromyography (EMG).
Outpatients with lower extremity dysesthesia underwent electrophysiologic studies and SUDOSCAN. They were classified as normal (group A), LS radiculopathy (group B), or PPNP (group C). Pain severity was measured by the Michigan Neuropathy Screening Instrument (MNSI) and visual analogue scale (VAS). Demographic features, electrochemical skin conductance (ESC) values on hands and feet, and SUDOSCAN-risk scores were analyzed.
There were no statistical differences in MNSI and VAS among the three groups. Feet-ESC and hands-ESC values in group C were lower than group A and B. SUDOSCAN-risk score in group B and C was higher than group A. With a cut-off at 48 microSiemens of feet-ESC, PPNP was detected with 57.1% sensitivity and 94.2% specificity (area under the curve [AUC]=0.780; 95% confidence interval [CI], 0646–0.915). With a SUDOSCAN-risk score cut-off at 29%, NCS and EMG abnormalities related to LS radiculopathy and PPNP were detected with 64.1% sensitivity and 84.2% specificity (AUC=0.750; 95% CI, 0.674–0.886).
SUDOSCAN can discriminate outpatients with abnormal electrophysiological findings and sudomotor dysfunction. This technology may be a complementary tool to NCS and EMG in outpatients with lower extremity dysesthesia.
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To assess the cross-sectional area (CSA) of the muscles for investigating the occurrence of asymmetry of the paraspinal (multifidus and erector spinae) and psoas muscles and its relation to the chronicity of unilateral lumbar radiculopathy using magnetic resonance imaging (MRI).
This retrospective study was conducted between January 2012 to December 2014. Sixty one patients with unilateral L5 radiculopathy were enrolled: 30 patients had a symptom duration less than 3 months (group A) and 31 patients had a symptom duration of 3 months or more (group B). Axial MRI measured the CSA of the paraspinal and psoas muscles at the middle between the lower margin of the upper vertebra and upper margin of the lower vertebra, and obtained the relative CSA (rCSA) which is the ratio of the CSA of muscles to that of the lower margin of L4 vertebra.
There were no differences in the demographics between the two groups. In group B, rCSA of the erector spinae at the L4–5 level, and that of multifidus at the L4–5 and L5–S1 levels, were significantly smaller on the involved side as compared with the uninvolved side. In contrast, no significant muscle asymmetry was observed in group A. The rCSA of the psoas was not affected in either group.
The atrophy of the multifidus and erector spinae ipsilateral to the lumbar radiculopathy was observed only in patients suffering from unilateral radiculopathy for 3 months or more.
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To observe the contrast spread in superoposterior transforaminal epidural steroid injection (SP TFESI) and investigate the correlation between spread patterns and efficacy.
Thirty-one patients with lumbosacral radiculopathy underwent single-level TFESI under fluoroscopy. The final needle tip position was targeted toward the SP quadrant of the intervertebral foramen. To observe the spread, 1 mL of contrast material was injected, followed by a steroid injection. The contrast spread was graded anteroposteriorly and vertically in the epidural space. The effect of SP TFESI was evaluated by proportional pain score reduction.
Levels injected were L4-5 (n=20) and L5-S1 (n=11). Seventeen cases were lateral, and 14 were central herniated disc (HD). Baseline mean visual analog scale score was 6.23. Contrast dispersed dorsally in all the cases, and 45.2% cases showed a concurrent ventral spread. The proportion of the pain reduction after 2 weeks showed no difference between the two groups. In vertical spreading analysis, mean cephalic/caudal grades were 1.40/1.55 at L4-5 level and 1.73/1.64 at L5-S1 level. The HD location had no effect on contrast dispersion.
In SP TFESI, ventral contrast spread did not guarantee a better effect; however, the extent of cephalic flow in ventral expansion group correlated with the proportion of pain reduction.
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Neuromyelitis optica spectrum disorders (NMOSD) is a demyelinating syndrome of the central nervous system. This case report describes a 31-year-old woman whose electromyography revealed radiculopathy in the left L5-S1 spinal segment without anatomical abnormalities on lumbosacral magnetic resonance imaging (MRI). She was diagnosed with NMOSD based on gadolinium contrast whole spine and brain MRI and anti-aquaporin-4 antibody findings. Her peripheral nervous system might have been damaged during the early course of NMOSD. Therefore, it is necessary to consider NMOSD for patients who have radiculopathy in electromyography if lumbosacral MRI shows no abnormalities.
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Patients with C5 or C6 radiculopathy complain of shoulder area pain or shoulder girdle weakness. Typical idiopathic neuralgic amyotrophy (INA) is also characterized by severe shoulder pain, followed by paresis of shoulder girdle muscles. Recent studies have demonstrated that magnetic resonance neurography (MRN) of the brachial plexus and magnetic resonance imaging (MRI) of the shoulder in patients with INA show high signal intensity (HSI) or thickening of the brachial plexus and changes in intramuscular denervation of the shoulder girdle. We evaluated the value of brachial plexus MRN and shoulder MRI in four patients with typical C5 or C6 radiculopathy. HSI of the brachial plexus was noted in all patients and intramuscular changes were observed in two patients who had symptoms over 4 weeks. Our results suggest that HSI or thickening of the brachial plexus and changes in intramuscular denervation of the shoulder girdle on MRN and MRI may not be specific for INA.
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Intestinal entrapment between two vertebral bodies is very rare. In all previous cases, it occurred by major trauma. However, the bowel entrapment between two vertebral bodies without trauma has never been reported, not to mention as the cause of lower extremity radicular pain. We describe the case of an 82-year-old female patient with right lower extremity radicular pain without recent trauma history. The patient was diagnosed sigmoid colon entrapment between the L5 and S1 vertebrae by lumbar spinal computerized tomography and magnetic resonance imaging, and showed improvement in radicular pain after manual reduction of interpositioned colon during surgery. Intestinal entrapment between two vertebrae without trauma is caused by degenerative and vacuum changes of the intervertebral disc combined with the anterior longitudinal ligament injury.
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To determine clinical and radiological factors that predict the successful outcome of percutaneous disc decompression (PDD) in patients with lumbar herniated nucleus pulposus (HNP).
We retrospectively reviewed the clinical and radiological features of patients who underwent lumbar PDD from April 2009 to March 2013. Sixty-nine patients with lumbar HNP were studied. Clinical outcome was assessed by the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). Multivariate logistic regression analysis was performed to assess relationship among clinical and radiological factors and the successful outcome of the PDD.
The VAS and the ODI decreased significantly at 1 year follow-up (p<0.01). One year after PDD, the reduction of the VAS (ΔVAS) was significantly greater in the patients with pain for <6 months (p=0.03) and subarticular HNP (p=0.015). The reduction of the ODI (ΔODI) was significantly greater in the patients with high intensity zone (p=0.04). Multivariate logistic regression analysis revealed the following 5 factors that were associated with the successful outcome after PDD: pain duration for <6 months (odds ratio [OR]=14.036; p=0.006), positive straight leg raising test (OR=8.425, p=0.014), the extruded HNP (OR=0.106, p=0.04), the sequestrated HNP (OR=0.037, p=0.026), and the subarticular HNP (OR=10.876, p=0.012).
PDD provided significant improvement of pain and disability of patients. The results of the analysis indicated that the duration of pain <6 months, positive straight leg raising test, the subarticular HNP, and the protruded HNP were predicting factors associated with the successful response of PDD in patients with lumbar HNP.
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We report a case of a 53-year-old male with traumatic cervical spinal cord injury (SCI). He could not maintain a standing position because of painful spasticity in his lower limbs. A magnetic resonance imaging and electromyography indicated chronic lumbosacral radiculopathy, explaining his chronic low back pain before the injury. For diagnostic as well as therapeutic purposes, transforaminal epidural steroid injection (ESI) to the right L5 root was performed. After the intervention, the spasticity decreased and his ambulatory function improved. This case illustrates that lumbar radiculopathy concomitant with a cervical SCI can produce severe spasticity and it can be dramatically improved by ESI.
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To delineate cervical radiculopathy that is found in combination with traumatic cervical spinal cord injury (SCI) and to determine whether attendant cervical radiculopathy affects the prognosis and functional outcome for SCI patients.
A total of 66 patients diagnosed with traumatic cervical SCI were selected for neurological assessment (using the International Standards for the Neurological Classification of Spinal Cord Injury [ISNCSCI]) and functional evaluation (based on the Korean version Modified Barthel Index [K-MBI] and Functional Independence Measure [FIM]) at admission and upon discharge. All of the subjects received a preliminary electrophysiological assessment, according to which they were divided into two groups as follows: those with cervical radiculopathy (the SCI/Rad group) and those without (the SCI group).
A total of 32 patients with cervical SCI (48.5%) had cervical radiculopathy. The initial ISNCSCI scores for sensory and motor, K-MBI, and total FIM did not significantly differ between the SCI group and the SCI/Rad group. However, at discharge, the ISNCSCI scores for motor, K-MBI, and FIM of the SCI/Rad group showed less improvement (5.44±8.08, 15.19±19.39 and 10.84±11.49, respectively) than those of the SCI group (10.76±9.86, 24.79±19.65 and 17.76±15.84, respectively) (p<0.05). In the SCI/Rad group, the number of involved levels of cervical radiculopathy was negatively correlated with the initial and follow-up motors score by ISNCSCI.
Cervical radiculopathy is not rare in patients with traumatic cervical SCI, and it can impede neurological and functional improvement. Therefore, detection of combined cervical radiculopathy by electrophysiological assessment is essential for accurate prognosis of cervical SCI patients in the rehabilitation unit.
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To compare the long-term effects and advantages of ultrasound (US)-guided selective cervical nerve root block with fluoroscopy (FL)-guided transforaminal block.
From March 2009 to November 2012, 162 patients received steroid injections for lower cervical radicular pain. A total of 114 patients fulfilled the inclusion criteria. All procedures were performed by using US or FL. We compared the intravascular injections during the procedure with the effects and functional scales at 3, 6, and 12 months after the procedure between the two groups. Successful treatments occurred when patients obtained significant pain reliefs (as measured by >50% improvements in the verbal numerical scale [VNS] score and >40% improvements in the neck disability index [NDI] score) and reported a patient satisfaction score of 3 or 4 points at 12 months after the injection. Image analysis of intravascular injection and chart review were performed. Logistic regression was performed to reveal the correlations between successful treatments and variables (patient's age, gender, duration of the disease, cause, injection method, and radiologic finding).
The VNS and NDI improved 3 months after the injection and continued to improve until 12 months for both groups. But there were no statistical differences in changes of VNS, NDI, and effectiveness between these two groups. The proportion of patients with successful treatment is illustrated as 62.5% in US-guided group and 58% in FL-guided group at 12 months. There were no significant differences between the groups or during follow-up periods. Three cases of the intravascular injections were done in FL-guided group.
The US-guided selective cervical nerve root blocks are facilitated by identifying critical vessels at unexpected locations relative to the foramen and to protect injury to such vessels, which is the leading cause of reported complications from FL-guided transforaminal blocks. On treatment effect, significant long-term improvements in functions and pain reliefs were observed in both groups after the intervention. However, significant differences were not observed between the groups. Therefore, the US-guided selective cervical nerve root block was shown to be as effective as the FL-guided transforaminal block in pain reliefs and functional improvements, in addition to the absence of radiation and protection vessel injury at real-time imaging.
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To identify the correlations between the location of multifidus atrophy and the level of lumbar radiculopathy.
Thirty-seven patients who had unilateral L4 or L5 radiculopathy were divided into 2 groups; the L4 radiculopathy (L4 RAD) group and the L5 radiculopathy (L5 RAD) group. Bilateral lumbar multifidus muscles at the mid-spinous process level of L4 vertebra (L4 MSP), the mid-spinous process level of L5 vertebra (L5 MSP), and the mid-sacral crest level of S1 vertebra (S1 MSC) were detected in T1 axial magnetic resonance imaging. The total muscle cross-sectional area of multifidus muscles (TMCSA) and the pure muscle cross-sectional area of multifidus muscles (PMCSA) were measured by a computerized analysis program, and the ratio of PMCSA to TMCSA (PMCSA/TMCSA) was calculated.
There were no significant differences in TMCSA between the involved and the uninvolved sides in both groups. PMCSA was only significantly smaller at the S1 MSC on the involved side as compared with the uninvolved side in the L5 RAD group. The ratio of PMCSA to TMCSA was the lowest at the L5 MSP on the involved side in the L4 RAD group and at the S1 MSC on the involved side in the L5 RAD group.
Our findings suggest that the most severe atrophy of multifidus muscle may occur at the mid-spinous process or mid-sacral crest level of the vertebra which is one level below the segmental number of the involved nerve root in patients with a single-level, unilateral lumbar radiculopathy.
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To clarify the relationship of skin temperature changes to clinical, radiologic, and electrophysiological findings in unilateral lumbosacral radiculopathy and to delineate the possible temperature-change mechanisms involved.
One hundred and one patients who had clinical symptoms and for whom there were physical findings suggestive or indicative of unilateral lumbosacral radiculopathy, along with 27 normal controls, were selected for the study, and the thermal-pattern results of digital infrared thermographic imaging (DITI) performed on the back and lower extremities were analyzed. Local temperatures were assessed by comparing the mean temperature differences (ΔT) in 30 regions of interest (ROIs), and abnormal thermal patterns were divided into seven regions. To aid the diagnosis of radiculopathy, magnetic resonance imaging (MRI) and electrophysiological tests were also carried out.
The incidence of disc herniation on MRI was 86%; 43% of patients showed electrophysiological abnormalities. On DITI, 97% of the patients showed abnormal ΔT in at least one of the 30 ROIs, and 79% showed hypothermia on the involved side. Seventy-eight percent of the patients also showed abnormal thermal patterns in at least one of the seven regions. Patients who had motor weakness or lateral-type disc herniation showed some correlations with abnormal DITI findings. However, neither pain severity nor other physical or electrophysiological findings were related to the DITI findings.
Skin temperature change following lumbosacral radiculopathy was related to some clinical and MRI findings, suggesting muscle atrophy. DITI, despite its limitations, might be useful as a complementary tool in the diagnosis of unilateral lumbosacral radiculopathy.
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Method Twenty-four patients who had cervical disc herniation in magnetic resonance imaging (MRI) were evaluated. The patients were divided into 2 groups; patients with unilateral cervical radiculopathy in electrodiagnosis (RAD) and patients without definite radiculopathy (HIVD). Twenty six controls without disc herniation were also evaluated. Cervical multifidus muscles from C4-5 to C7-T1 levels were detected in T1 axial MRI, and total cross-sectional area (CSA) of multifidus muscle (TMA) and pure muscle CSA (PMA) were measured.
Results The ratios of TMA in involved side to TMA in uninvolved side (ITMA/UTMA) and PMA in involved side to PMA in uninvolved side (IPMA/UPMA) in HIVD and RAD groups was significantly lower than those in control group especially at C7-T1 level (p＜0.05). We divided the levels of cervical spine into three parts according to lesions found in MRI or electrodiagnosis; above lesion level, at lesion level and below lesion level. Abnormal cases of IPMA/UPMA were not different among levels in HIVD group, but RAD group showed that most of abnormal cases were below lesion (60%).
Conclusion Asymmetric multifidus atrophy was seen in patients with cervical disc herniation and radiculopathy. The ratio of pure muscle CSA between involved and uninvolved sides might be a useful parameter to differentiate patients with unilateral cervical radiculopathy from patients without radiculopathy.
Method: MRI images were reviewed from thirty two patients who were diagnosed electrodiagnostically as unilateral S1 radiculopathy. Areas of herniated disc and spinal canal were measured and the ratio of disc herniation was calculated from the axial images stored and analyzed by PACS. The radiologic measurements were compared with the results of electrodiagnostic studies. Results: The presence of abnormal spontaneous activities in needle EMG and no response in H reflex were associated with larger disc herniation (p＜0.05). There was no other single electrodiagnostic study that showed correlation with any of radiologic measurements. With increasing number of abnormal electrodiagnostic tests, area of disc herniation grew larger (p＜0.05). Area of spinal canal and the ratio of disc herniation did not show difference between normal and abnormal groups in most of electrodiagnostic studies. Conclusion: There were limited correlations between electrodiagnostic results and severity of disc herniation. The size of disc herniation, regardless of the size of spinal canal, was associated with abnormal results of electrodiagnostic tests. (J Korean Acad Rehab Med 2008; 32: 194-199)
Method: The subjects were 37 patients and 30 normal controls. The patient group was composed of 28 patients with L5 radiculopathy and 9 patients with S1 radiculopathy, which were confirmed by clinical, radiological, and electrodiagnostic studies. Tibialis anterior H-reflex (TA-H reflex) was recorded from maximally contracting tibialis anterior muscle by averaging technique and submaximal stimulation of common peroneal nerve. Sensitivities and specificities were delineated from the several diagnostic criteria.
Results: In the normal controls, mean side to side difference in the TA-H reflex latency was 0.66⁑0.48 msec and mean amplitude ratio was 75⁑16%. The diagnostic criteria of abnormal TA-H reflex were latency difference above 1.62 msec and amplitude ratio less than 42.2%. The abnormal TA-H reflexes were shown in 17 out of 28 patients with L5 radiculopathy and 1 out of 9 patients with S1 radiculopathy. Sensitivity and specificity of TA-H reflex as a diagnostic criteria of L5 radiculopathy were 61% and 89%, respectively.
Conclusion: Tibialis anterior H-reflex might be useful in the diagnosis of L5 radiculopathy.
Method: Electrodiagnostic data of 152 patients who had been diagnosed as lumbosacral radiculopathy with the findings of operative record were obtained retrospectively. The findings of needle electromyography were reviewed and the frequency of abnormal spontaneous activities in L5 and S1 myotomes was investigated. We selected 8 individual muscles which had high sampling rate. These muscles were combined into different muscle screens and the detection rates were calculated that the frequency with which one or more muscles in the screen displayed abnormal spontaneous activity was divided by the total number of radiculopathies.
Results: The detection rates of lumbosacral radiculopathy were compared according to the number of muscle screens. Including paraspinal muscle, the detection rate of 6 muscle screens was higher than 5 muscle screens (p＜0.05), but there was no significant difference of detection rate between 6 muscle screens and 7 muscle screens. The detection rates of each muscle screens without paraspinal muscle were lower than those including paraspinal muscle for all screens (p＜0.05).
Conclusion: Although there is controversy about selection of muscles, six muscle screen including paraspinal muscles may be optimal number for detecting lumbosacral radiculopathy. (J Korean Acad Rehab Med 2003; 27: 63-69)
Objective: It is a widely accepted belief that paraspinal muscles tend to show spontaneous activity on needle electromyography early on in a radiculopathy and distal muscles become abnormal later on. But most studies have shown the limitations of using symptom duration when interpreting electrodiagnostic findings in radiculopathy. The purpose of this study was to determine the relationship between symptom duration and abnormal spontaneous activity in S1 radiculopathy confined to abnormal H-reflex.
Method: A retrospective study that collected the informations on symptom duration and spontaneous activity in paraspinal muscle and gastrocnemius for 112 patients with S1 radiculopathy diagnosed by unilateral H-reflex abnormality was undertaken.
Results: Abnormal spontaneous activity in paraspinal muscle had shown a significant negative correlation with symptom duration, that is a tendency to decrease its expression over symptom duration. On the contrary abnormal spontaneous activity in gastrocnemius muscle was rare at first a few weeks and became to show after 7 weeks. Patients with symptom duration over 1 year had higher incidence of having no abnormal spontaneous activities both in paraspinal and gastrocnemius muscle.
Conclusion: These results suggested that symptom duration had a potential role in the diagnosis of S1 radiculopathy when H-reflex were abnormal unilaterally.
Objective: The purposes of this study were to evaluate the diagnostic value of dermatomal somatosensory evoked potentials (DSEPs) in the unilevel/unilateral lumbosacral radiculopathies.
Method: The study was performed on 41 patients with herniated lumbosacral disc which was confirmed by magnetic resonance imaging, and the patients with clinical lumbosacral radiculopathies (L5 radiculopathy in 33 cases and S1 radiculopathy in 8 cases). Stimulation sites were over the dorsum of the foot on the distal fifth metatarsal bone for the S1 dermatome and at the interdigital web space between first and second toe for the L5 dermatome. Recordings were made at Cz' and reference to Fz. Conventional nerve conduction study, needle EMG and H-reflex were also examined.
Results: While the needle EMG showed abnormalities in 32 patients (78.0%), the abnormalities of DSEPs were in 13 patients (31.7%): 33.3% for the L5 radiculopathy and 25.0% for the S1 radiculopathy, respectively. Moreover, there was no significant relationship between the abnormal findings of needle EMG and DSEPs (p＞0.05). The H-reflexes were abnormal in 6 of 7 patients (85.7%). And then two of them were found abnormal in S1 DSEPs.
Conclusion: The conventional needle EMG appears to be the more useful electrophysiological technique in the diagnosis of lumbosacral radiculopathies. The ultimate diagnostic value of DSEPs in lumbosacral radiculopathies is doubtful and controversial.
Objective: The purpose of the this study was to determine whether pain location indicated in pain drawings was related to the specific lumbo-sacral radiculopathy.
Method: The study group consisted of 153 patients (62 men, 91 women) complaining low back pain with or without radiating pain. Nerve conduction study and electromyographic evaluation were performed for the diagnostic purpose. Chi-square test and multivariate stepwise discriminant analysis were used to identify the patients with radiculopathy on the basis of their pain drawings.
Results: There was significant relationship between pain location indicated in the pain drawing and the lumbar radiculopathy (p＜0.05). In patient without the anterolateral thigh pain, the positivity of S1 radiculopathy was high. In patients with anterolateral thigh and leg pain without posterior thigh pain, the positivity of L5/S1 radiculopathy was high. For predicting the level of the lesion there were three discriminant functions (p＜0.05). Patients with S1 radiculopathy showed negative correlation with anterolateral thigh pain. L5/S1 radiculopathy showed negative correlation with posterior thigh pain but were predicted by pain drawing on anterolateral lower leg.
Conclusion: The results of this study indicate that pain drawings may be helpful in identifying specific radiculopathy. As with any evaluation, the drawings should be considered in combination with findings from other diagnostic methods and interpreted with caution and in light of the full clinical picture.
Objective: To determine the therapeutic efficacy of fluoroscopic and electrical stimulation guided perineural selective nerve root injection in cervical radiculopathy patients.
Method: The gold standard of the diagnosis of cervical radiculopathy was based on clinical features, MRI and electrodiagnostic findings. Considering the natural regression of pain in cervical radiculopathy, only patients (n=27, 14 male and 13 female) who had suffered from persisting or aggravating pain for at least 6 weeks or longer duration after the onset of symptoms, were received a selective nerve root injection (SNRI) of steroids to a target nerve root.
Patients were followed up at 2 weeks and 2 months, and interviewed via telephone or re-examined at an average of 37.8 weeks 68 weeks after injection by a independent physician. Criteria for a successful outcome were greater than 50% reduction of pain on visual analogue scale and an ability to return to previous level of function.
Results: High proportion of patients reported a successful outcome at 2 weeks (88.9%, 24 of 27 patients). Twenty-two of twenty-four patients reported the outcome at 2 months and 20 of 22 patients were followed up for an averrge period of 37.3 weeks. Among these 20 patients 19 patients satisfied with the result of SNRI at an average follow up period of 68 weeks. There was no significant difference of the efficacy according to the duration of the symptoms. There were no complications in any of the patients after injections.
Conclusion: Fluoroscopic and electrical stimulation guided selective nerve root injections of corticosteroids were an effective and safe treatment modality in cervical radiculopathy. These could be considered as a first line treatment before a surgical intervention in whom another conservative treatments are not effective.
Objective: To determine if stretching the sciatic nerve in control and patients with lumbosacral radiculopathy significantly alters F-wave parameters.
Method: We studied F-waves in the deep peroneal & posterior tibial nerves of 20 patients with unilateral lumbosacral radiculopathies and 22 controls. F-waves were recorded bilaterally in the neutral position and supine in 30o & 60o straight leg raising (SLR). F-wave parameters included minimal latency (F min), maximal latency (F max), mean latency (F mean), latency difference between F min and F max (chronodispersion), mean duration (F dur) and side to side difference in F min, F max, F mean and F dur.
Results: In controls, the F-wave latency was found to be longer in supine with SLR than in neutral position. In patients with lumbosacral radiculopathy, significant differences of F max, F mean and F dur between sides during 30o SLR were noted in the deep peroneal nerves, but all parameters in the posterior tibial nerves during SLR were not changed.
Conclusion: In this study, we observed significant changes in F-wave latency in control during straight leg raising, but no significant changes in patients with lumbosacral radiculopathy. For the clinical application to lumbosacral radiculopathy, further study is needed.
Objective: To explore the clinical value of postoperative follow-up examination of F-wave and H-reflex in patients with lumbosacral radiculopathy and to clarify optimal timing of follow-up examination.
Method: The subjects were 17 patients with unilateral lumbosacral radiculopathy caused by disc herniation. In patients with the L5 radiculopathy, F-waves were obtained from extensor digitorum brevis and six parameters including minimal latency per height were used. In patients with the S1 radiculopathy, H-reflexes were obtained from gastrocnemius and amplitude and minimal latency were used as parameters. These parameters were evaluated preoperatively and postoperatively at week 1, 3, 6. These changes of the parameters and clinical findings were related.
Results: The parameters of peroneal F-wave and tibial H-reflex showed significant improvement at 3 weeks and 6 weeks after surgery. The improvements of these parameters were not related with clinical improvement at 1 week after operation, but these were significantly related with improvement of pain and muscle weakness at 3 weeks after operation.
Conclusion: These findings suggested that follow-up examination of F-wave and H-reflex were valuable for objective assessment of lumbosacral radiculopathy after operation and the optimal timing for follow-up study was 3 weeks after operation.
Objective: The purpose of this study was to examine the sensitivity and characteristics of F-wave abnormalities detected by various parameters in patients with lumbosacral radiculopathies and to evaluate the relationship of F-wave with needle EMG.
Method: The study was performed on 37 patients with lumbosacral disc herniation, which was confirmed by MRI and the patients with clinical lumbosacral radiculopathies (single lesion of L5 in 28 cases, S1 in 1 case, double lesion of L5 and S1 in 8 cases). F-waves were recorded by stimulating peroneal and tibial nerves at the ankle. Minimal latency (F min), maximal latency (F max), latency difference between F min and F max (F dif), mean duration (F dur) and side to side difference between sides in F min and F max were measured. Conventional nerve conduction study and needle EMG were also examined.
Results: The abnormal parameters of F-wave were so varied that the results could not lead any apparent conclusions as to which parameters were the most sensitive. However, F min and F dur seemed to be abnormal more frequently than F max and F dif. While the needle EMG showed abnormalities in 28 patients (75.7%), at least one of the different F-wave parameters was found to be abnormal in 18 patients (48.6%). Moreover, no significant relationship was observed between the abnormal findings of EMG and F-wave (p＞0.05).
Conclusion: The conventional needle EMG appears to be the more useful electrophysiological technique in the diagnosis of lumbosacral radiculopathies. Concerning the additional usefulness of F-wave, further study will be necessary.
Objective: To find the developing features of H reflex by the gradual increase of stimulation intensity, to evaluate the variability of each H reflex latency, and to verify the consistency of the side-to-side difference of bilateral H reflex latencies in normal population.
Method: Fifty normal persons (100 limbs) were studied. H reflexes were elicited using standardized technique from Braddom and Johnson.
Result: H reflex developed in the stimulation intensity at which M response was not evoked in 46 of total 100 limbs. The latency difference between the longest and shortest in each ipsilateral evoked potential was 0∼2.1 ms (mean 0.65±0.44 ms). In the side-to-side latency difference between the variously evoked H waves, the mean value of maximal one was 1.28±0.63 ms (0.4∼2.6 ms), and the mean value of the minimal one was 0.24±0.35 ms (0∼1.5 ms). The mean side-to-side latency difference between the H waves of maximal amplitudes was 0.69±0.46 ms (0.1∼1.6 ms), and the mean side-to-side difference between the shortest latencies was 0.61±0.53 ms (0∼2.1 ms). Among these findings the latency difference of the maximal amplitude was observed in 47 cases with 0∼1.5 ms, in 3 cases with more than 1.5 ms.
Conclusion: In diagnosing the S1 radiculopathy with the side-to-side latency difference it will be reasonable to use the latency of maximal amplitude or the shortest latency as diagnostic tool, and reevaluation will be needed with the diagnostic criteria of 1.5 ms latency difference.
Although diabetic thoracic radiculopathy (also called thoracoabdominal or truncal neuropathy) is now a well-recognized form of diabetic neuropathy, abdominal pain caused by diabetic thoracic radiculopathy is uncommon. We report a case of diabetic thoracic radiculopathy who had extensive gastrointestinal studies because of the upper abdominal pain as an unusual presenting symptom. EMG findings and the therapeutic response are also discussed.
Objectives: To determine the effect of facilitation on H reflex side-to-side amplitude ratio and to determine the effect of averaging under the assumption that an averaging could further stabilize the amplitude ratio in a facilitated condition.
Method: FCR H reflex amplitude ratios of direct and averaged potentials were measured in fifty asymptomatic subjects under three conditions, during rest, during a constant 5 pound isometric contraction under the hand-dynamometer monitoring, and during a moderate constant isometric contraction under the electromyographer's verbal guidance.
Results: The lower limits of the amplitude ratios that encompass 97.5% of subjects by the percentile method under three conditions were as follows; (1) during the rest (n=37); 0.47 (direct) and 0.50 (average), (2) during the constant 5 pound isometric contraction under the hand- dynamometer monitoring; 0.47 (direct) and 0.48 (average), and (3) during the moderate constant isometric contraction under the electromyographer's verbal guidance; 0.48 (direct) and 0.46 (average), respectively.
Conclusion: There seems to be no definite effect of facilitation and averaging on H reflex amplitude ratio. H reflex amplitude ratio measured in facilitated condition without averaging is still useful for the diagnosis of unilateral radiculopathy.
Objective: To evaluate the diagnostic values of segmental somatosensory evoked potentials (SEPs) in the unilevel/unilateral lumbosacral radiculopathies.
Method: Thirty-nine radiculopathy patients of whom diagnosis was confirmed by the surgery or selective nerve root injection and 20 subjects with no evidence of radiculopathy were included in the study. Before the treatment, superficial peroneal nerve segmental SEPs and sural nerve segmental SEPs were performed. Sensitivities and specificities were delineated from the several diagnostic criteria.
Results: The analysis of side-to-side mean cortical P1 latency difference (＞2.0 SD) reveals a segmental SEPs sensitivity for L5 radiculopathies of 12.1% and sensitivity for S1 radiculopathies of 0%. The analysis of side-to-side mean percent amplitude difference (2.0 SD) reveals a segmental SEPs sensitivity for L5 radiculopathies of 9.1% and sensitivity for S1 radiculopathies of 0%. The analysis of side-to-side mean cortical P1 latency difference (＞3 ms) and the side-to-side mean amplitude reduction (＞50%) show the similar results. The specificities of L5 radiculopathies and S1 radiculopathies are variable from 40.0% to 93.3%. Sensitivities of segmental SEPs are lower than needle EMG. It is not root specific, even the SEP is not obtainable unilaterally.
Conclusion: The diagnostic values of segmental somatosensory SEPs are questionable in the unilevel/unilateral lumbosacral radiculopathies which are confirmed by the surgery or selective nerve root injection.
Objective: To increase the accuracy and consistency in determining the level of radiculopathy by a needle electromyography (EMG) of multifidus muscle.
Method: We performed the EMGs on 29 patients with a low back pain to investigate an evidence of radiculopathy. All patients had the herniated nucleus pulposus (HNP) by a myelography, CT or MRI. The exclusion criteria were the patients with a scoliosis, spondylolisthesis or history of back surgery. We examined 5 points (P 1∼5) of the lumbosacral paraspinal muscles according to the paraspinal mapping by Haig et al and scored from 0∼4 according to the degree of abnormalities. The scores according to the points were correlated with the segments of radiculopathy and the levels of HNP.
Result: The maximal mean scores were 1.80⁑0.83 at P2 and 2.00⁑1.41 at P3 in a lumbar (L) 3, 4 radiculopathy, 2.00⁑0.56 at P5 in a L5 radiculopathy, and 2.13⁑0.64 at P4 and 2.63⁑0.51 at P5 in a S1 radiculopathy. The sensitivity/specificity was high at P2, P3 in a L3, 4 radiculopathy, at P4 in a L5 radiculopathy, at P5 in a S1 radiculopathy.
Conclusion: The results suggest that the localization of lumbosacral radiculopathy by a needle EMG of multifidus muscles provides an easy accessibility, better accuracy and consistency to determine the level of radiculopathy.
Objective: To compare the diagnostic significance of H reflex and somatosensory evoked potential(SEP) in the diagnosis of S1 radiculopathy, and to explore the possible interpretations on the discrepancies of the test results.
Method: Twenty-eight patients who were diagnosed as a S1 radiculopathy by the clinical and radiological correlations, and thirty-five controls with no evidence of S1 radiculopathy by the clinical or radiological studies were studied by the H reflex, sural SEP, and needle electromyography.
Results: The sensitivity of H reflex study was 64% for the S1 radiculopathy, and the specificity was 86%. The sensitivity and the specificity of the sural SEP study for the S1 radiculopathy were 50% and 80% respectively. Within 1 month from the onset, the sensitivity of H reflex increased to 75%. The needle electromyography showed 19% for the sensitivity and 100% for the specificity. The probability of the S1 radiculopathy was 70% in 10 cases who had the abnormal H reflex and normal SEP values and 36% in 8 cases who had the normal H reflex and abnormal SEP values.
Conclusion: H reflex study was the most sensitive test in the electrodiagnosis of the S1 radiculopathy and the electrodiagnostic significance of sural SEP was obscure.
The F wave has been thought to be useful in assessing the proximal neuropathy such as radiculopathy. However the sensitivity of F wave in radiculopathy is varying from 18% to 65%. The aim of this study is to compare the relative diagnostic value of 20 averaging technique and 20 sequential stimulation technique in recording the F waves and to determine the usefulness of F wave for the evaluation of radiculopathy.
Animals employed were rabbits that were divided into a study group of 17 rabbits(31 legs) and control group of 14 rabbits(25 legs). In the study group, the sciatic nerve was exposed after the dissection of gluteus maximus muscle and the nerve trunk was traced up to reach the spinal canal level. One of the two nerve roots composing the sciatic nerve was dissected randomly. F wave parameters were measured using both of 20 averaging technique and 20 sequential stimulation technique.
The parameters which showed significant change after the root dissection were the amplitude by employing 20 electronic averaging technique, and mean latency, minimal latency, mean amplitude by employing 20 sequential stimulation technique.
We concluded that 20 electronic averaging technique had no benefit over the 20 sequential stimulation technique and F wave measurement was not useful for the electrodiagnosis of radiculopathy because of the wide range of control values.
The purposes of this study were to verify the effect of selective nerve root injection for sciatica caused by lumbosacral radiculopathy and to compare the difference of the therapeutic effects with the various clinical parameters and the morphologic types of herniated intervertebral disc on MRI finding.
Forty-two patients, 14 males and 28 females, with an average age of 51 years (range, 26∼71) and an average duration of symptoms of 17.8 months (range, 1∼120) presenting with sciatica thought to be due to lumbosacral nerve root compromise were admitted to the study. All of the patients underwent clinical examination and lumbosacral MRI. Epiradicular infiltration of corticosteroids and local anesthetics by the transforaminal route under the image intensifier was done as a treatment. All the patients were followed up at 2 weeks and 3 months after the injection.
A high proportion of patients made a satisfactory relief of sciatica with a selective nerve root injection at 2 weeks (85.7%) and 3 months (76.2%) follow-up. Among the patients who showed a significant symptom relief at 3 months, 12 patients were followed up and the relieved symptoms lasted for 6 months to 1 year in majority of those patients. In a few patients with clinical improvements at 2 weeks after the injection, the symptoms recurred at 3 months (9/36, 25%) and between 6 months to 1 year (3/12, 25%). There were no differences of the therapeutic effects according to the duration of the disease, neurologic findings on physical examination and the MRI findings of herniated intervertebral discs.
The selective nerve root injection can be an effective therapeutic modality for the treatment of sciatica in lumbosacral radiculopathy.
In this study, we measured the intervertebral foramina on the plain radiographs of cervical spine of fifty three patients who were over forty-year-old, and with single or multiple unilateral cervical radiculopathies on EMG. In order to determine if the foraminal stenosis on plain radiographs can determine the presense of radiculopathy, four parameters such as vertical diameter, mid-transverse diameter, inferior transverse diameter, and area were measured by a digital caliberator(CD-15C, Mitutoyo, Japan) and an image analyzer(VIDAS 2.0, Kontron, Germany) in 194 foramina of both sides(affected and unaffected groups). Another 80 foramina were also measured as control group in ten age-matched patients who did not show any abnormality on EMG.
In control group, C4/5 intervertebral foramen showed maximal values of the parameters among foramina, with vertical diameter of 10.55⁑0.35 mm(mean⁑S.D.), mid-transverse diameter of 6.22⁑0.33 mm, inferior transverse diameter of 5.09⁑0.19 mm and area of 0.77⁑0.05 cm2. The minimal values were noted in C6/7 foramen except those of the vertical diameter which were noted in C4/5 foramen. The mid-transverse diameter and area of C7/T1 intervertebral foramen of affected group were significantly smaller than those of control and unaffected groups(p＜0.05). The other values in affected group were also smaller among the groups but they did not reach statistical significance.
In conclusion, the mid-transverse diameter and area of intervertebral foramen on plain cervical radiographs are somewhat useful to determine the encroachment of nerve root within the intervertebral foramen, especially in the lower cervical spine, in patients with cervical radiculopathy.
Widespread neurological disorders following herpes zoster are rare. These include radiculopathy, myelitis, contralateral hemiparesis, encephalitis and postherpetic neuralgia. Herpes zoster can be easily diagnosed by the appearance of the vesicular eruption following a dermatomal distribution, and the associated radiculopathy can be confirmed by electromyography. We present clinical symptoms, signs and electrodiagnostic findings of two cases of radiculopathy related to herpes zoster infection.
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