title: Symptom provocation of fluoroscopically guided cervical nerve root stimulation. Are dynatomal maps identical to dermatomal maps?
abstract: METHODS
  This prospective study consisted of mechanical stimulation of cervical nerve roots C4 to C8 in patients with cervical radicular symptoms undergoing diagnostic selective nerve root block.
  
  
  OBJECTIVE
  To document the distribution of pain and paresthesias that result from stimulation of specific cervical nerve roots and compare that distribution to documented sensory dermatomal maps.
  
  
  BACKGROUND
  Cervical dermatomes were first studied in the late 19th century. The results of those studies underpin current clinical decision making for patients with neck and arm pain. However, it has been observed that patients with radicular symptoms may have cervical pathology by radiographic imaging that is not corroborative, or have imaging studies that suggest a lesion at a level other than the one suggested by the patient's dermatomal symptoms. These observations may suggest that cervical dermatomal mapping is inaccurate or the distribution of referred symptoms (dynatome) from cervical root irritation is different than the sensory deficit outlined by dermatomal maps.
  
  
  METHODS
  Inclusion criteria consisted of consecutive patients undergoing fluoroscopically guided diagnostic cervical selective nerve root blocks from C4 to C8. Immediately preceding contrast injection, mechanical stimulation of the root was performed. An independent observer interviewed and recorded the location of provoked symptoms on a pain diagram. Visual data was subsequently compiled using a 793 body sector bit map. Forty-three clinically relevant body regions were defined on this bit map. Frequencies of symptom provocation and likelihood of symptom location from C4 to C8 stimulation of each nerve root were generated.
  
  
  RESULTS
  One hundred thirty-four cervical nerve root stimulations were performed on 87 subjects. There were 4 nerve root stimulations at C4, 14 at C5, 43 at C6, 52 at C7, and 21 at C8. Analyzing the frequency of involvement of the predetermined clinically relevant body regions either individually or in various combinations yielded more than 1,000 bits of data. Although the distribution of symptom provocation resembled the classic dermatomal maps for cervical nerve roots, symptoms were frequently provoked outside of the distribution of classic dermatomal maps.
  
  
  CONCLUSIONS
  The current study demonstrates a distinct difference between dynatomal and dermatomal maps.
authors.affiliation: Department of Rehabilitation Medicine, University of Pennsylvania Medical Center, USA.
authors.forename: C W
authors.initials: CW
authors.lastname: Slipman
authors.forename: C T
authors.initials: CT
authors.lastname: Plastaras
authors.forename: R A
authors.initials: RA
authors.lastname: Palmitier
authors.forename: C W
authors.initials: CW
authors.lastname: Huston
authors.forename: E B
authors.initials: EB
authors.lastname: Sterenfeld
mesh_terms: D002574:Cervical Vertebrae; D004558:Electric Stimulation; D005471:Fluoroscopy / Q000379:methods*; D006801:Humans; D009407:Nerve Block / Q000379:methods*; D010146:Pain / Q000503:physiopathology; D059408:Pain Management; D011446:Prospective Studies; D011843:Radiculopathy / Q000628:therapy*; D012867:Skin / Q000294:innervation; D013126:Spinal Nerve Roots / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000502:physiology