EVALUATINGEVALUATING THETHE PATIENTPATIENT WITHWITH SUSPECTEDSUSPECTED RADICULOPATHYRADICULOPATHY
Timothy R. Dillingham, M.D., M.S Professor and Chair, Department of Physical Medicine and Rehabilitation The Medical College of Wisconsin. RadiculopathiesRadiculopathies
PathophysiologicalPathophysiological processesprocesses affectingaffecting thethe nervenerve rootsroots VeryVery commoncommon reasonreason forfor EDXEDX referralreferral CAUSESCAUSES OFOF RADICULOPATHYRADICULOPATHY HNPHNP RadiculiitisRadiculiitis SpinalSpinal StenosisStenosis SpondylolisthesisSpondylolisthesis InfectionInfection TumorTumor FacetFacet SynovialSynovial CystCyst Diseases:Diseases: Diabetes,Diabetes, AIDPAIDP MUSCULOSKELETALMUSCULOSKELETAL DISORDERSDISORDERS :: UPPERUPPER LIMBLIMB ShoulderShoulder BursitisBursitis LateralLateral EpicondylitisEpicondylitis DequervainsDequervains TriggerTrigger fingerfinger FibrositisFibrositis FibromyalgiaFibromyalgia // regionalregional painpain syndromesyndrome NEUROLOGICALNEUROLOGICAL CONDITIONSCONDITIONS MIMICKINGMIMICKING CERVICALCERVICAL RADICULOPATHYRADICULOPATHY
Entrapment/CompressionEntrapment/Compression neuropathiesneuropathies –– Median,Median, Radial,Radial, andand UlnarUlnar BrachialBrachial NeuritisNeuritis MultifocalMultifocal MotorMotor NeuropathyNeuropathy NeedNeed ExtensiveExtensive EDXEDX studystudy toto R/OR/O otherother conditionsconditions MUSCULOSKELETALMUSCULOSKELETAL DISORDERSDISORDERS :: LOWERLOWER LIMBLIMB HipHip arthritisarthritis TrochantericTrochanteric BursitisBursitis IlliotibialIlliotibial BandBand SyndromeSyndrome PatellofemoralPatellofemoral PainPain PesPes AnserinusAnserinus BursitisBursitis BakersBakers CystCyst PlantarPlantar FasciitisFasciitis MortonsMortons NeuromaNeuroma NEUROLOGICALNEUROLOGICAL CONDITIONSCONDITIONS MIMICKINGMIMICKING LSRLSR
DiabeticDiabetic AmyotrophyAmyotrophy MononeuropathiesMononeuropathies –– FemoralFemoral –– TibialTibial –– CommonCommon PeronealPeroneal NeedNeed ExtensiveExtensive EDXEDX studystudy AnatomyAnatomy ANATOMYANATOMY ANDAND IMPLICATIONSIMPLICATIONS SensorySensory (DRG)(DRG) inin thethe intervertebralintervertebral foramen,foramen, sparedspared withwith radiculopathiesradiculopathies PLL;PLL; predisposespredisposes toto posterolateralposterolateral HNPHNP CaudaCauda EquinaEquina –– SpinalSpinal cordcord endsends atat T11T11--L1L1 –– NerveNerve rootsroots extendingextending toto intervertebralintervertebral foramenforamen –– LesionLesion fromfrom T12T12 toto SacrumSacrum cancan produceproduce samesame EMGEMG findingsfindings MustMust knowknow brachialbrachial andand LL--SS plexusplexus andand musclemuscle innervationsinnervations Cauda Equina HistoryHistory andand PhysicalPhysical ExaminationExamination PHYSICALPHYSICAL EXAMEXAM
FocusedFocused NeuromuscularNeuromuscular –– AffectedAffected limblimb andand contralateralcontralateral –– IfIf NeckNeck symptomssymptoms--lowerlower limbslimbs toto looklook forfor myelopathymyelopathy –– CranialCranial nervesnerves-- ?CVA,?CVA, MG,MG, AIDPAIDP ReducedReduced ReflexesReflexes withwith AcuteAcute SpinalSpinal ShockShock ALGORITHMICALGORITHMIC APPROACHAPPROACH SymptomsSymptoms –– GeneralizedGeneralized (2(2 oror moremore limbs)limbs) –– FocalFocal (single(single limb)limb) SignsSigns –– SensorySensory lossloss –– WeaknessWeakness –– ReflexesReflexes NotNot perfectperfect taxonomytaxonomy-- RadicsRadics andand EntrapmentsEntrapments Patient Presentation (Pain, Weakness, Gait disturbance, Sensory Symptoms, Paresthesias)
No sensory loss on Exam Sensory loss on Exam
Generalized Focal Symptoms Generalized Focal Symptoms Symptoms Symptoms (With Weakness)
–MMN Reduced Reflexes –Entrapment –Radiculopathy –Polyneuropathy –Radiculopathy –Entrapment Neuropathy –Bilateral CR –Mononeuropathy –Plexopathy –Bilateral LSR –Motor Neuron –Musculoskelatal disorder –Mononeuropathy –Cauda equina Syndr. Disease –Myofascial pain syndrome –Myopathy –Neuromuscular Junction Disorder Increased Reflexes –Cervical Myelopathy Generalized Symptoms –Thoracic Myelopahty (No Weakness) –Multiple Sclerosis –Fibrositis –Other Myelopathies –Polymyalgia Rheumatica SymptomsSymptoms andand EDXEDX StudyStudy OutcomeOutcome forfor UpperUpper LimbLimb andand LowerLower LimbLimb StudiesStudies Lauder et al 2000 AJPMR
SymptomsSymptoms hadhad lowlow sensitivitiessensitivities LowLow specificitiesspecificities NonNon--significantsignificant OddsOdds RatiosRatios PHYSICALPHYSICAL EXAMEXAM FINDINGSFINDINGS
Weakness,Weakness, reflexreflex change,change, oror sensorysensory lossloss inin thethe legleg –– 33--66 timestimes thethe probabilityprobability ofof havinghaving aa positivepositive studystudy ((Lauder et al, 2000 AJPMR) – 3-14 times the probability of having an electrodiagnostically confirmed radiculopathy (Lauder et al, 2000 AJPMR) PHYSICALPHYSICAL EXAMEXAM FINDINGSFINDINGS
Weakness,Weakness, reflexreflex change,change, oror sensorysensory lossloss inin thethe armarm –– 44--55 timestimes thethe probabilityprobability ofof havinghaving aa positivepositive studystudy ((Lauder et al, 2000 Arch PMR) – 2-9 times the probability of having an electrodiagnostically confirmed CR (Lauder et al, 2000 Arch PMR) ElectrodiagnosisElectrodiagnosis ElectrodiagnosticElectrodiagnostic StudiesStudies
NerveNerve ConductionConduction StudiesStudies SSEPsSSEPs FF waveswaves andand HH reflexesreflexes EMGEMG AAEMAAEM GUIDELINESGUIDELINES 19991999 MuscleMuscle andand NerveNerve ExamineExamine musclesmuscles representingrepresenting allall myotomesmyotomes PSMPSM localizelocalize lesionlesion toto rootroot levellevel OneOne motormotor andand oneone sensorysensory NCSNCS ELECTRODIAGNOSTICELECTRODIAGNOSTIC TESTINGTESTING PerformPerform thethe basicbasic teststests relatedrelated toto suspectedsuspected conditioncondition AdjustAdjust andand modifymodify studystudy asas datadata areare acquiredacquired MayMay needneed serialserial studiesstudies LowLow thresholdthreshold toto studystudy contralateralcontralateral limblimb oror upperupper (lower)(lower) limblimb USEFULLNESSUSEFULLNESS OFOF ELECTRODIAGNOSISELECTRODIAGNOSIS ConfirmConfirm clinicalclinical suspicionsuspicion RaiseRaise otherother unsuspectedunsuspected diagnosticdiagnostic possibilitiespossibilities ExcludeExclude entitiesentities onon thethe differentialdifferential diagnosisdiagnosis IdentifyIdentify regionregion toto imageimage TailorsTailors otherother diagnosticdiagnostic testingtesting NerveNerve ConductionConduction StudiesStudies
SensorySensory NCSNCS shouldshould bebe normalnormal MotorMotor NCSNCS shouldshould bebe normalnormal –– SometimesSometimes lowlow amplitudeamplitude withwith severesevere diseasedisease FF--WAVESWAVES MotorMotor axonsaxons andand axonalaxonal poolpool atat spinalspinal cordcord levellevel longlong pathwayspathways differentdifferent axonsaxons involvedinvolved withwith eacheach responseresponse MinimalMinimal latencylatency,, meanmean latency,latency, dispersiondispersion InconsistentInconsistent morphologymorphology andand latencylatency MaximalMaximal stimulusstimulus responseresponse NotNot helpfulhelpful forfor radiculopathy,radiculopathy, goodgood screenscreen forfor polyneuropathypolyneuropathy HH--REFLEXESREFLEXES MonosynapticMonosynaptic electricalelectrical AchillesAchilles reflexreflex LongLong pathwaypathway AbnormalAbnormal inin sciaticsciatic n.n. plexopathy,plexopathy, S1S1 radicradic SubmaximalSubmaximal stimulusstimulus responseresponse ConsistentConsistent inin latencylatency andand morphologymorphology ExtinguishesExtinguishes withwith supramaximalsupramaximal stimulusstimulus OnlyOnly 50%50% sensitivesensitive forfor S1S1 radiculopathyradiculopathy butbut highhigh specificityspecificity 91%91% MayMay helphelp withwith L5L5 vsvs S1S1 BetterBetter screenscreen forfor polyneuropathypolyneuropathy ElectromyographyElectromyography
MostMost importantimportant testtest forfor suspectedsuspected radiculopathyradiculopathy GoodGood confirmatoryconfirmatory testtest HelpsHelps clarifyclarify relevancerelevance ofof imagingimaging findingsfindings EDXEDX CRITERIACRITERIA FORFOR RADICULOPATHYRADICULOPATHY AbnormalitiesAbnormalities inin 22 oror moremore musclesmuscles –– SameSame nervenerve rootroot –– DifferentDifferent peripheralperipheral nervesnerves MuscleMuscle innervatedinnervated byby adjacentadjacent nervenerve rootsroots areare normalnormal OtherOther conditionsconditions areare excludedexcluded EMGEMG SENSITIVITIESSENSITIVITIES FORFOR LUMBOSACRALLUMBOSACRAL RADICULOPATHIESRADICULOPATHIES VariesVaries widelywidely RangesRanges fromfrom aboutabout 50%50% toto 80%80% VariousVarious diagnosticdiagnostic standardsstandards Study Sample Gold standard EMG size sensitivity %
Lumbosacral radiculopathy Clinical+imaging HNP Weber and Albert [55] 42 60 Clinical Nardin et al [28] 47 55 Clinical Kuruoglu et al [8] 100 86 Clinical Khatri et al [56] 95 64 Clinical Tonzola et al [57] 57 49 Surgically proven Schoendinger [58] 100 56 Surgically proven Knutsson [45] 206 79 Clinical an imaging Young et al [3] 100 84 Myelography and CT Linden and Berlit [3] 19 78 EMGEMG SENSITIVITYSENSITIVITY FORFOR CERVICALCERVICAL RADICULOPATHIESRADICULOPATHIES
VariesVaries widelywidely AboutAbout 50%50% toto 70%70% UsuallyUsually clinicalclinical and/orand/or myelographicmyelographic Study Sample Gold standard EMG size sensitivity % Lumbosacral spinal stenosis 68 Clinical+myelogram 92 Hall et al [46] 64 Clinical+myelogram 88 Johnsson et al [59] Cervical radiculopathy Berger et al [60] 18 Clinical 61 Partanen et al [61] 77 Intraoperative 67 Leblhuber et al [9] 24 Clinical+myelogram 67 So et al [62] 14 Clinical 71 Yiannikas et al [18] 20 Clinical/radiographic 50 Tackman and Radu [15] 20 Clinical 95 Hong et al [63] 108 Clinical 51 LUMBARLUMBAR SPINALSPINAL STENOSISSTENOSIS
EMGEMG findingsfindings areare lessless wellwell studiedstudied thanthan forfor singlesingle levellevel radiculopathiesradiculopathies ClinicalClinical entityentity withwith variousvarious clinicalclinical presentationspresentations ImagingImaging isis vital,vital, butbut hashas gradationsgradations ofof severityseverity –– DynamicDynamic aspectsaspects ofof spinalspinal canal,canal, narrownarrow withwith extensionextension –– BoneyBoney spursspurs ++ facetfacet hypertrophyhypertrophy ++ ligamentligament hypertrophyhypertrophy ++ HNPHNP EMGEMG inin LumbosacralLumbosacral SpinalSpinal StenosisStenosis HallHall andand ColleaguesColleagues (1985)(1985) 6868 patientspatients--myelographicallymyelographically proven/surgicallyproven/surgically confirmedconfirmed LumbarLumbar stenosis.stenosis. PseudoclaudicationPseudoclaudication (94%)(94%) NumbnessNumbness (63%)(63%) WeaknessWeakness (43%)(43%) BilateralBilateral symptomssymptoms (68%)(68%) EMGEMG inin LumbosacralLumbosacral SpinalSpinal StenosisStenosis HallHall andand colleaguescolleagues (1985)(1985)--cont.cont. EMGEMG positivepositive inin 3434 ofof 3737 patientspatients studiedstudied –– 1111 bilateralbilateral EMGEMG findingsfindings withwith paraspinalparaspinal fibsfibs –– 1717 bilateralbilateral EMGEMG findingsfindings withoutwithout paraspinalparaspinal fibrillationsfibrillations –– 66 showedshowed singlesingle rootroot EMGEMG findingsfindings (bilateral(bilateral inin 33 cases)cases) ParaspinalParaspinal findingsfindings oftenoften lackinglacking onon EMGEMG ““EMGEMG moremore helpfulhelpful thanthan physicalphysical examexam”” SPINAL STENOSIS vs POLYNEUROPATHY Adamova B, Vohanka S, Dusek L. Differential diagnostics in patients with mild lumbar spinal stenosis:the contributions and limits of various tests. Eur Spine J. 2003;12:190-196. DifficultDifficult DDxDDx ThreeThree groups:groups: –– 2929 personspersons withwith imagingimaging confirmedconfirmed clinicalclinical mildmild lumbarlumbar spinalspinal stenosis,stenosis, –– 2424 subjectssubjects hadhad diabeticdiabetic polyneuropathy,polyneuropathy, –– 2525 healthyhealthy ageage--matchedmatched volunteersvolunteers participatedparticipated SPINALSPINAL STENOSISSTENOSIS vsvs POLYNEUROPATHYPOLYNEUROPATHY SuralSural sensorysensory amplitudesamplitudes distinguisheddistinguished thethe diabeticdiabetic polyneuropathypolyneuropathy groupgroup –– 4.2microvolts4.2microvolts oror lessless waswas foundfound inin 47%47% ofof diabeticdiabetic patientspatients andand onlyonly 17%17% ofof stenosisstenosis patients).patients). UlnarUlnar FF wavewave waswas prolongedprolonged inin polyneuropathypolyneuropathy patientspatients RadialRadial SNAPSNAP waswas reducedreduced inin polyneuropathypolyneuropathy patients.patients. SensorySensory testingtesting andand FF--wavewave testingtesting inin thethe involvedinvolved extremityextremity andand anan upperupper limblimb AANEMAANEM (England et al: Muscle & Nerve 2005) ElectrodiagnosticElectrodiagnostic findingsfindings criticalcritical SuralSural sensorysensory andand peronealperoneal motormotor nervenerve conductionsconductions areare thethe mostmost sensitivesensitive forfor detectingdetecting aa distaldistal symmetricsymmetric polyneuropathypolyneuropathy WillWill notnot excludeexclude allall polyneuropathiespolyneuropathies.. CaseCase 1:1: ElderlyElderly patientpatient withwith chronicchronic lowlow backback pain,pain, rightright legleg painpain andand somesome numbnessnumbness inin bothboth feetfeet
SIXSIX MUSCLEMUSCLE SCREENSCREEN RIGHTRIGHT PeroneusPeroneus longus(L5longus(L5--S1)S1) NormalNormal VastusVastus MedMed (L3(L3--L4)L4) NormalNormal AnteriorAnterior TibialisTibialis (L4(L4--L5)L5) NormalNormal TFL(L5TFL(L5--S1)S1) NormalNormal MedialMedial gastrocgastroc (S1(S1--S2)S2) 2+2+ fibsfibs PSMPSM (Multiple(Multiple levels)levels) NormalNormal CaseCase 1:1: StudyStudy moremore musclesmuscles SIXSIX MUSCLEMUSCLE SCREENSCREEN PlusPlus RIGHTRIGHT PeroneusPeroneus longus(L5longus(L5--S1)S1) NormalNormal VastusVastus MedMed (L3(L3--L4)L4) NormalNormal GluteusGluteus Maximus(L5Maximus(L5--S1)S1) NormalNormal AnteriorAnterior TibialisTibialis (L4(L4--L5)L5) NormalNormal TFL(L5TFL(L5--S1)S1) NormalNormal FlexorFlexor DigitorumDigitorum BrevisBrevis (S1(S1-- 2+2+ fibsfibs S2)S2) FootFoot musclemuscle MedialMedial gastrocgastroc (S1(S1--S2)S2) 2+2+ fibsfibs PSMPSM (Multiple(Multiple levels)levels) NormalNormal CaseCase 1:1: StudyStudy moremore musclesmuscles SIXSIX MUSCLEMUSCLE SCREENSCREEN PlusPlus RightRight LeftLeft PeroneusPeroneus longus(L5longus(L5--S1)S1) NormalNormal NormalNormal VastusVastus MedMed (L3(L3--L4)L4) NormalNormal NormalNormal GluteusGluteus Maximus(L5Maximus(L5--S1)S1) NormalNormal AnteriorAnterior TibialisTibialis (L4(L4--L5)L5) NormalNormal NormalNormal TFL(L5TFL(L5--S1)S1) NormalNormal NormalNormal FlexorFlexor DigitorumDigitorum BrevisBrevis (S1(S1-- 2+2+ fibsfibs S2)S2) FootFoot musclemuscle MedialMedial gastrocgastroc (S1(S1--S2)S2) 2+2+ fibsfibs 2+2+ fibsfibs PSMPSM (Multiple(Multiple levels)levels) NormalNormal NormalNormal CaseCase 11
SuggestiveSuggestive ofof bilateralbilateral sciaticsciatic neuropathies,neuropathies, polyneuropathy,polyneuropathy, oror bilateralbilateral S1S1 radiculopathies.radiculopathies. RememberRemember thatthat PSMPSM inin lumbarlumbar SpinalSpinal stenosisstenosis maymay bebe normalnormal WhatWhat dodo youyou dodo toto sortsort thisthis out?out? CaseCase 11 NerveNerve conductionsconductions
SuralSural sensorysensory responsesresponses absentabsent bilaterally.bilaterally. InIn thisthis case:case: ––PolyneuropathyPolyneuropathy –– BilateralBilateral sciaticsciatic neuropathiesneuropathies –– unlikelyunlikely –– BilateralBilateral lumbosacrallumbosacral plexopathiesplexopathies –– unlikelyunlikely –– BilateralBilateral S1S1 radiculopathiesradiculopathies lessless likely.likely. WhatWhat else?else? CaseCase 11 MoreMore NCSNCS
PeronealPeroneal motormotor studiesstudies lowlow normalnormal CMAPCMAP EMGEMG ofof rightright FDIFDI (in(in hand)hand) waswas ++ forfor fibsfibs RadialRadial sensorysensory waswas lowlow inin amplitudeamplitude andand slightlyslightly prolongedprolonged inin latencylatency CaseCase 11 SummarySummary
AbnormalAbnormal study:study:
FindingsFindings suggest:suggest: –– MotorMotor andand sensorysensory primarilyprimarily axonalaxonal polyneuropathypolyneuropathy.. COMPARING SURGICAL AND EMG FINDINGS IN LSR TSAO, LEVIN AND BODNER Muscle and Nerve 2003
4545 patientspatients withwith imaging,imaging, EMGEMG andand surgicallysurgically confirmedconfirmed LSRLSR LittleLittle overlapoverlap betweenbetween L2L2--L4L4 ,, L5,L5, andand S1S1 RadiculopathiesRadiculopathies TibialisTibialis anterioranterior L5L5 GastrocnemiusGastrocnemius S1S1 BicepsBiceps S1S1 IDENTIFICATIONIDENTIFICATION
DifferentDifferent conceptconcept fromfrom SensitivitySensitivity ConditionalConditional probabilityprobability –– HowHow muchmuch testing,testing, givengiven thatthat EDXEDX testingtesting willwill identifyidentify aa disorderdisorder IfIf aa disorderdisorder cancan bebe confirmedconfirmed byby EDX,EDX, howhow muchmuch testingtesting isis necessarynecessary toto recognizerecognize thisthis possibilitypossibility CAVEATSCAVEATS ANDAND LIMITATIONSLIMITATIONS
NeedleNeedle EMGEMG isis notnot anan effectiveeffective screeningscreening testtest alonealone (Radiculopathy)(Radiculopathy) MRIMRI betterbetter screenscreen forfor structuralstructural causescauses BetterBetter specificityspecificity-- DiagnosisDiagnosis confirmationconfirmation MotorMotor AxonalAxonal lossloss necessarynecessary forfor fibsfibs RADICULOPATHIESRADICULOPATHIES
SomeSome cannotcannot bebe confirmedconfirmed byby EMGEMG –– SensorySensory rootsroots affectedaffected –– NoNo axonalaxonal lossloss NoNo amountamount ofof musclesmuscles willwill helphelp confirmconfirm NeedNeed toto abbreviateabbreviate studystudy inin thisthis scenarioscenario EnoughEnough musclesmuscles toto reachreach thisthis conclusionconclusion WhenWhen cancan aa needleneedle EMGEMG bebe stoppedstopped withwith aa confidenceconfidence thatthat therethere isis aa lowlow probabilityprobability ofof missingmissing aa confirmableconfirmable radiculopathyradiculopathy PROSPECTIVEPROSPECTIVE LSRLSR IDENTIFICATIONIDENTIFICATION Dillingham,Dillingham, etet al,al, AmJPM&RAmJPM&R,, 20002000 MulticenterMulticenter studystudy 102102 patientspatients withwith EDXEDX LSRLSR StandardStandard screenscreen withwith 1111 musclesmuscles FiveFive musclesmuscles withwith PSM:PSM: 9494--98%98% SixSix musclesmuscles withwith PSM:PSM: 9898--100%100% WithoutWithout PSMPSM eighteight muscles;muscles; 90%90% Six-muscle screen identification of patients with lumbosacral radiculopathies
Screen Neuropathic Spontaneous (%) Activity (%) Six muscles without paraspinals ATIB, PTIB, MGAS, RFEM, SHBF, LGAS 89 78 VMED, TFL, LGAS, PTIB, ADD, MGAS 83 70 VLAT, SHBF, LGAS, ADD, TFL, PTIB 79 62 ADD, TFL, MGAS, PTIB, ATIB, LGAS 88 79
Six muscles with paraspinals ATIB, PTIB, MGAS, PSM, VMED, TFL 99 93 VMED, LGAS, PTIB, PSM, SHBF, MGAS 99 87 VLAT, TFL, LGAS, PSM, ATIB, SHBF 98 87 ADD, MGAS, PTIB, PSM, VLAT, SHBF 99 89 VMED, ATIB, PTIB, PSM, SHBF, MGAS 100 92 VMED, TFL, LGAS, PSM, ATIB, PTIB 99 91 ADD, MGAS, PTIB, PSM, ATIB, SHBF 100 93 PROSPECTIVEPROSPECTIVE CERVICALCERVICAL RADICULOPATHYRADICULOPATHY IDENTIFICATIONIDENTIFICATION Dillingham,Dillingham, et.al,et.al, AmJPM&RAmJPM&R,, 20002000 MulticenterMulticenter--fivefive institutionsinstitutions StandardStandard ScreenScreen 101101 patientspatients withwith EDXEDX CRCR sixsix musclesmuscles withwith PSM:PSM: 9494--99%99% SevenSeven musclesmuscles withwith PSM:PSM: 9696--100%100% WithoutWithout PSM:PSM: eighteight musclesmuscles 9292--95%95% Six-muscle screen identifications of patients with cervical radiculopathies MuscleMuscle screenscreen Neuropathic % Spontaneous activity % Without paraspinals Delt, APB, FCU, triceps, PT, FCR 9393 6666 Bic, tric, FCU, EDC, FCR, FDI 8787 5555 Delt, tric, EDC, FDI, FCR, PT 8989 6464 Bic, tric, EDC, PT, APB, FCU 9494 6464 WithWith paraspinalsparaspinals Delt, tric, PT, APB, EDC, PSM 9999 8383 Bic, tric, EDC, FDI, FCU, PSM 9696 7575 Delt, EDC, FDI, PSM, FCU, tric 9494 7777 Bic, FCR, APB, PT, PSM, tric 9898 7979 ““ ToTo minimizeminimize harm,harm, sixsix inin thethe legleg andand sixsix inin thethe armarm”” Suspected Radiculopathy
–Six muscles (with PSM)-lumbar screen –Six muscles (with PSM)-cervical screen
If all muscles negative, stop If one muscle is positive, EMG exam in this limb expand study The patient will not have an Determine if EMG reflects; electrodiagnostically confirmable radiculopathy. 1) Radiculopathy (which level), They may; 2) Entrapment neuropathy, 1) not have radiculopathy, or 3) Generalized condition, or 4) Findings that are of uncertain 2) have a radiculopathy but you will not relevance. confirm this with EMG. Other diagnostic tests must be utilized such as MRI or SNRB. Case 2 Person with sciatica for two months. Normal strength, reflexes, and sensation, +SLR.
SIXSIX MUSCLEMUSCLE SCREENSCREEN FINDINGSFINDINGS VastusVastus Medialis(L3Medialis(L3--L4)L4) NormalNormal TibialisTibialis AnteriorAnterior (L4(L4--L5)L5) 2+2+ fibsfibs MedialMedial GastrocGastroc (S1(S1--S2)S2) NormalNormal SHSH ofof BicepsBiceps Femoris(L5Femoris(L5--S1)S1) NormalNormal TensorTensor FasciaFascia LataLata (L5(L5--S1)S1) NormalNormal LumbarLumbar PSMPSM (Multiple(Multiple roots)roots) 1+1+ fibsfibs Case 2 Additional muscles after Six muscle screen.
SIXSIX MUSCLESMUSCLES PLUSPLUS MOREMORE FINDINGSFINDINGS VastusVastus Medialis(L3Medialis(L3--L4)L4) NormalNormal AdductorAdductor LongusLongus (L3(L3--L4)L4) NormalNormal TibialisTibialis AnteriorAnterior (L4(L4--L5)L5) 2+2+ fibsfibs TibialisTibialis Posterior(L5Posterior(L5--S1)S1) 1+1+ fibsfibs MedialMedial GastrocGastroc (S1(S1--S2)S2) NormalNormal LateralLateral Gastroc(S1Gastroc(S1--S2)S2) NormalNormal SHSH ofof BicepsBiceps Femoris(L5Femoris(L5--S1)S1) NormalNormal TensorTensor FasciaFascia LataLata (L5(L5--S1)S1) NormalNormal LumbarLumbar PSMPSM (Multiple(Multiple roots)roots) 1+1+ fibsfibs CaseCase 22 ConclusionsConclusions
AbnormalAbnormal StudyStudy FinishFinish it;it; {sural S. and peroneal M. NCS were normal} FindingsFindings suggest:suggest: ––L5L5 lumbosacrallumbosacral radiculopathyradiculopathy withwith recentrecent (acute)(acute) motormotor axonalaxonal loss.loss. Recommendations:Recommendations: –– ConsiderConsider imagingimaging thethe lumbarlumbar spinespine ifif notnot alreadyalready pursued.pursued. CaseCase 3:3: 4949 y/oy/o withwith rightright armarm pain,proximalpain,proximal weakness,weakness, andand handhand numbnessnumbness forfor 33 months.months. 3/53/5 shouldershoulder abductionabduction andand ER,ER, otherwiseotherwise normalnormal strength,strength, reflexes,reflexes, sensationsensation
SIXSIX MUSCLEMUSCLE SCREENSCREEN RightRight sideside DeltoidDeltoid 3+3+ fibs,fibs, CRDCRD TricepsTriceps NormalNormal EDCEDC NormalNormal FDIFDI NormalNormal APBAPB NormalNormal CervicalCervical ParaspinalsParaspinals NormalNormal CaseCase 3:3: MoreMore EMGEMG SIXSIX MUSCLEMUSCLE SCREENSCREEN RightRight DeltoidDeltoid 3+3+ fibs,fibs, CRDCRD InfraspinatusInfraspinatus 2+2+ fibsfibs BicepsBiceps 2+2+ fibs,CRDfibs,CRD TricepsTriceps NormalNormal EDCEDC NormalNormal FDIFDI NormalNormal APBAPB NormalNormal CervicalCervical ParaspinalsParaspinals NormalNormal CaseCase 3:3: MoreMore EMGEMG SIXSIX MUSCLEMUSCLE SCREENSCREEN LeftLeft RightRight DeltoidDeltoid 3+3+ fibs,fibs, CRDCRD InfraspinatusInfraspinatus 2+2+ fibsfibs BicepsBiceps normalnormal 2+2+ fibs,CRDfibs,CRD TricepsTriceps NormalNormal NormalNormal EDCEDC NormalNormal NormalNormal FDIFDI NormalNormal NormalNormal APBAPB NormalNormal CervicalCervical ParaspinalsParaspinals NormalNormal NormalNormal AnteriorAnterior tibialistibialis NormalNormal NormalNormal CaseCase 33
NCSNCS ofof MedianMedian andand UlnarUlnar MotorMotor andand SensorySensory werewere normalnormal RadialRadial sensorysensory normalnormal LACLAC normalnormal NormalNormal rightright medianmedian FF--WaveWave CaseCase 3:3: SummarySummary
AbnormalAbnormal StudyStudy FindingsFindings suggest:suggest: –– RightRight UpperUpper TrunkTrunk BrachialBrachial PlexopathyPlexopathy OROR RightRight C5C5--C6C6 CervicalCervical RadiculopathyRadiculopathy
–– SuggestSuggest imagingimaging ofof bothboth thethe rightright brachialbrachial plexusplexus andand cervicalcervical spinespine LUMBOSACRALLUMBOSACRAL PSMPSM EMG:EMG: PREVALENCEPREVALENCE OFOF FIBRILLATIONSFIBRILLATIONS ININ NORMALSNORMALS DumitruDumitru,, Diaz,Diaz, andand KingKing (2001)(2001) ProspectiveProspective studystudy 5050 normalsnormals L4/L5L4/L5 levelslevels MonopolarMonopolar needle,needle, recordedrecorded potentialspotentials ExaminedExamined firingfiring raterate andand rhythmrhythm FibrillationFibrillation inclusioninclusion criteria;criteria; regularregular firingfiring raterate 4%4% falsefalse positivepositive fibrillationsfibrillations inin paraspinalparaspinal musclesmuscles CERVICALCERVICAL PSMPSM (Date et al Muscle &Nerve 2006) CervicalCervical PSMPSM inin assymptomaticassymptomatic personspersons C56C56 andand C67C67 areasareas BilaterallyBilaterally FourFour quadrantsquadrants MUSTMUST BEBE REGULARLYREGULARLY firingfiring forfor 1s1s oror moremore MonopolarMonopolar needleneedle 12%12% inin 6666 showedshowed PSWsPSWs nonenone showedshowed fibsfibs FALSEFALSE NEGATIVENEGATIVE (no(no fibsfibs oror PSW)PSW) ONON EMGEMG ININ RADICULOPATHYRADICULOPATHY
SensorySensory rootroot involvementinvolvement onlyonly MotorMotor rootroot involvementinvolvement withoutwithout axonalaxonal lossloss –– DemyelinationDemyelination,, conductionconduction blockblock MotorMotor axonalaxonal lossloss balancedbalanced withwith reinnervationreinnervation MUSCLEMUSCLE INJURYINJURY CAUSINGCAUSING FIBRILLATIONSFIBRILLATIONS PartanenPartanen etet alal 19821982 MuscleMuscle && NerveNerve StudyStudy ofof 4343 patientspatients withwith EMGEMG beforebefore andand afterafter MuscleMuscle biopsybiopsy 50%50% hadhad fibrillationsfibrillations 66--77 daysdays afterafter biopsybiopsy AtAt 1616 daysdays 100%100% hadhad fibrillationsfibrillations FibrillationsFibrillations persistedpersisted upup toto 1111 monthsmonths postpost biopsybiopsy SymptomSymptom DurationDuration isis notnot RelatedRelated toto FibrillationFibrillation PotentialsPotentials LongLong heldheld notionnotion inin thethe electrodiagnosticelectrodiagnostic literatureliterature regardingregarding radiculopathiesradiculopathies ParaspinalParaspinal (PSM)(PSM) musclesmuscles denervatedenervate first,first, thenthen moremore distaldistal ReinnervationReinnervation thoughtthought toto occuroccur firstfirst inin PSMPSM thenthen distaldistal NoNo evidenceevidence toto supportsupport thisthis modelmodel SYMPTOM DURATION AND EMG FIBRILLATIONS Dillingham et al, 1998, 1998, 2000; Pezzin et al 1999 FourFour separateseparate investigationsinvestigations –– TwoTwo retrospectiveretrospective (Cervical(Cervical andand Lumbosacral)Lumbosacral) –– TwoTwo prospectiveprospective (Cervical(Cervical andand Lumbosacral)Lumbosacral) ProbabilityProbability ofof findingfinding fibrillationsfibrillations inin aa musclemuscle (proximal(proximal oror distal)distal) waswas notnot relatedrelated toto symptomsymptom duration.duration. SimplisticSimplistic modelmodel ofof symptomsymptom durationduration doesndoesn’’tt explainexplain thethe complexcomplex pathophysiologypathophysiology ofof radiculopathiesradiculopathies andand theirtheir EMGEMG correlatescorrelates NaturalNatural HistoryHistory ofof RadiculopathyRadiculopathy RADICULOPATHIESRADICULOPATHIES
CervicalCervical radiculopathyradiculopathy inin absenceabsence ofof myelopathymyelopathy-- goodgood outcomesoutcomes withwith conservativeconservative carecare LumbosacralLumbosacral radiculopathy,radiculopathy, withoutwithout caudacauda equinaequina symptomssymptoms--goodgood outcomesoutcomes withwith conservativeconservative carecare CERVICALCERVICAL RADICULOPATHYRADICULOPATHY OUTCOMEOUTCOME
SaalSaal,, SaalSaal,, YurthYurth.. SpineSpine 19961996 ––2626 patientspatients withwith CervicalCervical HNPHNP ––TxTx:: PainPain meds,meds, cervicalcervical traction,traction, epiduralsepidurals ifif poorpoor painpain controlcontrol ––2424 ofof 2626 achievedachieved successfulsuccessful outcomesoutcomes PROGRESSION OF CERVICAL SPONDYLOTIC CORD COMPRESSION Bednarik et al Spine 2004 6666 patientspatients withwith MRIMRI mildmild cervicalcervical cordcord compressioncompression butbut nono signssigns ofof myelopathymyelopathy FollowedFollowed forfor 22 yearsyears 20%20% developeddeveloped signssigns ofof myelopathymyelopathy PROGRESSION OF CERVICAL SPONDYLOTIC CORD COMPRESSION Bednarik et al Spine 2004 SymptomaticSymptomatic cervicalcervical radiculopathyradiculopathy andand EMGEMG showingshowing motormotor axonalaxonal lossloss inin 22 myotomesmyotomes predictedpredicted withwith 90%90% accuracyaccuracy thosethose whowho progressedprogressed toto symptomaticsymptomatic myelopathymyelopathy.. OddsOdds ratioratio 12.512.5 (p<0.001)(p<0.001) forfor EMGEMG OddsOdds ratioratio 36.936.9 (p<0.001)for(p<0.001)for clinicalclinical radiculopathyradiculopathy (motor(motor oror sensorysensory signs)signs) BACKBACK SURGERYSURGERY RATESRATES ININ THETHE UNITEDUNITED STATESSTATES
CherkinCherkin etet al,al, SpineSpine 19941994 UnitedUnited StatesStates –– 55 timestimes thatthat ofof EnglandEngland –– IncreasedIncreased linearlylinearly withwith increasingincreasing numbernumber ofof surgeonssurgeons LUMBARLUMBAR DISCECTOMYDISCECTOMY PREDICTORSPREDICTORS OFOF OUTCOMESOUTCOMES
Spengler,Spengler, etet al,al, JBJSJBJS 19901990 DevelopedDeveloped scalescale forfor surgicalsurgical candidatecandidate selectionselection 100100 pointspoints ––NeurologicalNeurological SignsSigns (EMG)(EMG) (25)(25) ––SciaticSciatic TensionTension SignsSigns (25)(25) ––MMPIMMPI (25)(25) ––LumbarLumbar MyelogramMyelogram oror CTCT (25)(25) LumbarLumbar DiscectomyDiscectomy OutcomesOutcomes
SpenglerSpengler etet alal JBJSJBJS 19901990 ––PreoperativePreoperative assessmentassessment ofof probabilityprobability ofof goodgood outcomesoutcomes ––PatientsPatients withwith << 5050 points:points: NoNo surgerysurgery ––BestBest outcomesoutcomes areare >80>80 pointspoints NATURALNATURAL HISTORYHISTORY OFOF SCIATICASCIATICA BushBush etet al,al, SpineSpine 19921992 165165 patientspatients withwith SciaticaSciatica –– 86%86% mademade satisfactorysatisfactory recoveryrecovery –– 76%76% HNPsHNPs resolvedresolved onon f/uf/u MRIMRI TxTx consistedconsisted ofof painpain meds,meds, epiduralsepidurals ConclusionsConclusions
ElectrodiagnosisElectrodiagnosis importantimportant adjunctiveadjunctive andand confirmatoryconfirmatory testtest ExcludesExcludes confoundingconfounding diagnosesdiagnoses HasHas importantimportant limitationslimitations youyou needneed toto understandunderstand