Journal of Medical Ultrasonics

https://doi.org/10.1007/s10396-017-0855-9

ORIGINAL ARTICLE

Investigation of the effectiveness of therapeutic ultrasound

with high‑resolution ultrasonographic cross‑sectional area
measurement of cervical nerve roots in patients with chronic cervical
radiculopathy: a prospective, controlled, single‑blind study
Burcu Metin Ökmen1   · Korgün Ökmen2 · Lale Altan1,3

Received: 7 July 2017 / Accepted: 6 December 2017

© The Japan Society of Ultrasonics in Medicine 2018

Abstract
Purpose  The purpose of our study was to evaluate the effects of therapeutic ultrasound (US) on chronic cervical radiculopathy
(CR) patients using both the clinical parameters and the cross-sectional area (CSA) values of the cervical nerve roots (NR)
measured by high-resolution ultrasonography (HRUS).
Methods  Thirty-two patients with chronic CR were included in this prospective, controlled, and single-blind study. All
of the patients received therapeutic US at continuous mode, 1-MHz frequency, and 1.5-W/cm2 intensity for 10 sessions.
The patients were assessed using VAS for pain, Modified Neck Disability Index, and Short-form 12, and cervical NR were
examined with HRUS. The data were obtained before treatment (W0), the second week immediately after treatment (W2),
and at the sixth week (W6).
Results  Twenty-nine patients and a total of 42 affected cervical NR and 42 unaffected cervical NR (control group) were
evaluated. A significant improvement was observed for all clinical parameters and CSA values of affected cervical NR both
at W2 and W6 compared to pre-treatment values (p < 0.05).
Conclusions  We found therapeutic US to be beneficial in improvement of pain, disability, and quality of life of patients
with chronic CR. We suggest that CSA measurements may also contribute to both diagnosis and post-treatment evaluation
in chronic CR.

Keywords  Chronic cervical radiculopathy · Therapeutic ultrasound · High-resolution ultrasonography · Cervical nerve
root · Cross-sectional area

Introduction

Cervical radiculopathy (CR) is a pathological process

* Burcu Metin Ökmen
burcumetinokmen@gmail.com
1 imaging (MRI) is an established diagnostic tool for CR,
Department of Physical Medicine and Rehabilitation, Bursa
Yuksek Ihtisas Training and Research Hospital, University
of Health Sciences, Mimar Sinan Mah, Emniyet Street,
Yıldırım, Bursa, Turkey
2
Department of Anesthesiology and Reanimation, Bursa
Yuksek Ihtisas Training and Research Hospital, University
of Health Sciences, Bursa, Turkey
3
Department of Physical Medicine and Rehabilitation, Uludag
University Faculty of Medicine, Bursa, Turkey
involving entrapment and inflammation of the cervical nerve
roots (NR) [1]. Diagnosis of CR is usually made based on
the symptoms of pain and paresthesia in the dermatome of
the affected segment, neurological examination, radiology,
and electrodiagnostic tests [1, 2]. While magnetic resonance
some patients do not have access to MRI because of its cost
and scheduling problems [3]. High-resolution ultrasonogra-
phy (HRUS) has been gaining popularity in diagnosis and
monitoring of several peripheral and central nervous sys-
tem disorders as a portable, noninvasive, radiation-free, less
expensive, and easily accessible tool [4].

13
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Ultrasonographic imaging allows measurement of the
cross-sectional area (CSA) of the peripheral nerve and detec-
tion of segmentary or diffuse constriction or swelling of the
affected nerve as well as the changes in its echogenicity [5].
It has been previously documented that CSAs of the cervical
NR on the affected side are larger compared to the unaf-
fected side in CR patients according to measurements made
by HRUS [6, 7].
Immobilization, manipulation, medical treatment, and
several physical therapy modalities are used for treatment
of CR. Therapeutic ultrasound (US) is frequently used in
conservative treatment of CR because of its thermal and
non-thermal effects [8, 9]. Typically, the thermal effects are
employed for treatment of pain, reduction of subacute and
chronic inflammation and muscle spasm, and stretching of
collagenous tissue in joint and connective tissue contractures
[10]. Low-dose non-thermal US is used for stimulation of
tissue repair [11] and reduction of edema [10]. US has also
been shown to increase muscle temperature and blood flow,
nerve conduction velocity, and extensibility of the connec-
tive tissue [12–15].
While there have been several studies assessing the effects
of therapeutic US on chronic neck pain [16, 17], we could
not find a report as to its specific effects on chronic CR. For
this reason, the purpose of our study was to evaluate the
effects of therapeutic US on chronic CR patients primarily
based on the CSA values of the cervical NR measured by
HRUS and secondarily using the clinical parameters.
Materials and methods
This study was planned as a prospective, controlled, and
single-blind study. After receiving local ethics committee
approval (Decision number 2011-KAEK-25 2016/16-09), 40
patients with CR were evaluated for eligibility.
Patients
The inclusion criteria were: (1) ages between 30 and
65 years; (2) neck pain for more than 3 months; (3) CR
diagnosis with history and physical examination findings
[segmental sensory disturbances corresponding to MRI find-
ings, minimal motor deficits (muscle strength 4 or 4 +/5)];
(4) C5, C6, and C7 NR pressure evident on cervical MRI;
and (5) electromyography findings consistent with cervical
MRI and clinical examination.
The exclusion criteria were: (1) diabetes mellitus, (2)
peripheral and central nervous system disease, (3) poly-
neuropathy, (4) inflammatory rheumatic disease, (5) malig-
nancy, (6) history of surgical intervention on the neck area,
and (7) certain surgical indications (e.g., progressive neu-
rological deficit).
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Journal of Medical Ultrasonics
Thirty-two patients who were eligible for the study were
given detailed information about the study, and an informed
consent form was signed by each of them. Forms detailing
the patients’ demographic characteristics and pre-treatment
(W0) measurements were filled in. All US measurements
were performed by a single physician trained and specialized
in musculoskeletal nerve US. Patient histories, clinical find-
ings, and MRI results were not accessible by the researcher
who made the measurements (Fig. 1).
Interventions
A BTL 4625 US device (BTL, Czech Republic) was applied
in continuous mode, 1-MHz frequency, and 1.5-W/cm2
intensity over the neck surface area. The headpiece area of
the device was 5 cm2. The headpiece was placed on the para-
vertebral muscles and trapezius muscle in the posterolateral
zone of the neck. The application was performed with the
head of the device positioned perpendicular to and in full
contact with the skin for 10 min using gel and a continuous
circular motion for 5 consecutive days a week for 2 weeks
(a total of 10 sessions).
Evaluation parameters
Primary outcome measures
High-resolution ultrasonography measurements were
performed using a 12- to 18-MHz linear probe (Esaote
Mylab30, Genova, Italy). All patients were seated with lat-
eral flexion of the neck with their heads facing the opposite
side of the NR examined. Contralateral unaffected NR were
also evaluated as a control. To prevent anisotropy during
measurement with HRUS, the transducer was held at right
angles, applied with minimum pressure, and the transducer
was rotated to find the point where the CSA was minimal.
C5 and C6 transverse processes have apical anterior and
posterior tubercles, and the C7 transverse process has a
rudimentary anterior tubercle and a distinctive posterior
tubercle. For this reason, the level of C7 vertebra was first
detected by ultrasound scanning [6]. The anterior and pos-
terior tubercles of C6 were scanned in the transverse plane
where the nerve root passed between the tubercles for imag-
ing of the nerve root. The transducer was moved superiorly
from the C6 transverse process to image the C5 nerve root or
otherwise inferiorly to image the C7 root [6]. C5, C6, and C7
cervical NR were evaluated in an axial view in accordance
with the shapes of the transverse processes. The transducer
was maintained at the most proximal location possible, typi-
cally at the point where the nerve root exited over the trans-
verse process [6] (Fig. 2).
Journal of Medical Ultrasonics

Enrollment
Patients Assessed ForEligibity (n=40)

Not Included (n=8)

• Diabetes Mellitus (n=5)
• with a history of surgical
intervention of neck area (n=1)
• polyneuropathy (n=2)

Patients Included the Study (n=32)

Patients evaluated with VAS, mNDI, SF-12

and CNR were examined with CSA at W0
(n=32)

Patients Received Therapeutic Ultrasound

Therapy (n=32)

Patients evaluated with VAS, mNDI, SF-12 Patients did not attend follow-ups
and CNR were examined with CSA at W2 because of the private reasons (n=3)
(n=32)

Patients evaluated with VAS, mNDI, SF-12

and CNR were examined with CSA at W6
(n=29)

Patient analyzed (n=29)

W0:Week 0 (Pretreatment), W2:Week 2 (Immediately after treatment ), W6: Week 6

CNR: Cervical nerve roots, CSA: Cross-Sectional Area
VAS: Visual Analog Scale, mNDI: Modified Neck Disability Index, SF-12: Short form 12

Fig. 1  Flowchart of the study

Secondary outcome measures
Visual analog scale (VAS) The VAS is a widely used scale
developed by Price and colleagues to assess the severity of
the pain felt by the patient. The patient rated pain on a 0–10
scale, with 0 representing no pain and 10 representing the
worst pain imaginable [18].
Modified Neck Disability Index (mNDI) Disability was
assessed using mNDI, which comprises ten parts evaluating
neck pain intensity, self-care, lifting load, reading, headache,
concentration, working, driving, sleeping, and leisure time
activities. Each part has six possible answers scored from 0
(no disability) to 5 (complete disability) giving a total score
of 0 (no disability) to 50 (total disability) or a percentage

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Fig. 2  Measurement of CSA of a C7 cervical spinal nerve roots, b C6 cervical spinal nerve roots, and c C5 cervical spinal nerve roots via US in
patients with cervical radiculopathy
of 0–100. Turkish validity and reliability was performed by
Kesiktaş and colleagues [19].
Short-form 12 (SF-12): Twelve different items were
taken from the eight different headings of SF-36, and the
shorter SF-12 form was created. The SF-12 has physical
(SF-12-PCS) and mental (SF-12-MCS) state assessment
scales, of which regression analyses have been performed
in the general public. The physical and mental health sum
scales were computed using the scores of twelve questions
and range from 0 to 100, where a zero score indicates the
lowest level of health measured by the scales and 100 indi-
cates the highest level of health [20].
No drug was given to the patients throughout the study.
The same researcher completed the second (W2) and
sixth week (W6) evaluations. The researcher who performed
W0 HRUS measurements again performed NR CSA meas-
urements in W2 and W6 (Figs. 1, 3).
Statistical analysis
Analysis of the collected data was performed using IBM
SPSS 22.0 statistical package program. Descriptive statistics
were calculated to summarize the data. Normal distribution
Fig. 3  Pre- and post-treatment HRUS images of C7 cervical spinal nerve root. a Pre-treatment image, b post-treatment image. PT posterior
tubercle, VA vertebral artery
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Journal of Medical Ultrasonics
of the data was tested using the Shapiro–Wilk test. Nor-
mal distribution was found. Paired samples t test was used
to compare the difference in the CSA between the affected
and unaffected nerve roots, and it was also used in intra-
group analysis of other evaluation parameters. Spearman
rank-order correlations were assessed between the CSA
of the affected nerve root and the duration of symptoms.
Values with a probability of (p) α < 0.05 were accepted as
significant.
Results
Three patients abandoned the study for personal reasons.
The present study was completed with 29 patients. No
patient was left out of the study due to any side effect of the
treatment (Fig. 1).
The distribution of age, sex, body mass index, and com-
plaint duration of the patients are presented in Table 1. Pre-
treatment (W0), second (W2), and sixth (W6) week evalua-
tion of the parameters are presented in Table 2. A significant
improvement was observed for all parameters both at W2
Journal of Medical Ultrasonics

Table 1  Analysis of the demographic data of the patients
Patients (n = 29)
Age 44.97 ± 7.90
Gender (F/M) 20/9 (69%/31%)
BMI (kg/m2) 24.55 ± 2.25
Symptom duration (month) 26.83 ± 36.2
Mean ± SD
BMI body mass index
and W6 compared to the pre-treatment values (p < 0.05)
(Table 2).
Nine of 29 patients were affected in only the C5 root
(n = 9), four in only the C6 root (n = 4), three in only the
C7 root (n = 3), nine in both the C5 (n = 9) and C6 (n = 9)
roots (a total of 18 roots), and four in both the C6 (n = 4)
and C7 (n = 4) roots (a total of 8 roots). Thus, a total of 42
affected NR (which were correlated with electromyography
findings consistent with cervical MRI and clinical examina-
tion) and 42 unaffected NR (control group) were evaluated
in our study. The distribution of the affected NR according
to their level is presented in Table 3.
In affected NR, a significant improvement was observed
for CSA values both at W2 and W6 compared to the
pre-treatment values (p  <  0.05). In unaffected (control
group) NR, there was no statistically significant difference
in CSA values both at W2 and W6 compared to the pre-
treatment values (p > 0.05) (Table 3).
Comparison of the affected and control NR showed that
CSA values were significantly higher on the affected side
at all evaluation periods (W0, W2, and W6) (p < 0.05)
(Table 3).
A statistically significant correlation in the positive direc-
tion was found by correlation analysis of symptom duration
and affected NR (Spearman’s R for C5: 0.707, p = 0.001,
Spearman’s R for C6: 0.842, p < 0.001, Spearman’s R for
C7: 0.777, p = 0.040) (Fig. 4).
Discussion
The results of our study showed that therapeutic US pro-
vided improvement in the parameters of pain, disability, and
quality of life in patients with chronic CR. HRUS meas-
urements revealed a significant decrease in CSAs of the
affected NR. However, CSA values of the affected NR were
still higher than those of the control side at W6, despite the
significant decrease in the former at W6 compared to W0
measurements.

Table 2  Intra-group comparison W0 W2 p (W2–W0) W6 p (W6–W0)

of W0, W2, and W6 values
VAS 7.07 ± 1.36 5.00 ± 1.34 < 0.001 2.59 ± 1.24 < 0.001
mNDI 36.02 ± 15.66 24.11 ± 11.07 < 0.001 14.21 ± 7.20 < 0.001
SF-12
 PCS 37.63 ± 6.22 42.31 ± 4.82 < 0.001 47.83 ± 3.67 < 0.001
 MCS 32.67 ± 6.13 38.18 ± 5.10 0.003 44.56 ± 4.00 < 0.001

Mean ± SD
W0 week 0 (pre-treatment), W2 week 2 (immediately after treatment), W6 week 6, VAS Visual Analog
Scale, mNDI Modified Neck Disability Index, SF-12 short-form 12, PCS physical component score, MCS
mental component score

Table 3  Comparison of W0, Nerve roots W0 W2 W6 p (W2–W0) p (W6–W0)

W2, and W6 values of affected
and unaffected nerve CSA Affected C5 (n = 18) 8.83 ± 0.99 7.67 ± 0.97 6.94 ± 1.06 < 0.001 < 0.001
­(mm2) values
Unaffected C5 (n = 18) 5.78 ± 0.73 5.67 ± 0.97 5.67 ± 0.97 0.430 0.430
p < 0.001 < 0.001 0.002
Affected C6 (n = 17) 14.18 ± 2.40 12.94 ± 2.25 11.12 ± 1.90 < 0.001 < 0.001
Unaffected C6 (n = 17) 9.88 ± 1.27 9.76 ± 1.48 9.76 ± 1.48 0.163 0.163
p < 0.001 < 0.001 0.005
Affected C7 (n = 7) 14.00 ± 2.38 12.57 ± 2.07 11.71 ± 1.70 0.003 0.002
Unaffected C7 (n = 7) 10.57 ± 1.51 10.29 ± 1.80 10.14 ± 1.68 0.172 0.078
p 0.008 0.015 0.033

Mean ± SD
W0 week 0 (pre-treatment), W2 week 2 (immediately after treatment), W6 week 6, CSA cross-sectional area

13

Fig. 4  Correlation analysis of symptom duration and CSA values of the affected NR. a Correlation of C5 roots, b correlation of C6 roots, and c
correlation of C7 roots
CR is characterized by inflammation of the dorsal or
ventral NR in the proximal segment of the intervertebral
foramen [1]. Disk herniation is known to be the most fre-
quent etiologic factor in CR [21].
In entrapment neuropathies, external compression on a
peripheral nerve causes impairment of the internal neural
structure [22]. In cases where herniation accompanies the
neuropathic process, degeneration of the axons and the
myelin sheath and derangement of venous flow result in
increased intraneural interstitial pressure and reversible
intraneural edema. Compression of the NR for longer peri-
ods has been reported to gradually decrease intraneural
blood flow and lead to chronic edema and fibrosis in the
NR [23–26].
HRUS has been used in several studies to detect struc-
tural changes in neural tissue [6, 7]. Using HRUS measure-
ments, Kim et al. found that the CSA values were signifi-
cantly higher in the affected NR than in the control side
in patients with herniated neuropathy at C5, C6, and C7
[6]. In another study performed with a larger number of
CR patients and also healthy volunteers, Takeuchi et al.
observed that the CRA values were higher in the affected
NR than both in the unaffected side of the patients and the
volunteers based on HRUS measurements [7].
Therapeutic US has often been used for treatment of
various muscular conditions because of its beneficial ther-
mal effects on the affected tissue [27]. It has been shown
in previous studies [14, 15, 28] that mild heating of mus-
cle accelerates the metabolic rate, and moderate heating
reduces muscle spasms, pain, and chronic inflammation
and increases blood flow. The pulse mode has been sug-
gested to be more effective during acute inflammation
because of its positive effect on macrophage activity and
angiogenesis [29]. Since the pulse mode does not have a
substantial effect on angiogenesis beyond the acute stage
[29], the continuous mode has been suggested to better
provide a heating effect during the chronic stage [30]. We
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Journal of Medical Ultrasonics
used the continuous mode in our study to treat chronic CR
in accordance with the latter suggestion.
In one of the few studies [16, 17, 31, 32] investigating
the efficiency of therapeutic US in chronic neck pain, Reda
et al. compared the effects of continuous US therapy applied
at 1 MHz with an intensity of 1.0 W/cm2 for 5 min and
for a total of eight sessions versus static stretch (SS) of the
upper fibers of the trapezius (UT) in patients with chronic
mechanical neck pain and obtained similar improvement in
both treatment groups [31]. Celik et al. compared the effects
of US alone, US + TENS, and sham US + TENS in 71
patients with acute non-specific neck pain who were ran-
domized into three groups and concluded that therapeutic
US was effective in reducing the pain and sensitivity level
of painful points on the cervical region and improving the
functional status by increasing the cervical range of motion.
They also reported that continuous application was observed
to be more effective for functional recovery [32]. However,
there have been a number of studies that do not corroborate
the above results [16, 17]. Costello et al. failed to obtain
improvement in 23 patients with neck and arm pain and
neural mechanical sensitivity with a single session of pulse
US treatment at a dose of 0.5 W/cm2, sonication time of
50%, and frequency of 1 MHz [16]. However, much of the
research that has demonstrated significant clinical benefit
has employed treatments at regular and relatively frequent
intervals [30]. In another randomized clinical study, continu-
ous US at 0.5 W/cm2 for 15 sessions in addition to exercise
and TENS was not found to be significantly superior to sham
US plus exercise and TENS in 100 patients with neck pain
[17]. However, it is possible to speculate at this point that the
failure to observe beneficial effects of the therapeutic effects
of US in the latter studies may have been due to the rela-
tively low US dose based on the suggestion of Draper et al.
that the dose of 0.5 W/cm2 is not sufficient to elicit substan-
tial thermal effects of US [33]. We observed improvement
in pain, disability, and quality of life, and also a significant
Journal of Medical Ultrasonics
decrease in NR CSA with the dose of 1.5 W/cm2 employed
in our study, and we believe this US dose is more efficient
in the treatment of chronic CR.
There have been several studies that used HRUS meas-
urements to monitor treatment results in peripheral nerve
disorders [34, 35]. Vögelin et al. [34] observed a significant
decrease in median nerve CSA values on average 6 days
after surgical decompression in patients with carpal tunnel
syndrome (CTS), and Cartwright et al. [35] reported similar
results 1 week after steroid injection in CTS patients, both
according to HRUS measurements.
We found a significant decrease in CSA of the affected
NR and improvement in pain, disability, and quality of life in
29 patients with chronic CR, both immediately and 4 weeks
after treatment. We attribute these results to a decrease in
the amount of edema in and around the NR provided by
therapeutic US. However, the lack of studies using HRUS
for evaluation of NR in CR patients precludes further com-
parative discussion of our results. We should also note that
CSA values of the affected NR were still higher compared to
the unaffected side at W6 measurements. We speculate that
this may be due to the persisting edema in the NR arising
from irreversible intraneural fibrosis due to the effects of
chronic compression in CR [6]. The positive correlation of
disease duration and CSA values seen in our study may sup-
port that speculation. In addition, because therapeutic ultra-
sound could not release mechanical compression, the high
level of CSA values at the cervical NR persisted. However,
it is obvious that this point should be further delineated by
studies with longer follow-up periods. The relatively small
patient population and short follow-up period may be noted
as limitations of our study.
Conclusions
We found therapeutic US to be beneficial in the improve-
ment of pain, disability, and quality of life in patients with
chronic CR. We suggest that CSA measurements by HRUS
may contribute to both diagnosis and post-treatment evalu-
ation of NR in chronic CR.
Compliance with ethical standards  Antropol. 2012;36:921–8.
Conflict of interest  There are no financial or other relations that could
lead to a conflict of interest.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
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