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Background: Cervical radiculopathy (CR) is a clinical diagnosis defined as a combination of neck, shoulder, and arm pain, often accompanied by sensory and motor symptoms. CR is often caused by degenerative spine pathology associated with impingement of a cervical nerve root, and this pathology can be visualized using magnetic resonance imaging (MRI) or computed tomography (CT). [Correction added September 4, 2019, after online publication: 'computer tomography' corrected to 'computed tomography'] Factors that are associated with the onset of CR have not been explored., Objective: To investigate the types and frequencies of patient-reported inciting events associated with CR in patients with imaged-confirmed pathologies that correlate with symptoms., Design: Prospective observational case series., Setting: Two spine physiatry and three orthopedic spine surgery practices., Patients: One hundred twenty-two patients with symptoms suggestive of CR were recruited. Of these, 107 patients had MRI or CT evidence of cervical disk herniation or foraminal stenosis that correlated with symptoms and matched our inclusion criteria., Methods: We categorized patient-reported inciting events associated with onset of CR into six categories reflecting increasing severity of inciting event, and recorded the clinical characteristics, physical examination findings, pain intensity, and disability. We analyzed the characteristics of patients based on subgroups of inciting events., Results: Two-thirds of patients reported that they either awoke with symptoms or symptoms began without a memorable event, and one-third of patients reported inciting physical activity or trauma associated with the onset of CR. Clinical characteristics of CR were not influenced by categories of inciting events., Conclusion: Most CR with correlating spine pathology was found to have onset without a specific inciting events. Furthermore, physical inciting events did not influence the severity of clinical manifestation of CR., Level of Evidence: IV., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Study Design: Case series., Objective: This study compared the locations of arm pain, sensory symptoms, and subjective complaints of arm weakness in patients with cervical radiculopathy from MRI confirmed C6 and C7 nerve root compression., Summary of Background Data: Cervical radiculopathy is defined as arm pain, sensory and motor symptoms caused by irritation of a cervical nerve root. The C6 and C7 roots are most commonly involved, and differentiating symptoms associated with each root has proven difficult. Cervical MRI allows accurate identification of nerve root compression and therefore makes it possible to explore symptom patterns that may differentiate C6 from C7 radiculopathy., Methods: A total of 122 patients with symptoms suggestive of cervical radiculopathy were recruited. Of these, 30 patients had MRI confirmed C6 and 39 patients C7 nerve root compression. By completing a study questionnaire, patients reported specific arm weakness, and marked the location of arm pain and tingling/numbness on graphic representations of the arm. Marked areas were interpreted by superimposing a grid that divided the arm into 54 distinct areas. The frequencies of reported symptoms with C6 and C7 were totaled and then compared with likelihood rations. Power analysis calculated that 27 patients would be needed in each group based on the assumption that a 30 percentage point difference in frequency of specific symptom would be clinically useful for differentiating C6 from C7 radiculopathy., Results: Arm pain and sensory symptoms were diffuse, and were not distinctly different for C6 or C7 radiculopathy. Some weakness was reported by 41 percent of patients, with specific descriptions of weakness having limited value for differentiating between radiculopathies., Conclusion: The location of pain and sensory symptoms, and specific weakness complaints associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting root involvement based on symptoms., Level of Evidence: 3.

Background Context: Classification criteria are recommended for diseases that lack specific biomarkers to improve homogeneity in clinical research studies. Because imaging evidence of lumbar disc herniations (LDHs) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are required., Purpose: This study aimed to produce clinical classification criteria to identify patients with radicular pain caused by LDH., Study Design: The study design was a two-stage process. Phase 1 included a Delphi process and Phase 2 included a cohort study., Patient Sample: The patient sample included outpatients recruited from spine clinics in five countries., Outcome Measures: The outcome measures were items from history and physical examination., Materials and Methods: In Phase 1, 17 spine experts participated in a Delphi process to select symptoms and signs suggesting radicular pain caused by LDH. In Phase 2, 19 different clinical experts identified patients they confidently classified as presenting with (1) radicular pain caused by LDH, (2) neurogenic claudication (NC) caused by lumbar spinal stenosis, or (3) non-specific low back pain (NSLBP) with referred leg pain. Patients completed survey items and specialists documented examination signs. A score to predict radicular pain caused by LDH was developed based on the coefficients of the multivariate model. An unrestricted grant of less than US$15,000 was received from MSD: It was used to support the conception of the Delphi, data management, and statistical analysis. No fees were allocated to participating spine specialists., Results: Phase 1 generated a final list of 74 potential symptoms and signs. In Phase 2, 209 patients with pain caused by LDH (89), NC (63), or NSLBP (57) were included. Items predicting radicular pain caused by LDH (p<.05) were monoradicular leg pain distribution, patient-reported unilateral leg pain, positive straight leg raise test <60° (or femoral stretch test), unilateral motor weakness, and asymmetric ankle reflex. The score had an AUC of 0.91. An easy-to-use weighted set of criteria with similar psychometric characteristics is proposed (specificity 90.4%, sensitivity 70.6%)., Conclusions: Classification criteria for identifying patients with radicular pain caused by LDH are proposed. Their use could improve the homogeneity of patients enrolled in clinical research studies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background Context: Cervical radiculopathy is a common disorder caused by compression of the cervical nerve roots and is characterized by arm pain and altered sensory-motor function. Incongruity in the locations of C6 and C7 dermatomes in competing versions of historical dermatome maps has plagued interpretation of impaired sensation associated with C6 and C7 radiculopathies. Magnetic resonance imaging (MRI) allows accurate identification of the C6 or C7 nerve root compression and therefore makes it possible to explore sensory findings that are associated with compression of specific nerve root., Purpose: This study compared the locations of impaired sensation in subjects with cervical radiculopathy from MRI-confirmed C6 and C7 nerve root compression., Study Design: Case series was used for this study., Patient Sample: A total of 122 subjects with symptoms suggestive of cervical radiculopathy were recruited by 11 spine specialist from 5 practice locations. Of these, 30 subjects had MRI-confirmed C6 and 40 subjects C7 radiculopathy., Outcome Measures: Standardized pinprick sensory examination of the forearm and hand of every subject was performed, and the locations of sensory impairments were recorded., Methods: Sensory examination was performed before reviewing MRI results or performing motor or reflex examination. Areas of impaired sensation were recorded on drawings of the palmar and dorsal forearm and hand, and translated using a grid into 36 specific areas for analysis. Chi-square was used to compare frequencies of findings for each grid area for C6 and C7 radiculopathies. Power analysis suggested that a minimum of 27 subjects in each group were needed to detect a 30 percentage point difference in frequency of sensory impairments. Significance was set at ≤.05., Results: Approximately 80% of subjects had impaired sensation in at least 1 grid area, most often in the distal forearm and hand, and many had findings in multiple areas. There was nearly complete overlap for locations of impaired sensation for C6 and C7 radiculopathy, and the frequencies of impaired sensation differed only in the dorsal aspect of the distal radial forearm where it was twice as common in C6 radiculopathy (p=.02)., Conclusions: The location of sensory impairments associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting compression of either the C6 or C7 nerve roots based on locations of impaired sensation. Impaired sensation in the radial aspect of the distal forearm is more common in C6 radiculopathies., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Prior studies of nonoperative treatment for lumbosacral radiculopathy have identified potential predictors of treatment failure, defined by persistent pain, persistent disability, lack of recovery, or subsequent surgery. However, few predictors have been replicated, with the exception of higher leg pain intensity, as a predictor of subsequent surgery., Questions/purposes: We asked two research questions: (1) Does higher baseline leg pain intensity predict subsequent lumbar surgery? (2) Can other previously identified "candidate" predictors of nonoperative treatment failure be replicated?, Methods: Between January 2008 and March 2009, 154 participants with acute lumbosacral radicular pain were enrolled in a prospective database; 128 participants (83%) received nonoperative treatment and 26 (17%) received surgery over 2-year followup. Ninety-four nonoperative participants (73%) responded to followup questionnaires. We examined associations between previously identified "candidate" predictors and treatment failure defined as (1) subsequent surgery; (2) persistent leg pain on a visual analog scale; (3) persistent disability on the Oswestry Disability Index; or (4) participant-reported lack of recovery over 2-year followup. Confounding variables including sociodemographics, clinical factors, and imaging characteristics were evaluated using an exploratory bivariate analysis followed by a multivariate analysis., Results: With the numbers available, higher baseline leg pain intensity was not an independent predictor of subsequent surgery (adjusted odds ratio [aOR], 1.22 per point of baseline leg pain; 95% confidence interval [CI], 0.98-1.53; p = 0.08). Prior low back pain (aOR, 4.79; 95% CI, 1.01-22.7; p = 0.05) and a positive straight leg raise test (aOR, 4.38; 95% CI, 1.60-11.9; p = 0.004) predicted subsequent surgery. Workers compensation claims predicted persistent leg pain (aOR, 9.04; 95% CI, 1.01-81; p = 0.05) and disability (aOR, 5.99; 95% CI, 1.09-32.7; p = 0.04). Female sex predicted persistent disability (aOR, 3.16; 95% CI, 1.03-9.69; p = 0.05) and perceived lack of recovery (aOR, 2.44; 95% CI, 1.02-5.84; p = 0.05)., Conclusions: Higher baseline leg pain intensity was not confirmed as a predictor of subsequent surgery. However, the directionality of the association seen was consistent with prior reports, suggesting Type II error as a possible explanation; larger studies are needed to further examine this relationship. Clinicians should be aware of potential factors that may predict nonoperative treatment failure, including prior low back pain or a positive straight leg raise test as predictors of subsequent surgery, workers compensation claims as predictors of persistent leg pain and disability, and female sex as a predictor of persistent disability and lack of recovery., Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Study Design: Comparative study using combined data from 2 prospective cohort studies., Objective: To expose the differences between the clinical characteristics of neurogenic claudication from magnetic resonance image-documented lumbar spinal stenosis (LSS) and lumbosacral radicular syndrome from acute, magnetic resonance image-documented, lumbar disc herniation (LDH)., Summary of Background Data: LSS and LDH are the common lumbar disorders that produce lower extremity pain. Though known factors such as pain induced by walking for LSS and the rapid onset of symptoms for LDH are useful for differentiating these disorders, exploration of differences in other factors has received limited study., Methods: This study included participants aged 60 yr or older from 2 previous studies. One examined walking limitations caused by LSS and the second the natural history of LDH in elderly adults. The clinical features of both groups were compared by calculating means, medians, and standard deviations for continuous variables, and frequencies for categorical variables. χ test was used to explore differences between LSS and LDH for categorical variables, and Student t test or Mann-Whitney test for continuous variables., Results: Participants with LSS had more medical comorbidity, less intense leg pain, and less disability than those with LDH. Leg pain was more common in the anterior thigh, anterior knee and shin in LDH, and in the posterior knee in LSS. Trunk flexion was more impaired in LDH. Positive straight leg raising and femoral stretch signs were common in LDH, and rare in LSS. Abnormal Achilles reflexes were noted more frequently in LSS., Conclusion: In addition to established factors, greater leg pain intensity, greater disability, and pain in the anterior leg are more common in the elderly with LDH than in the elderly with LSS. Normal trunk flexion, absence of nerve root tension signs and abnormal Achilles reflexes are more common in LSS., Level of Evidence: 3.

Objectives: To determine recurrence rates of lower-extremity radicular pain after nonsurgical treatment of acute symptomatic lumbar disk herniation (LDH), and to identify predictors of recurrence., Design: Prospective inception cohort., Setting: Outpatient spine clinic., Participants: Patients (N=79) reporting resolution of radicular pain after magnetic resonance imaging confirmation of LDH., Interventions: Individualized nonsurgical treatment tailored to the patient. All patients received education, but other treatments varied depending on the individual., Main Outcome Measures: Resolution of radicular pain was defined as a pain-free period of ≥1 month. Patients who reported resolution of radicular pain within 1 year after seeking care for acute LDH were asked whether pain had recurred at 1 year after seeking care and were also reassessed 1 year after the time of resolution of radicular pain and 2 years after seeking care. Patients reported on recurrence and the date of recurrence, if any. We evaluated the 1-year incidence of recurrence, using Kaplan-Meier survival plots. We examined predictors of recurrence using bivariate and multivariate Cox proportional hazards models. We examined the secondary outcome of back pain recurrence using identical methods., Results: Twenty-five percent (95% confidence interval [CI], 15-35) of individuals with resolution of radicular pain for at least 1 month reported subsequent recurrence of pain within 1 year after resolution. The only factor independently associated with radicular pain recurrence was the number of months prior to resolution of pain (hazard ratio per month=1.24; 95% CI, 1.13-1.37; P<.001). The 1-year incidence of back pain recurrence was 43% (95% CI, 30-56), and older age decreased the hazard of recurrence., Conclusions: Recurrence of radicular pain is relatively common after nonsurgical treatment of LDH and is predicted by longer time to initial resolution of pain., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: No prior studies have examined systematic bias in the musculoskeletal physical examination. The objective of this study was to assess the effects of bias due to prior knowledge of lumbar spine magnetic resonance imaging findings (MRI) on perceived diagnostic accuracy of the physical examination for lumbar radiculopathy., Methods: This was a cross-sectional comparison of the performance characteristics of the physical examination with blinding to MRI results (the 'independent group') with performance in the situation where the physical examination was not blinded to MRI results (the 'non-independent group'). The reference standard was the final diagnostic impression of nerve root impingement by the examining physician. Subjects were recruited from a hospital-based outpatient specialty spine clinic. All adults age 18 and older presenting with lower extremity radiating pain of duration ≤ 12 weeks were evaluated for participation. 154 consecutively recruited subjects with lumbar disk herniation confirmed by lumbar spine MRI were included in this study. Sensitivities and specificities with 95% confidence intervals were calculated in the independent and non-independent groups for the four components of the radiculopathy examination: 1) provocative testing, 2) motor strength testing, 3) pinprick sensory testing, and 4) deep tendon reflex testing., Results: The perceived sensitivity of sensory testing was higher with prior knowledge of MRI results (20% vs. 36%; p = 0.05). Sensitivities and specificities for exam components otherwise showed no statistically significant differences between groups., Conclusions: Prior knowledge of lumbar MRI results may introduce bias into the pinprick sensory testing component of the physical examination for lumbar radiculopathy. No statistically significant effect of bias was seen for other components of the physical examination. The effect of bias due to prior knowledge of lumbar MRI results should be considered when an isolated sensory deficit on examination is used in medical decision-making. Further studies of bias should include surgical clinic populations and other common diagnoses including shoulder, knee and hip pathology.

Study Design: Consecutive case series of patients with C6 and C7 radiculopathies., Objectives: To explore the clinical utility and reliability of manual muscle testing of forearm pronation strength in C6 and C7 radiculopathies., Summary of Background Data: EMG evidence of denervation of the pronator teres was the most common finding in C6 radiculopathies, and frequently present in C7 radiculopathies. Clinical evaluation of the pronator teres through manual muscle testing of forearm pronation has never been explored; therefore, its clinical utility is unknown as compared with the muscle groups that are traditionally evaluated., Methods: Fifty-five subjects with diagnostic imaging evidence of either C6 (n = 25) or C7 (n = 30) cervical root compression and clinical symptoms consistent with cervical radiculopathy were recruited for this study. These subjects underwent manual muscle testing of forearm pronation, wrist extension, elbow flexion, and elbow extension. The frequency of impaired strength was recorded and compared for C6 and C7 radiculopathies. A second examiner evaluated each subject, with his or her findings compared with the first examiner only for the determination of interrater reliability., Results: In C6 radiculopathy subjects, forearm pronation weakness was present in 72%, was twice as common as wrist extension weakness, was present in all cases where elbow flexion or wrist extension weakness was noted, and was found in all but 2 subjects where elbow extension weakness was present. In C7 radiculopathy subjects, forearm pronation weakness accompanies elbow extension weakness in 23% of subjects and was the only weakness in 10% of subjects. Manual muscle testing demonstrated adequate interrater reliability., Conclusions: Forearm pronation weakness is the most frequent motor finding in C6 radiculopathies and may be noted is some cases of C7 nerve root compression.

Study Design: This prospective cohort study evaluated four office tests of quadriceps strength in symptomatic adults with radiographic evidence of L3 or L4 nerve root compression., Objective: The study observed the performance of each test for its ability to detect quadriceps weakness when compared to the asymptomatic side. To determine the potential influence of radicular pain on the performance of the four tests, a control group of patients over the age of 40 with clinical and radiographic L5 or S1 radiculopathies underwent identical testing of quadriceps strength., Summary of Background Data: The L3 and L4 nerve roots innervate the quadriceps; therefore, quadriceps weakness may be a consequence of L3 or L4 radiculopathies. There are no standardized or validated methods to evaluate quadriceps strength in the clinical office setting. This may lead to inconsistent detection by clinicians of quadriceps weakness in cases of L3 or L4 radiculopathy., Methods: Thirty-three consecutive patients with L3 or L4 radiculopathies and 19 with L5 or S1 radiculopathies were studied. The four tests of quadriceps strength included: 1) single leg sit-to-stand test; 2) step-up test; 3) knee-flexed manual muscle testing; and 4) knee-extended manual muscle testing. Results from a second examiner repeating the four tests were used to calculate interrater reliability., Results: In L3 and L4 radiculopathies, unilateral quadriceps weakness was detected by the single leg sit-to-stand test in 61%, by knee-flexed manual muscle testing in 42%, by step-up test in 27% and by knee-extended manual muscle testing in 9% of patients. The sit-to-stand test detected weakness in all but one case when weakness was detected by another test. All patients with L5 or S1 radiculopathies could perform the sit-to-stand test. Kappa coefficient was high for sit-to-stand test (0.85), step-up (0.83), and knee-flexed manual muscle testing (0.66), and low for knee-extended manual muscle testing (0.08)., Conclusion: In L3 and L4 radiculopathies, unilateral quadriceps weakness was best detected by a single leg sit-to-stand test. Patients of similar age with radicular pain caused by L5 or S1 radiculopathies could perform this test. As the interrater reliability of the single leg sit-to-stand test is high, clinicians should consider utilizing this test for assessing quadriceps strength in cases of L3 and L4 radiculopathies.

Background: Cervical radiculopathy (CR) is a clinical diagnosis defined as a combination of neck, shoulder, and arm pain, often accompanied by sensory and motor symptoms. CR is often caused by degenerative spine pathology associated with impingement of a cervical nerve root, and this pathology can be visualized using magnetic resonance imaging (MRI) or computed tomography (CT). [Correction added September 4, 2019, after online publication: 'computer tomography' corrected to 'computed tomography'] Factors that are associated with the onset of CR have not been explored.Objective: To investigate the types and frequencies of patient-reported inciting events associated with CR in patients with imaged-confirmed pathologies that correlate with symptoms.Design: Prospective observational case series.Setting: Two spine physiatry and three orthopedic spine surgery practices.Patients: One hundred twenty-two patients with symptoms suggestive of CR were recruited. Of these, 107 patients had MRI or CT evidence of cervical disk herniation or foraminal stenosis that correlated with symptoms and matched our inclusion criteria.Methods: We categorized patient-reported inciting events associated with onset of CR into six categories reflecting increasing severity of inciting event, and recorded the clinical characteristics, physical examination findings, pain intensity, and disability. We analyzed the characteristics of patients based on subgroups of inciting events.Results: Two-thirds of patients reported that they either awoke with symptoms or symptoms began without a memorable event, and one-third of patients reported inciting physical activity or trauma associated with the onset of CR. Clinical characteristics of CR were not influenced by categories of inciting events.Conclusion: Most CR with correlating spine pathology was found to have onset without a specific inciting events. Furthermore, physical inciting events did not influence the severity of clinical manifestation of CR.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Abstract: Background context: No prior study has investigated the frequency of patient-identified inciting events in lumbar disc herniation (LDH) or their clinical significance. Purpose: To examine the clinical frequency of patient-identified inciting events in LDH, and to identify associations between the presence of inciting events and the severity of the clinical presentation. Study design/setting: Cross-sectional analysis of data from a cohort study with prospective recruitment, with retrospective data collection on inciting events. The setting was a hospital-based specialty spine clinic. Patient sample: One hundred fifty-four adults with lumbosacral radicular pain and LDH confirmed by magnetic resonance imaging. Outcome measures: Self-report measures of disability measured by the Oswestry Disability Index (ODI), the visual analog scale (VAS) for leg pain, and the VAS for back pain. Methods: Dependent variables included the presence of a patient-identified inciting event, which were categorized as spontaneous onset, nonlifting physical activity, heavy lifting (>35 lbs), light lifting (<35 lbs), nonexertional occurrence, or physical trauma. We examined the association of an inciting event, or a lifting-related event, with each outcome, first using univariate analyses, and second using multivariate modeling, accounting for important adjustment variables. Results: Sixty-two percent of LDH did not have a specific patient-identified event associated with onset of symptoms. Nonlifting activities were the most common inciting event, comprising 26% of all LDH. Heavy lifting (6.5%), light lifting (2%), nonexertional occurrences (2%), and physical trauma (1.3%) accounted for relatively small proportions of all LDH. Patient-identified inciting events were not significantly associated with a more severe clinical presentation in crude analyses. Spontaneous LDH was significantly associated with higher baseline ODI scores in multivariate analysis, although the magnitude of this effect was small. There were no significant associations (p≤.05) between the presence of a lifting-associated event and the outcomes of ODI, VAS leg pain, or VAS back pain. Conclusions: The majority of LDH occurred without specific inciting events. A history of an inciting event was not significantly associated with a more severe clinical presentation. There was no significant association between the occurrence of a lifting-related event and the severity of the clinical presentation. This information may be useful in the counseling of patients recovering from acute LDH. [Copyright &y& Elsevier]