Unilateral S1 Research Articles

A comparison of H-reflex in the triceps surae muscle group in patients with S1 radiculopathy

Despite differences in the anatomical and physiological characteristics of the medial gastrocnemius (MG), lateral gastrocnemius (LG), and soleus (Sol) muscles, it is common practice to investigate them as single triceps surae H-reflex recordings. The aim of this study was to compare the latencies of H-reflex recordings from the Sol, MG, and LG in patients with explicit magnetic resonance imaging (MRI) evidence of unilateral S1 radiculopathy and also compare their diagnostic yield in varied clinical characteristics (i.e., symptom duration and severity of involvement). We found a significant difference between H-reflex latencies of Sol and the two others (p < 0.05 for both comparisons). Although Sol had more sensitivity in patients with positive straight leg raising (SLR) of 30°–50° and also the sub-acute phase of the disease, and MG and LG had more sensitivity in the acute phase of the disease and patients with positive SLR of 50°–70°, there were no statistically significant differences between diagnostic ability of the three heads of the triceps surae in various clinical settings and they can be used interchangeably in patients with suspected S1 radiculopathies.

Assessment of pelvic injuries treated with ilio-sacral screws: injury severity and accuracy of screw positioning.

The aim of this study was to analyse possible indicative parameters for percutaneous ilio-sacral stabilisation and to identify parameters associated with screw misplacement. Cohort study, level I trauma centre. (1) unstable pelvic injury, (2) percutaneous ilio-sacral screws placement. (1) sacral dysmorphy, (2) failed closed reduction, (3) navigated techniques. Indicative parameters were age, gender, body mass index, number of screws, screw angulation, fracture type and injury severity. End points were ilio-sacral screw position and associated complications. Screw placement accuracy was graded as follows: grade 0, no perforation; grade 1, perforation <2mm; grade 2, perforation from 2 to 4mm; grade 3, ≥4mm perforation. Between March 2008 and March 2013, 102 (53 women) patients were included (mean age, 48.5 ± 21.4years). The Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 18.9 ± 9.9 and 22.3 ± 22.3, respectively. The positions of 137 ilio-sacral screws were analysed. Of all screws, 87.6% (120) were placed satisfactory (<2mm perforation). The incidence of screw misplacement was significantly higher in the case of two unilateral S1 screws compared with a single screw (failure rate: two unilateral screws 23.1% vs single screw 7.0%; p < 0.05). Screw perforation anterior to the lateral mass (in-out-in) represented the most frequent malposition. Revision was necessary in three cases due to malpositioning. Furthermore, no major complication occurred. We conclude, that twofold ilio-sacral screw positioning from one side increases the risk for screw misplacement. In this case, alternative techniques like navigation should be considered. Anterior screw perforation represents a common problem with a high incidence and warrants particular attention.

Potential Advantages of the H-Reflex of the Biceps Femoris-Long Head in Documenting S1 Radiculopathy

A novel H-reflex method using the biceps femoris-long head (BF-LH) was investigated to collect the normative data for this reflex arc and assess its clinical utility for S1 radiculopathy evaluation. Comparability with conventional tibial and Sol H-reflex findings was also determined. BF-LH H-reflexes were recorded using surface electrodes to S1-root stimulation in 43 unilateral S1 radiculopathy patients (radiculopathy group) and 34 normal subjects (control group) from March 2009 to December 2011. H-M interval and peak-to-peak amplitudes were measured. The BF-LH H-reflex and the H-reflex from the soleus muscle (Sol H-reflex) to both tibial nerve stimulation (tibial H-reflex) and S1-root stimulation were used and compared for application in S1 radiculopathy evaluation. BF-LH H-reflexes were reliably recorded for all control group subjects. Abnormal BF-LH H-reflexes were recorded for 40 (93.0%) radiculopathy group patients in the involved extremity, and abnormal involved side tibial H-reflexes and Sol H-reflexes were recorded in 31 (72.1%) and 41 (95.3%) radiculopathy group patients, respectively. The BF-LH H-reflex exhibited significantly higher sensitivity for evaluation of S1 radiculopathy, accurate in 40 (93.0%) radiculopathy group patients, than that provided by the conventional tibial H-reflex of only 31 (72.1%) (P < 0.05). The BF-LH H-reflex is a highly sensitive and reliable clinical tool for evaluation of the S1 spinal reflex pathway in radiculopathy that is distinct from the Sol H-reflex and conventional tibial H-reflex arcs.

Diagnostic advantage of S1 foramen-evoked H-reflex for S1 radiculopathy in patients with diabetes mellitus

Hoffmann reflex to tibial nerve stimulation at the popliteal fossa (tibial H-reflex) is routinely used to evaluate S1 radiculopathy. However, it lacks sensitivity because other lesions along this reflex circuit affect the H-reflex bilaterally. This study was undertaken to determine whether the H-reflex evoked by stimulating proximally at the S1 foramen (S1 foramen H-reflex) could improve S1 root lesion evaluation sensitivity in patients with diabetes mellitus. A randomized paired study was designed to evaluate tibial and S1 foramen H-reflexes; bilateral H-M interval (HMI) and H-reflex latency were compared in 22 diabetic patients with unilateral S1 radiculopathy. Other electrophysiological evaluations included standard tibial conduction studies, sural conduction studies and needle electromyography (EMG). The S1 foramen H-reflex had a significantly higher sensitivity (91.0%, 20 of 22) in evaluating S1 radiculopathy than the conventional tibial H-reflex (63.6%, 14 of 22, p < 0.05). Bilateral tibial compound muscle action potential amplitudes were reduced in 3 patients, and sural sensory nerve action potential amplitudes decreased in 7 patients. Needle EMG revealed denervation restricted to the paraspinal muscle and myotomes supplied by the S1 nerve root on the ipsilateral side in 18 patients, and multiple lumbosacral nerve roots were involved bilaterally in the other 4 patients. Our results demonstrate that the S1 foramen H-reflex is a more sensitive assessment of S1 compressive radiculopathy in patients with diabetes mellitus.

H-reflex to S1-root stimulation improves utility for diagnosing S1 radiculopathy

The H-reflex on stimulation of the tibial nerve in the popliteal fossa is routinely used in the diagnosis of first sacral (S1) nerve-root radiculopathy. The H-reflex latency, however, is considered to lack sensitivity since a small change from the focal root pathology can be diluted in a relatively long reflex latency. We have studied the soleus H-reflex elicited by stimulation of the S1 nerve root at the S1 foramen. The normal values for the S1-foramen H-reflex have been reported in a previous study, but there are no definitive reports in patients with S1 radiculopathy. This study was undertaken to determine whether stimulating at the S1 nerve root can improve the utility of the H-reflex for detecting an S1-root lesion. A randomised paired-study design was utilised to evaluate two H-reflexes: one elicited with tibial nerve stimulation and one elicited with S1-root stimulation. Fifty-five patients with unilateral S1 radiculopathy, confirmed by clinical, electrodiagnostic and magnetic resonance imaging (MRI) evidences were studied. A high-voltage electrical stimulator was used to elicit H-reflexes bilaterally at the S1 foramen and L4/L5 spine level. Latencies were compared with previously generated normal values and similar responses from the asymptomatic leg, focussing on the interval between the peak of M- and H-waves (HMI). On the symptomatic side, 39 of the 55 patients had abnormal tibial H-reflex latencies and 54 patients had abnormal responses on S1-foramen stimulation (absent in 18; HMI prolonged >0.4ms in 36). On the asymptomatic side, all 55 patients had normal tibial H-reflexes, and 52 had normal responses on S1-foramen stimulation. In three patients, the HMI was abnormal on S1-foramen stimulation. In 46 patients tested with L4/L5-level stimulation, H-reflex was present in 39 and absent in seven. The latency of the M-wave to S1 stimulation was normal. Abnormal S1-root H-reflexes reveal lesions at the S1 root in patients with normal tibial H-reflexes; therefore, enhancing diagnostic sensitivity. The appearance of the H-reflex to L4/L5-level stimulation in patient with absent H-reflex to S1-foramen stimulation further localises the site of S1 nerve-root lesion to the L5/S1 spine level. Thus, H-reflex to S1-root stimulation significantly increases the diagnostic sensitivity for S1 radiculopathy. In our study, the S1-root H-reflex with high-voltage electrical stimulation has shown greater sensitivity than the tibial H-reflex in evaluating S1 compressive radiculopathies. An abnormal S1-root H-reflex helps to localise the lesion to the S1 root in patients with concurrent abnormal tibial nerve H-reflex, which may increase diagnostic specificity.

The distribution of primary nitric oxide synthase- and parvalbumin- immunoreactive afferents in the dorsal funiculus of the lumbosacral spinal cord in a dog.

1. The aim of the present study was to examine the distribution of unmyelinated, small-diameter myelinated neuronal nitric oxide synthase immunoreactive (nNOS-IR) axons and large-diameter myelinated neuronal nitric oxide synthase and parvalbumin-immunoreactive (PV-IR) axons in the dorsal funiculus (DF) of sacral (S1-S3) and lumbar (L1-L7) segments of the dog.2. nNOS and PV immunohistochemical methods were used to demonstrate the presence of nNOS-IR and PV-IR in the large-diameter myelinated, presumed to be proprioceptive, axons in the DF along the lumbosacral segments.3. Fiber size and density of nNOS-IR and PV-IR axons were used to compartmentalize the DF into five compartments (CI-CV). The first compartment (CI) localized in the lateralmost part of the DF, containing both unmyelinated and small-diameter myelinated nNOS-IR axons, is homologous with the dorsolateral fasciculus, or Lissauer tract. The second compartment (CII) having similar fiber organization as CI is situated more medially in sacral segments. Rostrally, in lower lumbar segments, CII moves more medially, and at upper lumbar level, CII reaches the dorsomedial angle of the DF and fuses with axons of CIV. CIII is the largest in the DF and the only one containing large-diameter myelinated nNOS-IR and PV-IR axons. The largest nNOS-IR and PV-IR axons of CIII (8.0-9.2 mum in diameter), presumed to be stem Ia proprioceptive afferents, are located in the deep portion of the DF close to the dorsal and dorsomedial border of the dorsal horn. The CIV compartment varies in shape, appearing first as a small triangular area in S3 and S2 segments, homologous with the Philippe-Gombault triangle. Beginning at S1 level, CIV acquires a more elongated shape and is seen throughout the lumbar segments as a narrow band of fibers extending just below the dorsal median septum in approximately upper two-thirds of the DF. The CV is located in the basal part of the DF. In general, CV is poor in nNOS-IR fibers; among them solitary PV-IR fibers are seen.4. The analysis of the control material and the degeneration of the large- and medium-caliber nNOS-IR fibers after unilateral L7 and S1 dorsal rhizotomy confirmed that large-caliber nNOS-IR and and PV-IR axons, presumed to be proprioceptive Ia axons, and their ascending and descending collaterals are present in large number in the DF of the lumbosacral intumescence. However, in the DF of the upper lumbar segments, the decrease in the number of nNOS-IR and PV-IR fibers is quite evident.

Cerebrospinal Fluid Biomarkers in Experimental Spinal Nerve Root Injury

Cerebrospinal fluid biomarkers were evaluated in a setup using established pig models to mimic clinical disc herniation. To investigate biomarkers for nerve tissue injury, inflammation, and pain in cerebrospinal fluid after mechanical compression and/or nucleus pulposus application to spinal nerve roots. The association between mechanical compression, biochemical effects of nucleus pulposus, and nerve root injury in degenerative disc disorders is incompletely investigated. The unilateral S1 nerve root was exposed in 20 pigs. The animals were divided into four groups (n = 5 each): 1) slow-onset mechanical compression with an ameroid constrictor; 2) autologous nucleus pulposus application; 3) mechanical compression plus nucleus pulposus; and 4) sham operation. After 1 week, 6 mL of cerebrospinal fluid was collected, and four structural nerve proteins, neurofilaments, S-100, glial fibrillary acidic protein, neuron-specific enolase, the proinflammatory cytokine interleukin-8, the neurotransmitter nociceptin, and substance P endopeptidase activity were analyzed using immunoassays. The concentration of neurofilament was increased in the mechanical compression group (17.0 microg/L +/- 5.0) and in the mechanical compression plus nucleus pulposus group (19.8 +/- 12.1 microg/L) compared with the sham group (0.9 +/- 0.9 microg/L) and the nucleus pulposus group (0.4 +/- 0.1 microg/L) (P < 0.01 for both). The concentration of nociceptin was increased significantly in the mechanical compression group (24.0 +/- 8.6 fm/mL) and in the mechanical compression plus nucleus pulposus group (31.2 +/- 6.6 fm/mL) compared with the sham group (7.0 +/- 1.3 fm/mL) (P < 0.05 and P < 0.01, respectively). A correlation was found between concentrations of neurofilament and nociceptin (r = 0.50, P < 0.05). There were no intergroup differences regarding glial fibrillary acidic protein, neuron-specific enolase, S-100, interleukin-8, or substance P endopeptidase activity. The present study demonstrates increased concentrations of neurofilament and nociceptin in cerebrospinal fluid after nerve root compression. A simultaneous application of nucleus pulposus did not increase the response.

Correlation of nerve root pain with dermatomal sensory threshold and back pain with spinal movement in single level lumbar spondylosis

We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain. A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain.

Magnetoneurographic 3D localization of conduction blocks in patients with unilateral S1 root compression

Objectives: Tibial nerve somatosensory evoked magnetic fields (tSEFs) over the lower back reflect the propagation of compound action currents along fibers of plexus, nerve roots and cauda equina. One clinical perspective for this `magnetoneurography' is the non-invasive 3D localization of focal slowing or blocks of conduction. Here, first tSEF mappings in 3 consecutive patients with acute unilateral S1 nerve root compression are reported. Methods: Right and left tibial nerves were electrostimulated in alternation; tSEF responses were recorded using a multichannel SQUID-detector; additionally, spinal and cortical SEP, F-wave and H-reflex studies were performed. Results: In all patients an intraindividual side-to-side comparison of spinal tSEF mappings was obtained: using a dipolar source model compound action, currents could be visualized propagating along plexus, nerve roots and cauda equina on the non-affected side whereas on the affected side normally-propagating dipolar field patterns could be recorded only distal to the spinal transforaminal root entrance; this reflects focal slowing or block of conduction in nerve root fibers as indicated by the SEP, F-wave and H-reflex study results. Conclusion: With a registration time of 15 min a 3D localization of proximal slowing or block of conduction was successfully performed in patients suffering from acute nerve root lesions.

P135 Retest reliability in facial nerve conduction studies

The H-reflex on stimulation of the tibial nerve in the popliteal fossa is routinely used in the diagnosis of first sacral (S1) nerve-root radiculopathy. The H-reflex latency, however, is considered to lack sensitivity since a small change from the focal root pathology can be diluted in a relatively long reflex latency. We have studied the soleus H-reflex elicited by stimulation of the S1 nerve root at the S1 foramen. The normal values for the S1-foramen H-reflex have been reported in a previous study, but there are no definitive reports in patients with S1 radiculopathy. This study was undertaken to determine whether stimulating at the S1 nerve root can improve the utility of the H-reflex for detecting an S1-root lesion.A randomised paired-study design was utilised to evaluate two H-reflexes: one elicited with tibial nerve stimulation and one elicited with S1-root stimulation. Fifty-five patients with unilateral S1 radiculopathy, confirmed by clinical, electrodiagnostic and magnetic resonance imaging (MRI) evidences were studied. A high-voltage electrical stimulator was used to elicit H-reflexes bilaterally at the S1 foramen and L4/L5 spine level. Latencies were compared with previously generated normal values and similar responses from the asymptomatic leg, focussing on the interval between the peak of M- and H-waves (HMI).On the symptomatic side, 39 of the 55 patients had abnormal tibial H-reflex latencies and 54 patients had abnormal responses on S1-foramen stimulation (absent in 18; HMI prolonged >0.4 ms in 36). On the asymptomatic side, all 55 patients had normal tibial H-reflexes, and 52 had normal responses on S1-foramen stimulation. In three patients, the HMI was abnormal on S1-foramen stimulation. In 46 patients tested with L4/L5-level stimulation, H-reflex was present in 39 and absent in seven. The latency of the M-wave to S1 stimulation was normal.Abnormal S1-root H-reflexes reveal lesions at the S1 root in patients with normal tibial H-reflexes; therefore, enhancing diagnostic sensitivity. The appearance of the H-reflex to L4/L5-level stimulation in patient with absent H-reflex to S1-foramen stimulation further localises the site of S1 nerve-root lesion to the L5/S1 spine level. Thus, H-reflex to S1-root stimulation significantly increases the diagnostic sensitivity for S1 radiculopathy.In our study, the S1-root H-reflex with high-voltage electrical stimulation has shown greater sensitivity than the tibial H-reflex in evaluating S1 compressive radiculopathies. An abnormal S1-root H-reflex helps to localise the lesion to the S1 root in patients with concurrent abnormal tibial nerve H-reflex, which may increase diagnostic specificity.

Normal limits of side-to-side H-reflex amplitude variability

Our hypothesis was that side-to-side difference in the tibial H-reflex amplitude can aid in the diagnosis of unilateral S1 radiculopathy with an otherwise normal side-to-side H-reflex latency difference. We studied 47 healthy subjects, (mean ± SD, 35 ± 10 years) using methods similar to those described by Braddom and Johnson. Only those with side-to-side latency difference less than 1.5msec were included (n = 45). Current was increased in 0.5 to 1.0 mA increments until the H-reflex amplitude maximized and then fell; on each side the response with the maximal peak-to-peak amplitude was measured for peak-to-peak amplitude and onset latency. The amplitude on the side of the smaller response was expressed as a ratio of the contralateral amplitude; this mean value (±SD) was 0.74 ± 0.17. We conclude that a side-to-side amplitude ratio smaller than 0.4 (mean − 2 SD) in the face of a normal side-to-side latency difference is probably abnormal.

Myelin breakdown and elimination in the posterior funiculus of the adult cat after dorsal rhizotomy: a light and electron microscopic qualitative and quantitative study.

Adult cats were subjected to unilateral dorsal L6, L7, and S1 rhizotomy. After survival times of 1-1,552 days the degeneration of axons and myelin sheaths and the elimination of degenerating myelin was studied qualitatively and quantitatively with light and electron microscopy and in Marchi-stained sections in the posterior funiculus in T12-L2. Degeneration was first observed as swollen or shrunken nerve fibers. Somewhat later there was an increased occurrence of collapsed myelin sheaths. The latter lost their myelin periods and appeared to be transformed into myelin bodies. The occurrence of myelin bodies coincided temporally with the presence of many Marchi-positive bodies. Later, an increasing number of intracellularly located lipid droplets occurred, paralleled by the occurrence of a great number of Marchi-positive granules and crystalline structures. Profiles of collapsed myelin sheaths, myelin bodies, and lipid droplets were frequently seen in the cytoplasm of microglial cells. Later, astrocytes and perivascular cells became filled with numerous lipid droplets. The findings suggest that microglial cells take up collapsed myelin sheaths and within these cells the sheaths become transformed into myelin bodies and subsequently into lipid droplets. These two products of myelin disintegration appear to correspond to the Marchi-positive structures seen during the degeneration process. The lipid droplets appear to be transported to astrocytes and perivascular cells.

The diagnostic value of H-index in S1 root compression.

The H-index was studied in 42 healthy subjects and in 20 patients showing unilateral S1 root compression. When compared to the normal subjects, all patients showed a decreased H-index, or an increased difference in H-index between the sides or both. These results indicate that both parameters are valuable in the diagnosis of S1 root impairment due to intervertebral disc protrusion.

Anatomical changes in cat dorsal horn cells after transection of a single dorsal root

Adult cats were subjected to unilateral L6, L7, or S1 rhizotomy. After survival times of 3 to 224 days each cat's spinal cord segments L1 to S2 were serially sectioned and stained with either Golgi or Nissl stains. The Nissl-stained material was used to determine whether or not significant cell death occurred as a result of transneuronal degeneration. The Golgi material was used to determine if changes in dendritic structure occurred. Laminae IV to VI were used for these analyses. There were no statistically significant changes in cell counts when the operated side was compared with the normal side, suggesting that cell death was rare or absent. However, dendritic complexity (mean number of branches of different orders per cell) and total dendritic length decreased with time after L7 rhizotomy in segments L3 to S2. There were no significant changes in segments L1 and L2. Atrophy of dendrites was most rapid and severe in the L7 segment, decreasing as a function of distance from L7. Two hypotheses are advanced, on the basis of these data: (a) The rapidity and degree of atrophy of a dendrite is a function of severity of deafferentation of that dendrite; and (b) rapid dendritic atrophy without cell death, as is seen in L6 to S1 after L7 rhizotomy, is possible because some dendrites are totally or largely deprived of their synaptic complement, but enough of the neuron's total synaptic input is left intact to sustain the cell and prevent cell death.