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ELSEVIER

Pain

CLINICAL
SIGNS IN PATIENTS
BRACHIALGIA
AND SCIATICA:
A COMPARATIVE
STUDY

WITH

Chris Woertgen, M.D., Matthias Holzschuh, M.D., Ralf Dirk Rothoerl, M.D., and
Alexander Brawanski, M.D., Ph.D.
Neurosurgical Clinic, University of Regensburg, Regensburg Germany

Woertgen C, Holzschuh M, Rothoerl RD, Brawansld A. Clinical


signs in patients with brachialgia and sciatica: a comparative
study. Surg Neurol 1998;49:210-4.
BACKGROUND

The aim of the study was to compare the clinical signs of


patients with cervical and lumbar root affections.
METHODS

From January 1994 to January 1995, we performed a pro


spective study on 395 patients. The study comprised 93
patients with a cervical and 302 patients with a lumbar
root affection. 338 patients underwent surgery. General
data, case histories, and neurological findings were
analyzed.
RESULTS

The patients with brachialgia had a nonradicular pain


radiation in 67%, the patients with sciatica only in 35%. All
other data showed no significant differences. The investigation also shows that a radicular pain radiation is
significantly correlated with an unequivocal radicular deficit. In particular, the patients with a cervical radicular
pain radiation had a highly significant incidence of a
radicular neurological deficit.
CONCLUSIONS

We could demonstrate in this prospective study that only


about one third of the patients with a cervical root affection showed an unequivocal radicular pain radiation.
This contradicts the traditional medical textbook concept of a cervical root compression syndrome. This difference in respect of the clinical signs of lumbar and
cervical root compressions might be explained by the
anatomical variations of cervical root anastomoses. To
determine the affected cervical root level, further investigation of the myotomes is recommended.
0 1998 by
Elsevier Science Inc.
KEY WORDS

BACKGROUND

n clinical studies and in several authoritative


medical textbooks, pain and neurological
symptoms arising from spinal nerve root compression
are described as being well defined, and are often
precisely located concerning the site of the lesion
[9,11-131. According to Frykholm, a dorsolateral
cervical disc herniation
is able to compress filaments of two spinal segments and additionally,
variations in the cervical spinal segments are wide
spread [1,3,4,6,7]. Yoss showed that the overlap is
less likely in the cervical myotomes
than in the
dermatomal
[ 141. He concluded that examination
of
the cervical myotomes
has a greater specificity
than the reflex or sensory investigation
[ 141. Friis et
al investigated the pain distribution
of 249 patients
with cervical and lumbar monoradicular
affections.
He reported that the distribution
of pain became
uncertain at least in the periphery of the limbs and
for that reason it was of limited diagnostic value [2].
Assignment of the complaints and the neurological
findings to one spinal root is therefore not always
very easy [ 13,151. Up to now, there is no study in
the Medline data base that compares the clinical
signs of patients with cervical and lumbar root compressions and the neurological
deficit of patients
with a nonradicular
pain radiation
as compared
with patients with a radicular one. The aim of this
study was to obtain further information
in this field.

Clinical signs,spinal root affection, disc hemiation.

METHODS

Address correspondence
and reprint requests to: Chris Woertgen, M.D.,
Neurosurgical
Clinic, University
of Regensburg,
Franz-.JosefStra&-Allee
11, D-93042 Regensburg, Germany
Received June 13, 1996; accepted May 7, 1997.

Between January 1994 and January 1995, we investigated 395 inpatients with a tentative diagnosis of
spinal root compression
in a prospective study at
the Neurosurgery
Division of the University of Regensburg Hospital.
Twenty-four
percent (93 patients) of all the patients had a cervical and 76%

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0 1998 by Elsevier Science Inc.


of the Americas, New York, NY 10010

Clinical Signs of Root Compressions

II

Surg Neurol
1998;49:210-4

Affected Levels of all Patients

AFFECTED
LEVEL

PERCENT

AFFEcTED
LEVEL

c 314
415
C 516
C 617
CI/Thl

91
35
40
2

Brachialgia

13

*Patients not operated


root affection.

on, because the imaging diagnostic

PERCENT

L 314
213
L 4j5
L 5/s1

:
51

Sciatica*

13

ROOT
C6
c7

C8
L3
L4
L5
Sl

patients, in 18% of the cases with a lumbar root


affection and in 19% of the patients with a cervical
root affection.
A statistical analysis including the Fishers PLSD,
the Scheffes and the Bonferroni/Dunnetts
post hoc
tests was performed on the actual numbers in each
group.

30

showed no

(302 patients) had a lumbar root affection. Of these


patients, 338 were operated on a single root compression caused by a herniated disc and/or a spondylotic root irritation.
The levels of affection in all
the patients are shown in Table 1.
We recorded the general data, case histories and
all neurological findings. The assignment of the dermatomes, myotomes, and reflexes to nerve roots
was done according to the description given in Table 2. Findings that differed from these descriptions
were categorized as nonradicular.
A hyporreflexia
of the affected limb involving more than one nerve
root mentioned in Table 2 was categorized as nonradicular [9,11,13]. The findings were analyzed with
reference to their distribution
in patients with cervical and lumbar root compression.
Most of the patients (79%) received a computed
tomography
(CT) preoperatively.
Only 35% of the
patients had a magnetic resonance imaging (MRl);
28% underwent a myelography.
The CT showed a
sequestrated disc fragment in 33% of the cases, 44%
had a prolapse, and 9% had a prolapse in combination with a bony stenosis. A solitary bony stenosis
alone was detected in 7%; the remaining CTs (7%)
showed no significant root affection. A second minor finding on the CT scan was seen in 28% of all

2 11

RESULTS
COMPLAINTS
AND NEUROLOGICAL
SIGNS
On admission 95% of all patients had a radiating
pain, with 35% of the patients reporting a nonradicular pain and the remaining patients a radicular
one. Fifty-five percent of all patients had a radicular
sensory loss, and 22% had hypesthesia in more than
one dermatome.
Twenty-three percent were without sensory loss. Radicular paresis was found in
49%, and 45% showed no motor weakness. Six percent showed a diffuse weakness of the limbs. Approximately
56% had normal reflexes, 8% had a
hyporreflexia
involving more than one nerve root,
and 36% had a radicular hyporreflexia.
COMPLAINTS
AND NEUROLOGICAL
SIGNS
OF PATIENTS
WITH CERVICAL
AND LUMBAR
ROOT
COMPRESSION
Table 3 shows that there is no significant difference
in respect of the general data such as sex, age,
weight and height in the groups with cervical and
lumbar symptoms. We did not find any significant
difference in the two groups concerning the neurological deficits (Table 3). However, we found a
highly significant difference for the pain radiation.
Patients with brachialgia
complained
of a nonradicular radiation in 67%, the patients with a lumbar
root affection had a nonradicular
radiation in only

Allocation of the Clinical Signs to the Nerve Roots


PAIN RADIATION

SENSORY

Thumb, index finger

Thumb, index finger

Long and ring fingers


Little finger, hypothenar

Long and ring fingers


Little finger, hypothenar

Ventral thigh, medial


knee
Ventral tibia1
Dorsum of the foot, big
toe
Lateral margin of the
foot, small toes

Ventral thigh, medial


knee
Ventral tibia1
Dorsum of the foot, big
toe
Lateral margin of the
foot, small toes

MOTOR

WEAKNESS

Elbow flexion

Brachioradialis

Elbow-finger extension
Finger flexion, finger
abduction
Flexion of the thigh

Triceps reflex
(Triceps reflex)

reflex

Knee extension
Foot-big toe extension

Patellar reflex
Tibialis posterior reflex

Foot flexion

Ankle reflex

Adductor reflex

2 12

Surg Neurol
1998:49:210-4

Woertgen et al

Comparison of the Clinical Signs of Patients with Brachialgia and Sciatica


Cu~lcfi

BRACHIALGIA

SIGNS

47
75
171
39%
67%(65%)
47%(51%)
44%(46%)
43%(45%)

Age (mean, years)


Weight (mean, kg)
Height (mean, cm)
Sex (female)
Nonradicular radiation
Radicular sensory loss
Radicular paresis
Hyporreflexia

n = 395.
Results for operated patients are shown in parentheses
*Significant for all patients and for operated patients.
**NO significance for both.
***For all patients p = 0.0531.

SCIATICA

45
79
173
29%
35%(27%)
57%(61%)
51%(57%)
34%(38%)

SIGNIFICANCE

n.s.
n.s.
n.s.
p :d.oool*

n.s.**
n.s.**
n.s.***

(n = 338).

35% @ < 0.0001). This significant difference


also seen in the operated group (Table 3).

was

CLINICAL
SIGNS
IN THE GROUPS
WITH RADICULAR
AND
NONRADICULAR
RADIATION
Comparing the clinical signs of all the patients, we
found that patients with a radicular pain radiation
more often had an additional unequivocal radicular
neurological
deficit (Table 4). The difference is statistically significant. Women were more often in the
group with a nonradicular
radiation;
39% versus
27% with a radicular radiation @ < 0.05, Table 4).
Table 5 shows the clinical signs of patients with
radicular and non-radicular
pain radiation split up
into subgroups with cervical and lumbar root compression. The results show that patients with a
cervical root compression and a radicular radiation
statistically
significantly
more often had a further
unequivocal
radicular
neurological
deficit, compared to the group with a nonradicular
radiation. In
the group of patients with a lumbar root affection
and a radicular pain radiation there is only a statistical difference from the group with a nonradicular
radiation in respect of the sensory loss; 70% radicular sensory loss in the group with a radicular ra-

diation as compared with 38% in the group with a


nonradicular
sensory loss (Table 5). There were
more women with a nonradicular
pain radiation
only in the group with cervical root affection @ <
0.05, Table 5).

DISCUSSION
Contrary to authoritative
medical textbooks, the
clinical signs and neurological
deficits of cervical
and lumbar root affections seem to differ from each
other. We saw more cases with nonradicular
pain
radiation among patients with a cervical root compression compared with patients with a lumbar
root affection. In agreement with other studies, the
pain radiation could therefore not be used for assignment of the affected level of the cervical spine
[2,14]. In his largescale retrospective
series of 846
patients with a cervical root affection, Henderson
reported that 45.5% of patients had a nondermato
ma1 pain radiation [5]. We saw (probably as a result
of the prospective study design) more patients with
a nonradicular
pain radiation (67%). Regarding the
neurological deficits, there was a slight tendency to
a more radicular deficit of the patients with lumbar

Clinical Signs of Patients Split up into Groups With Radicular and Nonradicular Radiation
CLINICAL SIGNS

NONRADICULAR

Age (mean, years)


Weight (mean, kg)
Height (mean, cm)
Sex (female)
Radicular sensory loss
Radicular paresis
Hyporreflexia
*Only significant

for patients

RADIATION

46.7
77.4
171.6
39%
28%
42%
28%
with paresis.

hDICIJIAR

RADIATION

45.2
77.6
172.4
27%
69%
54%
40%

SIGNIIWANCE

n.s.
n.s.
p :sd.os
p < 0.0001
p < 0.005*
p < 0.05

Surg Neurol
1998;49:210-4

Clinical Signs of Root Compressions

2 13

Clinical Signs of Patients Split up into Groups With Radicular and Non-radicular Radiation
NONRADICULAR

RADICIJLAR
RADIATION

RADIATION

SIGNIFICANCE

CLINICAL SIGNS

CS

Is

cs

Is

cs

Is

Age (mean, years)


Weight (mean, kg)
Height (mean, cm)
Sex (female)
Radicular sensory loss
Radicular paresis
Hyporreflexia

48
77
170
49%
33%
43%
33%

46
80
174
35%
38%
49%
31%

45
78
173
23%
85%
52%
67%

46
77
173
31%
70%
60%
41%

n.s.
ns.

n.s.
n.s.
n.s.

p %.05
p < 0.0001
p < 0.0005*
p < 0.05

p :*sd.o5

n.s.
n.s.

*Only significant for patients with paresis.


CS, cervical spine; LS, lumbar spine.

root compressions,
but this difference was not significant (Table 3). The anatomical correlations
for
these clinical differences are probably the anastomoses between the dorsal roots and the overlapping of medullary segments [ 6,7]. Anatomists of the
18th century, such as Hilbert,
had already described ascending and descending anastomoses between the dorsal roots [6]. Pallie and Manuel saw
these connections more often in the lower cervical
and lumbar spinal segments [lo]. Lang could confirm this observation
only for the lower cervical
spine [6]. He saw, for example, an anastomosis between the left dorsal C 5 and C 6 root in 56% and on
the right side in 54% [6]. Interestingly,
these anastomoses occurred more often in the dorsal afferent
root than in the ventral efferent root. Here Lang
found them more often in the upper cervical spine,
at C4/5 on the right side in 18% and on the left in
21% [8]. This special anatomical feature could be a
reason for the more uniform neurological deficits of
patients with cervical root compressions
and the
more multisegmental
pain radiation of these patients. According to Lang the anatomical relations
of the ventral and dorsal lumbar roots seem to be
more uniform. This fact seems to be reflected in the
more homogeneous
clinical signs of the lumbar
root affections [ 71.
Our investigation
also shows that a radicular pain
radiation
is significantly
associated with an unequivocal radicular deficit (Table 4). Here especially the patients with a cervical radicular pain
radiation had a highly significant incidence of a
radicular neurological
deficit (Table 5). This result
is consistent with the traditional
conception of a
spinal root compression and seems to be obvious,
but unfortunately this group of patients (33%) is the
minority
of the patients with brachialgia.
In the
group of patients with sciatica, two thirds of patients have an unequivocal
radicular affection. For

further determination
of the affected cervical root
level, the examination
of the myotomes provided
the most information,
because 43% of the patients
with a nonradicular
pain radiation had a radicular
paresis.

CONCLUSION
In a prospective study we show that only about one
third of the patients with a cervical root affection
showed an unequivocal
radicular pain radiation.
This contradicts
the traditional
medical textbook
concept of a cervical root compression syndrome.
The reasons for this difference between the clinical
signs of lumbar and cervical root compressions are
probably the anatomical variations of the anastomoses of the cervical roots. To determine the affected cervical root level, further investigation
of
the myotomes is recommended.
REFERENCES
1. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil 1994;75:342-52.
2. Friis ML, Gulliksen GC, Rasmussen P, Husby J. Pain
and spinal root compression. Acta Neurochirurgica
1977;39:241-9.
3. Frykholm R. Die cervikalen Bandscheibenschaden. In
Olivecrona H, Tijnnis W, Krenkel W, eds. Handbuch
der Neurochirurgie. Vol. VII. Berlin Heidelberg New
York: Springer, 1969:73-163.
4. Frykholm R. Cervical nerve root compression resulting from disc degeneration and root sleeve fibrosis.
Acta Chir Stand 1951;160:1-149.
5. Henderson CM, Hennessy RG, Shuey HM, Shackelford
EG. Posterior-lateral foraminotomy as an exclusive
operative technique for cervical radiculopathy: a review of 846 consecutively operative cases. Neurosurgery 1983;13:504-12.
6. Lang J. Funktionelle Anatomie der Halswirbelslule
und des benachbarten Nervensystems. In Hohmann

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7.

8.
9.
10.
11.
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15.

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1998;49:210-4

D, Kiigelgen B, Liebig K, Schirmer M, eds. Neuroorthopidie 1. Berlin: Springer, 1983:1-118.


Lang J. Morphologie und funktionelle Anatomie der
Lendenwirbelslule
und des benachbarten Nervensysterns. In Hohmann D, Ktigelgen B, Liebig K, Schirmer
M eds. Neuroorthopadie
2. Berlin: Springer, 1984:155.
Lang J. Klinische Anatomie der Halswirbelslule.
Stuttgart: Thieme, 1991.
Mumenthaler M, Schliack H, eds. Llsionen peripherer
Nerven. 5th ed. Stuttgart York: Thieme, 1987.
Pallie W, Manuel JK. Intersegmental anastomoses be
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Acta Anat 1968;70:341-51.
Schirmer M ed. Neurochirurgie.
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Wien Baltimore: Urban & Schwarzenberg,
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Tindall CT, Cooper PR, Barrow DL eds. The Practice
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Wilkins RH, Rengachary SS eds. Neurosurgery.
Vol.
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Yoss RE, Corbin KB, McCarthy CS, Love JG. Significance of symptoms and signs in localization of involved root in cervical disc protrusion. Neurology
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Youmans JR ed. Neurological Surgery. 3d ed. Philadelphia: W.B Saunders Company, 1990.

COMMENTARY
The authors present a very interesting
namely that nonradicular
pain is much
monly associated
with symptomatic
disease than in the lumbar region. If this

observation

can be substantiated

hypothesis,
more comspondylitic

interesting
by other studies,

it might

indicate

why

the outcome

after

cervical

disc disease surgery is much more variable than


that with the radiculopathy
associated with lumbar
disease.
The physiologic mechanisms for this are far from
clear and will require the same sort of study as
performed by Dr. Woertgen and colleagues, only
this time using multisegmental
electrodiagnostic
tests.

The National

Alan Crockard, FRCS


Department of Sqical
Neurology
Hospital for Neurology & Neurosurgery
London, England, United Kingdom

Although I think the authors are confusing uncomfortable paresthesia with sharp and aching pain,
the study does seem to be worthwhile in pointing
out that from the pain alone, one cannot determine
the specific nerve root that is being entrapped. This
is not new information,
by the way; I think it has
been pretty well emphasized over the years in many
texts and papers that there is considerable overlap
between the nerve roots. For instance, it is well
known that 15% of patients have the deltoid muscles innervated by C6 rather than C5.
Ronald

P. Pawl, M.D., F.A.C.S.


Neurosurgeon
Lake Forest, Illinois