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Evaluating the Patient with Suspected Radiculopathy

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Evaluating the Patient with Suspected Radiculopathy 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
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