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Cervical Multifidus Muscle Atrophy in Patients with Unilateral Cervical Radiculopathy

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Cervical Multifidus Muscle Atrophy in Patients with Unilateral Cervical Radiculopathy J Korean Acad Rehab Med 2010; 34: 743-751 Original Article Cervical Multifidus Muscle Atrophy in Patients with Unilateral Cervical Radiculopathy Sang Han Chae, M.D.1, Seong Jae Lee, M.D., Ph.D.1, Min Seok Kim, M.D.1, Tae Uk Kim, M.D.1, Jung Keun Hyun, M.D., Ph.D.1,2,3 Departments of 1Rehabilitation Medicine, College of Medicine, 2Nanobiomedical Science and WCU Research Center of Nanobiomedical Science, 3Institute of Tissue Regeneration Engineering (ITREN), Dankook University, Cheoan 330-715, Korea Objective To assess the atrophy of cervical multifidus muscles in patients with unilateral cervical disc herniation or radiculopathy quantitatively and to investigate whether asymmetric muscle atrophy has the relationship with the severity of cervical disc herniation or radiculopathy. 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. Key Words Cervical radiculopathy, Cross-sectional area, Multifidus muscle, Electrodiagnosis, Magnetic resonance imaging INTRODUCTION es of neck pain include various lesions and trauma, such as cervical radiculopathy, myofascial pain syn- Neck pain is a very common symptom from which drome, and whiplash injury; however, cervical para- two of three people suffer during their lifetime,1 with spinal muscle weakness can also be a cause of neck more frequent occurrence in office workers.2 The caus- pain because cervical muscle weakness has been re- Received April 22, 2010; Accepted August 26, 2010 Corresponding author: Jung Keun Hyun Department of Nanobiomedical Science, Dankook University, San 16-5 Anseo-dong, Dongnam-gu, Cheonan 330-715, Korea Tel: +82-41-550-6640, Fax: +82-41-551-7062, E-mail: [email protected] Copyright © 2010. Korean Academy of Rehabilitation Medicine Sang Han Chae, et al. ported in patients with neck pain3 and strengthening signs suspicious of unilateral cervical radiculopathy by exercises of the neck could reduce neck pain.2,4 Cervical physiatrists in the department of rehabilitation medicine paraspinal muscle weakness may lead to cervical in- in Dankook University Hospital and diagnosed with cer- stability because critical load of osteoligamentous struc- vical disc herniation from the C4-5 to C7-T1 levels ture in the cervical spine has been reported in only through MRI were selected. This research was per- about 20% of the weight of head5 and the paraspinal formed in accordance with a research protocol ap- muscles surrounding the cervical region support the proved by the Institutional Review Board of Dankook rest of its weight. University and agreement forms were received from all Cervical paraspinal muscles are innervated by cer- subjects. Exclusion criteria included bilateral symptoms, vical roots; therefore, cervical radiculopathy can lead to signs or electrophysiologic findings, spinal fracture, spi- cervical paraspinal muscle atrophy. Using contrast-en- nal tumors or previous cervical spine operation affect- hanced magnetic resonance imaging (MRI), Hayashi et ing cervical paraspinal muscle abnormalities, and poly- al. reported that abnormal findings in unilateral para- neuropathy or peripheral nerve lesions affecting electro- spinal muscles were observed in patients with unilat- physiologic abnormalities. We also evaluated 26 normal eral cervical root avulsion injury.6 Atrophy or fatty in- controls, who had no clinical symptoms or signs and filtration of paraspinal muscles can be detected and no disc herniation in MRI for detection of a normal quantified using MRI and analysis software, and several range of cervical paraspinal and multifidus muscles. researchers have reported these findings in patients All subjects underwent cervical MRI and patients were with whiplash injury and chronic tension-type headache.7-9 also evaluated by electrophysiologic study using an elec- However, no study has reported on unilateral atrophy trodiagnostic machine (Medelec Synergy, Oxford Instru- in cervical paraspinal or multifidus muscles in cervical ments Medical, Inc., Oxfordshire, U.K). Electrodiagnostic radiculopathy and the relationships between unilateral criterion for cervical radiculopathy was the detection of muscle atrophy and cervical disc herniation or cervical abnormal spontaneous activities at rest in unilateral radiculopathy. cervical paraspinal muscles and/or involved upper ex- Therefore, this study was designed prospectively to tremity muscles, and this criterion was the same as delineate the atrophy of cervical multifidus muscles in that used in our previous study.10 We then divided pa- patients with unilateral cervical disc herniation or radi- tients into 2 groups: patients with unilateral cervical culopathy quantitatively and to investigate the question radiculopathy in electrodiagnosis (n=11; RAD) and pa- of whether asymmetric muscle atrophy has a relation- tients without definite radiculopathy (n=13; HIVD). ship with the severity of cervical disc herniation or There was no statistical difference in gender between radiculopathy. controls and patients (p=0.053); however, the number of females in the control group was greater than that in the patient groups. Mean ages in the control and the MATERIALS AND METHODS HIVD and RAD groups were 40.42 years, 47.25 years, and 54.88 years, respectively; therefore, the age in the Subjects RAD group was older than those in the control and Twenty four patients who had clinical symptoms and HIVD groups (Table 1). The symptom duration was de- Table 1. Characteristics of Subjects Controls HIVD RAD Total patients Number of subjects 26 13 11 24 Age (years) 40.42±12.51 47.25±11.30 54.88±12.47* 49.80±12.00 Gender (M：F) 11：15 9：49：218：6 Symptom duration (months) − 7.32±8.90 4.75±7.59 6.19±8.20 Values indicate numbers or mean±standard deviation. HIVD: Patients with cervical disc herniation in MRI but no radiculopathy in electrodiagnosis, RAD: Patients with cervical disc herniation in MRI and unilateral radiculopathy in electrodiagnosis *p＜0.05 from the control group by one-way ANOVA with Bonferroni post hoc test 744 Cervical Multifidus Muscle Atrophy in Unilateral Cervical Radiculopathy fined as the duration from the onset of clinical symp- were blinded to the subject’s clinical information, and toms or signs of suspicious unilateral cervical radiculop- the average of two values between the smallest and athy to the date in which patients received cervical largest values at each side in each level was used for MRI, and there was no difference of symptom duration quantitative analysis. between the HIVD and RAD groups (Table 1). Statistics Methods Statistical analysis was performed using SPSS 14.0 for MRI study was conducted on a 1.5 tesla MR scanner Windows. One-way analysis of variance and Bonferroni (Genesis-Signa Twin Speed, General Electric, Milwaukee, post hoc test were used for comparison of ages of con- WI, USA), and a T1-weighted fast spin-echo sequence trols and patients; chi-square test was used for com- was used. Axial images (Field of view=160 mm, TR= parison of gender in controls and patients, and in- 500 msec, TE=11 msec, flip angle α=90o, Section thick- dependent t-test was performed for comparison of the ness=3.0 mm, Matrix size=256×224) in four levels: C4-5, symptom duration between the HIVD and RAD groups. C5-6, C6-7, and C7-T1 were obtained and cross-sectional Kolmogorov-Smirnov test and Shapiro-Wilk test were areas on both sides at each level were measured using performed in order to reveal the normal distribution of an image analysis program (Rapidia analysis program, age, TMA, and PMA in controls and patients. Range of Infinitt, Seoul, Korea). At each level, images providing normal values of quantitative parameters in each level the best identification of both multifidus muscles were was determined within 2 standard deviations of the chosen among 2 or more slices at cervical disc levels. mean value or minimal value according to the optimal The Cross-sectional area (CSA) of each multifidus mus- sensitivity and specificity using ROC curves. cle was drawn manually using a mouse and a fat com- One-way analysis of variance and Bonferroni post hoc ponent in multifidus muscles was separated by the test were also performed for comparison of quantitative threshold technique based on visual differences in pixel parameters in each level from controls and the HIVD signal intensities (Fig. 1). and RAD groups, and Fisher’s exact test was performed Five parameters were used for quantitative analysis for comparison of numbers of abnormal cases in the of multifidus muscles; total muscle CSA (TMA), pure HIVD and RAD groups at each level and quantitative muscle CSA (PMA), which eliminates fat infiltration from parameters at three parts according to lesions found in TMA, ratio of PMA to TMA (PMA/TMA), ratio of TMA MRI or electrodiagnosis.
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