E l e c t ro d i a g n o s i s o f C e r v i c a l

Radiculopathy
Kevin Hakimi, MD*, David Spanier, MD

KEYWORDS
 Cervical  Radiculopathy  Electrodiagnosis  Electromyography

KEY POINTS
 To properly diagnose cervical radiculopathy, a combination of clinical signs/symptoms,
imaging, and electrodiagnostic studies should be used.
 Differential diagnosis must consider various causes of neuropathic and musculoskeletal
pain, which may be affecting the extremity.
 Needle electromyography is the most useful electrodiagnostic technique and provides
moderate sensitivity in the diagnosis of radiculopathies.
 Appropriate sampling of muscles must be done including paraspinals, if possible, to
ensure a diagnostically accurate study.
 Electrodiagnostic findings can be particularly useful for patients with atypical symptoms,
potential pain-mediated weakness, and nonfocal imaging findings.

INTRODUCTION

Cervical radiculopathy is a common disorder effecting people most often in the

fourth and fifth decades of life. Symptoms of pain, numbness, and/or tingling may
be mild, but in severe cases, cervical radiculopathy will be associated with motor
weakness. Efficient diagnosis can minimize pain and disability and also minimize
the direct and indirect costs of care. Treatment of cervical radiculopathy is based
on a clear understanding of its natural history, clinical evaluation, diagnostic testing,
and therapeutic options for this disorder. This article will provide an overview of the
pathophysiology, pertinent anatomy, history/examination findings, and imaging
options. It will focus on the electrodiagnosis of cervical radiculopathy. Electrodiagno-
sis is a critical part of the evaluation of patients presenting with signs and symptoms
of neuropathic upper extremity dysfunction, especially when coexisting with neck
pain. This article will review developing an appropriate differential diagnosis and

Rehabilitation Care Services, Department of Rehabilitation Medicine, VA Puget Sound, Rehabil-

itation Care Services (RCS-117), 1660 South Columbian Way, Seattle, WA 98108, USA
* Corresponding author.
E-mail address: [email protected]

Phys Med Rehabil Clin N Am 24 (2013) 1–12

http://dx.doi.org/10.1016/j.pmr.2012.08.012 pmr.theclinics.com
1047-9651/13/$ – see front matter Published by Elsevier Inc.
2 Hakimi & Spanier

choosing appropriate electrodiagnostic techniques with a focus on needle electro-

myography (EMG).

EPIDEMIOLOGY

An epidemiologic study of cervical radiculopathy was performed at the Mayo Clinic

between 1976 and 1990.1 Five hundred sixty-one cases were included in this study.
This research revealed the following:
Age ranged from 13 to 91 years (332 males, mean age 47.6  13.1 years; 229
females, mean age 48.2  13.8 years)
History of trauma or exertion was found in only 14.8% of cases
Previous history of lumbar radiculopathy was found in 41% of cases
Median duration of symptoms before diagnosis was 15 days
Monoradiculopathy involving nerve root C7 was most common, followed by nerve
roots C6, C8, and then C5 in decreasing frequency
Etiology included confirmed disc protrusion (21.9%) and spondylosis, disc, or both
(68.4%)
Recurrence over 4.9 years 5 31.7%
Surgery was performed in 26% of patients
Ninety percent of patients were asymptomatic or only mildly incapacitated at last
follow-up
A more recent study looked at the incidence of cervical radiculopathy in the US
military from 2000 to 2009.2 They found that age (40 years old and above) was the
greatest risk factor for cervical radiculopathy, and that female sex, white race, senior
military position, and service in the Army or Air Force were also risk factors.

ANATOMY

The cervical spine is comprised of 7 vertebrae. The first vertebra (C1, also called the
atlas) is a ring-shaped bone without a spinous process. It serves as the point of attach-
ment of the skull to the spine via the occipital condyles articulating with the superior
aspect of the C1 vertebra. C1 articulates directly with C2 without the presence of
an intervertebral disc. C2 has a bony superior process called the dens, which projects
into the ring of the atlas and serves as the axis of rotation.
Facet Joints (Zygapophyseal Joints)
Vertebrae C3 through C7 have posteriorly placed facet joints that serve as points of
articulation between the vertebrae. These are paired joints that arise at the junction
of the pedicle and the lamina. The superior facets project upward to articulate with
the inferior facets of the superior adjacent vertebra. The inferior facets project down-
ward to articulate with the superior facets of the inferior adjacent vertebra. These joints
are synovial with a surrounding capsule. The joints are innervated by the medial
branch of the dorsal primary ramus of the exiting spinal nerve. The joints provide direc-
tional stability and prevent relative translation of 1 vertebra upon another. They lie
posterior to the exiting spinal nerve root.
Uncovertebral Joints (Joints of Luschka)
Extending off the lateral surface of the cervical vertebral bodies are small bony projec-
tions called uncinate processes. The uncinate process makes contact with the disc
and vertebral body above. The points of contact are called uncovertebral joints, and
they are located anteromedial to the exiting nerve roots.
 Electrodiagnosis of Cervical Radiculopathy 3

Intervertebral Disc
Between cervical vertebrae C2 through C7 is a supporting intervertebral disc. The disc
is comprised of 2 layers; the outer layer is called the annulus fibrosis, which is made up
of approximately 20 concentric lamellae of orthogonally oriented fibers. The inner layer
is called the nucleus pulposis, comprised of 90% water, which desiccates with age.
The anterior annulus is reinforced by the anterior longitudinal ligament (ALL), and pos-
teriorly by the posterior longitudinal ligament (PLL). The PLL is not very broad, and
accordingly there is greater chance of nucleus pulposis herniation laterally as opposed
to centrally.

Spinal Canal
The spinal canal is made up of the consecutive vertebral foramen. In the intervertebral
spaces, the canal is protected posteriorly by the ligamentum flavum and anteriorly by
the PLL. The spinal canal has its greatest Anterior-Posterior (A-P) diameter in the
upper cervical spine between C1 and C3. During maximal cervical spine extension,
the canal narrows an additional 2 to 3 mm.

Spinal Motion
The specific motions of each cervical segment have been thoroughly described else-
where. Broadly speaking, most rotational movement of the head occurs in the upper
cervical spine, where flexion and extension occur predominantly in the lower cervical
spine. Accordingly, spondylotic disease arises most commonly in the lower cervical
spine.

Intervertebral Foramina
The foramina are bordered anteriorly by the vertebral body and disc, and posteriorly
by the facet joint. The pedicles form the superior and inferior margins of the foramen.
Additionally the uncinate processes are located at the anteromedial margin of the
foramen.

Neural Elements
The spinal cord is located within the central canal. There is an enlargement of the cord
diameter within the cervical spine from C3 through T2, and in the lumbar spine from L1
to S3. The spinal nerve is comprised of sensory fibers traveling through the dorsal root
and motor fibers from the ventral root. The dorsal root ganglia (DRG) are located on the
dorsal nerve roots, usually in the intervertebral foramen, just outside the spinal dural
layer. The DRG of C4 and C5 are located closer to the spinal cord than the lower
roots.3 The dorsal and ventral roots fuse to form the spinal nerve in the intervertebral
foramen. The spinal nerve continues for a few millimeters before it separates into the
dorsal and ventral rami. The dorsal rami supply the cervical paraspinals (PSPs) and
skin of the back of the neck. The ventral rami form the cervical and brachial plexuses.
The cervical nerve roots exit through the intervertebral foramen above the corre-
sponding cervical vertebral body. For example, the C5 nerve root exits through the
C4 to C5 intervertebral foramen. The C8 nerve root exits below the C7 vertebral
body and above the T1 vertebral body. Subsequent nerve roots exit below the corre-
sponding vertebral body.
Understanding the anatomy of the exiting spinal nerve with regards to both the
innervation of the PSP musculature and position of the DRG is critical in understanding
the results of the electrodiagnostic evaluation of cervical radiculopathy.
4 Hakimi & Spanier

ETIOLOGY

Radiculopathy arises from a process that affects the nerve root. These processes can
be divided into compressive and noncompressive causes. The compressive causes
include cervical spondylosis and disc herniation.

Compressive Causes
Cervical spondylosis
As the nerve root enters the foramen medially, it lies at the level of the superior articular
facet of the inferior vertebrae. Hypertrophy of either the uncovertebral joints or the fac-
ets joints may impinge mechanically on an exiting nerve root to cause radiculopathy.
The process of degenerative change in these joints is called spondylosis. Degenera-
tive change may also result in bone formation in these areas, producing an osteophyte
or hard disc.

Disc herniation The anatomy of the intervertebral disc has been discussed previously.
Circumferential tears in the annulus fibrosis begin to be present around the age of 20
and progress to fraying and splitting of collagen fibers. With the progression of degen-
eration, there is continued loss of the fluid properties of the nucleus pulposis, which
undergoes replacement with fibrous tissue. The combination of intervertebral pressure
and degenerative change of the disc can lead to tears in the annulus, which allow for
disc bulging and/or prolapse of the nucleus pulposis. This often results in deformation
of the DRG. The mechanical deformation (either compression or tension) causes
release of substance P, phospholipase 2, and vasoactive intestinal peptide from the
nucleus pulposis. This produces a chemical inflammation that is an additional insult
to the nerve root on top of any mechanical pressure.

Noncompressive causes
Although less common, noncompressive causes should always be considered. These
include demyelination, infection, tumor infiltration, root avulsion, and nerve root infarc-
tion. The dorsal and ventral roots may be affected (much more so than in compressive
etiologies). Deficits of noncompressive radiculopathies may span multiple myotomes
and dermatomes, and may be more complete or dense than are commonly seen in
compressive etiologies.

KEY HISTORY FINDINGS

The patient’s history is critical in evaluating a suspected radiculopathy, because there

is an extensive differential diagnosis to be considered. Symptoms may develop
acutely with an initial episode of neck pain followed by radiation in a dermatomal
pattern or weakness in the affected extremity. A herniated disk more often causes
acute radiculopathy, while spondylitic narrowing results in a more indolent course.
Patients may complain of neck pain, arm pain, chest or shoulder pain, pain in the inter-
scapular region, or pain in the face.4
Dermatomal paresthesia or numbness develops in 80% of patients. Subjective
weakness is less common than paresthesia.1 The patient may describe positions
that alleviate symptoms, such as rotating the head away from the affected side, and
the abducted shoulder sign, in which the patients describe pain relief with the affected
shoulder abducted and the hand resting on top of the head.
Some patients may describe a recent history of physical exertion or trauma
preceding symptom onset; however, most cases have no readily identifiable causative
event.4
 Electrodiagnosis of Cervical Radiculopathy 5

More concerning complaints that may suggest not only radiculopathy but also
myelopathy or infection must also be sought. Lhermitte sign (shock-like paresthesias
occurring with neck flexion), difficulty walking, or bowel and bladder symptoms are
suggestive of myelopathy or intramedullary pathology. Any history of fever, chills,
weight loss, or cancer should raise suspicion for tumor or infection.5

KEY PHYSICAL EXAMINATION FINDINGS

The initial physical examination includes observation of the patient, noting the position
of the head and neck contours. Atrophy can be detected with more severe or long-
standing lesions. Muscle wasting may suggest particular nerve root involvement:
C5 or C6: supra- or infrascapular fossae or deltoid
C7: triceps
C8: thenar eminence
T1: first dorsal interossei
Manual muscle testing has greater specificity than reflex or sensory abnormalities,
and might need to be performed repetitively or with the muscle at a mechanical disad-
vantage to elicit subtle weakness.6 Severe weakness (<3/5 on the Medical Research
Council grade) is less consistent with a single root lesion and should prompt the exam-
iner to search for multilevel pathology. Sensation to light touch, pinprick, and vibration
should be assessed. Upper motor neuron signs should also be assessed including
Hoffman sign and Babinski response.
Provocative maneuvers such as Spurling maneuver may be performed. This test is
performed by extending and rotating the neck to the painful side followed by the appli-
cation of downward pressure to the head.7 The test is positive if it reproduces limb
pain and/or paresthesia. Neck pain alone does not signify a positive test. The Spurling
maneuver has a high specificity but moderate-to-low sensitivity for cervical radiculop-
athy.8 A negative test does not rule out radicular pathology.

DIAGNOSTIC IMAGING
Plain Radiographs
Conventional radiographs are often obtained in the evaluation of neck pain, but their
utility in establishing a diagnosis is somewhat limited. Radiographs have relatively
low sensitivity in detecting tumor, infection, and disc herniation. Plain radiographs
may be completely normal in patients with tumor or infection. Conversely, patients
with compressive radiculopathy will likely have multilevel pathology identified on plain
radiographs. Furthermore, there is limited value in the finding of cervical intervertebral
narrowing in predicting nerve root compression.9

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is the imaging modality of choice when investi-
gating cervical radiculopathy.10 MRI generally provides superior evaluation of the
soft tissues when compared with computed tomography (CT), although bony abnor-
malities may be underestimated, while stenosis is often overestimated.11 T1 weighted
images show bone spurs and disc herniations as hypointense, making it difficult to
distinguish these structures from bone and ligament. T2 weighted images create
a myelographic effect as fluid (both cerebrospinal fluid [CSF] and water within the
nucleus pulposis) appears bright. Gadolinium enhanced images should be obtained
if there is suspicion of metastatic disease, osteomyelitis, or other inflammatory
6 Hakimi & Spanier

conditions. Radiographic abnormalities should always be interpreted within a clinical

context.

Computed Tomography
CT myelography is considered the gold standard in evaluating foraminal compression.
CT myelography is superior to MRI in distinguishing osteophyte from soft tissue mate-
rial, although there is some evidence that CT myelography may be inadequate to
assess developing osteophytes.12 Due to the exposure to ionizing radiation, CT and
CT myelography are usually reserved for patients who are claustrophobic or when
MRI is contraindicated or nondiagnostic.
The clinician should always be cognizant of the fact that normal age-related
changes may occur in the cervical spine in the absence of symptoms. Matsumoto
and colleagues13 recently reported a study of asymptomatic middle-aged patients
(mean age 48 years) in which over 90% of patients had cervical degenerative changes
on MRI – including posterior disc protrusion, anterior compression of the thecal sac,
and decrease in disc height.

DIFFERENTIAL DIAGNOSIS OF POTENTIAL UPPER EXTREMITY RADICULAR

SIGNS/SYMPTOMS

Patients with classical symptoms of neck pain and radicular type pain are often
referred to the electrodiagnostic laboratory to be evaluated for cervical radiculopathy.
However, often signs or symptoms will be more vague. The electromyographer
following a thorough history and directed physical examination should also consider
other diseases that may be mimicking a cervical radiculopathy and design an electro-
diagnostic study to evaluate for these other possibilities as appropriate. Differential
diagnoses are discussed in the following sections.

Peripheral Nerve Lesions

Median and ulnar neuropathies are very common and must always be considered
a possibility in patients with neurologic finding in the upper extremity. Even if a patient
has evidence of cervical radiculopathy, it is important to realize that peripheral nerve
entrapments often occur concomitantly and should be documented. Questioning
should include identification of numbness, paresthesias into the hand, repetitive
motion history, and other potential risk factors for nerve entrapments.

Brachial Plexopathies
While brachial plexus lesions are less common then peripheral nerve entrapments,
they must also be considered in the differential diagnoses. Traumas or mass lesions
are common causes of plexopathies. When considering the possibility of a mass
lesion, one should inquire about weight loss, fevers, night sweats, and smoking
history. Idiopathic brachial neuritis (Parsonage-Turner syndrome) should also be
considered, especially with a presentation of acute shoulder pain followed by muscle
weakness.

Other Conditions
It is important also to consider other conditions such as myelopathy secondary to
central spinal stenosis, which may present with more bilateral weakness, upper motor
neuron signs, and possible bowel/bladder involvement. Motor neuron disease should
be considered in a patient presenting with upper extremity weakness without
radicular-type pain or sensation changes on examination. Neurogenic thoracic outlet
 Electrodiagnosis of Cervical Radiculopathy 7

syndrome may also be considered but is a rare diagnosis to make in the electrodiag-
nostic laboratory. Non-neurologic causes of upper extremity pain should also be
considered such as facet disease, subacromial bursitis rotator cuff pathology, and
lateral/medial epicondylitis. Each of these processes may mimic radicular pain.

ROLE OF ELECTRODIAGNOSIS

Electrodiagnosis plays a critical role in the assessment of patients with symptoms and
signs of cervical radiculopathy. Electrodiagnosis is often referred to as an extension of
the neurologic examination, as it is able to provide physiologic evidence of nerve
dysfunction. The electrodiagnostic study can aid in clarifying the presumed diagnosis
of radiculopathy and is critical in identifying other possible nonroot-level causes of
neurologic dysfunction. The electrodiagnostic information and history, physical, and
imaging findings are combined to confirm the most likely diagnosis and to guide future
treatment. Electrodiagnostic findings can be particularly useful for patients with atyp-
ical symptoms, potential pain-mediated weakness, and nonfocal imaging findings.
Various types of electrodiagnostic studies may be considered when evaluating
a patient for cervical radiculopathy in the electrodiagnostic laboratory. Potential tests
include EMG, motor and sensory nerve conduction studies, late responses, and
somatosensory evoked potentials. These tests can all be considered based on the
clinical scenario and will be discussed individually.

ELECTROMYOGRAPHY

EMG is the most useful test for evaluating for radiculopathy. The EMG portion of the
examination can localize lesions to a particular root level and can provide information
on acuity of the disease process. The goal of EMG is to find a pattern of spontaneous
and/or chronic motor unit changes in a clear myotomal pattern. It is also important to
note the limitations of EMG. EMG can only detect change in the motor nervous
system; furthermore, it primarily detects damage to the axonal component of the
nerve versus myelin. Many early radiculopathies may have a primary sensory and
demyelinating component, and these types of radiculopathies would not be detected
with needle sampling.

Diagnostic Criteria for Needle EMG

To diagnose radiculopathy electrodiagnostically, needle study of 2 muscles that
receive innervation from the same nerve root, preferably via different peripheral
nerves, should be abnormal. Adjacent nerve roots should be unaffected unless a multi-
level radiculopathy is present. Since muscles receive innervation from multiple levels,
the pattern of abnormalities should point to a nerve root level that is primarily affected.
Various myotomal maps are available to assist the electromyographer in determining
the root level affected (Fig. 1).

Sensitivity of Needle EMG

The utility of needle EMG in diagnosing cervical radiculopathy with regards to sensi-
tivity was thoroughly reviewed in 1999 by the American Association for Electrodiagnos-
tic Medicine (AAEM), now known as the American Association for Neuromuscular and
Electrodiagnostic Medicine (AANEM), and published as a practice parameter.14 Estab-
lishing the sensitivity of electrodiagnostic testing (as well as many radiological proce-
dures) is difficult, because there is no gold standard by which one can definitively true
presence of disease.
8 Hakimi & Spanier

Fig. 1. Upper extremity myotomal chart showing major and significant nerve root innerva-
tion of upper extremity muscles. Boxes shaded in green represent a dominant contribution,
while boxes shaded in yellow represent a significant contribution. Minor contributions are
not shown.

The articles that were included in the AANEM review used a combination of clinical
and radiological findings as a comparison. The 9 studies they cited in their final review
revealed overall sensitivity of needle EMG in the diagnosis of cervical radiculopathy to
be between 50% and 71%, which they described as having moderate diagnostic
sensitivity. Studies that reported more motor deficits clinically had higher reported
sensitivities in their review. Based on these reported sensitivities, it is important to
understand that a negative EMG study for cervical radiculopathy does not rule out
the presence of disease.

Appropriate EMG Study Design

Following the publication of the AANEM practice parameter, Dillingham and
colleagues15 published an article discussing the sensitivity of needle EMG screening
in diagnosing cervical radiculopathies. The main question tackled in this study was
how many muscles should be sampled to provide good sensitivity in detecting radicul-
opathy. Most electromyographers would agree sampling a few muscles is not suffi-
cient to detect radiculopathy, but it is important to define the minimum number of
muscles needed to ensure a quality examination. The study looked at 101 patients
with cervical radiculopathy and tested 10 muscles in each patient. Analysis revealed
that testing 6 muscles including the cervical PSPs achieved a sensitivity of 94% to
98% for the presence of radiculopathy. If PSPs were not tested, they recommend
testing of 8 limb muscles to achieve a sensitivity of 92% to 95%.

PSP Findings
While the presence of fibrillations and positive sharp waves (PSWs) in the limb
muscles of normal subjects is considered very unusual, the documentation of these
 Electrodiagnosis of Cervical Radiculopathy 9

waveforms in the PSP muscles of normal subjects is more controversial. Two studies
showed presence of PSWs in the cervical PSPs in normal subjects without neck pain
or radicular arm pain. The first study found PSWs in 92% of PSPs in subjects older
than 40 years old and fibrillations in 8% of subjects greater than 40 years old. They
found no PSPs or fibrillations in patients under 40 years old.16 The second study noted
PSWs in 12% of the PSP muscles tested on asymptomatic subjects.17 These studies
illustrate some of the caveats of diagnosing radiculopathy based primarily on PSP
findings, particularly in an older population.
However, such studies do not negate the importance of the PSP examination. As
mentioned previously, Dillingham found that testing PSPs adds significant sensitivity
to the needle examination for cervical radiculopathy. The presence of PSP abnormal-
ities in combination with limb findings makes radiculopathy a more likely diagnosis.
Lack of PSP findings may indicate a more distal lesion localized to the brachial plexus
or peripheral nerve. The pattern of EMG abnormalities and nerve conduction study
findings would help also to differentiate nerve root- from nonroot-level causes of upper
extremity nerve dysfunction.
There are also other limitations to PSP muscle sampling. The proximity of the PSP to
the nerve root means it may be the first abnormality detected in an early acute radicul-
opathy (as soon as 7 days), but also it may be the first muscle to return to normal. So
based on the timing of the electrodiagnostic examination, a patient may have clear upper
extremity myotomal EMG pattern with absent or subtle PSP abnormalities. It is also
important to note that PSPs can also be positive in other diseases not related to nerve
root compression. For example, patients with both motor neuron disease and inflamma-
tory myopathies such as polymyositis may demonstrate PSWs in the PSP muscles.
Finally, PSPs may exhibit both PSWs and fibrillations many years following any posterior
approach spinal surgery. Some have also expressed concern of seeing some PSP
abnormalities related to muscle trauma from repeated epidural steroid injections.

SPECIFICITY OF NEEDLE EMG

While sensitivity is a critical component in determining the utility of a test, a test must
also have good specificity to ensure low false-positive results. Anecdotal evidence,
clinical experience, and published studies involving normal subjects confirm high
specificity of needle EMG in diagnosis of radiculopathy. A recent study looking at
EMG patterns in the lower extremities showed no false-negative diagnoses of radicul-
opathy (ie, 100% specificity) when a pattern of acute changes was shown in 2 limbs
and the PSP muscles.18 Using less strict criteria of greater than 30% polyphasia in
the same muscle groups, specificity was still excellent, at 87% to 97%.

NERVE CONDUCTION STUDIES

The primary role of nerve conduction studies in patients with symptoms of cervical
radiculopathy is to determine if other neurologic processes exist as an explanation
for a patient’s clinical picture, or if another process coexists with a root level problem.
The AANEM’s 1999 practice parameter recommends performing at least 1 motor and
sensory study when evaluating a patient for cervical radiculopathy. In pure radiculop-
athy, the sensory nerve studies should be normal. As described in detail previously,
the pathologic lesion in radiculopathy typically occurs proximal to the DRG. Since
the DRG houses the cell bodies for the sensory nerves, the sensory nerve studies
should be normal. Marked abnormalities in sensory studies should prompt the electro-
myographer to look for disease processes that occur distal to the DRG, such as plex-
opathy, generalized peripheral neuropathy, or peripheral nerve entrapments. The
10 Hakimi & Spanier

motor nerve conduction studies are also typically normal in cervical radiculopathy
unless there is severe axon loss or multilevel disease.
The extent of the nerve conduction studies performed needs to be determined by
the clinical scenario, and the differential diagnosis should be generated following
the history and physical examination performed by the electromyographer. It is very
common for patients who present with neck pain and radicular symptoms to also
have symptoms that affect the hand, such as numbness. While neuropathic pain,
numbness, and/or paresthesias could be related to cervical radiculopathy, in these
cases, one must look more thoroughly for common nerve entrapments such as
median neuropathy at the wrist or ulnar neuropathy at the elbow. If trauma has
occurred or patients present with sudden shoulder pain followed by weakness, addi-
tional nerve conduction studies would also be considered to look for brachial plexus-
level issues related to trauma or an idiopathic acute brachial neuritis.
Ulnar neuropathy can mimic symptoms of C8/T1 radiculopathy. Ulnar motor studies
should be performed in patients presenting for evaluation of cervical radiculopathy
who also have paresthesias or symptoms in typical ulnar innervated areas. In patients
with predominantly median distribution symptoms or more diffuse sensory
complaints, nerve conduction studies looking for carpal tunnel syndrome are indi-
cated. Median motor studies and thorough sensory comparison evaluations such as
the Robinson Index should be considered to ensure accurate diagnoses.19
Nerve conduction studies are also important for patients who may have symptoms
of more generalized peripheral neuropathy. If the patient has symptoms of diffuse
paresthesias (upper and lower extremities) or other neuropathic risk factors such as
diabetes or alcohol use, the electromyographer may need to expand the electrodiag-
nostic study to include the contralateral limb, as well as potential nerve conduction
studies in the lower extremity. In an appropriately designed study, the nerve conduc-
tion studies should be able to differentiate between peripheral nerve entrapment and
a generalized process. The exception to this is when there is a severe peripheral
neuropathy with many absent responses.

LATE RESPONSES

The utility of late responses such as F-waves and H-reflexes in diagnoses of cervical
radiculopathy is debated. While H-reflexes can be useful in diagnosing S1 radiculo-
pathies, there is less evidence to support use of late responses in the upper extremity.
The 1999 AAEM practice parameter considers testing for F-waves and H-reflexes as
optional studies when considering the diagnosis of cervical radiculopthy. F-waves
are not sensitive in diagnosing radiculopathy and tend to be abnormal in severe disease.
Like EMG, F-wave study only tests motor fibers. Furthermore, it is not useful to localize
lesions. For example, F-waves recorded from the abductor pollicis brevis or abductor
digiti minimi are evaluating both C8 and T1 pathways, so abnormalities do not single
out a nerve root. Also, abnormalities of F-waves can be consistent with lesions in the
peripheral nerve, plexus, or nerve root. A more recent study, published in 2007, sug-
gested that various F-wave parameters may improve the diagnostic yield for cervical
radiculopathy when combined with needle EMG. However, the study also noted that
F-wave abnormalities could not localize a lesion to a specific cervical level.20 It is also
important to note that F-waves tend not to be well tolerated by patients, since they
require supramaximal stimulation. This, combined with questionable diagnostic utility,
contributes to the low use of these studies to diagnose cervical radiculopathy.
H-reflex study recording over the gastrocnemius or soleus muscle is commonly per-
formed when considering an S1 radiculopathy. In the upper extremities, C6/C7 levels
 Electrodiagnosis of Cervical Radiculopathy 11

can also be evaluated by stimulating the median nerve at the elbow to obtain an
H-reflex to the flexor carpi radialis. It is reported that this response is obtainable in
90% of normal subjects but may require facilitation techniques.21 Two more recent
studies reported that the upper extremity H-reflex can add utility in the diagnosis of
cervical radiculopathies, especially in cases when clinical symptoms are less clear
and needle EMG is normal.22,23

SOMATOSENSORY EVOKED POTENTIALS

There is conflicting evidence on the utility of somatosensory evoked potentials (SEPs)

in the diagnosis of cervical radiculopathy. Mixed nerve studies of the tibial, median,
and ulnar nerves may be useful in assessing patients with cervical myelopathy or other
central causes of neurologic symptoms (ie, multiple sclerosis). Dermatomal SEPs, in
theory, should provide information on single-root sensory nerve root dysfunction for
patients with cervical radiculopathy; however, review of clinical studies does not
provide clear evidence to support routine use of SEPs in the diagnoses of cervical
radiculopathy.24

SUMMARY

Referral for evaluation for cervical radiculopathy is a common request in electrodiag-

nostic laboratories. To properly diagnose cervical radiculopathy, a combination of clin-
ical signs/symptoms, imaging, and electrodiagnostic studies should be used. It is
crucial to generate a differential diagnosis to consider various causes of neuropathic
and musculoskeletal pain that may be affect the upper extremity. Based on these find-
ings, the provider can design an appropriate study based on the differential diagnoses.
It is also critical to understand the spinal anatomy of the cervical region, both with
regards to the orientation of the spinal roots, as well as the location of the dorsal
root ganglion. Needle EMG is the most useful electrodiagnostic technique, and it
provides moderate sensitivity in the diagnosis of cervical radiculopathy. Appropriate
sampling of muscle must be done including PSPs, if possible, to ensure a diagnosti-
cally accurate study. Nerve conduction studies are often needed to rule out peripheral
nerve entrapments or atypical presentations for peripheral neuropathies.
Electrodiagnosis provides moderate sensitivity in diagnosing cervical radiculop-
athy. With good specificity, it is useful in confirming disease, excluding other diseases,
and helping to localize lesions. It is critical to remember that a normal study does not
rule out the presence of cervical radiculopathy. Electrodiagnostic findings can be
particularly useful for patients with atypical symptoms, potentially pain-mediated
weakness, and nonfocal imaging findings.

REFERENCES

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1990. Brain 1994;117(2):325–35.
2. Schoenfeld AJ, George AA, Bader JO, et al. Incidence and epidemiology of
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