• Professor, Chief of Department

of Physical Medicine &

Rehabilitation, Marmara
University, Istanbul TURKEY
• Secretary General of
Mediterranean Forum of Physical
Medicine and Rehabilitation
• Interest:
• Algology/Pain rehabilitation
• Clinical Neurophysiology
• Osteoporosis
Gulseren AKYUZ • Cancer rehabilitation
MD • Enjoys : Travel, sudoku
• Contact: gulserena@gmail.com
 Low Back Pain (LBP)

 The prevelance of lifetime : 60-80 %

 Risk of recurrent in lifetime : 85 %
 Low back pain >2 weeks : 14 %
 There is only 10 % sciatica
 Sciatica > 2 weeks : 1.6 %
 Highest prevalence : Between the age of 45-64
 Symptomatic lumbar disc herniation : 1-2 %
 70% will recover within one month and 95% within 3 months

Lawrence RC: Arth Rheum 1998; Deyo RA et al: Spine 1987; Boden SD et al: J Bone Joint Surg Am 1990
 Advanced Age (> 50)
 Gender (F:M; 2:1)
 Overweight
 Cigarette smoking
 Occupation
 Vibrational exposure
 Repetitive heavy lifting
 Prolonged sitting
 Psychological factors
 Mechanical conditions Nonmechanical
conditions
Lumbar strain, sprain Neoplasia
Lumbar disc herniation Multiple myeloma
Degenerative processes of disks and Metastatic carcinoma
facets Lymphoma and leukemia
Chronic degenerative disc Spinal cord tumors
disease Retroperitoneal tumors
Spinal stenosis Primary vertebral tumors
Osteoporotic fracture Infection
Spondylolisthesis Osteomyelitis
Traumatic fracture Septic diskitis
Congenital disease Paraspinous abscess
Severe kyphosis Epidural abscess
Severe scoliosis Inflammatory arthritis (often
Transitional vertebrae associated with HLA-B27)
Internal disk disruption or diskogenic Ankylosing spondylitis
low back pain Psoriatic spondylitis
Presumed instability Reiter’s syndrome
Inflammatory bowel disease
Scheuermann’s disease
(osteochondrosis)
Paget’s disease
Visceral causes
Disease of pelvic organs
Prostatitis
Endometriosis
Chronic pelvic inflammatory disease
Renal disease
Nephrolithiasis
Pyelonephritis
Perinephric abscess
Aortic aneurysm
Gastrointestinal disease
Pancreatitis
Cholecystitis
Penetrating ulcer
McDonough, KA, Wipf, JE,
Deyo, RA. Low back pain.
In: Office Practice of
Medicine, 4th ed, Branch,
WT (Ed), Saunders 2003
 Disc herniation (lifting heavy items e.g.)
 Spondylosis
 Spondylolisthesis
 Spinal stenosis
 Trauma (fractures, dislocations)
 Tumors
 Primary (neural-bone)
 Metastasis
 Infections
 Diabetes mellitus
 Cervical and lumbosacral radiculopathies are
among the most common orders referring to
the electrophysiology laboratory
  Plain X-rays
 MRI
 CT
 Bone scan
 Myelography

• Need after the first 4 to 6 weeks when the presence

of risk factors
 Imaging studies

 Plain Films: In most situations should be initial

imaging study ordered
 Computerized Tomography: Frequently
ordered in trauma cases to detect fractures
 Magnetic Resonance Imaging: Excellent soft
tissue contrast
Radionuclide Scan, Thermography, Discography,
CT Discography
 These imaging modalities may be
 too nonspecific (thermography)
 carry additional risk (discography)

 Radyonuclide scan can be useful to detect

stress fractures or metastasis
American College of Radiology. ACR Appropriateness Criteria www.acr.org
Why we should not order imaging studies?

 Have high false positive ratios

 Do not always provide a diagnosis for back pain
 Focused on confirming a lesion
 Anotomical reason can not be found, but pain is
still real and needs to be managed
 Do not give a precise information about timing of
the lesion (new or former?)
 Electrodiagnosis (EDX) : a definition

 An extension of neurological examination developed

to diagnose the diseases of the lower motor neuron
system

 In peripheral nervous system, problems can be

caused by the motor neuron, peripheral nerve,
neuromuscular junction or muscle
To find out
 Etiology
 Level of pathology
 Localization of the involved structure (myelin
or axon)
 Severity of injury (mild, moderate, severe)
 Phase of injury (acute, chronic)
 If the root compression causes the axonal
loss, the findings of abnormal spontaneous
activity may be observed
 1 week later in the paraspinal muscles
 2-3 weeks later in the extremity muscles
 Radiculopathy
 Spinal stenosis
 Piriformis syndrome
 Pelvic tumors (causing plexopathy)
 Postoperative failed back
 Degenerative joint  Spondylolisthesis
disease  Scoliosis
 Ankylosing spondylitis  Fibromyalgia syndrome
 Osteoporosis  Myofascial Pain syndrome
 Fractures  Pregnancy
 Sprains  Vascular disorders
 Sensory only  Psychogenic disorders
radiculopathy
 Evaluation of the radiculopathies requires
strong functional anatomy knowledge

 The myotomal charts about the innervations

of muscles are prepared and some muscles
are accepted as the key muscles for specific
root levels due to multisegmental innervation
 A detailed physical examination is the most
important guide for the electrodiagnostic
testing
 It should be done prior to the investigation
 Motor and sensory nerve conduction studies
 Late responses (F waves, H reflex)
 Needle EMG
 Spinal root stimulation (SRS)
 Somatosensory evoked potentials (SEPs)
 Latency
 Amplitude
 Nerve conduction velocity
 Abnormal findings should be highligted

 Abnormalities can be recorded as “increased” or“

decreased”
 The evaluation of radiculopathy begins with
the sensory and motor nerve conduction
studies

 Generally no pathology has been seen

because the muscles take branches from
more than one root
 Since the lenght of root is very short, the nerve
conduction studies are found normal

 Motor and sensory nerve conduction studies in the

diagnosis of radiculopathy are very limited
 F wave is especially used to examine
the proximal nerve segments
 Because of the F responses are very
variable (different motor neurons are
stimulated in each stimulation) at
least 10 stimulations should be given
and the average of responses should
be taken
 Late Responses : F Wave - II

 When F wave parameters have found

normal, and the needle EMG findings have
been abnormal

 It is suggested that F wave could not define

radiculopathy in sufficient sensitivity
 The Hoffmann (H) reflex is recorded
most easily from the soleus muscle with
the use of the posterior tibial nerve
stimulation
 H-reflex is a monosynaptic reflex
 Pathognomonic for S1 root pathology
 Late Responses : H Reflex - II

 The latency asymmetry of the H reflex is very

sensitive in the diagnosis of S1 radiculopathy
 It can not be found unilaterally
 The upper limit reported for the lower
extremity side-to-side difference is between
1-1.8 ms
 Very important part of electrophysiological
assessment for radiculopathies
 Evaluation of electrical activity with a needle
electrode inserted in muscle
 Painful for the patient
 Dynamic process
 Used in many neuromuscular problems
 Findings in Needle EMG

 Insertional activity (increased/decreased/normal)

 Spontaneous activity (fibrillation potentials/PSWs/
myotonic discharges/fasciculations)

 MUAP morphology (duration/polyphasicity/amplitude)

 Recruitment (decreased/early/normal)
 Insertional activity

 When the needle electrode is inserted into the

muscle there is a silence period normally
 May be decreased due to the fibrosis of the
muscles in the chronic stage of radiculopathies
accompanied with atrophy
 May be increased due to nerve excitation
 Clinical importance in the diagnosis of radiculopathy
is very low
 In some pathological situations;
 Positive sharp waves (PSW),
 Fibrillation potentials
 Complex repetitive discharges
 Fasciculation potentials have been observed in
muscles at rest

 Complex repetitive discharges and fasciculation potentials may

be observed rarely but these potentials are only complementary
and can not lead to diagnosis alone
 First abnormality of EMG in relation to the
interruption of the muscle fibers-nerve continuity is
acute denervation findings, e.g. PSWs and
fibrillation potentials due to the negative course
of the resting membrane potential

Positive sharp waves

Fibrillation potentials
 The evaluation of MUAP characteristics is the most
important part of electrodiagnostic examination of
radicular lesions

 Following an injury of the nerve root

 The first sign of the axons loss is a reduced recruitment
pattern
 When the lesion has progress, the chronic neurogenic
MUAP’s characteristic findings have been seen
 When the force of contraction is increased, a lot of
MUAPs are recruited

 The reduced recruitment is the first detectable sign

of nerve root dysfunction

 But it is difficult to determine motor unit loss less

than 30%
Single ossilation
 In the subacute or chronic stage of radiculopathies, the giant
polyphasic potentials can be seen
 Reinnervation may occur as early as 5 to 6 weeks after root
injury
 In normal individuals, the number of polyphasic MUPs are
not more than 20%
 When reinnervation occurs, properties of MUAPs change :
 Polyphasic
 Low amplitude
 Prolonged MUAP
 Paraspinal EMG can increase sensitivity and
decrease the number of investigating muscles

 Spontaneous activities begin within 7-10 days in PS

muscles and 3-6 weeks in extremity muscles

 There is no another muscle in human body

innervated by a single root except spinal muscles
 Lying in the prone position
 Identification of L2-L5 spinal processes by palpation
corresponding to the iliac crest
 L2,3,4= 2.5 cm lateral and 1 cm superior to the
inferior aspect of the L2–4 spinous process.
 L5=between the posterior superior
iliac spine, 2.5 cm lateral to the S1
spinous process.
 Paraspinal Mapping
 Paraspinal mapping is the best predictor of increased
systematization and quantification of paraspinal
needle electromyography
 Four muscles investigation including the
paraspinal muscles define radiculopathy as
88-97%
 six muscles investigation define it as 98-
100%
You are here!
 PSM had higher sensitivity than either
peripheral EMG or imaging studies for lumbar
radiculopathy
 PSM had a higher sensitivity than MRI in
asymptomatic lumbar spinal stenosis

Yagci I, Gunduz OH, Ekinci G, Diracoğlu D, Us O, Akyuz G: The Utility of Lumbar

Paraspinal Mapping in the Diagnosis of Lumbar Spinal Stenosis. Am J Phys Med
Rehabil. 2009 Aug

Chiodo A, et al.Clin Neurophysiol. 2007 Apr;118(4):751-6.

Haig AJ.Muscle Nerve. 1993 May;16(5):477-84.

 Spinal root stimulation (SRS)

 Needle electrode stimulation performs to the

L5 and S1 levels with recordings from the
tibialis anterior or the flexor hallucis brevis
muscles for evaluating the L5 and S1 roots

 It may be diagnostic method especially in

such cases with no needle EMG abnormality

Bahadır C, Gündüz OH, Us O, Akyüz G: Is it useful to stimulate roots in the diagnosis of

cervical root compression Neurosurg Q 2008;18(3):182-7
Tsai, 1994; Pease, 1190; Berger, 1987
 SEPs are based on recording of spinal and cortical
potentials formed by stimulation of peripheral
nerves

 They provide information about central conduction

time, primary somatosensory cortex and thalamus
functions

 Amplitudes and latencies of the peripheral, spinal

and cortical potentials are evaluated
 The absence of the potentials is accepted the
most important abnormality
 May be obtained very small potentials from the
scalp which is another abnormal finding
 It is not a routine investigation of radiculopathy
because of nature
 It gives more reliable results in diseases affecting
many roots as lumbar stenosis
 Electrophysiologic investigation of
radiculopathies is a dynamic process and can not
be standardized

 It is complementary to neuroimaging studies

becuase EMG/NCV studies

 help making diagnosis

 give information about severity of the root nerve
involvement
 establishing prognosis of radiculopathy
Thank you

gulserena@gmail.com