Nghiên cứu đặc điểm lâm sàng, chẩn đoán điện và cộng hưởng từ ở bệnh nhân thoát vị đĩa đệm cột sống thắt lưng, cùng TT TIẾNG ANH

1

MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF HEALTH

HANOI MEDICAL UNIVERSITY

NGUYEN TUAN LUONG
STUDY ON CLINICAL CHARACTERISTICS AND
ELECTRICAL DIAGNOSTICS AND MAGNETIC
RESONANCE IMAGING IN HERNIATED DISC OF THE
SACRUM LUMBAR SPINE PATIENTS

Major:

Neurology

Code:

62720147

SUMMARY OF MEDICAL DOCTORAL DISSERTATION

HA NOI – 2022


2

THE THESIS WAS FULFILLED AT
HANOI MEDICAL UNIVERSITY

Supervisors:
Assoc. Prof. Nguyen Huu Cong
Assoc. Prof. Nguyen Van Lieu
Reviewer 1:
Reviewer 2:
Reviewer 3:

The dissertation is defended before the Committee of Hanoi Medical University
At room………, A1 Building, HMU:

For further detail of the dissertation, please search at:
-

The national library

-

The library of Hanoi Medical University

on

/ /2022


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THESIS RELATED PUBLICATIONS
1. Nguyen Tuan Luong, Nguyen Thi Thu Huyen (2019).” Study on the
characteristics of the H reflex recorded in the soleus muscle in patients
with sacrum lumbar disc herniation”, Vietnam Medical Journal, vol.

484, p. 590 – 596.
2. Nguyen Tuan Luong, Nguyen Huu Cong, Nguyen Van Lieu (2020).
“Investigation of nerve conduction characteristics in patients with
lumbar disc herniation and spinal stenosis”, Vietnam Medical Journal,
vol 492, p. 235 – 240.


1
INTRODUCTION
Low back pain is a common clinical manifestation. In 2009, it was
estimated that the annual cost of this disease in the US was about $90 billion.
Sacrum lumbar disc herniation is always a topical problem because it is one of
the common causes of low back pain. This pathology is the displacement of the
intervertebral disc nucleus beyond the physiological limit of the annulus,
causing compression on adjacent components (such as spinal cord, nerve roots,
etc.), the main manifestation. is low back pain and manifestations of
compression in the respective nerve roots.
The diagnosis of this disease is based on: clinical examination, magnetic
resonance imaging is not difficult with lumbar disc herniation, the same level.
But in fact, this lesion is often multi-layered with many forms and levels of
damage to the nerve root, so it is difficult to diagnose the affected nerve root.
The method of electrodiagnostic support for magnetic resonance is able to
assess nerve root function damage, damaged location, disease progression, etc.
In Vietnam, there are no studies on the coordination. Combination of clinical
examination, functional diagnosis and imaging to accurately assess the location
of nerve root damage due to disc herniation in this region. For the above
reasons, we conduct the thesis: "Study on clinical characteristics and
magnetic resonance imaging in herniated disc of the sacrum lumber spine
patients" with the follwing 2 objectives:
1. Describe clinical characteristics, nerve conduction indices and

electromyography in patients with disc herniation in the sacrum lumbar spine.
2. Evaluation of the compatibility between nerve conduction index,
electromyography and magnetic resonance imaging in patients with disc
herniation in the sacrum lumbar spine.


2
NEW CONTRIBUTIONS OF THE DISSERTATION
Describe in detail and comprehensively the clinical features, nerve
conduction indices and electromyography in patients with lumbar disc herniation.
Research has shown that when examining the F wave of the deep peroneal nerve
and the H reflex can help localize the location of the damaged L5, S1 nerve roots.
When examining the electromyogram, the most common spontaneous potentials
are muscle fiber twitches and positive spikes, which helps in early diagnosis of
this disease.
The study evaluated the concordance between nerve conduction index,
electromyography and magnetic resonance imaging in patients with lumbar disc
herniation, the same mainly common in L4, L5 and S1 nerve roots. The study also
showed that for early diagnosis of this disease, electromyography of the
paravertebral muscle group should be performed at the position of the multifidus
muscle, which will help to accurately identify L3, L4 and L5 nerve root damage.
The study recommends that in patients with lumbar disc herniation, the
combination of clinical examination, electrodiagnostic investigation and magnetic
resonance imaging should be combined in the diagnosis of this pathology. The
results and recommendations of the thesis have contributed to improving the
quality of diagnosis and treatment of herniated discs in the lumbar spine, a very
common group of diseases in clinical practice.
LAYOUT OF THE DISSERTATION
Dissertation include 148 pages, with 4 main parts:
- Introduction

2 pages
- Chapter I: Literature review
40 pages
- Chapter II: Methodology
31 pages
- Chapter II: Results
44 pages
- Chapter IV: Discussion
39 pages
- Conclusion
2 pages
- Recommendation
1 page
The dissertation includes 48 tables, 27 pictures, 6 figures and 116
references (in which, 31 Vietnamese references, 85 English references), 2
journal articles related to the dissertation.


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CHAPTER 1
LITERATURE REVIEW
1.1. Clinically herniated disc in the sacrum lumbar spine
Clinically herniated disc in the sacrum lumbar spine has been clearly
described by the authors Nguyen Van Thong, Ho Huu Luong, Nguyen Van
Chuong, Greenberg M.S, Martin Merkle.
The clinical condition of herniated disc is diverse and rich, depending on
the degree and stage of the disc herniation, etc. including:
* Spine syndrome:
- Lumbar spine pain: dull, sometimes sharp, pain increases when moving,
pain relief when lying down.

- Change in spine shape: scoliosis, loss of spinal physiological curvature.
- Limit movement of the lumbar spine to all sides.
- Schober index < 14/10 cm.
- Spasticity of paravertebral muscle mass.
- There is pain in the lumbar spine.
* Nerve root syndrome:
- Pain along the great sciatic nerve.
- Signs of nerve root tension: signs of Lasègue, Valleix, ringing bells...
depending on the severity of the disease.
- Root type sensory disturbances; There may be sensory disturbances in
the form of decreased, lost, increased, paresthesia or dysesthesia.
- Movement disorders: manifested as decreased muscle strength along the
nerve roots. Make it difficult for the patient to perform: walking on the tip of
the foot or walking on the heel.
- Disorders of tendon reflexes: decrease or loss of knee or heel tendon reflexes.
- Nutritional disorders manifest: muscle atrophy, dry skin, hair loss, ...


4
- If severe disc herniation completely compresses the nerve root cover, it
can cause cauda equina syndrome: sphincter disorders, nutritional disorders,
premature muscle atrophy, sensory disturbances, etc.
1.2. Electrodiagnostic survey techniques used in the diagnosis of herniated
disc in the sacrum lumbar spine.
Steps to perform an electrical diagnosis, including:
- Clinical neurologic examination.
- Measurement of nerve conduction: survey of motor conduction and F
waves of the tibial nerve, deep peroneal nerve. Investigation of sensory
conduction of calf nerve, superficial peroneal nerve. H reflex test.
- Electromechanical recording with needle electrodes: L2, L3, L4, L5.

Pelvic (lumbar) muscle, adductor long, rectus femoris, lateral wide, medial
broad, anterior tibialis, posterior tibialis, semi-tendon, big toe extensor, gluteus
medlar, biceps thighs, inner leg muscles, soleus muscles.
- Synthesize data to guide diagnosis and conclusions.
1.2.1. Nerve conduction measurement method
Nerve conduction survey method aims to study the conduction capacity of
peripheral nerves, it includes: determination of peripheral motor potential time;
nerve conduction velocity, including motor and sensory conduction rates; the
latent time of the F wave and the H reflection.

Picture 1.1. Diagram of electrodes recording motor conduction of deep peroneal
nerve


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1.2.2. ELectromyography method
1.2.2.1. Electromyography making techniques
Electromyography is a method of examining the action potential of
skeletal muscle with a needle electrode to evaluate the function of skeletal
muscle and nerve conduction function. In this study, we used a 75 mm coaxial
needle electrode, following these steps:
- Leave the patient relax the muscle to be examined, then insert the needle
electrode through the skin into the target muscle, surveying the electrical
activity of that muscle.
- Leave the needle in place in a fully relaxed muscle (no muscle contraction)
to find out the spontaneous electrical activity of that muscle (if any).
- Have the patient contract gently so that the motor units emit discrete
pulses, and examine the images of each motor unit potential.
- Ask the patient to gradually increase muscle contraction to investigate
the phenomenon of aggregation of motor units.

Picture 1.2. Electromyography survey steps


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1.2.2.2. Electromyography muscle groups
Electromyography is important in the investigation of nerve root injuries.
Each muscle is innervated by one or more nerve roots. Evaluation of muscle
damage can determine whether the nerve root is damaged.
The distribution of nerve roots by the main muscle group: L2, L3 due to
the lumbosacral, iliac, and long adductor muscles; L3, L4 due to rectus thigh
muscle, inner wide muscle, outer wide muscle, ...
Examination of the paraspinal muscles: electromyography of the
paraspinal muscles (position of the multifidus muscles) is very important in the
investigation of root lesions, based on the loss of nerve distribution in the
examined paravertebral muscles. According to the American Society of
Electrodiagnostic and Neuromuscular Disease (2017).
1.3. MRI technique used in the diagnosis of herniated disc in the sacrum
lumbar spine.
The patients underwent magnetic resonance imaging of the lumbar spine
at the Department of Diagnostic Imaging - Viet Tiep Friendship Hospital, Hai
Phong using a Phillips Achieva 1.5T machine placed in an air-conditioned
room (average temperature from 24-260C), diagnosed with lumbar disc
herniation, position and type of disc herniation.
Specifications: T1W pulse sequence: TR 500 ms, TE 5ms; 4 mm thick,
FOV: 300, voxel: 1x1x4 mm. T2W pulse sequence: TR 5000 ms, TE 550ms; 4
mm thick, FOV: 300, voxel: 1x1x4 mm.
Results analysis method: based on T1, T2 and cross-sectional images to
diagnose lumbar disc herniation, and describe herniated disc morphology. In
addition, depending on the medical condition, we can perform other pulse

sequences such as: STIR, T2*, T2 FAT SAT or T2 Myelo pulses.


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CHAPTER 2

METHOGOLOGY
2.1. Study subjects
All patients diagnosed with sacrum lumbar disc herniation were inpatient
treatment at Viet Tiep Friendship Hospital from January 2017 to November
2019 which eligibility to participate in the study
2.1.1. Criteria for selecting patients
According to the standards of the North American Spine Association
(2012). The patient was diagnosed as herniated disc when there were criteria:
* About clinical:
- Sensory disturbances along the nerve roots.
- Positive Lasègue sign.
- Positive buzzer sign.
- Decreased muscle strength due to damaged nerve roots.
* About subclinical:
The patient was confirmed by MRI of the lumbar spine. Diagnostic
criteria for disc herniation on magnetic resonance imaging include:
- Narrow the height of the combustion chamber.
- Decreased disc signal on T2W pulse.
- The nucleus pulposus of the disc is displaced from its normal position:
backward or laterally, ...
The patient underwent electrodiagnosis, including:
- Measurement of nerve conduction: survey of deep peroneal, tibial
nerve; sensory survey of superficial peroneal nerve, calf nerve; F waves and H
reflections.

- Electromyography using needle electrodes (electromyography) of the
muscles: paraspinal muscles, quadriceps, adductor muscles, anterior tibialis,
posterior tibialis and inner leg abdominal muscles, ...


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2.1.2. Patient exclusion criteria
- Patients with sacrum lumbar disc herniation have a history or are
suffering from neurological diseases affecting nerve conduction; use of
neuroleptic drugs or drugs with a risk of neuritis complications.
- The patient did not agree to participate in the study.
2.2. Study method
2.2.1. Ethical considerations
- This study is purely observational and descriptive, with no intervention
or treatment. The purpose of the research is to help improve the quality of
expertise, improve the quality of life and satisfaction for patients.
- The study had patient consent.
- The topic has been approved by the Ethics Council in Biomedical
Research of Hanoi Medical University and Viet Tiep Friendship Hospital, Hai
Phong.
2.2.2. Study design
- Description of the cluster of cases.
2.2.3. Sampling techniques and samples
- Select a formula sample, take the whole sample during the research
period.
- In our study, 108 patients met all of the above sampling conditions.


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2.2.4. Data collection method

Steps to conduct the research when the patient enters Viet Tiep Friendship
Hospital, the researcher will directly ask the patient, perform a thorough and
detailed clinical examination and do tests (magnetic resonance imaging and
electrical diagnosis) according to theform of detailed medical records. Purpose
of data collection for research.
Summary of the research steps:
Patients

Selecting criteria patients

Not join to the study

Join to the study

Clinical examination
Asking relevance factors
1. Spine syndrome examination:
+ Lumbar spine pain point.
+ Spinal deformity: loss of curvature, lumbar scoliosis.
+ Limit the range of motion of the lumbar spine.
2.Nerve root syndrome examination:
+ Nerve root pain.
+ Signs of nerve root tension.
+ Sensory, movement, reflex disorders.
Assess clinical severity.

MRI the sacrum lumber spine
+ Location of hernia.
+ Hernia.
+ Nerve root compression.

+ Anterior and posterior diameter of the spinal
canal, etc.

Electrodiagnostic
+ Survey of motor and sensory conduction
of the tibial, deep peroneal, superficial and
calf nerves.
+ Investigation of F waves, H reflections, ...
+ Electromyography of needles:
paravertebral muscles, distal muscles, ...

Clinical and laboratory description and suitability
assessment

Diagram 2.1: Diagram of study steps.


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CHAPTER 3
STUDY RESULTS
Our study collected 108 patients who met the sampling criteria. After
collecting and processing the data, the results obtained are as follows:
3.1. General characteristics of patients with sacrum lumbar disc
herniation
3.1.1. Epidemiology characteristics
Table 3.1: Age, gender, occupation distribution of patients with sacrum
lumbar disc herniation (n=108)
Charisteristics
< 60 y.o
60 – 69 y.o

Group of age
≥ 70 y.o
Mean age ± SD
Nam
Gender
Nữ
Manual work
Occupation
Intellectual work

No. patients
Rate (%)
51
47,2
30
27,8
27
25,0
60,2 ± 13,7
50
46,3
58
53,7
95
88,0
13
12,0

Comment: Among 108 patients participating in the study, the majority of
patients were of working age (<60 years old) (47.2%), with an average age of

60.2 ± 13.7 years old, the youngest patient is 33, the oldest is 91. Male/Female
ratio = 1/1.16 (the difference is not significant and not statistically significant).
In the group with 88% of patients in the study group of manual workers,
only 12% of patients were in the group of mental workers.


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3.1.2. Medical history
Table 3.2: Onset of pain symptoms (n=108)
Medical history
Right leg
Position of pain
Left leg
Both leg
L1
L2
Direction
of
L3
spread along nerve
L4
roots
L5
S1
1 rễ
2 rễ
No. pain roots
3 rễ
4 rễ
Pain in rest

Pain
Pain constantly
characteristics
Pain in moving
Slight pain
Moderate pain
Pain level
Much pain
Severe pain
Terrible pain

No.patients
26
24
58
1
1
10
63
96
65
23
44
39
2
0
80
28
3
16

83
5
1

Rate (%)
24,1
22,2
53,7
0,9
0,9
9,3
58,3
88,9
60,2
21,3
40,7
36,1
1,9
0
74,1
25,9
2,8
14,8
76,9
4,6
0,9

Comment: Symptoms of pain onset were successful: pain on both sides
accounted for the highest percentage (53.7%), mainly 2 and 3 nerve roots
(>36%), the common direction of spreading was along the nerve roots.

meridians L5 (88.9%), roots S1 (60.2%), and L4 (58.3%). The pain scale has
an average score of 4.72 ± 1.14 points, in which the pain level accounts for
76.9% and 74.1% of patients have continuous pain during the day. This is also
difficult for clinical diagnosis and treatment.


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3.2. Clinical characteristics of patients with sacrum lumbar disc herniation
3.2.1. Spine syndromes
Table 3.3: Location of sacrum lumbar spine pain along with the number of
disc floors (n=108)

Single-layer

Multi-layer

Pain position
Thorns L1/L2/L3
Thorns L4
Thorns L5
Thorns S1
2 layers
3 layers
≥ 4 layers

No.patients
0
1
13

1
57
28
7

Rate (%)
0
0,9
12,3
0,9
52,8
25,9
6,5

Comment: In the group of patients studied, the majority of patients showed
multi-stage pain: 2 floors (52.8%); 3 floors (25.8%) and 4 or more floors
(6.5%). When clinical examination shows that the location of pain is multilayered, there is a possibility of damage to many nerve roots, so the diagnosis
will be more difficult.
3.2.2. Nerve roots syndromes
Table 3.4: Sensory disorders along the nerve roots (n=108).
Signs
Decreased sensation
Normal
Increased sensation
Unusual sensation
Disorders sensation

No.patients
93
0

5
2
6

Rate (%)
86,1
0
4,6
1,9
5,5

Comment: Most of the patients clinically had decreased sensation
(86.1%). Besides, some other disorders such as dysesthesia (5.5%),
hyperesthesia (4.6%); paresthesia (1.85%).


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Table 3.5: Classification of clinical severity according to the Oswestry scale
(n=108).
ODI Classifiaction
Level 1 (ODI từ 0 – 20%)
Level 2 (ODI từ 21 – 40%)
Level 3 (ODI từ 41 – 60%)
Level 4 (ODI từ 61 – 80%)
Level 5 (ODI từ 81 – 100%)
Mean ± SD (max point of 50)

No. patients
Rate (%)
1

0,9
9
8,3
83
76,9
15
13,9
0
0,0
25,4 ± 4,6 (10 – 38)

Comment: The above table shows the classification of clinical severity
according to the Oswestry scale (ODI), with 76.9% of patients at level 3 (ODI
from 41 to 60%), the level of functional loss greatly affects the quality of life.
of the patient. If calculating the score as a percentage, it is ODI = 54.1 ± 9.4
(the lowest is 20.0 and the highest is 77.8).
3.3. Magnetic resonance imaging on patients with herniated discs in the
lumbar spine
3.3.1. Location of herniated disc
Table 3.6: Location of disc herniation on magnetic resonance imaging
Layer location of disc herniation
L1 – L2
L2 – L3
L3 – L4
L4 – L5
L5 – S1

No.patients
2
6

26
85
60

Rate (%)
1,9
5,6
24,1
78,7
55,6

Comment: On magnetic resonance imaging, the most common position of
lumbar disc herniation is L4 – L5 (78.7%); then L5 – S1 (55.6%); next to L3 –
L4 (24.1%). L1 – L2 disc location (1.9%), has the lowest rate.


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3.3.2. Number of disc herniation layer
Table 3.7: Number of disc hermination on MRI (n=108)
No. layer
1 layer
2 layer
3 layer
4 layer

No. patients
52
42
12
1

Rate (%)
48,2
38,9
12,0
0,9

Comment: The majority of herniated discs (51.8%), which is difficult in
clinical practice to determine the exact location of the damaged nerve root.
3.4. Results of nerve conduction in patients with sacrum lumbar disc
herniation
Table 3.8: Mean motor conduction of the deep peroneal and tibial nerves
(n=108)
Mean ± SD (Min – Max)
Deep peroneal nerves
Tibial nerves
Time of distal motor latency - DML (ms)
Left side
3,88 ± 0,46 (3,2 – 5,5)
5,11 ± 0,66 (3,3 – 6,0)
Right side
3,85 ± 0,52 (3,0 – 5,4)
5,21 ± 0,68 (3,4 – 6,5)
p
0,48
0,46
Motor Conduction velocity speed – MCV (m/s)
Left side
46,70 ± 3,37 (40,8 – 57,5) 46,10 ± 3,88 (39,0 – 66,0)
Right side

46,70 ± 3,2 (40,1 – 56,7) 45,84 ± 3,86 (38,4 – 67,4)
p
0,41
0,32
Amplitude M (mV)
Left side
3,62 ± 1,64 (1 – 8,1)
11,49 ± 3,76 (6,0 – 22,4)
Right side
3,48 ± 1,37 (1 – 8,4)
11,71 ± 4,42 (5,6 – 26,5)
p
0,41
0,49
Comment: Based on the analytical T-test in 108 patients, there is no
statistically significant difference between the two sides.


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3.5.

Concordance

in

diagnosis

between

clinical,

MRI

and

electromyography
3.5.1. Concordance of diagnosing the location of disc herniation
Table 3.9: Concordance of diagnosis of damaged nerve roots between
clinical, magnetic resonance and electrodiagnostic
Clinical
Injure location

No.
patient
1
1
11
71
103
66

Root L1
Root L2
Root L3
Root L4
Root L5
Rễ S1

Rate
%

0,9
0,9
10,2
65,7
95,4
61,1

MRI
No.
patient
2
4
21
65
77
24

Electrodiagnostic
Rate
%
1,9
3,7
19,4
60,2
71,3
22,2

No.
patient
0

2
13
72
101
61

Rate
%
0
1,9
12
66,7
93,5
56,5

Comment: All three methods give results to diagnose the location of
lesions, focusing mainly on three nerve roots L4, L5 and S1. However, there is
a difference between these three methods.

55%

45%

31%
14%

MRI, ED similar to clinical

MRI, ED different to clinical

MRI, ED different

MRI, ED similar

Figure 3.1: The compatibility of foot lesions diagnosis between clinical,
magnetic resonance imaging (MRI) and electrical diagnosis (ED)


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Comment: In the study group, 55% of patients had similar diagnostic
results between the 3 methods. There are 14% of patients with similar
diagnostic results on magnetic resonance imaging and electrodiagnosis but
different clinical and 31% of patients with different diagnostic results between
the 3 methods.
3.5.2. Concordance of the results of conduction measurements with the
diagnosis of disc herniation on magnetic resonance
When analyzing nerve conduction in the entire study sample (108
patients), we found no difference between the two sides. Therefore, we
analyzed separately in the group of unilateral nocturnal disc herniation, we
received 32 patients. This group conducted a nerve conduction study to
evaluate the statistically significant difference between the healthy side and the
diseased side.
Table 3.10: Results of F wave investigation on deep tibial and peroneal nerves (n=32)
Mean ± SD (Min – Max)
tibial nerve
Deep peroneal nerve
F min (ms)
Normal side
42,05 ± 7,60 (4,6 – 48,6)
Disease side

42,19 ± 8,12 (4,4 – 51,8)
P
0,43
Frequency of appearance of F waves (%)
Normal side
95,56 ± 14,32 (25 – 100)
Disease side
97,91 ± 6,30 (70 – 100)
p
0,36

42,93 ± 4,55 (27,3 – 48,2)
43,29 ± 5,11 (27,6 – 52,0)
0,04
74,81 ± 15,30 (19 – 100)
75,69 ± 13,90 (31 – 100)
0,03

Comment: Based on the Mann-Whitney test, there is no statistically
significant difference between the average F wave survey results of the tibial
nerve. However, there was a statistically significant difference in the deep
peroneal nerve.


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Table 3.11: Reflection survey results H (n=32)
Mean ± SD (Min – Max)
Normal
Disease side
Time of distal motor latency H 28,49 ± 2,1

28,96 ± 2,39
(ms)
(24,9 – 33,7) (25,4 – 34,3)
3,11 ± 1,61
2,70 ± 1,56
Amplitude H (mV)
(1 – 7,2)
(0,7 – 6,4)
35,12 ± 12,94 31,92 ± 12,77
Rate of H/M
(13,1 – 66,7)
(8,1 – 57,4)

p
0,01
0,03
0,02

Comment: Based on the Mann - Whitney test analyzed in 32 patients
diagnosed with disc herniation on one side on magnetic resonance, there was a
statistically significant difference (p < 0.05) between the mean H wave survey
results.
3.5.4. Concordance in clinical features, electrodiagnostic and magnetic
resonance

In 108 patients, we diagnosed herniated disc with damage to 284 nerve
roots on magnetic resonance and electrical diagnosis.
Table 3.12: Sensitivity, specificity of some muscle groups on electrodiagnosis
compared with magnetic resonance results (disc herniation root L5)
Disc hermination L5

Sensitively

Disc hermination 1 side (n=81)
Paravertebral muscle group L5
90.4
Semi-tendom muscle
78,2
Long big toe stretch
79,2
Distal muscle
group
Anterior tibial
80,2
Posterior tibial
79,2
Disc herniation 2 sides (n=203x2)
Paravertebral muscle group L5
94,5
Semi-tendom muscle
69,2
Long big toe stretch
73,9
Distal muscle
group
Anterior tibial
78,3
Posterior tibial
73,5

Specificity
75,2
80,4
73,5
69,7
74,5
70,5
77,3
98,1
67,5
69,2


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Comment: The L5 paravertebral muscle group showed high sensitivity in
diagnosing L5 root damage. However, the specificity is not high.
When analyzed on 51 patients, the diagnostic results were similar between
clinical and magnetic resonance. Because of current clinical practice, this
similarity criterion is often used to lead to intervention conclusions if surgical
treatment is required. In 51 patients with a diagnostic match between clinical
and magnetic resonance, we diagnosed herniated disc with damage to 130 nerve
roots on magnetic resonance and electrical diagnosis, we found that the results
were sensitive. The diagnosis between electrodiagnostic and magnetic
resonance imaging has been improved. Especially in the case of diagnosis of
disc herniation with L5 root damage (sensitivity 96.7%).
Table 3.13: Sensitivity, specificity of some muscle groups on electrodiagnosis
compared with magnetic resonance results (Disc herniation root L5)
Disc herniation L5

Sensitively

Disc hermination 1 side (n=30)
Paravertebral muscle group L5
94,4
Semi-tendom muscle
79,4
Long big toe stretch
78,4
Distal muscle
group
Anterior tibial
85,2
Posterior tibial
80,1
Disc hermination 2 sides (n=102x2)
Paravertebral muscle group L5
95,4
Semi-tendom muscle
72,4
Long big toe stretch
69,8
Distal muscle
group
Anterior tibial
86,5
Posterior tibial
85,4

Specificity
79,1

77,4
73,2
73,9
75,4
74,2
70,2
71,4
72,7
69,3

Comment: Sensitivity and specificity of L5 paraspinal muscle group is
higher than that of distal muscle group in diagnosing disc herniation with L5
root lesion. However, the specificity is not high.


19
CHAPTER 4
DISCUSSION
4.1.

Clinical

characteristics,

nerve

conduction

index

and

electromyography in patients with sacrum lumbar disc herniation.
4.1.1. Clinical characteristics
In our study, the average age of the disease was 60.2 ± 13.7 years old. The
proportion of working age accounts for the largest proportion (47.2%), this can
be explained because one of the causes of disc herniation is related to manual
labor, the bearing movements of sacral spine. This rate is similar to the study
of authors Phan Viet Nga (63.4%), Nguyen Van Chuong, Nhu Dinh Son,
Alexandros Tsarouhas (79.3%).
Regarding the sex ratio, we find that the male/female ratio is 1/1.16; quite
balanced (male accounted for 46.3%). Our study is in contrast to the study of
Nguyen Van Chuong and Nguyen Minh Hien (2.03/1). However, similar to the
study of M. Mondelli, A. Aretini (male 55%).
Our study found pain perception according to the L4 nerve root
(accounting for 58.3%); nerve root L5 (88.9%) and nerve root S1 (60.2%).
Anatomically, L4, L5 is the largest structure among lumbar vertebrae group, S1
is the weak position between the lumbar position and the sacrum. Therefore, it
is possible to explain the location of the lesion here or occurring in relation to
the anatomical structure. According to many authors, the rate of pain in one
location is often greater than in another. To assess pain, in the study we used
the VAS scale because it is easy to use and has been widely applied nationally
and internationally. The results obtained: the degree of pain accounted for the
majority (76.9%), the VAS score was 4.72 ± 1.14 points. Compared with some
studies, this result is low, such as Pham Van Thach's study, the mean
preoperative VAS score is 6.3 ± 1.19 points. Most of the patients in our study
had severe pain (76.9%) with continuous pain (74.1%).


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The characteristics of spinal syndrome in the studied patients showed that
the majority of patients had multi-layered pain: 2 floors (52.8%); 3 floors
(25.8%) and 4 or more floors (6.5%). When clinical examination shows that
the location of pain is multi-layered, there is a possibility of damage to many
nerve roots, so the definitive diagnosis will be more difficult.
The clinical severity rating scale (Oswestry scale (ODI)) showed the
highest proportion of level 3 expression (76.9%) with the mean score of the
Oswestry scale of 54.1 ± 1. 9.4 percentage points. When analyzing the
appropriateness of diagnosis of damaged roots between magnetic resonance
and electrodiagnostic, the results of lesions in the L5 roots accounted for the
highest percentage (>72%). The results of this study are similar to many studies
by other authors such as Nguyen Van Chuong (67.10 ± 0.50), Stefan Endres
(53.43 ± 10.12), etc.
Thus, the clinical characteristics of our study group with many
characteristics such as age, gender, background of onset, pain symptoms,
sensory disturbances, nerve root syndrome and sacral spine, VAS scale,
Oswestry scale have similar results with studies of many domestic and foreign
authors.
4.1.2. Characterization of nerve conduction index and electromyography.
Nerve conduction survey method aims to study the conduction ability of
peripheral nerves; At the foot, we choose positions that have diagnostic value
and practical clinical applications. The locations of nerve conduction
measurements are the deep peroneal nerve, the tibial nerve, the superficial
peroneal nerve, and the calf nerve..
Among 108 study patients, who were diagnosed with disc herniation on
magnetic resonance imaging, including hernia on one side and hernia on both
sides, we conducted a meta-analysis and found that: when investigating the
time of external motor potential micro, motor conduction velocity, amplitude
of the deep peroneal and tibial nerves; sensory conduction of the calf and

21
superficial peroneal nerves; There was no statistically significant difference
between the left and right side of F wave and H reflection. Our research is quite
similar to the authors Le Van Son, J. Kimura.
Regarding the electromyographic characteristics, in our study, we
investigated the damage to the lumbar nerve root due to herniated disc in this
region based on the paraspinal and distal muscle groups. The results obtained,
when surveying the needle according to the position of the dominant nerve root,
was that in 852 sites of electromyography, the normal needle puncture potential
was 39.91%, the increased needle puncture potential accounted for 45 percent.
,65%. Spontaneous potential: positive spike wave is 38.85%, the highest is
muscle fiber convulsion accounting for 50.7%. Motor unit potential we only
conduct evaluation in the distal muscle group. High amplitude accounted for
the highest rate 301/568 (52.99%), wide interval accounted for 45.07%,
polyphasic accounted for 43.13%, so these characteristics are very important in
assessing root damage. nerve. Many studies, there are similarities with our
results.
4.2. Concordance between nerve conduction index, electromyography
and MRI in patients with sacrum lumbar disc herniation
We conducted a separate analysis in the group of unilateral disc herniation,
we received 32 patients, when studying the F wave in this group of patients,
found: there was no statistically significant difference. between the median F
wave results in the tibial nerve but significant in the deep peroneal nerve. F
wave in the deep peroneal nerve with difference between diseased and healthy
side can help evaluate L5 nerve root damage due to disc herniation in this
region.
Similarly, when analyzing the H reflex in this group of 32 patients, we
found: there is a statistically significant difference (p<0.05) between the
average H wave survey results. This is very important. of significance in

clinical practice: on the role of the H reflex in the assessment of S1 nerve root


22
damage. The results of this study agree with some other authors such as Jaggar,
Thakur, Johnson, Kimura J who also concluded the same.
In our meta-analysis, we found that: 55% of patients had similar
diagnostic results between the 3 methods, 14% of patients had similar
diagnostic results on MRI and electrodiagnostic but different clinical and 31%
Patients have different diagnostic results between the 3 methods. Therefore, the
difference can only be explained by the fact that a patient can have a lumbar
disc herniation at the same time in many discs, so it is possible for many nerve
roots to be damaged at the same time. Thus, up to 45% of patients have
differences between the 3 methods, so clinical practice should pay attention to
coordinate with each other to avoid mistakes in diagnosing the exact location
of the lesion.
We analyzed and compared the sensitivity and specificity between
electrodiagnostic and magnetic resonance on each damaged nerve root site
because there was no surgery as a comparison criterion. The purpose is to help
clinicians diagnose more accurately the location of the lesion as well as to
choose diagnostic tests in clinical practice. Results in 108 study patients with a
total of 284 damaged nerve roots, the sensitivity of electrodiagnostic versus
magnetic resonance was 81.9% and that of magnetic resonance versus
electrodiagnostic was 63.5% lower. . However, when analyzing the sensitivity
of each nerve root, the sensitivity of herniated disc with damage to nerve roots
L3, L4, L5, S1 by electrodiagnosis is higher.
In the current clinical practice in the country, it is common to take the
lesion criteria on magnetic resonance imaging in combination with clinical
manifestations to conclude the surgical site if the patient has indications for
surgical treatment. Therefore, we conducted further analysis in 51 patients with

similar diagnostic results between clinical and magnetic resonance; take it as a
standard sample for comparison. In these 51 patients, we diagnosed herniated
disc with 130 nerve roots damage on magnetic resonance and electrodiagnostic