Journal of Back and Musculoskeletal Rehabilitation 26 (2013) 169–173 169

DOI 10.3233/BMR-2012-00364
IOS Press

Comparison of clinical and

electrophysiological findings in patients with
suspected radiculopathies
Esra E. İnala,∗ , Filiz Eserb , Lale A. Aktekinb , Ergun Öksüzc and Hatice Bodurb
a
Department of Physical Medicine and Rehabilitation, Nafiz Körez Sincan State Hospital, Ankara, Turkey
b
Department of Physical Medicine and Rehabilitation, Numune Education and Research Hospital, Ankara, Turkey
c
Family Medicine Unit Medicosocial Help Center, Faculty of Medicine, Başkent University, Ankara, Turkey

Abstract. Cervical and lumbar roots may be irritated or compressed due to the pathological conditions such as disc herniations,
degenerative foraminal stenosis, trauma and tumors. Electrophysiologic tests are frequently used in conjunction with imaging
modalities for evaluation of low back and neck pain radiating to extremities, primarily for the purpose of establishing the presence
or absence of a radiculopathy. In this study, we aimed to evalulate the relationship between clinic and electroneuromyographic
(ENMG) findings in patients with suspected radiculopathies. Forty one patients with radicular complaints in the upper extremities
and 51 patients with radicular complaints in the lower extremities were included in this study. McNemar test and Kappa
coefficients between the two methods were applied to each group of patients, in order to test the significance of the difference
between the two diagnostic procedures’ ability on finding out the pathology. The McNemar test identified a significant difference
between the two diagnostic approaches both for cervical and lumbar radiculopathies (p < 0.001). The Kappa coefficients
between the two methods were determined as 0.08 and 0.07, respectively. This means, efficacy of anamnesis and neurological
examination for the prediction of electrodiagnostic tests was found to be limited. Normal neurological examination results in
a patient with suspected radiculopathy can not eliminate abnormal electrodiagnostic test results; likewise, abnormal findings in
the neurological examination would not mean finding pathologies in the electrodiagnostic tests. For more accurate approach to a
patient, neurological examination and electrodiagnostic tests must be used and interpreted together.

Keywords: Electromyography, radiculopathy, radicular symptoms

1. Introduction ma and tumors. They mostly originate from disk her-

Radiculopathy is the term used to define similar clin-
ical conditions that are all caused by compromise of the
nerve roots. Cervical and lumbar radiculopathies are the
most common causes of referrals to a neurophysiology
laboratory. Cervical or lumbar roots may be irritated or
compressed due to the pathological conditions such as
disc herniations, degenerative foraminal stenosis, trau-
∗ Corresponding
author: Esra Erkol İnal, Elvan Mahallesi
20.Cadde 1890 sokak Atılım Sitesi B Blok No:34/21, Etimesgut,
Ankara, Turkey. Tel.: +90 312 3726240; Fax: +90 312 2735151;
E-mail: esraerkol@hotmail.com.
niations and spondylosis. Electrophysiologic tests are
frequently used in conjunction with imaging modalities
in the evaluation of low back and neck pain radiating
to extremities, primarily for the purpose of establishing
the presence or absence of a radiculopathy [1]. Even
though magnetic resonance imaging (MRI) seems to
have decreased the use of electrodiagnostic tests for
showing spinal root compression, it does not provide
a measurement for the physiologic integrity and func-
tions of the nerve root which is the most important data
for clinicians [1].
In this study we aimed to evalulate the relation-
ship between neurological examination and electroneu-
romyography (ENMG) findings and to determine the

ISSN 1053-8127/13/$27.50  2013 – IOS Press and the authors. All rights reserved
170 E.E. İnal et al. / Clinical and electromyographic findings in radiculopathies
diagnostic potential of physical examination compared
with ENMG method in patients with the symptoms of
radiculopathies.
2. Materials and methods
Forty one patients with radicular complaints in their
upper extremity and 51 patients with radicular com-
plaints in the lower extremity were included in this
study. Patients who were previously operated on be-
cause of lumbar or cervical disk herniations, patients
diagnosed entrapment neuropathy or polyneuropathy
during the ENMG studies and patients with cardiac
pacemakers or diabetics were not included in the study.
The study was conducted in accordance to the Helsinki
Declaration and approved by the Ethics Committee of
Numune Education and Research Hospital. All of the
patients were informed about the study and they gave
their consent to participate in the study.
Detailed neurological examination was performed in
all patients by a blinded physician (LAA). Neck and
arm pain, low back and leg pain, weakness, numb-
ness, tingling, and burning sensation of the patients
were studied. Motor, sensory and deep tendon reflexes
and pathological reflexes were tested. Symptoms were
recorded as present or absent and duration of symptoms
was recorded as in months. Sensory loss was record-
ed according to the dermatomes. Results of the phys-
ical examination were recorded as normal or abnor-
mal. Hypoesthesia, motor weakness and asymmetry of
deep tendon reflexes were accepted as signs of positive
physical examination for a radiculopathy.
Nihon Kohden Neuropack 2000, 2 channel ENMG
system was used by an experienced electromyographer
(EEİ) blinded from physical examination records. Nee-
dle electromyogram (EMG) was performed by using
a concentric needle electrode and electroneurograph-
ic assesments were recorded by bar electrodes. For
cervical radiculopathy, motor conduction studies were
performed on N. medianus and N. ulnaris. Sensorial
conduction studies were performed on N. radialis su-
perficialis, N. cutaneus antebrachialis medialis, N. me-
dianus and N. ulnaris. For lumbar radiculopathy, motor
conduction studies were performed on N. tibialis and
N. peronealis. Sensorial conduction studies were per-
formed on N. saphenous, N. peronealis superficialis and
N. suralis. Pathological EMG findings in two differ-
ent muscles innervated by two different nerves and/or
in spinal paravertebral muscle were interpreted favor-
ing radiculopathy. According to these findings; needle
EMG study was performed on 4 roots in 9 muscles for
the upper extremity (M. deltoideus, M. biceps brachii,
M. triceps, M. brachioradialis, M. flexor carpi ulnaris,
M. pronator teres, M. abductor pollicis brevis, first dor-
sal interosseous and cervical paraspinal muscles) and
on 4 roots in 9 muscles for the lower extremity (M.
abductor longus, M. vastus lateralis, M. tensor fascia
lata, shorter head of M. biceps femoris, M. tibialis an-
terior, M. peroneus longus, M. gastrocnemius lateralis,
M. tibialis posterior, and lumbar paraspinal muscles).
Presence of fibrillation or positive sharp wave
(PSW), polyphasic motor unit potentials (MUP) ratio
greater than 30%, increase in the amplitude and elon-
gation of duration of MUPs and reduced interference
pattern were accepted as the EMG findings of radicu-
lopathy. While presence of abnormal EMG findings for
paraspinal muscles were interpreted in favor of radicu-
lopathy, absence of pathological findings did not elim-
inate the diagnosis of radiculopathy made for other
muscles [2].
2.1. Statistical analyses
All statistical calculations were performed using the
statistical Package for the Social Sciences (SPSS ver-
sion 13). Significance defined as a p value less than
0.05. Mean values and standard deviations were calcu-
lated for variables like age or duration of complaints.
Similarity between the two diagnostic approaches was
assessed by the kappa score and McNemar’s test. Addi-
tionally, the sensitivity, specificity, positive predictive
value (PPV) and negative predictive value (NPV) of
physical examination were calculated, accepting EN-
MG as a reference standard.
3. Results
In this study, 41 patients (33 female and 8 male) with
radicular symptoms in the lower extremity and 51 pa-
tients (33 female and 18 male) with radicular symptoms
in the upper extremity were evaluated. Demograph-
ic features and clinical characteristics of the patients
with suspected cervical and lumbar radiculopathies are
summarized in Table 1. Distribution of radiculopathy
according to neurological examination and/or ENMG
in 41 patients with cervical radicular complaints and
51 patients with lumbar radicular complaints are seen in
Table 2. Cervical and lumbosacral radiculopathy were
found in 31 out of 41 (75.6%) and 40 out of 51 (78.4%)
patients on physical examination and in 12 out of 41
 E.E. İnal et al. / Clinical and electromyographic findings in radiculopathies 171

Table 1
Demographic features and characteristics of the patients with cervical and lumbar radiculopathies
Patients with cervical radicular Patients with lumbar radicular
complaints (n = 41) complaints (n = 51)
Age (yr) 43.54 ± 10.43 44.90 ± 11.42
Loss of strength (m) 7.83 ± 21.86 4.10 ± 18.02
Numbness (m) 18.15 ± 27.52 19.55 ± 48.99
Arm/leg pain (m) 35.42 ± 45.63 46.39 ± 67.65
Neck/ back pain (m) 38.88 ± 43.21 71.57 ± 77.51
Tingling (m) 13.02 ± 34.21 21.37 ± 53.27
Burning sensation (m) 2.42 ± 5.27 11.02 ± 29.43
∗ Values are mean ± standard deviation, m; month, yr; year.

Table 2
Distribution of cases with suspected cervical and lumbar radiculopa-
thy
EMG Findings
Pathologic Normal Total
Neurological Examination
Cervical radicular symptoms
Pathologic 10 21
Normal 2 8
Total 12 29
Lumbar radicular symptoms
Pathologic 9 31
Normal 1 10
Total 10 41
McNemar test and Kappa statistics were applied for each group, in
order to test the significance of the difference between two diagnostic
procedures ability on finding the pathology. For cervical pathologies,
McNemar p < 0.001, K:0.075 and p of Kappa:0.45. For lomber
pathologies, McNemar p < 0.001, K:0.067 and p of Kappa: 0.32.
(29, 2%) and 10 out of 51 (19, 6%) patients on ENMG,
respectively. In order to determine the diagnostic po-
tential of physical examination compared with ENMG
method, we have calculated the sensitivity, specificity,
PPV and NPV of physical examination, accepting EN-
MG as a reference standard. The values of sensitivi-
ty, specificity, PPV and NPV of physical examination
compared with ENMG were; 0.83, 0.28, 0.32 and 0.80
for cervical radiculopathy and 0.90, 0.24, 0.23 and 0.91
for lumbar radiculopathy, respectively.
McNemar test and Kappa coefficients between the
two methods were applied for each group, in order to
test the significance of the difference between two di-
agnostic procedures’ ability on finding out the pathol-
ogy. For cervical pathologies, McNemar p < 0.001,
Kappa coefficient: 0.075 and p of Kappa:0.45. For
lumbar pathologies, McNemar p < 0.001, Kappa co-
efficient: 0.067 and p of Kappa: 0.32. The McNe-
mar test identified a significant difference between the
two diagnostic approaches both for cervical and lumbar
radiculopathies (p < 0.001).
4. Discussion
It is accepted that ENMG and MRI are the types of
tests that can be used in determining the presence of
clinical radiculopathy in neck and lower back pain [3,
4]. However, both of these studies have limitations of
31 their own. For example, while no electromyographical
10 findings can be found, if EMG is performed in the
41 early period or when slight radiculopathy is present,
structural spinal changes not consistent with the clinical
40 picture can be seen in the EMG.
11 It has been reported that most of the cervical and lum-
51
bar radiculopathies can be diagnosed electrophysiolog-
ically with needle EMG studies involving paraspinal
muscles, 8 lower extremity muscles and 8 upper ex-
tremity muscles, and additional muscular studies would
not contribute to the diagnosis [5,6]. We therefore pre-
ferred to evaluate the paraspinal and 8 lower extremity
muscles and paraspinal and 8 upper extremity muscles
for the upper extremity.
In our study, we compared the ENMG findings with
the history of the disease and neurological examination
findings in total of 92 patients with suspected cervical
or lumbar radiculopathy. We did not find any statistical-
ly significant relationship between the clinical parame-
ters (duration of symptoms, duration of complaints, and
neurological examination findings) and ENMG find-
ings either in those with cervical radicular symptoms or
in those with lumbar radicular symptoms. In McNemar
test, physical examination and ENMG, two different
diagnostic procedures were found to be significantly
different in finding out the pathology; and the interpre-
tation of Kappa coefficient means that the similarities
between two diagnostic methods are very low, in terms
of both cervical and lumbar radiculopathies. Acording
to our results, we can also state that, the diagnostic
potential of physical examination seems weak, when
compared with ENMG method. In a similar article, the
anamnesis, physical examination and ENMG findings
172 E.E. İnal et al. / Clinical and electromyographic findings in radiculopathies
have been investigated in 170 patients with lower back
and upper extremity symptoms and it has been report-
ed that anamnesis and physical examination findings
were not reliable for the prediction of ENMG results
by themselves [7].
Physiological consequences of the anatomical le-
sion seen in EMG of radiculopathies can be deter-
mined. First of all, the most important factor affect-
ing the EMG study is timing. Spontaneous activities
in radiculopathies (PSW and fibrillations) are firstly
seen in paraspinal muscles within 7–10 days, and later
they spread to the involved myotomes of the extremi-
ties within 2–3 weeks. Reinnervation findings appear
in between 3 to 6 months. EMG gives negative results,
if performed before denervation or after disappearance
of the denervation findings or if reinnervation has not
occurred [4]. Secondly, possibility of finding sponta-
neous activity in the muscles can be related to which
axons have been involved in the root level, ratio and
size of denervation, rate of denervation and extension
of the remaining axons [8].
Major proximal and distal lower extremity needle
EMG was performed on 124 patients who had previ-
ously been diagnosed with cervical radiculopathy by
electrodiagnostic methods at least three years ago, and
similar to our study, there was no statistically signif-
icant relationship between the spontaneous activities
(PSW and fibrillation potentials) and duration of the
symptoms [8]. In another study, the duration of symp-
toms and abnormalities in paraspinal, proximal and dis-
tal muscles were compared in 139 patients with lum-
bosacral radiculopathy, and again there was no signif-
icant relationship [9]. The duration of symptoms and
spontaneous EMG activities were evaluated in 93 cer-
vical radiculopathy patients who were diagnosed with
electrodiagnostic methods and no significant relation-
ship was found [10].
The paraspinal and extremity muscles were evalu-
ated with needle ENMG in 179 patients with chronic
lumbosacral radiculopathy, and it has been conclud-
ed that paraspinal muscle ENMG was less valuable in
chronic radiculopathy [11]. In our study, the number
of patients was not sufficient enough to differentiate
between acute and chronic conditions.
There are also studies investigating the relation-
ship between the imaging studies and electrodiagnostic
studies. The results of EMG in 47 patients with cervi-
cal and lumbar radiculopathy were compared by using
MRI and physical examination, and it has been con-
cluded that MRI was not very compliant with EMG
and physical examination [12]. Not every radiculopa-
thy case requires electrophysiological tests, electrodi-
agnostic studies can be particularly helpful in individ-
uals with multi-level radiological pathologies and pa-
tients with inconstiences between physical examination
and imaging findings [13].
Anamnesis and physical examination findings were
compared with EMG findings in 255 patients with low-
er extremity neuropathic symptoms and it has been
shown that EMG significantly changes the clinical di-
agnosis [14]. Electrophysiological tests are very im-
portant for the differentiation of neuropathy in patients
applying with radicular complaints. However, we made
the differentiation between plexopathy, more distal en-
trapments, and peripheral neuropathy right at the begin-
ning with ENMG, and these patients were not included
in our study.
It has been investigated that whether presence of
musculoskeletal conditions like myofascial pain, im-
pingement syndrome, lateral epicondylitis, de Quer-
vain’s disease in 191 patients with cervical radiculopa-
thy could predict the results of EMG or not. While
the normal study prevalence is 69%, it was found as
29% for cervical radiculopathies and as 45% in those
with another musculoskeletal disorder; this difference
is statistically significant. However, high prevalence in
both groups limits the predictive value of this informa-
tion, and presence of musculoskeletal disorder does not
exclude the indication of electrodiagnostic test [15].
In conclusion, no significant relationships were
found in our study between the ENMG findings and
clinical parameters in radiculopathies, and efficacy of
anamnesis and neurological examination on the predic-
tion of electrodiagnostic tests was found to be limit-
ed. Normal neurological examination results in a pa-
tient with suspected radiculopathy can not eliminate
abnormal electrodiagnostic test results; likewise, ab-
normal findings in the neurological examination would
not mean pathologic finding in the EMG. The physical
examination should, no doubt, direct the performance
of the electrodiagnostic test; however, normal physical
examination results should not cause prejudice in the
electrodiagnostic test or cutting the electrodiagnostic
test short. For an accurate approach to a patient, physi-
cal examination and EMG must be used and interpreted
together.
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