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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
BACKGROUND
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%
009@3019/98/$19.00
PII SOO90-3019(97)002814
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II
Surg Neurol
1998;49:210-4
AFFECTED
LEVEL
PERCENT
AFFEcTED
LEVEL
c 314
415
C 516
C 617
CI/Thl
91
35
40
2
Brachialgia
13
PERCENT
L 314
213
L 4j5
L 5/s1
:
51
Sciatica*
13
ROOT
C6
c7
C8
L3
L4
L5
Sl
30
showed no
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
SENSORY
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
BRACHIALGIA
SIGNS
47
75
171
39%
67%(65%)
47%(51%)
44%(46%)
43%(45%)
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).
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-
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
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
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
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.
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
2 14
7.
8.
9.
10.
11.
12.
13.
14.
15.
Woertgen et al
Surg Neurol
1998;49:210-4
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
The National
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