Classification by pain pattern for patients with cervical spine radiculopathy.

OBJECTIVES: A prospective observational cohort study was conducted to (1) report the prevalence of Mechanical Diagnosis and Therapy (MDT) classifications, Centralization (CEN), and Non-CEN among patients with Cervical Spine Radiculopathy (CSR), and (2) describe the association between classification via CEN and Non-CEN and clinical outcomes at follow-up. METHODS: Data were collected from 680 consecutive patients who presented to outpatient, orthopedic physical therapy clinics with primary complaints of neck pain with and without radiculopathy; thirty-nine patients (6%) met the physical examination inclusion criteria for CSR. First examination and follow-up data were completed by 19 patients. RESULTS: Seventy-nine percent of patients' conditions were classified as Reducible Derangement at first examination and 21% were classified as either Irreducible Derangement, Entrapment, or Mechanically Inconclusive. The prevalence of CEN and Non-CEN was 36.8% and 47.4%, respectively. All patients treated via MDT methods made clinically significant improvements in disability, but not pain intensity, at follow-up. The magnitude of change in clinical outcomes was greatest for patients who exhibited CEN; however, the changes in disability and pain intensity at follow-up were not statistically significant compared to patients who exhibited Non-CEN at first examination. Patients who exhibited CEN were discharged, on average, ten days earlier and had one less treatment visit compared to patients who exhibited Non-CEN. DISCUSSION: The findings of this study show that patients with CSR can be classified and treated via MDT methods and experienced clinically significant improvements in disability, but not pain intensity, at follow-up. Providers should consider MDT classification and treatment to improve clinical outcomes for their patients affected by CSR.

How should we grade lumbar disc herniation and nerve root compression? A systematic review.

BACKGROUND: MRI is the gold standard for evaluating the relationship of disc material to soft tissue and neural structures. However, terminologies used to describe lumbar disc herniation and nerve root compression have always been a source of confusion. A clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers is vital for patient care and future research. QUESTIONS/PURPOSES: Through a systematic review of the literature, the purpose of this article is to describe lumbar disc terminology and comment on the reliability of various nomenclature systems and their application to clinical practice. METHODS: PubMed was used for our literature search using the following MeSH headings: "Magnetic Resonance Imaging and Intervertebral Disc Displacement" and "Lumbar Vertebrae" and terms "nomenclature" or "grading" or "classification". Ten papers evaluating lumbar disc herniation/nerve root compression using different grading criteria and providing information regarding intraobserver and interobserver agreement were identified. RESULTS: To date, the Combined Task Force (CTF) and van Rijn classification systems are the most reliable methods for describing lumbar disc herniation and nerve root compression, respectively. van Rijn dichotomized nerve roots from "definitely no root compression, possibly no root compression, indeterminate root compression, possible root compression, and definite root compression" into no root compression (first three categories) and root compression (last two categories). The CTF classification defines lumbar discs as normal, focal protrusion, broad-based protrusion, or extrusion. The CTF classification system excludes "disc bulges," which is a source of confusion and disagreement among many practitioners. This potentially accounts for its improved reliability compared with other proposed nomenclature systems. CONCLUSIONS: The main issue in the management of patients with lumbar disc disease and nerve root compression is correlation of imaging findings with clinical presentation and symptomatology to guide treatment and intervention. Although it appears that the most commonly supported nomenclatures have strong interobserver reliability, the classification term "disc bulges" is a source of confusion and disagreement among many practitioners. Additional research should focus on the clinical application of the various nomenclatures.

Clinical and radiographic changes after percutaneous endoscopic cervical discectomy: a long-term follow-up.

OBJECTIVE: Results following anterior cervical discectomy (ACD) without fusion are not well reported because of skepticism that the disturbed cervical spine anatomy after ACD might compromise clinical outcome. The purpose of this study was to determine whether ACD without fusion prompts the degenerative process significantly, and whether it is necessary to preserve disc height and cervical alignment for the sake of better clinical outcome following cervical spine surgery. BACKGROUND DATA: Out of 56 consecutive patients, 37 patients who replied and consequently underwent postoperative MRI from April to June 2009 were included in this study. MATERIAL AND METHODS: A total of 37 consecutive patients diagnosed as having cervical monoradiculopathy and treated with percutaneous endoscopic cervical discectomy (PECD) were investigated. Angle of cervical lordosis, change in cervical range of motion, disc height change, and degree of degenerative changes at the corresponding level were evaluated. The visual analogue scale (VAS) score for neck and arm pain and the neck disability index (NDI) were compared preoperatively and at the final follow-up. The mean follow-up period was 45.5 months. RESULTS: Despite prompted radiological deterioration such as loss of disc height (the posterior disc heights and central disc height ratio were significantly decreased from 3.6 to 2.6 mm, from 30.3% to 24.5%, respectively, p<0.05) or degenerative progression (from average grade of 2.8 to 4.1, p<0.05), the patients achieved significant improvement in clinical outcomes (VAS for neck and arm dropped from mean 6.3 and 7.5 to 2.7 and 2.6, respectively, and NDI score improved from 46.8% to 17.2%, p<0.05) after PECD. CONCLUSIONS: Neither loss of disc height nor progression of degeneration at disc space compromised clinical outcome after PECD without fusion on long-term follow-up.

[Clinical significance of pointed medicamental and non-medicamental therapy in the staged combined treatment of radiculopathies].

We analysed the results of the treatment of 4205 patients with different forms of vertebrogenic radiculopathy. They suggest the efficacy of differential application of graduated medicamental therapy, reflexo- and physiotherapy depending on the period of clinical course of the disease.

Inter-therapist agreement in classifying patients with cervical radiculopathy and patients with non-specific neck-arm pain.

Identification of differences in clinical presentation and underlying pain mechanisms may assist the classification of patients with neck-arm pain which is important for the provision of targeted best evidence based management. The aim of this study was to: (i) assess the inter-examiner agreement in using specific systems to classify patients with cervical radiculopathy and patients with non-specific neck-arm pain associated with heightened nerve mechanosensitivity (NSNAP); (ii) assess the agreement between two clinical examiners and two clinical experts in classifying these patients, and (iii) assess the diagnostic accuracy of the two clinical examiners. Forty patients with unilateral neck-arm pain were examined by two clinicians and classified into (i) cervical radiculopathy, (ii) NSNAP, (iii) other. The classifications were compared to those made independently by two experts, based on a review of patients' clinical assessment notes. The experts' opinion was used as the reference criterion to assess the diagnostic accuracy of the clinical examiners in classifying each patient group. There was an 80% agreement between clinical examiners, and between experts and 70%-80% between clinical examiners and experts in classifying patients with cervical radiculopathy (kappa between 0.41 and 0.61). Agreement was 72.5%-80% in classifying patients with NSNAP (kappa between 0.43 and 0.52). Clinical examiners' diagnostic accuracy was high (radiculopathy: sensitivity 79%-84%; specificity 76%-81%; NSNAP: sensitivity 78%-100%; specificity 71%-81%). Compared to expert opinion, clinicians were able to identify patients with cervical radiculopathy and patients with NSNAP in 80% of cases, our data supporting the reliability of these classification systems.

Clinical classification of patients with lumbar spinal stenosis based on their leg pain syndrome: its correlation with 2-year surgical outcome.

STUDY DESIGN: Prospective follow-up and retrospective review of 174 patients surgically treated for degenerative lumbar spinal stenosis. OBJECTIVE: To examine whether the type of leg pain syndrome associated with lumbar spinal stenosis is correlated with outcome. SUMMARY OF BACKGROUND DATA: Although classifying patients based on their leg pain syndrome is useful in planning surgical decompression, there is no validated method of classification and its prognostic significance remains unknown. METHODS: Based on the type of leg pain, the patients were classified into 2 groups: unilateral and bilateral. Improvement in functional status was evaluated using the Quebec Back Pain Disability Scale; the symptoms were rated on a visual analog scale and the change from baseline to 2-year evaluation was noted. Associations between score changes and baseline variables were examined using multivariate analysis. RESULTS: The type of leg pain was independently associated with improvements in function and leg symptom scores but was not associated with improvement in the back pain score. After surgery, patients with unilateral leg pain had significantly greater improvements in function and leg symptoms than patients with bilateral leg pain. CONCLUSION: In patients undergoing surgery for degenerative lumbar spinal stenosis, the preoperative type of leg pain predicts function and leg symptom outcomes.

A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.

Clinical provocative tests of the neck, which position the neck and arm inorder to aggravate or relieve arm symptoms, are commonly used in clinical practice in patients with a suspected cervical radiculopathy. Their diagnostic accuracy, however, has never been examined in a systematic review. A comprehensive search was conducted in order to identify all possible studies fulfilling the inclusion criteria. A study was included if: (1) any provocative test of the neck for diagnosing cervical radiculopathy was identified; (2) any reference standard was used; (3) sensitivity and specificity were reported or could be (re-)calculated; and, (4) the publication was a full report. Two reviewers independently selected studies, and assessed methodological quality. Only six studies met the inclusion criteria, which evaluated five provocative tests. In general, Spurling's test demonstrated low to moderate sensitivity and high specificity, as did traction/neck distraction, and Valsalva's maneuver. The upper limb tension test (ULTT) demonstrated high sensitivity and low specificity, while the shoulder abduction test demonstrated low to moderate sensitivity and moderate to high specificity. Common methodological flaws included lack of an optimal reference standard, disease progression bias, spectrum bias, and review bias. Limitations include few primary studies, substantial heterogeneity, and numerous methodological flaws among the studies; therefore, a meta-analysis was not conducted. This review suggests that, when consistent with the history and other physical findings, a positive Spurling's, traction/neck distraction, and Valsalva's might be indicative of a cervical radiculopathy, while a negative ULTT might be used to rule it out. However, the lack of evidence precludes any firm conclusions regarding their diagnostic value, especially when used in primary care. More high quality studies are necessary in order to resolve this issue.

Genetic disorders producing compressive radiculopathy.

Back pain is a frequent complaint seen in neurological practice. In evaluating back pain, neurologists are asked to evaluate patients for radiculopathy, determine whether they may benefit from surgery, and help guide management. Although disc herniation is the most common etiology of compressive radiculopathy, there are many other causes, including genetic disorders. This article is a discussion of genetic disorders that cause or contribute to radiculopathies. These genetic disorders include neurofibromatosis, Paget's disease of bone, and ankylosing spondylitis. Numerous genetic disorders can also lead to deformities of the spine, including spinal muscular atrophy, Friedreich's ataxia, Charcot-Marie-Tooth disease, familial dysautonomia, idiopathic torsional dystonia, Marfan's syndrome, and Ehlers-Danlos syndrome. However, the extent of radiculopathy caused by spine deformities is essentially absent from the literature. Finally, recent investigation into the heritability of disc degeneration and lumbar disc herniation suggests a significant genetic component in the etiology of lumbar disc disease.

The Modic classification: inter- and intraobserver error in clinical practice.

STUDY DESIGN: A reliability study of the Modic classification. OBJECTIVE: To determine the reliability and reproducibility of the Modic classification for lumbar vertebral marrow changes. SUMMARY OF BACKGROUND DATA: In 1988, Modic et al described two degenerative stages of vertebral marrow and endplate morphology. These were type 1 (inflammatory phase) and type 2 (a fatty phase). Later in 1988, he added a third variety: type 3 where there was marked sclerosis adjacent to the endplates. No formal reliability or reproducibility studies had been performed on this Modic classification. METHODS: This study involved five independent observers of differing spinal experience using the Modic classification to grade 50 sagittal T1- and T2-weighted magnetic resonance imaging scans. The observers repeated the assessment at 3 weeks. Intra- and interobserver reliabilities were assessed using kappa statistics. RESULTS: There were 7 type 1, 40 type 2, 1 type 3, and 2 normal levels. The individual intraobserver agreement was substantial or excellent with kappa values ranging from 0.71 to 1. The overall interobserver agreement was excellent with a kappa value of 0.85. There was complete agreement in 78% of the levels, a difference of one type in 14% and a difference of two or more in 8% of levels. The level of experience of the observer did not correlate with a better score. CONCLUSIONS: We have shown that the classification is both reliable and reproducible. It is simple and easy to apply for observers of varying clinical experience. We therefore recommend its use in clinical research and practice.

MR image-based grading of lumbar nerve root compromise due to disk herniation: reliability study with surgical correlation.

A system for grading lumbar nerve root compromise (no compromise, contact of disk material with nerve root, deviation of nerve root, and compression of nerve root) was tested in the interpretation of routine magnetic resonance images of 500 lumbar nerve roots in 250 symptomatic patients. Intra- and interobserver reliability was assessed for three independent observers. In the 94 nerve roots evaluated at surgery, surgical grading was correlated with image-based grading. kappa statistics indicated substantial agreement between different readings by the same observer and between different observers (for intraobserver agreement, kappa = 0.72-0.77; for interobserver agreement, kappa = 0.62-0.67). Correlation of image-based grading with surgical grading was high (r = 0.86). The image-based grading system enabled reliable evaluation and reporting of nerve root compromise.

Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.

STUDY DESIGN: A blinded, prospective diagnostic test study was conducted. OBJECTIVES: To assess the reliability and accuracy of individual clinical examination items and self-report instruments for the diagnosis of cervical radiculopathy, and to identify and assess the accuracy of an optimum test-item cluster for the diagnosis of cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Although cervical radiculopathy remains largely a clinical diagnosis, the reliability and diagnostic accuracy of clinical examination items, individually or in combination, for cervical radiculopathy is largely unknown. METHODS: Patients with suspected cervical radiculopathy or carpal tunnel syndrome received standardized electrophysiologic examination of the symptomatic upper quarter followed by a standardized clinical examination by physical therapist examiners blinded to diagnosis. Diagnostic properties were assessed using a neural impairment reference criterion standard. RESULTS: The study involved 82 patients. More than two thirds of 34 clinical examination items had reliability coefficients rated at least fair or better, and 13 items had likelihood ratio point estimates above 2 or below 0.50. A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3. The 95% confidence intervals for all likelihood ratio point estimates in this study were wide. CONCLUSIONS: Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item. Upper limb tension Test A was the most useful test for ruling out cervical radiculopathy. Further investigation is required both to validate the test item cluster and to improve point estimate precision.

Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography.

OBJECT: The authors describe a new magnetic resonance (MR) imaging technique to demonstrate the status of the cervical nerve roots involved in brachial plexus injury. They discuss the accuracy and reproducibility of a MR imaging-derived classification for diagnosis of nerve root avulsion compared with those of myelography combined with computerized tomography (CT) myelography. METHODS: The overlapping coronal-oblique slice MR imaging procedure was performed in 35 patients with traumatic brachial plexus injury and 10 healthy individuals. The results were retrospectively evaluated and classified into four major categories (normal rootlet, rootlet injuries, avulsion, and meningocele) after confirming the diagnosis by surgical exploration with or without spinal evoked potential (EP) measurements and by referring to myelography and CT myelography findings. The reliability and reproducibility of the MR imaging-based classification was prospectively assessed by eight independent observers, and its diagnostic accuracy was compared with that of traditional myelography/CT myelography classification, correlated with surgical and spinal EP findings in another 50 cervical roots in 10 patients with traumatic brachial plexus injury. CONCLUSIONS: In the retrospective study in which MR imaging and myelography/CT myelography findings involving 175 cervical roots in 35 patients were compared, the sensitivity of detection of the cervical nerve root avulsion was the same (92.9%) with both modalities. In the prospective study, interobserver reliability and intraobserver reproducibility showed that there was no statistically significant difference between MR imaging and myelography/CT myelography and that their accuracy for detecting cervical root avulsion was the same as that in the retrospective study. The overlapping coronal-oblique slice MR imaging technique is a reliable and reproducible method for detecting nerve root avulsion. The information provided by this modality enabled the authors to assess the roots of the brachial plexus and provided valuable data for helping to decide whether to proceed with exploration, nerve repair, primary reconstruction, or other imaging modalities.