AANEM MONOGRAPH
Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part II)
Timothy R. Dillingham MD MS,
Thiru M. Annaswamy MD, MA, FAAPMR,
Christopher T. Plastaras MD,
Corresponding Author
Timothy R. Dillingham MD MS
Department of Physical Medicine and Rehabilitation, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
Correspondence
Timothy Dillingham, University of Pennsylvania, 1800 Lombard St. First Floor, Philadelphia, PA 19146.
Email: [email protected]
Search for more papers by this authorThiru M. Annaswamy MD, MA, FAAPMR
Electrodiagnostic and Spine Sections, VA North Texas Health Care System, Dallas VA Medical Center, Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
Search for more papers by this authorChristopher T. Plastaras MD
Musculoskeletal Spine & Sports Rehabilitation Medicine, MossRehab, Einstein Spine Institute, Co-Chair, Albert Einstein Healthcare Network, Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
Search for more papers by this authorTimothy R. Dillingham MD MS,
Thiru M. Annaswamy MD, MA, FAAPMR,
Christopher T. Plastaras MD,
Corresponding Author
Timothy R. Dillingham MD MS
Department of Physical Medicine and Rehabilitation, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
Correspondence
Timothy Dillingham, University of Pennsylvania, 1800 Lombard St. First Floor, Philadelphia, PA 19146.
Email: [email protected]
Search for more papers by this authorThiru M. Annaswamy MD, MA, FAAPMR
Electrodiagnostic and Spine Sections, VA North Texas Health Care System, Dallas VA Medical Center, Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
Search for more papers by this authorChristopher T. Plastaras MD
Musculoskeletal Spine & Sports Rehabilitation Medicine, MossRehab, Einstein Spine Institute, Co-Chair, Albert Einstein Healthcare Network, Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
Search for more papers by this authorAbbreviations: AANEM, American Association of Neuromuscular and Electrodiagnostic Medicine; CRD, complex repetitive discharge; CSM, cervical spondylotic myelopathy, CT, computed tomography, DRG, dorsal root ganglion; EDX, electrodiagnostic; EMG, electromyography; ESI, epidural steroid injection; LBP, low back pain; LDRS, lumbar dorsal root syndrome; MRI, magnetic resonance imaging; NA, neuralgic amyotrophy; NASS, North American Spine Society; NCS, nerve conduction study; NSAID, nonsteroidal anti-inflammatory drugs; PL, peroneus longus; PM, paraspinal mapping; PSW, positive sharp wave; PT, pronator teres; SCI, spinal cord injury; SNAP, sensory nerve action potential; TA, tibialis anterior; TP, tibialis posterior
Answer questions and earn CME https://education.aanem.org/URL/MM67.
Abstract
The electrodiagnostic (EDX) examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and complements imaging of the spine. In this second of a two-part review, the implications of electrodiagnostic findings for diagnosis and clinical management of persons with radiculopathy are reviewed. An EMG confirmed lumbosacral radiculopathy is associated with better clinical outcomes for persons undergoing aggressive conservative management. A positive EMG test portends a better clinical response to epidural corticosteroid injections. If a person undergoes spine surgery, a positive pre-operative EMG for radiculopathy is also associated with better outcomes.
Abstract
REFERENCES
- 1Dumitru D, Diaz CA, King JC. Prevalence of denervation in paraspinal and foot intrinsic musculature. Am J Phys Med Rehabil. 2001; 80(7): 482-490.
- 2Date ES, Mar EY, Bugola MR, Teraoka JK. The prevalence of lumbar paraspinal spontaneous activity in asymptomatic subjects. Muscle Nerve. 1996; 19: 350-354.
10.1002/(SICI)1097-4598(199603)19:3<350::AID-MUS11>3.0.CO;2-W CAS PubMed Web of Science® Google Scholar
- 3Nardin R, Raynor EM, Rutkove SB. Electromyography of lumbrosacral paraspinal muscles in normal subjects. Neurology. 1997; 48: A147.
- 4Haig AJ. Clinical experience with paraspinal mapping. I: neurophysiology of the paraspinal muscles in various spinal disorders. Arch Phys Med Rehabil. 1997; 78(11): 1177-1184.
- 5Haig AJ, Geisser ME, Tong HC, et al. Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms. J Bone Joint Surg Am. 2007; 89(2): 358-366.
- 6Haig AJ, Tong HC, Yamakawa KS, et al. The sensitivity and specificity of electrodiagnostic testing for the clinical syndrome of lumbar spinal stenosis. Spine (Phila Pa 1976). 2005; 30(23): 2667-2676.
- 7Haig AJ, Tzeng HM, LeBreck DB. The value of electrodiagnostic consultation for patients with upper extremity nerve complaints: a prospective comparison with the history and physical examination. Arch Phys Med Rehabil. 1999; 80: 1273-1281.
- 8Haig AJ. Clinical experience with paraspinal mapping. II: a simplified technique that eliminates three-fourths of needle insertions. Arch Phys Med Rehabil. 1997; 78(11): 1185-1190.
- 9Haig AJ. Paraspinal denervation and the spinal degenerative cascade. Spine J. 2002; 2(5): 372-380.
- 10Haig AJ. The prevalence of lumbar paraspinal spontaneous activity in asymptomatic subjects. Muscle Nerve. 1996; 19(11): 1503-1504.
- 11Haig AJ, Goodmurphy CW, Harris AR, Ruiz AP, Etemad J. The accuracy of needle placement in lower-limb muscles: a blinded study. Arch Phys Med Rehabil. 2003; 84(6): 877-882.
- 12Haig AJ, LeBreck D, Powley S. Paraspinal mapping. Quantified needle electromyography of the paraspinal muscles in persons without low back pain. Spine (Phila Pa 1976). 1995; 20(6): 715-721.
- 13Haig AJ, Tong HC, Yamakawa KS, et al. Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Arch Phys Med Rehabil. 2006; 87(7): 897-903.
- 14Tong HC, Haig AJ, Yamakawa KS, Miner JA. Paraspinal electromyography: age-correlated normative values in asymptomatic subjects. Spine (Phila Pa 1976). 2005; 30(17): E499-E502.
- 15Tong HC, Haig AJ, Yamakawa KS, Miner JA. Specificity of needle electromyography for lumbar radiculopathy and plexopathy in 55 to 79 year old asymptomatic subjects. Am J Phys Med Rehabil. 2006; 85(11): 908-912.
- 16Tong HC. Specificity of needle electromyography for lumbar radiculopathy in 55 to 79 year old subjects with low back pain and sciatica without stenosis. Am J Phys Med Rehabil. 2011; 90(3): 233-238. quiz 239–242. Erratum in Am J Phys Med Rehabil 2011;90(10):874.
- 17Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. J Anat. 1982; 134(Pt 2): 383-397.
- 18Kottlors M, Glocker FX. Polysegmental innervation of the medial paraspinal lumbar muscles. Eur Spine J. 2008; 17: 300-306.
- 19Levin KH. Electrodiagnostic approach to the patient with suspected radiculopathy. Neurol Clin N Am. 2002; 20: 397-342.
- 20Caress JB, Rutkove SB, Carlin M, Khoshbin S, Preston DC. Paraspinal muscle hematoma after electromyography. Neurology. 1996; 47(1): 269-272.
- 21London Z, Quint DJ, Haig AJ, Yamakawa KS. The risk of hematoma following extensive electromyography of the lumbar paraspinal muscles. Muscle Nerve. 2012; 46(1): 26-30.
- 22LaBan MM, Meerschaert JR, Perez L, Goodman PA. Metastatic disease of the paraspinal muscles: electromyographic and histopathologic correlation in early detection. Arch Phys Med Rehabil. 1978; 59: 34-36.
- 23LaBan MM, Tamler MS, Wang AM, Meerschaert JR. Electromyographic detection of paraspinal muscle metastasis. Correlation with magnetic resonance imaging. Spine (Phila Pa 1976). 1992; 17(10): 1144-1147.
- 24Kuncl RW, Cornblath DR, Griffin JW. Assessment of thoracic paraspinal muscles in the diagnosis of ALS. Muscle Nerve. 1988; 11: 484-492.
- 25See DH, Kraft GH. Electromyography in paraspinal muscles following surgery for root compression. Arch Phys Med Rehabil. 1975; 56: 80-83.
- 26Danner R. Occurrence of transient positive sharp wave like activity in the paraspinal muscles following lumbar puncture. Electromyogr Clin Neurophysiol. 1982; 22: 149-154.
- 27Date ES, Kim BJ, Yoon JS, Park BK. Cervical paraspinal spontaneous activity in asymptomatic subjects. Muscle Nerve. 2006; 34(3): 361-364.
- 28Gilad R, Dabby R, Boaz M, Sadeh M. Cervical paraspinal electromyography: normal values in 100 control subjects. J Clin Neurophysiol. 2006; 23(6): 573-576.
- 29Dreyer SJ, Dreyfuss PH. Low back pain and the zygapophysial (facet) joints. Arch Phys Med Rehabil. 1996; 77(3): 290-300.
- 30Min JH, Choi HS, Ihl Rhee W, Lee JI. Association between radiculopathy and lumbar multifidus atrophy in magnetic resonance imaging. J Back Musculoskelet Rehabil. 2013; 26(2): 175-181.
- 31Sihvonen T, Partanen J. Segmental hypermobility in lumbar spine and entrapment of dorsal rami. Electromyogr Clin Neurophysiol. 1990; 30(3): 175-180.
- 32Zhou L, Schneck C, Shao Z. The anatomy of dorsal ramus nerves and its implications in lower back pain. Neurosci Med. 2012; 3: 192-201.
10.4236/nm.2012.32025 Google Scholar
- 33Bogduk N. Lumbar dorsal ramus syndrome. Med J Aust. 1980; 2(10): 537-541.
- 34Sihvonen T, Lindgren KA, Airaksinen O, Leino E, Partanen J, Hanninen O. Dorsal ramus irritation associated with recurrent low back pain and its relief with local anesthetic or training therapy. J Spinal Disord. 1995; 8(1): 8-14.
- 35Mathur JG. Lumbar dorsal ramus syndrome. Med J Aust. 1981; 2(8): 388.
- 36Annaswamy TM, Bierner SM, Doppalapudi H. Does lumbar dorsal ramus syndrome have an objective clinical basis? PM R. 2013; 5(12): 996-1006.
- 37Dillingham TR, Pezzin LE, Lauder TD. Cervical paraspinal muscle abnormalities and symptom duration: a multivariate analysis. Muscle Nerve. 1998; 21: 640-642.
10.1002/(SICI)1097-4598(199805)21:5<640::AID-MUS11>3.0.CO;2-Z CAS PubMed Web of Science® Google Scholar
- 38Dillingham TR, Pezzin LE, Lauder TD. Relationship between muscle abnormalities and symptom duration in lumbosacral radiculopathies. Am J Phys Med Rehabil. 1998; 77: 103-107.
- 39Pezzin LE, Dillingham TR, Lauder TD, et al. Cervical radiculopathies: relationship between symptom duration and spontaneous EMG activity. Muscle Nerve. 1999; 22: 1412-1418.
10.1002/(SICI)1097-4598(199910)22:10<1412::AID-MUS11>3.0.CO;2-U CAS PubMed Web of Science® Google Scholar
- 40Dillingham TR, Pezzin LE, Lauder TD, et al. Symptom duration and spontaneous activity in lumbosacral radiculopathy. Am J Phys Med Rehabil. 2000; 79: 124-132.
- 41Zambelis T, Piperos P, Karandreas N. Fibrillation potentials in paraspinal muscles in chronic lumbosacral radiculopathy. Acta Neurol Scand. 2002; 105: 314-317.
- 42Savage NJ, Fritz JM, Kircher JC, Thackeray A. The prognostic value of electrodiagnostic testing in patients with sciatica receiving physical therapy. Eur Spine J. 2015; 24: 434-443.
- 43Rigler I, Podnar S. Impact of electromyographic findings on choice of treatment and outcome. Eur J Neurol. 2007; 14(7): 783-787.
- 44Forero JJ, Ortiz-Corredor F, Díaz-Ruiz J, Lozano-Castillo A, Mendoza-Pulido C. Changes in electromyographic results of patients with lumbar radiculopathy: a follow-up study. Arch Phys Med Rehabil. 2013; 94(7): 1287-1292.
- 45Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005; 353: 392-399.
- 46Polston D. Cervical radiculopathy. Neurol Clin. 2007; 25(2): 373-385.
- 47Zhang Y, Chee A, Shi P, et al. Intervertebral disc cells produce interleukins found in patients with back pain. Am J Phys Med Rehabil. 2016; 95(6): 407-415.
- 48Sen O, Aydin MV, Bagdatoglu C, et al. Can E-selectin be a reliable marker of inflammation in lumbar disc disease? Neurosurg Rev. 2005; 28: 214-217.
- 49Lee SJ, Han TR, Hyun JK, Jeon JY, Myong NH. Electromyographic findings in nucleus pulposus-induced radiculopathy in the rat. Spine (Phila Pa 1976). 2006; 31(18): 2053-2058.
- 50Saal JS, Franson RC, Dobrow R, Saal JA, White AH, Goldthwaite N. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Spine (Phila Pa 1976). 1990; 15(7): 674-678.
- 51Casey E. Natural history of radiculopathy. Phys Med Rehabil Clin N Am. 2011; 22(1): 1-5.
- 52Weber H, Holme I, Amilie E. The natural course of acute sciatica, with nerve root symptoms in a double blind placebo-controlled trial evaluating the effect of piroxicam. Spine. 1993; 18: 1433-1438.
- 53Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004; 29(23): 2593-2602.
- 54Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010; 11: 1149-1168.
- 55Kennedy DJ, Plastaras C, Casey E, et al. Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospective, randomized, double-blind trial. Pain Med. 2014; 15(4): 548-555.
- 56Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015; 313(19): 1915-1923.
- 57Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). 1983; 8(2): 131-140.
- 58Wenger HC, Cifu AS. Treatment of low back pain. JAMA. 2017; 318(8): 743-744.
- 59Hakelius A. Prognosis in sciatica: a clinical follow-up of surgical and non surgical treatment. Acta Orthop Scand Suppl. 1970; 129: 1-76.
- 60Johnson EW, Fletcher FR. Lumbosacral radioculopathy: review of 100 consecutive cases. Arch Phys Med Rehabil. 1981; 62(7): 321-323.
- 61Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine (Phila Pa 1976). 1989; 14(4): 431-437.
- 62Saal JA. Dynamic muscular stabilization in the nonoperative treatment of lumbar pain syndromes. Orthop Rev. 1990; 19(8): 691-700.
- 63Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017; 166(7): 514-530.
- 64Herrmann WA, Geertsen MS. Efficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomised, double-blind, multicentre, parallel-group study. Int J Clin Pract. 2009; 63(11): 1613-1621.
- 65Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE Randomized Clinical Trial. JAMA. 2018; 319(9): 872-882.
- 66Pareek A, Chandurkar N, Chandanwale AS, Ambade R, Gupta A, Bartakke G. Aceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone. Eur Spine J. 2009; 18(12): 1836-1842.
- 67Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016; 315(15): 1624-1645.
- 68Baron R, Freynhagen R, Tölle TR, et al. The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy. Pain. 2010; 150(3): 420-427.
- 69Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. New Engl J Med. 2017; 376(12): 1111-1120.
- 70Bush K, Cowan N, Katz DE, Gishen P. The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976). 1992; 17(10): 1205-1212.
- 71Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994; 117(Pt 2): 325-335.
- 72Lees F, Turner JW. Natural history and prognosis of cervical spondylosis. Br Med J. 1963; 2: 1607-1610.
- 73Spurling R, Segerberg L. Lateral intervertebral disk lesions in the lower cervical region. JAMA. 1953; 151(5): 354-359.
- 74Martin G, Corbin K. An evaluation of conservative treatment for patients with cervical disk syndrome. Arch Phys Med Rehabil. 1954; 35: 87.
- 75Honet J, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil. 1976; 57: 12.
- 76Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc. 1997; 29(7) Suppl: S236-S245.
- 77Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine (Phila Pa 1976). 1996; 21(16): 1877-1883.
- 78Ghasemi M1, Masaeli A, Rezvani M, Shaygannejad V, Golabchi K, Norouzi R. Oral prednisolone in the treatment of cervical radiculopathy: a randomized placebo controlled trial. J Res Med Sci. 2013; 18(Suppl 1): S43-S46.
- 79Benzon HT. Epidural steroid injections for low back pain and lumbosacral radiculopathy. Pain. 1986; 24(3): 277-295.
- 80Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014; 14(1): 180-191.
- 81Hopwood MB, Abram SE. Factors associated with failure of lumbar epidural steroids. Reg Anesth. 1993; 18(4): 238-243.
- 82Deyo RA, Battie M, Beurskens AJ, et al. Outcome measures for low back pain research. A proposal for standardized use. Spine (Phila Pa 1976). 1998; 23(18): 2003-2013.
- 83Radcliff K, Hilibrand A, Lurie JD, et al. The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. J Bone Joint Surgery Am. 2012; 94(15): 1353-1358.
- 84van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014; 15(7): 1100-1108.
- 85Annaswamy TM, Bierner SM, Chouteau W, Elliott AC. Needle electromyography predicts outcome after lumbar epidural steroid injection. Muscle Nerve. 2012; 45(3): 346-355.
- 86Fish DE, Shirazi EP, Pham Q. The use of electromyography to predict functional outcome following transforaminal epidural spinal injections for lumbar radiculopathy. J Pain. 2008; 9(1): 64-70.
- 87McCormick Z, Cushman D, Caldwell M, et al. Does electrodiagnostic confirmation of radiculopathy predict pain reduction after transforaminal epidural steroid injection? A multicenter study. J Nat Sci. 2015; 1(8): e–140.
- 88Batistaki C, Angelopoulou A, Smyrnioti ME, Kitsou MC, Kostopanagiotou G. Electromyographic findings after epidural steroid injections in patients with radicular low back pain: a prospective open-label study. Anesth Pain Med. 2017; 7(6):e62556.
- 89Bigos S, Bowyer O, Braen G. Acute Low Back Problems in Adults. AHCPR Clinical Practice Guidelines, No. 14. Report No.: 95-0642. Rockville, MD: Agency for Health Care Policy and Research (AHCPR); 1994.
- 90Matz PG, Anderson PA, Holly LT, et al. Joint section on disorders of the spine and peripheral nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. The natural history of cervical spondylotic myelopathy. J Neurosurg Spine. 2009; 11(2): 104-111.
- 91Spengler DM, Freeman CW. Patient selection for lumbar discectomy. An objective approach. Spine (Phila Pa 1976). 1979; 4(2): 129-134.
- 92Spengler DM, Ouellette EA, Battie M, Zeh J. Elective discectomy for herniation of a lumbar disc: additional experience with an objective method. J Bone Joint Surg. 1990; 72A: 230-237.
- 93Alrawi MF, Khalil NM, Mitchell P, Hughes SP. The value of neurophysiological and imaging studies in predicting outcome in the surgical treatment of cervical radiculopathy. Eur Spine J. 2007; 16(4): 495-500.
- 94E1 K, Luoma K, Pitkäniemi J, Kerttula L, Grönblad M. Correlation of size and type of modic types 1 and 2 lesions with clinical symptoms: a descriptive study in a subgroup of patients with chronic low back pain on the basis of a university hospital patient sample. Spine (Phila Pa 1976). 2012; 37(2): 134-139.
- 95Robinson LR. Electromyography, magnetic resonance imaging, and radiculopathy: it's time to focus on specificity. Muscle Nerve. 1999; 22(2): 149-150.
10.1002/(SICI)1097-4598(199902)22:2<149::AID-MUS1>3.0.CO;2-S CAS PubMed Web of Science® Google Scholar
- 96Nardin R, Patel M, Gudas T, et al. Electromyography and magnetic resonance imaging in the evaluation of radiculopathy. Muscle Nerve. 1999; 22: 151-155.
10.1002/(SICI)1097-4598(199902)22:2<151::AID-MUS2>3.0.CO;2-B CAS PubMed Web of Science® Google Scholar
- 97Boden S, Davis D, Dina T, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg. 1990; 72: 403-408.
- 98Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. New Engl J Med. 1994; 331(2): 69-73.
- 99Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015; 40(6): 392-398.
- 100Yagci I, Gunduz OH, Ekinci G, Diracoglu D, Us O, Akyuz G. The utility of lumbar paraspinal mapping in the diagnosis of lumbar spinal stenosis. Am J Phys Med Rehabil. 2009; 88(10): 843-851.
- 101Kreiner DS, Shaffer WO, Baisden JL, et al. North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013; 13(7): 734-743. Review.
- 102Nicotra A, Khalil NM, O'Neill K. Cervical radiculopathy: discrepancy or concordance between electromyography and magnetic resonance imaging? Br J Neurosurg. 2011; 25(6): 789-790.
- 103Soltani ZR, Sajadi S, Tavana B. A comparison of magnetic resonance imaging with electrodiagnostic findings in the evaluation of clinical radiculopathy: a cross-sectional study. Eur Spine J. 2014; 23: 916-921.
- 104Lee JH, Lee SH. Physical examination, magnetic resonance imaging, and electrodiagnostic study of patients with lumbosacral disc herniation or spinal stenosis. J Rehabil Med. 2012; 44: 845-850.
- 105Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G. An international comparison of back surgery rates. Spine (Phila Pa 1976). 1994; 19(11): 1201-1206.
- 106Fox J, Haig AJ, Todey B, Challa S. The effect of required physiatrist consultation on surgery rates for back pain. Spine (Phila Pa 1976). 2013; 38(3): E178-E184.
- 107Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018; 360:j5790.
- 108Tong HC, Young IA, Koch J, Haig AJ, Yamakawa KSJ, Wallbom A. Paraspinal electromyography that compares concentric with monopolar needles: a blinded study. Am J Phys Med Rehabil. 2003; 82: 917-924.
Citing Literature
