T h e El e c t ro d i a g n o s t i c

Evaluation of
Radiculopathy
Christopher T. Plastaras, MD*, Anand B. Joshi, MD, MHA

KEYWORDS
 Electromyography  Radiculopathy  Electrodiagnosis
 Spinal stenosis

The clinical diagnosis of radiculitis indicates limb pain emanating from a spinal nerve or
spinal nerve root. Objective findings of strength or reflex deficits or electrodiagnostic
changes suggest nerve root dysfunction termed radiculopathy. Although commonly
caused by structural lesions, such a herniated nucleus pulposus or degenerative spon-
dylosis, radiculopathy can also be caused by inflammatory, infectious, or malignant
disorders.1 Structural causes of radiculopathy may be readily apparent through
common imaging modalities, such as MRI or computed axial tomography.2 However,
MRI is associated with a significantly high false-positive rate in asymptomatic individuals
and increases with age.3,4 In such equivocal cases, imaging may be complemented by
electrodiagnostic testing. Electrodiagnostic testing is a functional evaluation of the
nervous system. Electrodiagnostic testing also has the added benefit of allowing objec-
tive documentation of the chronicity and severity of peripheral nervous system disease.5

DEFINITION

Electrodiagnosis is a broad term encompassing multiple electrodiagnostic tech-

niques, including needle electrode examination (NEE); motor and sensory nerve
conduction studies (NCS), including late responses; and evoked potentials. These
tests are frequently used in various combinations in the evaluation of radiculopathy
primarily to rule out other disorders in the peripheral and central nervous system;
however, the NEE is considered the crucial component in the electrodiagnostic eval-
uation of radiculopathy. To meet the electrodiagnostic criteria for a radiculopathy,
abnormalities must be demonstrated in at least 2 muscles innervated by the same
nerve root but different peripheral nerves with no abnormalities detected in muscles
innervated by the adjacent nerve roots.

The authors have nothing to disclose.

Penn Spine Center, Department of Physical Medicine & Rehabilitation, University of Pennsylvania,
3400 Spruce Street, Ground Floor, White Building, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: [email protected]

Phys Med Rehabil Clin N Am 22 (2011) 59–74

doi:10.1016/j.pmr.2010.10.005 pmr.theclinics.com
1047-9651/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.

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60 Plastaras & Joshi

HISTORY AND EXAMINATION

The symptoms of many musculoskeletal and peripheral nerve disorders overlap with
the clinical presentation of radiculopathy, therefore electrodiagnostic testing may be
ordered for these populations to aide in establishing a diagnosis. Electrodiagnostic
testing is not infallible and may be painful and expensive, therefore, as with many other
forms of advanced diagnostic testing, electrodiagnosis should only be used as an
extension of the history and physical examination. There have been studies done to
evaluate the relationship between physical examination and electrodiagnostics.
When 170 subjects were referred to an electrodiagnostic laboratory, 32% were diag-
nosed with a musculoskeletal disorder by standardized physical examination.6
However, of those subjects with normal electrodiagnostic studies, the prevalence of
musculoskeletal disorders increased to 55%. When there was electrodiagnostic
evidence of radiculopathy, the presence of a musculoskeletal disorder was still 21%.
The significant overlap between the presence of lower-extremity musculoskeletal
disorders and lumbosacral radiculopathy suggests that the presence or absence of
a musculoskeletal diagnosis does not accurately predict which patients will have
normal electrodiagnostic studies.6 In another study Lauder and colleagues7 calculated
sensitivities, specificities, and predictive values of various symptoms and signs for
those with an abnormal electrodiagnostic study. No historical feature was found to
be significantly associated with an abnormal electrodiagnostic study. The most sensi-
tive historical feature was the presence of radicular leg pain (86%), though this symptom
had a specificity of only 12%. The investigators evaluated several physical examination
findings and found the following sensitivities and specificities (sensitivity/specificity):
reduced vibration or pinprick sensation (50%/62%), Achilles or patellar reflex deficit
(25%/87%), weakness of any muscle (69%/53%), and positive straight leg raise
(21%/87%). However, in subjects that had any 4 abnormal physical findings there
was a greater than 6 times likelihood that the electromyogram (EMG) study would be
abnormal when compared with cases with a normal physical examination.
As with lumbosacral radiculopathies, the value of the history and physical examina-
tion in predicting cervical radiculopathies has also been studied.8 Subjects with symp-
toms of numbness, tingling, and subjective weakness were more than twice as likely to
have abnormal electrodiagnostic testing.8 Unfortunately, none of these symptoms
were significant for radiculopathy specifically. In contrast, the presence of weakness,
abnormal reflexes, or abnormal sensation on physical examination indicates a greater
than 4 times likelihood of having an abnormal electrodiagnostic study, with a greater
than 2 times likelihood of confirming a cervical radiculopathy. A particularly valuable
physical examination finding is an abnormal biceps reflex, which increases the odds
ratio of making an EMG diagnosis of cervical radiculopathy to 10. In general, the
combination of having weakness and a reduced reflex was a strong predictor of
both an abnormal electrodiagnostic study, including radiculopathy specifically.
Notably, up to 48% of individuals with abnormal electrodiagnostic results will have
a normal physical examination, emphasizing the physical examination’s relative lack
of sensitivity when using electrodiagnosis as a gold standard.

NERVE ROOT VARIATION

As previously described, the electrodiagnosis of radiculopathy relies upon a myotomal

pattern of abnormalities found on NEE. However, variation in the anatomic pattern of
nerve roots is known to exist and must be accounted for in the interpretation of the
NEE. A study of 200 spontaneously aborted fetuses revealed 107 (53.5%) to show
significant variation from the most common arrangement of the brachial plexus.9

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 The Electrodiagnostic Evaluation of Radiculopathy 61

The most common variants of brachial plexus organization are described as the
prefixed and postfixed plexus. These variants have been variously defined10 and
emphasize the contributions of the C4 and T2 roots. A prefixed plexus is characterized
by a C4 branch that is larger than the branch from T2.11 The electromyographic impli-
cations of this are that C4 may contribute to the innervation of the shoulder girdle
musculature, which is more typically C5. In contrast, a postfixed plexus contains
a large contribution from T2, and a small contribution from C4.11 Prefixation may be
seen in up to 48% of specimens9,12; whereas, postfixation is seen in 0.5% to 4.0%
of cases.9,12
Precise localization through the NEE is similarly challenged in the electrodiagnosis
of lumbosacral radiculopathy. Though the vast majority of lumbosacral radiculopa-
thies occur at either L5 (47.6%) or S1 (30%),13 both of these nerve roots may show
significant variation from normal patterns of innervations. In a study of 50 subjects
undergoing lumbar decompression surgery, intraoperative stimulation of the L5 and
S1 nerve roots revealed 16% to have significant deviations from normal.14 Common
anomalies in this study include dominant nerve roots that were expressed more
heavily in muscles than normal, and such anomalies were more frequent in subjects
with transitional vertebral segments. A novel study15 compared the neurologic symp-
toms generated by selective nerve root blocks using electrical stimulation in subjects
with transitional and normal lumbar segments. In this study, when L5 is sacralized, the
function of the L5 nerve root becomes similar to the S1 nerve root. Such normal vari-
ations in peripheral nervous system anatomy must be accounted for in the perfor-
mance of the NEE.

SENSITIVITY OF EMG

Although the diagnosis of radiculopathy hinges upon the NEE, the sensitivity of EMG in
detecting radiculopathy is limited by several factors. First this procedure is targeted
exclusively toward motor axons. Radiculopathies with predominant sensory root
involvement, even if severe, will not elicit any needle electrode abnormalities.5
However, substantial demyelinating disease may be detected on the NEE by changes
in motor unit recruitment. Unfortunately, significant demyelination at the level of the
nerve root is uncommon.5 Secondly, the electrodiagnostic confirmation of a radiculop-
athy rests upon an identification of a myotomal pattern of abnormalities. Such identi-
fication may not occur if axonal compromise is not severe enough to be detected by
the needle electrode or widespread enough to localize to a particular myotome.16
Thirdly, the appearance of fibrillation potentials is time dependent and may not appear
in limb muscles several weeks after axonal damage.16 Therefore, if done too early, an
NEE will not appreciate fibrillations because they have not yet developed. Also, if done
too late, fibrillation potentials are known to shrink because of muscle atrophy and thus
become more difficult to appreciate. This effect has happened 6 months after the
onset of cervical radiculopathies17 and 12 to 18 months after the onset of lumbosacral
radiculopathies.5
Besides these inherent limitations, measurement of the sensitivity of electrodiag-
nostic studies is complicated by the lack of a gold standard. In determining the sensi-
tivity of electrodiagnostic testing, various criterion standards have been used, such as
clinical, surgical, and radiological findings. The clinical sensitivity of electrodiagnostic
testing in lumbosacral radiculopathy ranges between 49%18 and 84%.14 Haig and
colleagues19 performed a stringent study using validated, anatomic needle placement
into the limb muscles and a quantified “paraspinal mapping” technique to evaluate the
sensitivity and specificity of electrodiagnostic testing in lumbar spinal stenosis. The

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62 Plastaras & Joshi

composite limb and paraspinal fibrillation score showed a sensitivity of 47.8% and
a specificity of 87.5%. This finding agrees with the 44% sensitivity and 86% specificity
obtained by Coster and colleagues20 using radiological evidence of nerve root
compression as a gold standard. In comparison, although the prevalence of both
disc bulges and protrusions increases with age, if not stratified by age, MRI of the
lumbar spine shows a specificity of 36%; only 36% of people without back pain will
have a normal disc at all levels.4 The much higher sensitivity of MRI justifies its appro-
priateness as a screening test; whereas, the greater specificity of electrodiagnostics
suggests that it is better used as a confirmatory test.
Similar to lumbosacral radiculopathy, the electrodiagnostic evaluation of cervical
radiculopathies also shows a wide range of sensitivities, from 50%21 to 95%.22 The
false positive rate of cervical MRI is somewhat lower, but still significant at 14% of
asymptomatic individuals aged less than 40 years and 28% of those aged greater
than 40 years.3 Therefore, electrodiagnostics and MRI can be complementary rather
than competing modalities. Electrodiagnostic studies and MRI will agree in 60% of
patients with symptoms suggestive of radiculopathy and in 76% of cases when weak-
ness is present.2

SENSORY NERVE CONDUCTION STUDIES

Abnormalities in sensory nerve action potentials (SNAP) are not part of the electro-
diagnostic criteria of radiculopathy. However, their performance is necessary to eval-
uate for other disorders that are part of the differential diagnosis of radiculopathy, such
as peripheral polyneuropathy or entrapment mononeuropathy.23 As symptoms of pain
are typically mediated by C-fibers, which are too small to be accessible by standard
electrodiagnostic techniques, sensory nerve parameters, such as amplitude, distal
latency, and nerve conduction velocity, are not expected to be abnormal in radiculop-
athy.24 Also, in radiculopathy the usual location of the lesion is proximal to the dorsal
root ganglion, and degeneration will proceed centrally rather than peripherally.5
However, important exceptions to this dictum must be recognized. When pathology
extends from the intraspinal space into the neural foramen and affects the dorsal
root ganglion, as can happen with malignancy or infection, SNAP amplitude reduction
will occur as a result of wallerian degeneration.24 Additionally, SNAP amplitudes may
be reduced when the dorsal root ganglion has an intraspinal location making it vulner-
able to lesions resulting from lumbar spondylosis. This reduction may occur in L5 rad-
iculopathies, causing reduction of superficial peroneal nerve amplitudes. Reduction of
superficial peroneal nerve amplitudes are seen in 21.1% of patients with L5 radiculop-
athy who are aged less than 60 years.25
Evaluation of possible entrapment mononeuropathy is an important reason to
perform nerve conduction studies in the electrodiagnostic evaluation of radiculopathy.
For example, the prevalence of carpal tunnel syndrome in patients with cervical rad-
iculopathy has been estimated at 22.1%,26 which is significantly greater than esti-
mates for the general population (0.52% for men and 1.49% for women).27 The
double crush hypothesis was put forth in 1973 by Upton and McComas and proposes
that a proximal lesion along an axon, such as that caused by radiculopathy, predis-
poses it to injury at a more distal site.28 Such a mechanism is one hypothesis as to
why the incidence of carpal tunnel syndrome seems to be increased in patients with
cervical radiculopathy.26 However, another study did not reveal any correlation
between the presence of C6 or C7 radiculopathy and abnormal median sensory
responses and C8 radiculopathy and abnormal median motor responses.29 Prior
studies have shown similar results.30,31 Other possible reasons why the incidence of

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 The Electrodiagnostic Evaluation of Radiculopathy 63

carpal tunnel syndrome is increased in patients with cervical radiculopathy is that both
disorders have a common etiology, such as osteoarthritis that leads to both cervical
foraminal and carpal tunnel stenosis.26

MOTOR NERVE CONDUCTION STUDIES

Compound muscle action potentials (CMAP) may be abnormal in the presence of

a radiculopathy if axon loss is occurring. The amplitude of the CMAP can provide
a semiquantitative measure of the number of axons supplying the muscle from which
the recording was made.32 Therefore, L5 and S1 radiculopathies may cause reduction
of peroneal CMAPs, recording from the extensor digitorum brevis and the abductor
hallucis, respectively. However, the CMAP amplitude is not perfectly sensitive to the
presence of a lumbosacral radiculopathy. Significant reduction in CMAP amplitudes
occurs with loss of approximately 50% of motor axons24 and it is rare for this many
nerve root fibers to degenerate.5 Additionally, muscles typically have an overlapping
nerve supply, allowing for redundancy even if individual nerve roots are compromised.
Another limitation of using the CMAP amplitude to diagnose is emphasized in the
evaluation of cervical radiculopathies. The most commonly performed upper extremity
motor nerve conduction studies are the median and ulnar motor nerve conduction
studies to the abductor pollicis brevis and the abductor digiti minimi, respectively.
These muscles are predominantly subserved by the C8 and T1 nerve roots. However,
the most common cervical radiculopathies occur at C7 and C6,5,33 implying that the
most commonly performed upper extremity motor nerve conduction studies will be
insensitive for the most common cervical radiculopathies.

LATE RESPONSES

Late responses are so named because their latency exceeds that of the more
commonly studied M-wave. Their theoretical advantages include their ability to study
the proximal nerve segments where the pathology of radiculopathy lies.
H Reflex
The H reflex was first described by Hoffman in 191834 and subsequently hypothesized
by Magladery to be a monosynaptic reflex that assesses the afferent Ia sensory nerve
and an efferent alpha motor nerve.35 However, other experimental studies have
concluded that the pathways generating the H reflex likely receive an oligosynaptic
contribution.36 In clinical practice, the H reflex is most commonly obtained by stimu-
lating the tibial nerve in the popliteal fossa and recording over the gastroc-soleus to
assess the S1 nerve root, although the H reflex may also be obtained from the flexor
carpi radialis in the forearm. The H reflex requires a longer-duration stimulus that is opti-
mally between 0.5 and 1.0 ms.37 The sensitivity of the H reflex for nerve pathology has
been estimated to be between 82%38 and 89%,39 and can be compromised through
preferential sparing of the fibers that mediate the reflex.5 However, specificity for radi-
culopathy is compromised by several factors. The entire H reflex arc travels through
peripheral nerve, lumbosacral plexus, and spinal nerve roots. Abnormalities in any of
these segments can disturb the H reflex5 and cannot be considered specific for radicul-
opathy. Additionally, H reflexes may not normalize once they become abnormal, limiting
their use in monitoring patients with known S1 radiculopathies.5 Finally, H reflexes may
be abnormal bilaterally in patients aged more than 60 years or secondary to peripheral
polyneuropathy.5 Both latency and amplitude have been used as parameters to eval-
uate the H reflex. Amplitude has been criticized as less sensitive40 because of its vari-
ation with posture, muscle contracture, age, and temperature.41 However, comparative

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64 Plastaras & Joshi

studies have suggested amplitude ratio to be a better parameter of S1 radiculopathy,

particularly when H reflexes are present bilaterally.41 Various techniques have been
described for eliciting the tibial H reflex (Figs. 1 and 2).42,43
More recently, a simple and reproducible method known as the half and half tech-
nique44 described by Nishida has the advantages of producing a biphasic waveform
with initial negative deflection. Such a waveform has easier-to-determine amplitude
and latency parameters in comparison to the triphasic waveforms generated by the other
methods (Figs. 3 and 4).44 However, this method has no published normative data and
has been criticized as producing nonphysiologic wave-forms; further study will be
needed to determine its validity.45
The H reflex may also be obtained in the upper limb by recording from the flexor
carpi radialis (FCR).46 The H reflex may be obtained from the flexor carpi radialis in
90%46 to 95%47 of patients. This test may be used in the electrodiagnosis of C6
and C7 radiculopathies and will remain normal in patients with C5 and C8 radiculopa-
thies.48 The sensitivities and specificities of the FCR H-reflex have been found to be
50% and 86% for C6 radiculopathy and 75% and 86% for C7 radiculopathy.49
The upper limit of normal latency is 21.0 ms with 1.5 ms of side-to-side variation.34
The FCR H reflex may be elicited by the technique described by Jabre in which the
E-1 is placed over the belly of the FCR (one-third of the distance between the medial
epicondyle and radial styloid), the reference over the brachioradialis, and the ground
between the stimulator and the E-1 electrode (Figs. 5 and 6)46:

F Wave
So named because they were originally recorded in the intrinsic foot muscles,35 the F
wave is a late response produced by supramaximal stimulation resulting in antidromic
activation of motor neurons.34 Latency is the parameter most frequently used in the
evaluation of F waves.34 Minimum latency is reported most commonly24 but mean F
wave latencies may dilute measurement error and produce more consistent results.50
When used to evaluate L5/S1 radiculopathy, the sensitivity of F wave abnormalities is
impressively close to that of the NEE.51,52 Additionally, the F wave may be used as
a dynamic test because standing for 3 minutes increases F-wave chronodispersion
in patients with lumbar spinal stenosis.53 However, the specificity of F waves
may be limited by the dilution effect of latency abnormalities being hidden by the
lengthy course of nerve fibers and, like H reflexes, abnormalities will result from any
pathology affecting proximal nerve segments in addition to radiculopathy.5

Fig. 1. Tibial H-Reflex Setup. (Technique suggested by Johnson and Braddom).

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 The Electrodiagnostic Evaluation of Radiculopathy 65

Fig. 2. Tibial H-Reflex Waveform. (Technique suggested by Johnson and Braddom).

EVOKED POTENTIALS

Evoked potentials are the responses of the central nervous system to external stimuli
and somatosensory evoked potentials (SEP) occur as a result of stimulation of afferent
peripheral nerve fibers.54 The use of SEPs in the evaluation of radiculopathy remains
controversial16 and the most recent American Association of Neuromuscular and

Fig. 3. Tibial H-Reflex Setup. (Technique suggested by Nishida).

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66 Plastaras & Joshi

Fig. 4. Tibial H-Reflex Waveform. (Technique suggested by Nishida).

Electrodiagnostic Medicine (AANEM) guideline devoted to the subject indicated that

dermatomal and sensory evoked potentials may be useful to direct further evaluation
and treatment of lumbosacral spinal stenosis.54 The great strength of dermatomal
SEPs is their ability to evaluate segmental level function throughout the neuraxis, in
contrast to mixed nerve action potential.55 Kraft postulates that the abnormalities of
lumbosacral spinal stenosis may be caused by demyelination caused by chronic
compression,55,56 rather than axon loss. Therefore, needle electrode examination
may be unrevealing; whereas, conduction deficits may be readily detected by derma-
tomal SEPs. When using either computed tomography or MRI as a gold standard,
dermatomal somatosensory evoked potentials are found to have 78% sensitivity and
a 93% positive predictive value of multiple root disease indicative of spinal stenosis.57
However, somatosensory evoked potentials must be interpreted in light of their
several disadvantages.24 Dermatomal SEPs cannot distinguish between the various
causes of multiple-root disease, such as lumbosacral spinal stenosis or arachnoiditis,
and are also not felt to be useful for acute radiculopathy.55,56,58 Amplitude

Fig. 5. FCR H-Reflex Setup. (Technique suggested by Jabre).

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 The Electrodiagnostic Evaluation of Radiculopathy 67

Fig. 6. FCR H-Reflex Waveform. (Technique suggested by Jabre).

measurements have too much normal variation to have clinical significance. Additionally,
focal slowing in the root may be diluted by normal conduction in the remainder of the
sensory pathway. Furthermore, somatosensory evoked potentials evaluate the larger
fiber tracts modulating proprioception and vibration, rather than the pain-mediating
tracts that seem to most commonly elicit symptoms. Finally, the technically demanding
nature of the procedure combines with the previous limitations to discourage their
routine use.24

NEEDLE ELECTRODE EXAMINATION

The concept of using a myotomal distribution of abnormalities on NEE to localize a spinal

segment dates back to at least 194459 and is now a cornerstone of the electrodiagnosis
of radiculopathy. The NEE is considered diagnostic of radiculopathy when abnormalities
are noted in at least 2 muscles innervated by the same root, but different peripheral
nerves, provided that muscles innervated by adjacent roots are normal.5 Needle electro-
myography evaluates for axonal loss and will reveal demyelination through reduced
recruitment of motor units only when conduction block is present.5,24,60
The NEE may also provide information regarding the length of time that a muscle
has been denervated. A study of 69 subjects who suffered traumatic peripheral nerve
injury revealed that fibrillation amplitude may be used as an index of estimating
the time since nerve injury.61 The mean amplitude of fibrillations within 2 months after
denervation was 612 mV and decreased to less than 100 mV after 12 months. The same
study found that reduction of fibrillation potential amplitudes also correlated with
muscle fiber atrophy in a guinea pig model.61
Similar findings were replicated in the upper extremities of 173 subjects who
suffered complete denervation of the biceps brachii caused by brachial plexus
injury.62 In this study, fibrillation amplitude within 2 months was 501 mV, but in contrast
to Kraft’s study, remained greater than 100 mV (262 mV) after 12 months. Consistent
with prior animal studies,61 the reduction in fibrillation amplitude correlated with
muscle fiber atrophy and that Type II muscle fiber atrophy is more rapid than Type I.
The most recent AANEM guidelines indicate that, at least, one muscle in myotomes
C5-T1 and cervical paraspinal muscles should be studied in the evaluation of cervical

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68 Plastaras & Joshi

radiculopathy.23 However, the guidelines do not specify how many muscles to study.
Clearly, the NEE is uncomfortable to patients and studying the minimum number of
muscles that is required is desirable. Additionally, not all radiculopathies are confirm-
able by EMG.5 These radiculopathies are exclusively sensory5 or radiculopathies in
which the rate of denervation is balanced by the rate of reinnervation.63 Radiculopathies
that are not confirmable by EMG will not be found regardless of how many muscles are
studied.63 The concept of a screening NEE was developed to determine the minimum
number of muscles that need to be studied to maximize the probability of detecting
an electrodiagnostically confirmable radiculopathy.63 A previous retrospective study64
determined that 7-muscle screens that included cervical paraspinals would identify
93% to 98% of all electrodiagnostically confirmed cervical radiculopathies. However,
prospective evidence specifying the optimal number of muscles to include in the NEE
to detect a cervical radiculopathy arrived in 2001, when Dillingham and colleagues65
determined that 6 muscles that included the cervical paraspinals was the optimal
screen. When using motor recruitment changes as diagnostic criteria, a 6-muscle
screen was found to identify 94% to 99% of cervical radiculopathies, with additional
muscles adding only minimal sensitivity. An important point noted is that if paraspinal
muscles cannot be studied, then 8-limb muscles are necessary to detect greater than
92% of cervical radiculopathies. Also notable is that the study does not prescribe
a specific set of muscles, but rather indicates the number of muscles that must be
studied. However, their data does indicate that various possible screens have differing
specificities and sensitivities. For example, a screen of paraspinals, deltoid, triceps,
pronator teres, extensor digitorum communis, and abductor pollicis brevis yielded
sensitivity of 99% using recruitment changes as diagnostic and 83% using abnormal
spontaneous activity as diagnostic.65
Finally, should any muscle be abnormal within the 6-muscle screen, additional
muscles may need to be studied to confirm the radiculopathy.65
Similar to cervical radiculopathies, the optimal number of muscles required in the
screening NEE of the lower extremities was not clearly elucidated until recently. Prior
retrospective evidence66 suggested that a 5-muscle screen was sufficient. However,
subsequent evidence confirmed that, in fact, 6 muscles constitute the optimal
screening NEE when paraspinals are included, and that 8 are required if paraspinals
cannot be included.63 As with cervical screening examinations, no specific combina-
tion of muscles is recommended, although varying sensitivities are clearly achieved
with different muscles studied. For example, a screen of paraspinals, adductor longus,
medial gastrocnemius, tibialis posterior, tibialis anterior, and short head biceps femo-
ris yielded sensitivity of 100% using recruitment changes as diagnostic and 93% using
abnormal spontaneous activity as diagnostic.63 Even a 4-muscle screen that includes
the paraspinals will detect 97% of lumbosacral radiculopathies.63 Clearly, the
screening NEE does not replace a directed history and physical examination. Rather,
a screen provides a ceiling to the number of muscles studied when neither the history
nor the physical examination are localizing and allow the NEE to be targeted toward
specific abnormalities.63–66
A myotomal pattern of abnormalities on NEE is necessary for the diagnosis of rad-
iculopathy. These abnormalities may encompass any of a variety of neuropathic find-
ings, such as polyphasia, reduced recruitment, increased insertional activity, complex
repetitive discharges, or large-amplitude and long-duration motor unit action poten-
tials (MUAP). With chronic denervation and subsequent reinnervation, the duration
of MUAPs increases, commensurate with the degree of collateral sprouting.5,16 Unfor-
tunately, reliably determining MUAP duration requires the quantitative evaluation of at
least 20 motor units,67 which is far too lengthy a procedure to recommend for clinical

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 The Electrodiagnostic Evaluation of Radiculopathy 69

practice. Polyphasic MUAPs contain greater than 4 phases and may indicate motor
unit remodeling caused by chronic denervation and reinnervation.5,16 Early series68,69
indicated that isolated polyphasia may be the only finding in 35% to 75% of cases.
However, using polyphasia as the sole diagnostic criterion for radiculopathy is prob-
lematic. Polyphasic MUAPs are not inherently abnormal and up to 20% of MUAPs
in normal muscle may be polyphasic.5,16 As with duration, differentiation of true poly-
phasia from pseudopolyphasia requires the use of a delay and trigger line,70 which
may not be done in routine NEE.
The use of spontaneous activity, such as fibrillations and positive sharp waves, may
be more reliable than the motor unit remodeling parameters previously described.
However, certain pitfalls must also be recognized with these. Conventionally, sponta-
neous activity occurring after acute radiculopathy is thought to appear first in the para-
spinals in approximately 1 week and to manifest in more distal limb muscles in several
weeks,5,16 indicating that an improperly timed study may miss abnormalities.
However, recent prospective evidence has challenged this long-held theory, and indi-
cated no correlation between the presence of paraspinal spontaneous activity and
symptom duration in both the cervical and lumbar spine.71

SEGMENTAL LOCALIZATION

In 50 subjects with surgically proven single-root lesions, the following patterns of posi-
tive sharp waves or fibrillations on NEE emerged72:
 C5 radiculopathy: In C5 radiculopathy, the infraspinatus, supraspinatus, biceps,
deltoid, and brachioradialis showed approximately equal incidences of sponta-
neous activity.
 C6 radiculopathy: A C6 root lesion produces the most variable pattern of abnor-
malities and can mimic the findings of C5 radiculopathy with the addition of
pronator teres and the other pattern quite similar to that of a C7 radiculopathy.
 C7 radiculopathy: In C7 radiculopathies, the flexor carpi radialis, anconeus,
pronator teres, and triceps were most frequently affected.
 C8 radiculopathy: C8 radiculopathy most typically affected the first dorsal inter-
osseus; extensor indicus proprius; abductor digiti minimi; and, less frequently,
the flexor pollicis longus and abductor pollicis brevis.72
A similar study was conducted of the preoperative needle electrode patterns of 45
subjects with surgically documented single-level lumbosacral radiculopathies and
showed the following38:
 L2-4: No meaningful pattern was found that distinguished one level from another.
This finding may be because of the low incidence of radiculopathies at these
levels (7 subjects). This finding correlates with previous estimates of only 10%
of lumbosacral radiculopathies affecting these nerve roots.70 Surprisingly,
none of the confirmed L4 radiculopathies in this series showed involvement of
the tibialis anterior.
 L5: The muscles affected most of the time (73%–100%) were peroneus longus,
tensor fascia lata, tibialis posterior, extensor digitorum brevis, tibialis anterior, and
extensor hallucis longus. However, needle electrode localization of the peroneus
longus may be inaccurate, perhaps reducing the value of studying this muscle.73
 S1: The muscles affected most of the time (64%–100%) were the long head of
the biceps femoris, lateral gastrocnemius, short head of the biceps femoris,
medial gastrocnemius, abductor digiti quinti, and gluteus maximus.38

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70 Plastaras & Joshi

THE PARASPINAL MUSCLES

Abnormalities of the paraspinal muscles are considered to localize a lesion as being

proximal to the plexus.74 However, spontaneous activity in the paraspinals may be
found in a variety of conditions, including diabetes5; after minor trauma, such as
lumbar puncture75; after laminectomy76; and in up to 4% of asymptomatic, healthy
people.77 Notably, the presence of paraspinal abnormalities on needle electrode is
not part of the electrodiagnostic criteria of radiculopathy.23 Therefore, the evaluation
of paraspinal abnormalities must be made in light of the remainder of the electrodiag-
nostic findings and in corroboration with the history and physical examination.

OUTCOMES

Electrodiagnosis may also be used as a prognostic indicator of epidural injections. A

retrospective comparison has been conducted of 18 subjects with electrodiagnosti-
cally proven lumbosacral radiculopathy to 21 subjects with negative examinations,78
all of whom underwent transforaminal epidural steroid injection (TFESI). Although the
two groups had statistically similar preinjection Oswestry Disability Index (ODI)
scores, the group with electrodiagnostically proven radiculopathy had significantly
greater improvements in ODI scores after TFESI. The group with electrodiagnostic
radiculopathy had higher, although statistically nonsignificant, scores upon the
Verbal Rating Scales (VRS) of current pain. However, the improvement in mean
VRS scores was not significantly different between the two groups following TFESI.
The results of this study suggest that electrodiagnosis may serve an important prog-
nostic function in guiding interventional spine procedures and that patients with elec-
trodiagnostically proven radiculopathy may show significant functional improvements
after TFESI.
Additionally, electrodiagnostic confirmation of a radiculopathy may have important
implications when surgery is contemplated. In a small sample size study, Alrawi and
colleagues79 demonstrated that subjects with electrodiagnostically confirmed cervical
radiculopathy had improved outcomes following discectomy and anterior fusion when
compared with postoperative subjects who did not have electrophysiologic evidence
of radiculopathy. Conversely, Tullberg and colleagues80 studied 30 subjects with
lumbosacral radiculopathy and demonstrated that when visual analogue scores
were used as an outcome measure, the absence of electrodiagnostic confirmation
was correlated with poor post-operative results.

SUMMARY

Radiculopathy is a sometimes challenging diagnosis resulting from multiple etiologies.

Although imaging may elucidate the structural causes of radiculopathy, imaging
cannot pinpoint the cause of radiculopathy when either multiple structural abnormal-
ities are present or when radiculopathy results from nonstructural causes. Electrodiag-
nosis provides a means of functional assessment of the nerve root and may also
provide prognostic information regarding functional outcomes of patients with
radiculopathy.

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