{"paper_id":"11675a91-c973-404b-9d82-baa103dd6091","body_text":"Evaluation of the Diagnostic Value of Ultrasound-guided Radicular Provocation Test in Identifying Responsible Lesions in Cervical Radiculopathy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the Diagnostic Value of Ultrasound-guided Radicular Provocation Test in Identifying Responsible Lesions in Cervical Radiculopathy 天亮 盛, 六月 魏, 辛 邓, 必须 跑, 崔林 辽, 胡安 张, 盛 邱 This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5716936/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Accurately identifying responsible lesions in multi-segmental cervical radiculopathy is challenging due to the lack of reliable diagnostic methods. While selective nerve root block (SNRB) is commonly used, its specificity remains suboptimal. Objective This study aims to evaluate the clinical diagnostic value of the ultrasound-guided radicular provocation test (US-guided RPT) in localizing responsible lesions in multi-segmental cervical radiculopathy. Methods This study included patients diagnosed with cervical radiculopathy (with unclear responsible lesions) who visited the Department of Pain Medicine at the First Affiliated Hospital of GanNan Medical University between December 2023 and August 2024. All patients underwent US-guided RPT for suspected lesions before surgery. The pain intensity [Visual Analog Scale (VAS) score] of the original symptoms at the site of pain provoked during US-guided RPT was recorded. Based on US-guided RPT results, patients received single-segment computed tomography (CT)-guided percutaneous endoscopic cervical foraminoplasty (CT-guided PECF). Postoperative follow-up assessed pain relief and functional improvement, with ≥ 50% improvement in pain symptoms (VAS score) at 3 days post-surgery used as the standard for surgical effectiveness. Lesions confirmed to be responsible based on effective pain relief were considered responsible lesions, while other suspected lesions were deemed non-responsible. By analyzing the provocation data of responsible and non-responsible lesions obtained from US-guided RPT and correlating these findings with clinical outcomes, a receiver operating characteristic (ROC) curve was generated to determine the area under the curve (AUC) and the optimal cutoff value. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of US-guided RPT were then calculated. Results A total of 56 patients (114 US-guided RPT procedures) with cervical radiculopathy meeting the inclusion criteria were included in this study. ROC analysis yielded an AUC of 0.874. A pain intensity ≥ 60% at the original symptom site was identified as the optimal cutoff, with sensitivity of 91.1%, specificity of 75.9%, accuracy of 83.3%, PPV of 78.5%, and NPV of 89.8%. Pain intensity at responsible lesions [6 (5, 7.75)] was significantly higher than at non-responsible lesions [0 (0, 3.25)] ( P < 0.0001 ). Postoperative VAS scores significantly decreased from 6.59 ± 1.11 preoperatively to 1.57 ± 1.20 at 3 days, 0.59 ± 0.65 at 1 month, and 0.38 ± 0.62 at 3 months. Neck Disability Index (NDI) scores similarly improved from 27.86 ± 2.05 preoperatively to 11.34 ± 1.87 at 3 days, 4.38 ± 1.21 at 1 month, and 1.43 ± 1.29 at 3 months. Conclusions US-guided RPT demonstrates diagnostic value in identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy. Additionally, following the diagnosis of responsible lesions by US-guided RPT, patients with multi-segmental cervical radiculopathy showed high efficacy when treated with CT-guided PECF. Cervical Radiculopathy Radicular Provocation Test Responsible Lesions Ultrasound Guidance Diagnosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Cervical Radiculopathy is one of the most common conditions causing neck, shoulder, and upper limb pain, with an incidence of approximately 83.2 per 100,000 population. The primary cause is cervical degenerative changes [ 1 , 2 ]. In aging populations, the prevalence of multi-segmental involvement on imaging is significantly higher due to progressive intervertebral disc degeneration and the exacerbation of cervical spondylosis [ 3 , 4 ]. The development of multi-segmental degeneration or stenosis in cervical radiculopathy is closely associated with the unique anatomical and biomechanical properties of the cervical spine [ 5 ]. The cervical spine bears the weight of the head while providing a wide range of lateral motion. This combination of high load and flexibility increases the risk of intervertebral disc wear and degeneration. Additionally, chronic poor posture and cervical strain further exacerbate disc degeneration, which can lead to compensatory osteophyte formation, ligamentum flavum hypertrophy, and calcification, all of which contribute to nerve root compression [ 5 ]. Clinically, patients with such conditions often present with complex symptoms and signs, making precise localization of the responsible lesion challenging. Solely relying on imaging, symptoms, or physical examination findings is insufficient to accurately identify the responsible lesion in these cases. Selective nerve root block (SNRB) is commonly used to further localize responsible lesions in cervical radiculopathy [ 6 , 7 ]. However, its diagnostic accuracy diminishes in multi-segmental cases due to factors such as atypical pain distribution, subjective pain perception, mixed etiologies, and the need for repeated procedures [ 8 ]. Currently, there are still significant shortcomings in the diagnostic methods for accurately identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy. While the majority of patients with cervical radiculopathy experience significant symptom relief with conservative treatment, surgical intervention becomes unavoidable for those who fail to respond adequately to non-surgical therapies. Minimally invasive posterior cervical foraminotomy (MI-PCF) is an effective surgical option for cervical radiculopathy [ 9 – 12 ], with percutaneous endoscopic cervical foraminoplasty (PECF) offering distinct advantages among various MI-PCF techniques [ 13 – 15 ]. However, achieving precise and effective treatment relies heavily on accurate preoperative localization of the affected segment, particularly in patients with multi-segmental suspected lesions of cervical radiculopathy. Accurate localization is critical for ensuring the effectiveness of precision surgery. Radicular provocation test (RPT) is a diagnostic technique that utilizes imaging guidance and specific puncture methods to inject saline into the suspected lesion site of a nerve root. This procedure induces transient mechanical stimulation of the affected nerve, provoking symptoms that can be compared to the patient’s usual complaints, thereby identifying the affected nerve and responsible lesion [ 16 , 17 ]. Wu et al. and Lin et al. [ 16 , 17 ] have demonstrated the advantages of RPT in identifying responsible lesions in lumbar disc herniation when compared with discography. However, effective diagnostic methods for precisely localizing responsible lesions in cervical radiculopathy remain lacking. In this study, we applied RPT for the localization of responsible lesions in cervical radiculopathy and quantified RPT-related parameters to further evaluate its diagnostic performance. Conventional CT-guided posterior cervical foramen puncture often targets the outer margin of the intervertebral foramen. With advancements in ultrasound technology, ultrasound-guided cervical foramen puncture allows real-time visualization to avoid critical structures such as blood vessels and nerves, enabling safe needle placement within the foramen. In this study, we performed US-guided RPT through an anterolateral approach to puncture the cervical foramen[ 18 ]. The accuracy of needle placement was further verified under CT guidance. This approach aims to offer a safe, simple, and radiation-free diagnostic method for identifying responsible lesions in cervical radiculopathy. Methods Patient Population This study was reviewed and approved by the Medical Ethics Committee of the First Affiliated Hospital of GanNan Medical University (Approval No. LLSC-2023-521). Written informed consent was obtained from all participants. This study included patients diagnosed with cervical radiculopathy (with unclear responsible lesions) who visited the Pain Department of the First Affiliated Hospital of Gannan Medical University from December 2023 to August 2024 (Fig. 1 ) . All patients underwent ultrasound-guided radicular provocation test (US-guided RPT) followed by single-segment computed tomography (CT)-guided percutaneous endoscopic cervical foraminoplasty (CT-guided PECF) for suspected lesions before surgery. During the US-guided RPT, pain intensity at the original pain site was recorded when all suspected lesions were provoked. Postoperatively, patients were followed up to assess the degree of pain relief and functional improvement. A ≥ 50% improvement in pain intensity, measured using the Visual Analog Scale (VAS) score, within 3 days after surgery was defined as a criterion for surgical efficacy. The lesion identified as the surgical target was considered the responsible lesion, while other suspected lesions were classified as non-responsible lesions. The data from US-guided RPT stimulation of responsible and non-responsible lesions were analyzed and correlated with clinical outcomes. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC) was calculated to determine the optimal cutoff value. Sensitivity, specificity, accuracy, positive predictive (PPV) value, and negative predictive value (NPV) were also calculated to evaluate the diagnostic performance of US-guided RPT in identifying responsible lesions in multi-segmental cervical radiculopathy. Fig. 1. A 50-year-old patient presented with clinical symptoms of pain in the right shoulder and back, lateral upper arm, and lateral forearm, accompanied by numbness in the thumb, index finger, and middle finger. (a): Preoperative sagittal cervical MRI showing narrowing of the C5/6 and C6/7 intervertebral foramina. (b, c): Axial cervical images at the C5/6 and C6/7 levels. Inclusion criteria 1. Age between 18 and 75 years; 2. Patients with cervical radiculopathy and multi-segmental suspected lesions, in whom the responsible lesion cannot be clearly identified by symptoms, signs, or imaging studies; 3. Persistent moderate or severe pain (VAS score ≥ 4) despite ≥3 months of conservative treatment; 4. Patients who consent to undergo US-guided RPT preoperatively; 5. Patients who consent to undergo single-segment CT-guided PECF. Exclusion Criteria 1. Age < 18 years or > 75 years; 2. Patients with cervical radiculopathy and clearly identified single-segment pathology; 3. Presence of severe comorbidities or other psychiatric or psychological disorders preventing cooperation with the researcher; 4. Patients with postoperative pain relief <50%, making the identification of the responsible lesion unfeasible. Procedures US-guided RPT After the patient was positioned in the operating room, the lateral decubitus position on the unaffected side was adopted. A high-frequency linear transducer was used for ultrasound scanning. Segmental levels were identified starting from the 'chair-back' hyperechoic appearance of the C7 transverse process, characterized by the absence of an anterior tubercle. The intervertebral foramen was visualized between the vertebral body and the corresponding facet joint. Following sterilization and draping, in-plane puncture technique was employed. Under real-time ultrasound guidance, a 7# × 90 mm needle was inserted via the anterolateral approach toward the target intervertebral foramen. The needle tip was advanced to the anterior surface of the facet joint bone and slid along the bone into the intervertebral foramen by approximately 5 mm (Fig. 2). CT scanning was performed to confirm whether the needle tip was located within the target foramen. If not, the position was adjusted under CT guidance. Once the needle tip reached the target point, a 2 mL syringe was used to aspirate and prepare a mixture of 0.9% saline and iohexol contrast agent (9:1). At each target point, 2 mL of the mixture was injected at a steady rate over 3 seconds by the same operator. The patient was monitored for the provocation of symptoms, such as pain or numbness consistent with their usual complaints. Injection was immediately stopped upon symptom provocation, with a maximum injection volume of ≤ 2 mL. After the induced symptoms subsided completely, the next step was performed. During the procedure, CT scans were used to observe the distribution of the injected contrast agent (Fig. 3). Fig. 2. Using ultrasound-guided puncture of the C6/7 intervertebral foramen as an example: (a-b): Transverse ultrasound images of the C6 nerve root located between the anterior and posterior tubercles of the C6 transverse process. Scanning from the cranial to caudal direction, the posterior tubercle of the C6 transverse process disappears, and the facet joint and intervertebral foramen appear. (c): Scanning the C6/7 intervertebral foramen area reveals scattered vascular distribution, with no vascular structures along the puncture pathway. (d): The puncture needle enters the C6/7 intervertebral foramen. The patient’s position, probe placement, and puncture entry point are shown in the central image. The in-plane approach guided by ultrasound is used, with the needle tip advanced from lateral to medial into the intervertebral foramen. yellow arrow: needle shaft. Fig. 3. CT imaging of the targeted puncture site in the cervical intervertebral foramen under ultrasound guidance and the diffusion of contrast agent. Yellow arrow: Needle tip position. Red arrow: 0.9% saline mixed with contrast agent. Black arrow: C5/6 and C6/7 intervertebral foramina. CT-guided PECF The surgery was performed according to the standard procedures for spinal endoscopy, using a posterior approach to the cervical spine. Under CT guidance, a puncture was made to locate the target point, after which a guidewire was placed. Gradually, a dilatation tube and working cannula were inserted. The endoscope was used to expose the interlaminar space and the bone surface of the surgical field. A curved bone drill was employed to remove part of the facet joint and lamina to access the spinal canal. Bone decompression was carried out to relieve nerve compression, with herniated tissue excised and hemostasis achieved. Nerve adhesions were released, and the endoscope revealed the restoration of the compressed nerve root’s shape, along with improved pulsation and local blood circulation. CT scans confirmed that the target herniated tissue was completely removed and the area of foraminal stenosis was widened, concluding the surgery (Fig. 4). Fig. 4. (a, b) CT sagittal and axial images showing the establishment of the endoscopic channel during surgery (C6/7). (c) Postoperative immediate CT axial image demonstrating enlargement of the right C6/7 intervertebral foramen. Evaluation Methods Diagnostic Value of US-guided RPT: To assess the diagnostic value of US-guided RPT, we first need to define a “positive” provocation threshold for the percentage of radiating pain triggered. We performed a ROC analysis to evaluate diagnostic performance, using the AUC as the criterion, and the Youden index to determine the optimal diagnostic cutoff. True positives are defined as a positive response to the responsible lesion, while false positives are defined as a positive response to non-responsible lesions. True negatives are defined as a negative response to non-responsible lesions, and false negatives are defined as a negative response to the responsible lesion. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of US-guided RPT were calculated. Follow-up and Efficacy Evaluation: Postoperative clinical efficacy was evaluated using the VAS and the Neck Disability Index (NDI). The VAS was used to assess the pain intensity induced by the US-guided RPT, and the percentage of pain intensity induced at the original pain site in the patients was reassessed. Effectiveness Criteria for CT-guided PECF: The effectiveness of CT-guided PECF was defined as (Preoperative VAS score - 3-day postoperative VAS score) / Preoperative VAS score ≥ 50%. Outcome Measures Primary Outcome Measures 1.AUC for US-guided RPT; 2.VAS score at 3 days postoperatively; 3.VAS pain intensity at the original pain site induced by provocation of each suspected lesion during US-guided RPT. Secondary Outcome Measures 1.Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of US-guided RPT; 2.VAS scores at 1 and 3 months postoperatively; 3.NDI scores at 3 days, 1 month, and 3 months postoperatively. Statistical Analysis Statistical analysis was performed using SPSS version 27.0 (IBM Corporation, Armonk, NY). Measurement data conforming to a normal distribution were expressed as mean ± standard deviation, with inter-group comparisons performed using the t -test, and multi-group comparisons conducted via one-way analysis of variance (ANOVA). For data not conforming to a normal distribution, values were expressed as median (interquartile range) [M (P25, P75)], with inter-group comparisons performed using the Mann-Whitney U test, and intra-group comparisons conducted using the Wilcoxon signed-rank test. A P value < 0.05 was considered statistically significant. Results Patients: This study included a total of 56 patients with multi-segmental suspected lesions of cervical radiculopathy who met the inclusion criteria. Among them, 21 were male and 35 were female, with an average age of 57.04 ± 9.34 years. Preoperative VAS score was 6.59 ± 1.11, and NDI score was 27.86 ± 2.05. Of the 56 patients, 54 had two suspected segments, and 2 had three suspected segments. All suspected lesions underwent US-guided RPT before surgery, with a total of 114 US-guided RPTs performed. All patients subsequently underwent CT-guided PECF to confirm the lesions. The final responsible lesions were identified as follows: C4/5: 3, C5/6: 16, C6/7: 36, C7/T1: 1. Non-responsible lesions were identified as follows: C4/5: 2, C5/6: 38, C6/7: 15, C7/T1: 3 (Table 1). Table 1. Characteristics of the patients. Characteristic Baseline Gender (Male/Female) 21/35 Age (years) 57.04±9.34 Preoperative VAS Score 6.59±1.11 Preoperative NDI Score 27.86±2.05 Provoked Segments (C4/5, C5/6, C6/7, C7/T1) 5/54/51/4 ROC Curve ( Fig. 5 ) Analysis and Diagnostic Value of US-guided RPT: The ROC analysis to determine the optimal cutoff for the positive criterion of US-guided RPT yielded the following results (Table 2). The AUC was 0.874. The best cutoff for a positive US-guided RPT result was a pain intensity ≥60% at the patient’s original symptom site. There were 51 true positives, 44 true negatives, 14 false positives, and 5 false negatives. The sensitivity of US-guided RPT was 91.1% (51/56), specificity was 75.9% (44/58), accuracy was 83.3% (95/114), PPV was 78.5% (51/65), and NPV was 89.8% (44/49). Fig. 5. The Receiver Operating Characteristic (ROC) Curve for Diagnosing Responsible Lesions in Multi-Segmental Suspected Cervical Radiculopathy Using Ultrasound-Guided Radicular Provocation Test (US-guided RPT). Comparison of US-guided RPT Diagnostic Parameters ( Fig. 6) : When diagnosing responsible lesions with US-guided RPT, the pain intensity (VAS score) induced at the responsible lesion site was 6 (5, 7.75), while the pain intensity induced at the non-responsible lesion site was 0 (0, 3.25). The pain intensity induced at responsible lesions was significantly higher than that at non-responsible lesions, with a statistically significant difference ( P < 0.0001 ). Postoperative Results: All patients underwent single-segment CT-guided PECF. Postoperative pain was significantly reduced compared to preoperative levels. All patients were followed up at 3 days, 1 month, and 3 months after surgery. The postoperative VAS score significantly decreased from a preoperative value of 6.59 ± 1.11 to 1.57 ± 1.20 at 3 days, 0.59 ± 0.65 at 1 month, and 0.38 ± 0.62 at 3 months (Fig. 7a). The postoperative NDI score decreased from a preoperative value of 27.86 ± 2.05 to 11.34 ± 1.87 at 3 days, 4.38 ± 1.21 at 1 month, and 1.43 ± 1.29 at 3 months (Fig. 7b). Table 2. Results of receiver-operator characteristic (ROC) analysis for cutoff value for the definition of a positive result Cutoff Value (%) Sensitivity (%) Specificity (%) Accuracy (%) Positive Predictive Value (%) Negative Predictive Value (%) ≥10 94.6 62.1 78.1 74.7 92.3 ≥20 94.6 62.1 78.1 74.7 92.3 ≥30 94.6 63.8 78.9 71.6 93.2 ≥40 94.6 63.8 78.9 71.6 93.2 ≥50 94.6 70.7 82.5 75.7 93.2 ≥60 91.1 75.9 83.3 78.5 89.8 ≥70 83.9 75.9 79.8 77.0 83.0 ≥80 76.8 81.0 78.9 79.6 78.3 ≥90 67.9 87.9 78.1 84.4 73.9 =100 51.8 93.1 72.8 87.9 66.7 The cutoff value represents the percentage of radiating pain induced compared to the patient’s usual pain state. Fig. 6. The pain intensity provoked by responsible lesions was significantly higher than that induced by non-responsible lesions (P < 0.0001). RL: Responsible Lesions; NRL: Non-Responsible Lesions. Fig. 7. (a) Postoperative VAS scores were significantly lower compared to preoperative scores (P < 0.001). (b) Postoperative NDI scores were significantly lower compared to preoperative scores (P < 0.0001). Discussion We propose the use of US-guided RPT for the localization and diagnosis of responsible lesions in multi-segmental suspected lesions of cervical radiculopathy and evaluate the diagnostic value of US-guided RPT, including its sensitivity, specificity, accuracy, and predictive value. The findings of this study demonstrate that US-guided RPT holds significant value in diagnosing responsible lesions in multi-segmental suspected lesions of cervical radiculopathy and can effectively guide surgical intervention. With the advancement of minimally invasive and endoscopic techniques, precise localization of the responsible segment and targeted treatment have become key clinical objectives, aiming to minimize unnecessary surgical trauma and complications. However, distinguishing which segment or segments are truly responsible for nerve root compression remains a challenge. Currently, the localization and diagnosis of responsible lesions in cervical radiculopathy primarily rely on clinical manifestations [ 19 , 20 ], imaging examinations [ 21 ], discography [ 22 ], and selective nerve root block [ 7 , 23 – 25 ]. However, these diagnostic methods still have limitations when applied to cervical radiculopathy with multi-segmental imaging changes. Previous studies have found that 26% of patients still experience significant pain during postoperative follow-up [ 26 ], which raises doubts about the accuracy of responsible lesion determination, especially in patients with multi-segmental disc herniation or foraminal stenosis. Clinical studies by Siivola et al. [ 27 ] and Anderberg et al. [ 28 ] on cervical nerve roots and the distribution of pain in their corresponding dermatomes show that the pain distribution in most patients does not follow the typical dermatome pattern. In Siivola’s study, approximately 76% of symptomatic patients did not present typical dermatomal pain. Anderberg’s study found that about 50% of patients had pain distributions that did not align with the classical nerve root distribution pattern. Therefore, in patients with multi-segmental suspected lesions of cervical radiculopathy, relying solely on MRI, neurological examination, and the distribution of pain in dermatomes is not entirely accurate for diagnosing responsible lesions. Discography has some diagnostic value for localizing responsible lesions in multi-segmental suspected lesions of cervical radiculopathy, especially when other diagnostic methods fail to provide clear results. However, cervical discs are smaller than lumbar discs, making cervical discography more technically challenging. Moreover, compared to lumbar diseases, the incidence of discogenic cervical radiculopathy (specifically, nucleus pulposus herniation) is lower, accounting for only 20–25% of cases [ 29 ]. Since the primary role of discography is to assess the structural condition of the disc itself, its diagnostic value is limited for non-discogenic causes. SNRB, commonly used in clinical practice, plays an important role in locating the responsible lesion. However, its sensitivity and specificity in diagnosis can vary significantly, and the technical operation can influence the diagnostic results [ 30 ]. In the diagnosis of multi-segmental suspected lesions in cervical radiculopathy, its limitations are further magnified. For such patients, SNRB cannot directly determine the specific segment of the lesion. Each suspected lesion must be tested individually, and the symptom improvement after blocking at each site must be compared to identify the responsible segment. This method increases the number of tests, medical resource consumption, and patient discomfort, and may also introduce more risks [ 1 , 31 ]. Furthermore, due to factors such as individual anatomical variations, nerve root cross-innervation, drug diffusion to adjacent nerve roots, and subjective biases in patient judgments [ 7 ], diagnostic results may also contain errors. In addition, when there is peripheral pathology within the nerve distribution area [ 32 ], symptom relief after SNRB cannot effectively differentiate between nerve root pathology and peripheral lesions, potentially leading to false-positive results. In fact, there is currently no simple and effective method for accurately locating the responsible lesion in multi-segmental suspected lesions of cervical radiculopathy. Furthermore, there are no studies that use ROC analysis to determine the ideal cutoff value for the positive diagnosis of the responsible lesion in multi-segmental suspected lesions of cervical radiculopathy using existing diagnostic methods. Our research team has proposed the RPT, which involves using specific puncture techniques under imaging guidance to inject a certain volume of saline into the suspected nerve root lesion area. This procedure induces mechanical stimulation at the affected nerve, triggering symptoms of nerve compression. These induced symptoms are compared to the patient’s usual symptoms to evaluate their consistency, thereby achieving diagnostic localization of the lesion. Selecting an appropriate puncture target and imaging guidance is critical for the successful implementation of RPT. Based on varying risks of nerve compression, the cervical intervertebral foramen can be divided into the entrance zone, middle zone, and exit zone, with each area contributing differently to nerve compression. In the entrance zone, nerve root compression is typically caused by disc herniation or uncovertebral joint osteophytes. Due to its smaller diameter, this area is a high-risk zone for nerve root compression [ 33 ]. Therefore, to simulate effective stimulation of the lesion, the injection target should be positioned as close as possible to the entrance zone of the intervertebral foramen. With the advancement of ultrasound technology, ultrasound-guided cervical intervertebral foramen puncture has become increasingly refined. Real-time visualization under ultrasound guidance allows for effective avoidance of structures such as blood vessels and nerves during the procedure. Furthermore, ultrasound is radiation-free, cost-effective, and convenient, making it more acceptable to patients compared to X-ray or CT imaging. In this study, cervical intervertebral foramen puncture was performed under ultrasound guidance using an anterolateral approach. Compared to the traditional posterior approach, the anterolateral puncture route better conforms to the anatomical structure of the cervical intervertebral foramen. The puncture needle can directly reach the intervertebral foramen along the surface of the facet joint, bringing the target closer to the region of nerve pathology. Additionally, the anterolateral approach effectively avoids critical structures such as the spinal cord and vertebral artery, thereby reducing the risk of direct injury to these vital anatomical structures [ 34 , 35 ]. However, the anterolateral puncture route is adjacent to important structures such as the trachea, esophagus, and carotid artery. This proximity poses risks of complications such as tracheal or esophageal injury, which can lead to dysphagia or pneumothorax [ 36 ]. In this study, strict control of the puncture angle was maintained during ultrasound-guided anterolateral intervertebral foramen puncture. Using the transverse process facet joint as a safe landmark, the needle was advanced to the facet bone surface and then slid inward along the joint surface into the intervertebral foramen. No severe complications, such as tracheal, esophageal, or arterial injuries, occurred during the procedures, effectively preventing adverse events. Although no significant adverse events or additional puncture-related injuries occurred in this study, the risks and technical challenges associated with ultrasound-guided anterolateral cervical intervertebral foramen puncture remain high. The procedure requires the operator to possess substantial experience and advanced skills to ensure safety and success. Additionally, to verify the accuracy of ultrasound-guided anterolateral cervical intervertebral foramen puncture, CT scans were performed after the needle was positioned under ultrasound guidance to confirm whether the puncture needle reached the target location. If discrepancies were found, the needle was further adjusted under CT guidance to ensure accurate placement within the intervertebral foramen, allowing the injected medication to exert an effective provocative effect. For the mechanical stimulation to effectively target the affected nerve root, the injected solution must disperse around the target nerve root. In a study by Wu et al.[ 18 ]fluoroscopic imaging demonstrated that contrast agents injected during ultrasound-guided anterolateral cervical intervertebral foramen puncture successfully diffused around the cervical nerve root. Similarly, in this study, a small amount of contrast agent was mixed with the injected solution during the US-guided RPT procedure. The dispersion of the contrast agent was observed under CT imaging, revealing that the solution surrounded the nerve root, thereby confirming precise localization of the medication at the target site. This observation indicates that the US-guided RPT procedure can deliver mechanical stimulation effectively to the target nerve root. This study utilized US-guided RPT to provoke patients’ pre-existing symptoms and combined the findings with surgical outcomes to generate an ROC curve. The ROC curve analysis indicated that the optimal cutoff value for diagnosing responsible lesions in multi-segmental suspected lesions of cervical radiculopathy using US-guided RPT was a pain intensity at the original symptom site of ≥ 60%. The sensitivity was 91.1%, specificity was 75.9%, accuracy was 83.3%, PPV was 78.5%, NPV was 89.8%, and the AUC was 0.874. The high sensitivity and NPV suggest that US-guided RPT is effective in identifying responsible lesions, reducing the likelihood of missed diagnoses. Meanwhile, the specificity and PPV demonstrate moderate accuracy in ruling out non-responsible lesions, albeit with some risk of misdiagnosis. An AUC of 0.874 indicates that US-guided RPT has high diagnostic efficacy and robust discriminatory capability in differentiating between responsible and non-responsible lesions. These results support the reliability of US-guided RPT as a diagnostic tool for identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy, especially in scenarios where high sensitivity is crucial. Furthermore, given the lack of standardized assessments for sensitivity, specificity, and other key diagnostic metrics in current methods for multi-segmental suspected lesions of cervical radiculopathy, US-guided RPT fills this critical gap by providing quantifiable diagnostic data. The relatively lower specificity and PPV in this study may be attributed to the inclusion of patients with multi-segmental cervical disc protrusions or foraminal degenerative changes, where multiple sites had the potential for nerve compression. Additionally, during US-guided RPT, subjective factors from patients might have led to positive responses at non-responsible lesions, contributing to false-positive results. In this study, there was a significant difference in the intensity of provoked symptoms between responsible and non-responsible lesions using US-guided RPT. The pain intensity induced by US-guided RPT at responsible lesions was notably higher compared to non-responsible lesions, suggesting that US-guided RPT has the potential to reflect the pathophysiological state of the lesions and assess the severity of the pathological changes. The strong consistency between the provoked responses and patients’ actual symptoms further validates the clinical value of US-guided RPT. Additionally, this study demonstrates that by directly comparing the pain intensity induced at different lesion sites, US-guided RPT provides a more intuitive and quantitative measure to identify responsible lesions. This approach minimizes errors caused by variability in patients’ pain perception, nerve function, or symptoms over time, and eliminates the discomfort associated with repeated testing. Moreover, US-guided RPT addresses the limitations of SNRB, which often requires multiple tests at different times to identify responsible lesions. By offering a reliable and efficient diagnostic method, US-guided RPT reduces patient burden and enhances diagnostic accuracy. MI-PCF, as a minimally invasive method for treating cervical radiculopathy, has become increasingly popular due to its advantages of minimal postoperative trauma and rapid recovery. Compared to traditional anterior cervical discectomy and fusion (ACDF), it achieves similar postoperative outcomes [ 12 ]. Moreover, MI-PCF has several unique advantages: first, it preserves cervical spine mobility, reducing the risk of adjacent segment degeneration; second, it excels in alleviating postoperative pain and improving functionality, with a lower complication rate and shorter recovery time for patients [ 11 ]. Additionally, MI-PCF avoids the necessity of cervical fusion, thereby minimizing its impact on cervical stability. The recurrence risk after MI-PCF is also relatively low compared to other surgical methods [ 37 , 39 ]. Among the various MI-PCF techniques, PECF stands out as an innovative approach with unique benefits. By utilizing endoscopy for high-definition visualization, PECF ensures minimal trauma and greater precision, effectively removing pathological tissue compressing the nerves while reducing surgical time and intraoperative risks [ 14 , 38 ]. Compared to other minimally invasive procedures, PECF offers faster recovery, fewer complications, and lower recurrence rates, making it particularly suitable for multilevel compression or complex cases [ 13 , 15 ]. In this study, CT-guided PECF was employed as the “gold standard” procedure due to its superior performance in postoperative pain relief and functional improvement. Performing the procedure on a single segment at a time allowed for a more direct and effective determination of whether the operated segment was the responsible lesion. All patients in this study successfully underwent CT-guided PECF, with significant postoperative pain relief and short recovery times. At 1 and 3 months postoperatively, patients’ VAS and NDI scores showed further improvement. The favorable postoperative outcomes indicate that all operated lesion sites were responsible lesions, with no adverse events related to misjudgment of the responsible segments. These findings demonstrate the high effectiveness of US-guided RPT in identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy, providing accurate localization for subsequent surgical treatment. Limitations of the Study This study is limited to cervical radiculopathy patients with multilevel radiological lesions, with a relatively small sample size and a short follow-up period. Conclusions US-guided RPT demonstrates diagnostic value in identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy. Additionally, following the diagnosis of responsible lesions by US-guided RPT, patients with multi-segmental cervical radiculopathy showed high efficacy when treated with CT-guided PECF. Declarations Author Contribution Conceptualization: [J, W.]; Methodology: [T, S. X, D.]; Formal analysis and investigation: [T, S., R, R.]; Writing—original draft preparation: [T, S.]; Writing—review and editing: [T, S.]; Resources: [T, S., C, L., J, Z., S, Q.]; Supervision: [J, W.]. X, D. made significant contributions to the research process and is listed as a co-first author. All authors have reviewed the manuscript content and approved it for publication. References Bono CM, Ghiselli G, Gilbert TJ et al (2011) An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J 11(1):64–72. 10.1016/j.spinee.2010.10.023 Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT (1994) Epidemiology of cervical radiculopathy. 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Chin J Pain Med 27(6):465–473. https://doi.org/10.3969/j.issn.1006-9852.2021.06.012 Wu J, Xu Y, Pu S et al (2021) US-Guided Transforaminal Cervical Nerve Root Block: A Novel Lateral in-Plane Approach. Pain Med 22(9):1940–1945. 10.1093/pm/pnab008 van der Windt DA, Simons E, Riphagen II et al (2010) Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev 2CD007431 Published 2010 Feb 17. 10.1002/14651858.CD007431.pub2 Thoomes EJ, van Geest S, van der Windt DA et al (2018) Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J 18(1):179–189. 10.1016/j.spinee.2017.08.241 Schwarz D, Kele H, Kronlage M et al (2018) Diagnostic Value of Magnetic Resonance Neurography in Cervical Radiculopathy: Plexus Patterns and Peripheral Nerve Lesions. Invest Radiol 53(3):158–166. 10.1097/RLI.0000000000000422 Manchikanti L, Dunbar EE, Wargo BW, Shah RV, Derby R, Cohen SP (2009) Systematic review of cervical discography as a diagnostic test for chronic spinal pain. Pain Physician 12(2):305–321 Ehsanian R, Schneider BJ, Kennedy DJ, Koshkin E (2021) Ultrasound-guided cervical selective nerve root injections: a narrative review of literature. Reg Anesth Pain Med 46(5):416–421. 10.1136/rapm-2020-102325 Datta S, Everett CR, Trescot AM et al (2007) An updated systematic review of the diagnostic utility of selective nerve root blocks. Pain Physician 10(1):113–128 Shi C, Xu N, Sun B et al (2021) Clinical Outcomes of Posterior Percutaneous Endoscopic Cervical Foraminotomy and Discectomy Assisted with SNRB in Treating Cervical Radiculopathy with Diagnostic Uncertainty. Pain Physician 24(4):E483–E492 Sampath P, Bendebba M, Davis JD, Ducker T (1999) Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine (Phila Pa 1976) 24(6):591–597 Siivola SM, Levoska S, Tervonen O, Ilkko E, Vanharanta H, Keinänen-Kiukaanniemi S (2002) MRI changes of cervical spine in asymptomatic and symptomatic young adults. Eur Spine J 11(4):358–363. 10.1007/s00586-001-0370-x Anderberg L, Säveland H, Annertz M (2006) Distribution patterns of transforaminal injections in the cervical spine evaluated by multi-slice computed tomography. Eur Spine J 15(10):1465–1471. 10.1007/s00586-005-0024-5 Carette S, Fehlings MG (2005) Clinical practice. Cervical radiculopathy. N Engl J Med 353(4):392–399. 10.1056/NEJMcp043887 Eubanks JD (2010) Cervical radiculopathy: nonoperative management of neck pain and radicular symptoms. Am Fam Physician 81(1):33–40 Datta S, Manchikanti L, Falco FJ et al (2013) Diagnostic utility of selective nerve root blocks in the diagnosis of lumbosacral radicular pain: systematic review and update of current evidence. Pain Physician 16(2 Suppl):SE97–SE124 Ehsanian R, Schneider BJ, Kennedy DJ, Koshkin E (2021) Ultrasound-guided cervical selective nerve root injections: a narrative review of literature. Reg Anesth Pain Med 46(5):416–421. 10.1136/rapm-2020-102325 Zhao Q, Yang Y, Wu P et al (2020) Biomechanical study of the C5-C8 cervical extraforaminal ligaments. J Orthop Surg Res. ;15(1):477. Published 2020 Oct 16. 10.1186/s13018-020-02006-9 Schellhas KP, Pollei SR, Johnson BA et al (2007) Selective cervical nerve root blockade: experience with a safe and reliable technique using an anterolateral approach for needle placement. AJNR Am J Neuroradiol 28(10):1909–1914. 10.3174/ajnr.A0707 Chibbaro S, Cornelius JF, Mallereau CH et al (2023) Lateral Approach to the Cervical Spine to Manage Degenerative Cervical Myelopathy and Radiculopathy. Acta Neurochir Suppl 135:339–343. 10.1007/978-3-031-36084-8_51 Yee TJ, Swong K, Park P (2020) Complications of anterior cervical spine surgery: a systematic review of the literature. J Spine Surg 6(1):302–322. 10.21037/jss.2020.01.14 Emami A, Coban D, Changoor S et al (2022) Comparing Mid-Term Outcomes Between ACDF and Minimally Invasive Posterior Cervical Foraminotomy in the Treatment of Cervical Radiculopathy. Spine (Phila Pa 1976) 47(4):324–330. 10.1097/BRS.0000000000004140 Zou T, Wang PC, Chen H, Feng XM, Sun HH (2022) Minimally invasive posterior cervical foraminotomy versus anterior cervical discectomy and fusion for cervical radiculopathy: a meta-analysis. Neurosurg Rev 45(6):3609–3618. 10.1007/s10143-022-01882-5 Bydon M, Mathios D, Macki M et al (2014) Long-term patient outcomes after posterior cervical foraminotomy: an analysis of 151 cases. J Neurosurg Spine 21(5):727–731. 10.3171/2014.7.SPINE131110 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5716936\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":395102483,\"identity\":\"3d26f839-ef3b-40a0-a573-4ee98c134d94\",\"order_by\":0,\"name\":\"天亮 盛\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gannan Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"天亮\",\"middleName\":\"\",\"lastName\":\"盛\",\"suffix\":\"\"},{\"id\":395102484,\"identity\":\"af1f169a-ba5b-44ca-9e43-275755276a7f\",\"order_by\":1,\"name\":\"六月 魏\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYFACxgYDBoZ/cmzszQcOfPhBvJYDxnw8xxIPzuwh3qoDifMkcowPc7ARodbgeHNDMe+OO8ZsDDkfDjPwMMjzix0goOXMwQZj3jPP5NgYzm44XGDBYDhzdgJ+LWY3EoFa2piN2Rh7NxyewcOQYHCbkJb7D8FaEtuYeR4c5mEjRssNRpCWw4ltbDwMxGmxP5PYYDi3Lc2YjYfNABjIEoT9Itl+/JnB2zYbOfn5jx9/+PDDRp5fmoAWIGAzQOJIEFQOAswPiFI2CkbBKBgFIxcAAJjpR7UBToG7AAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"First Affiliated Hospital of Gannan Medical University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"六月\",\"middleName\":\"\",\"lastName\":\"魏\",\"suffix\":\"\"},{\"id\":395102485,\"identity\":\"10e65d11-024c-4f66-8931-e4e9b6c2e8b6\",\"order_by\":2,\"name\":\"辛 邓\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"First Affiliated Hospital of Gannan Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"辛\",\"middleName\":\"\",\"lastName\":\"邓\",\"suffix\":\"\"},{\"id\":395102486,\"identity\":\"6d645edf-8895-4aac-9c76-7bb213840228\",\"order_by\":3,\"name\":\"必须 跑\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"First Affiliated Hospital of Gannan Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"必须\",\"middleName\":\"\",\"lastName\":\"跑\",\"suffix\":\"\"},{\"id\":395102488,\"identity\":\"20f6e681-4721-4bcd-946e-470d3e4412c2\",\"order_by\":4,\"name\":\"崔林 辽\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gannan Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"崔林\",\"middleName\":\"\",\"lastName\":\"辽\",\"suffix\":\"\"},{\"id\":395102489,\"identity\":\"a0afa00e-baa7-4350-9396-e1cdfc1b5925\",\"order_by\":5,\"name\":\"胡安 张\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gannan Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"胡安\",\"middleName\":\"\",\"lastName\":\"张\",\"suffix\":\"\"},{\"id\":395102490,\"identity\":\"6fc81d36-a34b-4882-9536-3627b35743b5\",\"order_by\":6,\"name\":\"盛 邱\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gannan Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"盛\",\"middleName\":\"\",\"lastName\":\"邱\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-12-26 15:08:11\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5716936/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5716936/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":72645030,\"identity\":\"526ef761-e10e-4da3-8469-79924aaaf941\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:41:48\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":673636,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eA 50-year-old patient presented with clinical symptoms of pain in the right shoulder and back, lateral upper arm, and lateral forearm, accompanied by numbness in the thumb, index finger, and middle finger. (a): Preoperative sagittal cervical MRI showing narrowing of the C5/6 and C6/7 intervertebral foramina. (b, c): Axial cervical images at the C5/6 and C6/7 levels.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/f33d130b02163919e3534b70.png\"},{\"id\":72646049,\"identity\":\"f73044c6-589f-4329-b773-aa7b005c831b\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:49:48\",\"extension\":\"jpeg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":215760,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eUsing ultrasound-guided puncture of the C6/7 intervertebral foramen as an example: (a-b): Transverse ultrasound images of the C6 nerve root located between the anterior and posterior tubercles of the C6 transverse process. Scanning from the cranial to caudal direction, the posterior tubercle of the C6 transverse process disappears, and the facet joint and intervertebral foramen appear. (c): Scanning the C6/7 intervertebral foramen area reveals scattered vascular distribution, with no vascular structures along the puncture pathway. (d): The puncture needle enters the C6/7 intervertebral foramen. The patient’s position, probe placement, and puncture entry point are shown in the central image. The in-plane approach guided by ultrasound is used, with the needle tip advanced from lateral to medial into the intervertebral foramen. yellow arrow: needle shaft.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image2.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/3685735b2e2d0895910eb4f1.jpeg\"},{\"id\":72645029,\"identity\":\"187c3023-e742-433f-93c1-290e0e95db02\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:41:48\",\"extension\":\"jpeg\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":123826,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eCT imaging of the targeted puncture site in the cervical intervertebral foramen under ultrasound guidance and the diffusion of contrast agent. Yellow arrow: Needle tip position.\\u003c/p\\u003e\\n\\u003cp\\u003eRed arrow: 0.9% saline mixed with contrast agent. Black arrow: C5/6 and C6/7 intervertebral foramina.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image3.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/f0d4d2ce05c59c0b311b99b2.jpeg\"},{\"id\":72645044,\"identity\":\"2c92641e-3149-45c6-84cf-1c5c49bcda41\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:41:48\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":463421,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e(a, b) CT sagittal and axial images showing the establishment of the endoscopic channel during surgery (C6/7). (c) Postoperative immediate CT axial image demonstrating enlargement of the right C6/7 intervertebral foramen.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/4912d30eb3e5a4873bb294d9.png\"},{\"id\":72645045,\"identity\":\"ad900df7-06c5-4ce2-bf8d-c88dfff07548\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:41:48\",\"extension\":\"png\",\"order_by\":5,\"title\":\"Figure 5\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":79028,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe Receiver Operating Characteristic (\\u003cem\\u003eROC\\u003c/em\\u003e) Curve for Diagnosing Responsible Lesions in Multi-Segmental Suspected Cervical Radiculopathy Using Ultrasound-Guided Radicular Provocation Test (US-guided RPT).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image5.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/2f7ee829a29ef85e7ddf0612.png\"},{\"id\":72646050,\"identity\":\"188f78aa-59bb-4fb4-a8e9-de34ff159cb6\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:49:48\",\"extension\":\"png\",\"order_by\":6,\"title\":\"Figure 6\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":50964,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe pain intensity provoked by responsible lesions was significantly higher than that induced by non-responsible lesions (\\u003cem\\u003eP \\u0026lt; 0.0001\\u003c/em\\u003e). RL: Responsible Lesions; NRL: Non-Responsible Lesions.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image6.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/da352fe411972e66cc68eee9.png\"},{\"id\":72645058,\"identity\":\"7dd55e9c-d1c4-4f2a-afd7-39276da8a700\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:41:49\",\"extension\":\"png\",\"order_by\":7,\"title\":\"Figure 7\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":767222,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e(a) Postoperative \\u003cem\\u003eVAS\\u003c/em\\u003e scores were significantly lower compared to preoperative scores \\u003cem\\u003e(P \\u0026lt; 0.001\\u003c/em\\u003e). (b) Postoperative \\u003cem\\u003eNDI\\u003c/em\\u003e scores were significantly lower compared to preoperative scores (\\u003cem\\u003eP \\u0026lt; 0.0001\\u003c/em\\u003e).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image7.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/911c37681d00c0c4641369ec.png\"},{\"id\":73056713,\"identity\":\"974e96d5-6405-4c4a-861b-f3d7fcf231d0\",\"added_by\":\"auto\",\"created_at\":\"2025-01-06 10:18:08\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2855821,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5716936/v1/d98f3011-04f0-4fec-a8a0-8582676d1d5c.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Evaluation of the Diagnostic Value of Ultrasound-guided Radicular Provocation Test in Identifying Responsible Lesions in Cervical Radiculopathy\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eCervical Radiculopathy is one of the most common conditions causing neck, shoulder, and upper limb pain, with an incidence of approximately 83.2 per 100,000 population. The primary cause is cervical degenerative changes [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. In aging populations, the prevalence of multi-segmental involvement on imaging is significantly higher due to progressive intervertebral disc degeneration and the exacerbation of cervical spondylosis [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe development of multi-segmental degeneration or stenosis in cervical radiculopathy is closely associated with the unique anatomical and biomechanical properties of the cervical spine [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. The cervical spine bears the weight of the head while providing a wide range of lateral motion. This combination of high load and flexibility increases the risk of intervertebral disc wear and degeneration. Additionally, chronic poor posture and cervical strain further exacerbate disc degeneration, which can lead to compensatory osteophyte formation, ligamentum flavum hypertrophy, and calcification, all of which contribute to nerve root compression [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eClinically, patients with such conditions often present with complex symptoms and signs, making precise localization of the responsible lesion challenging. Solely relying on imaging, symptoms, or physical examination findings is insufficient to accurately identify the responsible lesion in these cases.\\u003c/p\\u003e \\u003cp\\u003eSelective nerve root block (SNRB) is commonly used to further localize responsible lesions in cervical radiculopathy [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. However, its diagnostic accuracy diminishes in multi-segmental cases due to factors such as atypical pain distribution, subjective pain perception, mixed etiologies, and the need for repeated procedures [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Currently, there are still significant shortcomings in the diagnostic methods for accurately identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy.\\u003c/p\\u003e \\u003cp\\u003eWhile the majority of patients with cervical radiculopathy experience significant symptom relief with conservative treatment, surgical intervention becomes unavoidable for those who fail to respond adequately to non-surgical therapies. Minimally invasive posterior cervical foraminotomy (MI-PCF) is an effective surgical option for cervical radiculopathy [\\u003cspan additionalcitationids=\\\"CR10 CR11\\\" citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e], with percutaneous endoscopic cervical foraminoplasty (PECF) offering distinct advantages among various MI-PCF techniques [\\u003cspan additionalcitationids=\\\"CR14\\\" citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. However, achieving precise and effective treatment relies heavily on accurate preoperative localization of the affected segment, particularly in patients with multi-segmental suspected lesions of cervical radiculopathy.\\u003c/p\\u003e \\u003cp\\u003eAccurate localization is critical for ensuring the effectiveness of precision surgery. Radicular provocation test (RPT) is a diagnostic technique that utilizes imaging guidance and specific puncture methods to inject saline into the suspected lesion site of a nerve root. This procedure induces transient mechanical stimulation of the affected nerve, provoking symptoms that can be compared to the patient\\u0026rsquo;s usual complaints, thereby identifying the affected nerve and responsible lesion [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eWu et al. and Lin et al. [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e] have demonstrated the advantages of RPT in identifying responsible lesions in lumbar disc herniation when compared with discography. However, effective diagnostic methods for precisely localizing responsible lesions in cervical radiculopathy remain lacking. In this study, we applied RPT for the localization of responsible lesions in cervical radiculopathy and quantified RPT-related parameters to further evaluate its diagnostic performance.\\u003c/p\\u003e \\u003cp\\u003eConventional CT-guided posterior cervical foramen puncture often targets the outer margin of the intervertebral foramen. With advancements in ultrasound technology, ultrasound-guided cervical foramen puncture allows real-time visualization to avoid critical structures such as blood vessels and nerves, enabling safe needle placement within the foramen. In this study, we performed US-guided RPT through an anterolateral approach to puncture the cervical foramen[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. The accuracy of needle placement was further verified under CT guidance. This approach aims to offer a safe, simple, and radiation-free diagnostic method for identifying responsible lesions in cervical radiculopathy.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003ePatient Population\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was reviewed and approved by the Medical Ethics Committee of the First Affiliated Hospital of GanNan Medical University (Approval No. LLSC-2023-521). Written informed consent was obtained from all participants.\\u003c/p\\u003e\\n\\u003cp\\u003eThis study included patients diagnosed with cervical radiculopathy (with unclear responsible lesions) who visited the Pain Department of the First Affiliated Hospital of Gannan Medical University from December 2023 to August 2024 (Fig. 1\\u003cstrong\\u003e)\\u003c/strong\\u003e. All patients underwent ultrasound-guided radicular provocation test (US-guided RPT) followed by single-segment computed tomography (CT)-guided percutaneous endoscopic cervical foraminoplasty (CT-guided PECF) for suspected lesions before surgery. During the US-guided RPT, pain intensity at the original pain site was recorded when all suspected lesions were provoked. Postoperatively, patients were followed up to assess the degree of pain relief and functional improvement. A \\u0026ge; 50% improvement in pain intensity, measured using the Visual Analog Scale (VAS) score, within 3 days after surgery was defined as a criterion for surgical efficacy. The lesion identified as the surgical target was considered the responsible lesion, while other suspected lesions were classified as non-responsible lesions. The data from US-guided RPT stimulation of responsible and non-responsible lesions were analyzed and correlated with clinical outcomes. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC) was calculated to determine the optimal cutoff value. Sensitivity, specificity, accuracy, positive predictive (PPV) value, and negative predictive value (NPV) were also calculated to evaluate the diagnostic performance of US-guided RPT in identifying responsible lesions in multi-segmental cervical radiculopathy.\\u003c/p\\u003e\\n\\u003cp\\u003eFig. 1. A 50-year-old patient presented with clinical symptoms of pain in the right shoulder and back, lateral upper arm, and lateral forearm, accompanied by numbness in the thumb, index finger, and middle finger. (a): Preoperative sagittal cervical MRI showing narrowing of the C5/6 and C6/7 intervertebral foramina. (b, c): Axial cervical images at the C5/6 and C6/7 levels.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eInclusion criteria\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e1. Age between 18 and 75 years;\\u003c/p\\u003e\\n\\u003cp\\u003e2. Patients with cervical radiculopathy and multi-segmental suspected lesions, in whom the responsible lesion cannot be clearly identified by symptoms, signs, or imaging studies;\\u003c/p\\u003e\\n\\u003cp\\u003e3. Persistent moderate or severe pain (VAS score \\u0026ge; 4) despite \\u0026ge;3 months of conservative treatment;\\u003c/p\\u003e\\n\\u003cp\\u003e4. Patients who consent to undergo US-guided RPT preoperatively;\\u003c/p\\u003e\\n\\u003cp\\u003e5. Patients who consent to undergo single-segment CT-guided PECF.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eExclusion Criteria\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e1. Age \\u0026lt; 18 years or \\u0026gt; 75 years;\\u003c/p\\u003e\\n\\u003cp\\u003e2. Patients with cervical radiculopathy and clearly identified single-segment pathology;\\u003c/p\\u003e\\n\\u003cp\\u003e3. Presence of severe comorbidities or other psychiatric or psychological disorders preventing cooperation with the researcher;\\u003c/p\\u003e\\n\\u003cp\\u003e4. Patients with postoperative pain relief \\u0026lt;50%, making the identification of the responsible lesion unfeasible.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eProcedures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eUS-guided RPT\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAfter the patient was positioned in the operating room, the lateral decubitus position on the unaffected side was adopted. A high-frequency linear transducer was used for ultrasound scanning. Segmental levels were identified starting from the \\u0026apos;chair-back\\u0026apos; hyperechoic appearance of the C7 transverse process, characterized by the absence of an anterior tubercle. The intervertebral foramen was visualized between the vertebral body and the corresponding facet joint. Following sterilization and draping, in-plane puncture technique was employed. Under real-time ultrasound guidance, a 7# \\u0026times; 90 mm needle was inserted via the anterolateral approach toward the target intervertebral foramen. The needle tip was advanced to the anterior surface of the facet joint bone and slid along the bone into the intervertebral foramen by approximately 5 mm (Fig. 2). CT scanning was performed to confirm whether the needle tip was located within the target foramen. If not, the position was adjusted under CT guidance. Once the needle tip reached the target point, a 2 mL syringe was used to aspirate and prepare a mixture of 0.9% saline and iohexol contrast agent (9:1). At each target point, 2 mL of the mixture was injected at a steady rate over 3 seconds by the same operator. The patient was monitored for the provocation of symptoms, such as pain or numbness consistent with their usual complaints. Injection was immediately stopped upon symptom provocation, with a maximum injection volume of \\u0026le; 2 mL. After the induced symptoms subsided completely, the next step was performed. During the procedure, CT scans were used to observe the distribution of the injected contrast agent (Fig. 3).\\u003c/p\\u003e\\n\\u003cp\\u003eFig. 2. Using ultrasound-guided puncture of the C6/7 intervertebral foramen as an example: (a-b): Transverse ultrasound images of the C6 nerve root located between the anterior and posterior tubercles of the C6 transverse process. Scanning from the cranial to caudal direction, the posterior tubercle of the C6 transverse process disappears, and the facet joint and intervertebral foramen appear. (c): Scanning the C6/7 intervertebral foramen area reveals scattered vascular distribution, with no vascular structures along the puncture pathway. (d): The puncture needle enters the C6/7 intervertebral foramen. The patient\\u0026rsquo;s position, probe placement, and puncture entry point are shown in the central image. The in-plane approach guided by ultrasound is used, with the needle tip advanced from lateral to medial into the intervertebral foramen. yellow arrow: needle shaft.\\u003c/p\\u003e\\n\\u003cp\\u003eFig.\\u0026nbsp;3. CT imaging of the targeted puncture site in the cervical intervertebral foramen under ultrasound guidance and the diffusion of contrast agent. Yellow arrow: Needle tip position.\\u003c/p\\u003e\\n\\u003cp\\u003eRed arrow: 0.9% saline mixed with contrast agent. Black arrow: C5/6 and C6/7 intervertebral foramina.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCT-guided PECF\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe surgery was performed according to the standard procedures for spinal endoscopy, using a posterior approach to the cervical spine. Under CT guidance, a puncture was made to locate the target point, after which a guidewire was placed. Gradually, a dilatation tube and working cannula were inserted. The endoscope was used to expose the interlaminar space and the bone surface of the surgical field. A curved bone drill was employed to remove part of the facet joint and lamina to access the spinal canal. Bone decompression was carried out to relieve nerve compression, with herniated tissue excised and hemostasis achieved. Nerve adhesions were released, and the endoscope revealed the restoration of the compressed nerve root\\u0026rsquo;s shape, along with improved pulsation and local blood circulation. CT scans confirmed that the target herniated tissue was completely removed and the area of foraminal stenosis was widened, concluding the surgery (Fig. 4).\\u003c/p\\u003e\\n\\u003cp\\u003eFig. 4. (a, b) CT sagittal and axial images showing the establishment of the endoscopic channel during surgery (C6/7). (c) Postoperative immediate CT axial image demonstrating enlargement of the right C6/7 intervertebral foramen.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEvaluation Methods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDiagnostic Value of US-guided RPT:\\u003c/strong\\u003eTo assess the diagnostic value of US-guided RPT, we first need to define a \\u0026ldquo;positive\\u0026rdquo; provocation threshold for the percentage of radiating pain triggered. We performed a ROC analysis to evaluate diagnostic performance, using the AUC as the criterion, and the Youden index to determine the optimal diagnostic cutoff. True positives are defined as a positive response to the responsible lesion, while false positives are defined as a positive response to non-responsible lesions. True negatives are defined as a negative response to non-responsible lesions, and false negatives are defined as a negative response to the responsible lesion. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of US-guided RPT were calculated.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFollow-up and Efficacy Evaluation:\\u003c/strong\\u003ePostoperative clinical efficacy was evaluated using the VAS and the Neck Disability Index (NDI). The VAS was used to assess the pain intensity induced by the US-guided RPT, and the percentage of pain intensity induced at the original pain site in the patients was reassessed.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEffectiveness Criteria for CT-guided PECF:\\u003c/strong\\u003eThe effectiveness of CT-guided PECF was defined as (Preoperative VAS score - 3-day postoperative VAS score) / Preoperative VAS score \\u0026ge; 50%.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eOutcome Measures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePrimary Outcome Measures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e1.AUC for US-guided RPT;\\u003c/p\\u003e\\n\\u003cp\\u003e2.VAS score at 3 days postoperatively;\\u003c/p\\u003e\\n\\u003cp\\u003e3.VAS pain intensity at the original pain site induced by provocation of each suspected lesion during US-guided RPT.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSecondary Outcome Measures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e1.Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of US-guided RPT;\\u003c/p\\u003e\\n\\u003cp\\u003e2.VAS scores at 1 and 3 months postoperatively;\\u003c/p\\u003e\\n\\u003cp\\u003e3.NDI scores at 3 days, 1 month, and 3 months postoperatively.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical Analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eStatistical analysis was performed using SPSS version 27.0 (IBM Corporation, Armonk, NY). Measurement data conforming to a normal distribution were expressed as mean \\u0026plusmn; standard deviation, with inter-group comparisons performed using the t -test, and multi-group comparisons conducted via one-way analysis of variance (ANOVA). For data not conforming to a normal distribution, values were expressed as median (interquartile range) [M (P25, P75)], with inter-group comparisons performed using the Mann-Whitney U test, and intra-group comparisons conducted using the Wilcoxon signed-rank test. A P value \\u0026lt; 0.05 was considered statistically significant.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003ePatients:\\u0026nbsp;\\u003c/strong\\u003eThis study included a total of 56 patients with multi-segmental suspected lesions of cervical radiculopathy who met the inclusion criteria. Among them, 21 were male and 35 were female, with an average age of 57.04 \\u0026plusmn; 9.34 years. Preoperative VAS score was 6.59 \\u0026plusmn; 1.11, and NDI score was 27.86 \\u0026plusmn; 2.05. Of the 56 patients, 54 had two suspected segments, and 2 had three suspected segments. All suspected lesions underwent US-guided RPT before surgery, with a total of 114 US-guided RPTs performed. All patients subsequently underwent CT-guided PECF to confirm the lesions. The final responsible lesions were identified as follows: C4/5: 3, C5/6: 16, C6/7: 36, C7/T1: 1. Non-responsible lesions were identified as follows: C4/5: 2, C5/6: 38, C6/7: 15, C7/T1: 3 (Table 1).\\u003c/p\\u003e\\n\\u003cp\\u003eTable\\u0026nbsp;1. Characteristics of the patients.\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"100%\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eCharacteristic\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 33px;\\\"\\u003e\\n \\u003cp\\u003eBaseline\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eGender (Male/Female)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 33px;\\\"\\u003e\\n \\u003cp\\u003e21/35\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eAge (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 33px;\\\"\\u003e\\n \\u003cp\\u003e57.04\\u0026plusmn;9.34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003ePreoperative VAS Score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 33px;\\\"\\u003e\\n \\u003cp\\u003e6.59\\u0026plusmn;1.11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003ePreoperative NDI Score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 33px;\\\"\\u003e\\n \\u003cp\\u003e27.86\\u0026plusmn;2.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eProvoked Segments (C4/5, C5/6, C6/7, C7/T1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 33px;\\\"\\u003e\\n \\u003cp\\u003e5/54/51/4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eROC Curve (\\u003c/strong\\u003eFig. 5\\u003cstrong\\u003e) Analysis and Diagnostic Value of US-guided RPT:\\u0026nbsp;\\u003c/strong\\u003eThe ROC analysis to determine the optimal cutoff for the positive criterion of US-guided RPT yielded the following results (Table 2). The AUC was 0.874. The best cutoff for a positive US-guided RPT result was a pain intensity \\u0026ge;60% at the patient\\u0026rsquo;s original symptom site. There were 51 true positives, 44 true negatives, 14 false positives, and 5 false negatives. The sensitivity of US-guided RPT was 91.1% (51/56), specificity was 75.9% (44/58), accuracy was 83.3% (95/114), PPV was 78.5% (51/65), and NPV was 89.8% (44/49).\\u003c/p\\u003e\\n\\u003cp\\u003eFig. 5. The Receiver Operating Characteristic (ROC) Curve for Diagnosing Responsible Lesions in Multi-Segmental Suspected Cervical Radiculopathy Using Ultrasound-Guided Radicular Provocation Test (US-guided RPT).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eComparison of US-guided RPT Diagnostic Parameters (\\u003c/strong\\u003eFig. 6)\\u003cstrong\\u003e:\\u003c/strong\\u003e When diagnosing responsible lesions with US-guided RPT, the pain intensity (VAS score) induced at the responsible lesion site was 6 (5, 7.75), while the pain intensity induced at the non-responsible lesion site was 0 (0, 3.25). The pain intensity induced at responsible lesions was significantly higher than that at non-responsible lesions, with a statistically significant difference (\\u003cem\\u003eP \\u0026lt; 0.0001\\u003c/em\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePostoperative Results:\\u0026nbsp;\\u003c/strong\\u003eAll patients underwent single-segment CT-guided PECF. Postoperative pain was significantly reduced compared to preoperative levels. All patients were followed up at 3 days, 1 month, and 3 months after surgery. The postoperative VAS score significantly decreased from a preoperative value of 6.59 \\u0026plusmn; 1.11 to 1.57 \\u0026plusmn; 1.20 at 3 days, 0.59 \\u0026plusmn; 0.65 at 1 month, and 0.38 \\u0026plusmn; 0.62 at 3 months (Fig. 7a). The postoperative NDI score decreased from a preoperative value of 27.86 \\u0026plusmn; 2.05 to 11.34 \\u0026plusmn; 1.87 at 3 days, 4.38 \\u0026plusmn; 1.21 at 1 month, and 1.43 \\u0026plusmn; 1.29 at 3 months (Fig. 7b).\\u003c/p\\u003e\\n\\u003cp\\u003eTable 2. Results of receiver-operator characteristic (ROC) analysis for cutoff value for the definition of a positive result\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eCutoff Value (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eSensitivity (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eSpecificity (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eAccuracy (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePositive Predictive Value (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eNegative Predictive Value (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e94.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e62.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e74.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e92.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e94.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e62.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e74.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e92.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e94.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e63.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e71.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e93.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e94.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e63.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e71.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e93.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;50\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e94.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e70.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e82.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e75.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e93.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;60\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e91.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e75.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e83.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e89.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e83.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e75.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e79.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e77.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e83.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;80\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e76.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e81.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e79.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ge;90\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e67.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e87.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e78.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e84.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e73.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e=100\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e51.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e93.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e72.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e87.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e66.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eThe cutoff value represents the percentage of radiating pain induced compared to the patient\\u0026rsquo;s usual pain state.\\u003c/p\\u003e\\n\\u003cp\\u003eFig. 6. The pain intensity provoked by responsible lesions was significantly higher than that induced by non-responsible lesions (P \\u0026lt; 0.0001). RL: Responsible Lesions; NRL: Non-Responsible Lesions.\\u003c/p\\u003e\\n\\u003cp\\u003eFig. 7. (a) Postoperative VAS scores were significantly lower compared to preoperative scores (P \\u0026lt; 0.001). (b) Postoperative NDI scores were significantly lower compared to preoperative scores (P \\u0026lt; 0.0001).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eWe propose the use of US-guided RPT for the localization and diagnosis of responsible lesions in multi-segmental suspected lesions of cervical radiculopathy and evaluate the diagnostic value of US-guided RPT, including its sensitivity, specificity, accuracy, and predictive value. The findings of this study demonstrate that US-guided RPT holds significant value in diagnosing responsible lesions in multi-segmental suspected lesions of cervical radiculopathy and can effectively guide surgical intervention.\\u003c/p\\u003e \\u003cp\\u003eWith the advancement of minimally invasive and endoscopic techniques, precise localization of the responsible segment and targeted treatment have become key clinical objectives, aiming to minimize unnecessary surgical trauma and complications. However, distinguishing which segment or segments are truly responsible for nerve root compression remains a challenge.\\u003c/p\\u003e \\u003cp\\u003eCurrently, the localization and diagnosis of responsible lesions in cervical radiculopathy primarily rely on clinical manifestations [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e], imaging examinations [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e], discography [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e], and selective nerve root block [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR24\\\" citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]. However, these diagnostic methods still have limitations when applied to cervical radiculopathy with multi-segmental imaging changes.\\u003c/p\\u003e \\u003cp\\u003ePrevious studies have found that 26% of patients still experience significant pain during postoperative follow-up [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e], which raises doubts about the accuracy of responsible lesion determination, especially in patients with multi-segmental disc herniation or foraminal stenosis. Clinical studies by Siivola et al. [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e] and Anderberg et al. [\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e] on cervical nerve roots and the distribution of pain in their corresponding dermatomes show that the pain distribution in most patients does not follow the typical dermatome pattern. In Siivola\\u0026rsquo;s study, approximately 76% of symptomatic patients did not present typical dermatomal pain. Anderberg\\u0026rsquo;s study found that about 50% of patients had pain distributions that did not align with the classical nerve root distribution pattern. Therefore, in patients with multi-segmental suspected lesions of cervical radiculopathy, relying solely on MRI, neurological examination, and the distribution of pain in dermatomes is not entirely accurate for diagnosing responsible lesions.\\u003c/p\\u003e \\u003cp\\u003eDiscography has some diagnostic value for localizing responsible lesions in multi-segmental suspected lesions of cervical radiculopathy, especially when other diagnostic methods fail to provide clear results. However, cervical discs are smaller than lumbar discs, making cervical discography more technically challenging. Moreover, compared to lumbar diseases, the incidence of discogenic cervical radiculopathy (specifically, nucleus pulposus herniation) is lower, accounting for only 20\\u0026ndash;25% of cases [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. Since the primary role of discography is to assess the structural condition of the disc itself, its diagnostic value is limited for non-discogenic causes.\\u003c/p\\u003e \\u003cp\\u003eSNRB, commonly used in clinical practice, plays an important role in locating the responsible lesion. However, its sensitivity and specificity in diagnosis can vary significantly, and the technical operation can influence the diagnostic results [\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. In the diagnosis of multi-segmental suspected lesions in cervical radiculopathy, its limitations are further magnified. For such patients, SNRB cannot directly determine the specific segment of the lesion. Each suspected lesion must be tested individually, and the symptom improvement after blocking at each site must be compared to identify the responsible segment. This method increases the number of tests, medical resource consumption, and patient discomfort, and may also introduce more risks [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. Furthermore, due to factors such as individual anatomical variations, nerve root cross-innervation, drug diffusion to adjacent nerve roots, and subjective biases in patient judgments [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e], diagnostic results may also contain errors. In addition, when there is peripheral pathology within the nerve distribution area [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e], symptom relief after SNRB cannot effectively differentiate between nerve root pathology and peripheral lesions, potentially leading to false-positive results.\\u003c/p\\u003e \\u003cp\\u003eIn fact, there is currently no simple and effective method for accurately locating the responsible lesion in multi-segmental suspected lesions of cervical radiculopathy. Furthermore, there are no studies that use ROC analysis to determine the ideal cutoff value for the positive diagnosis of the responsible lesion in multi-segmental suspected lesions of cervical radiculopathy using existing diagnostic methods.\\u003c/p\\u003e \\u003cp\\u003eOur research team has proposed the RPT, which involves using specific puncture techniques under imaging guidance to inject a certain volume of saline into the suspected nerve root lesion area. This procedure induces mechanical stimulation at the affected nerve, triggering symptoms of nerve compression. These induced symptoms are compared to the patient\\u0026rsquo;s usual symptoms to evaluate their consistency, thereby achieving diagnostic localization of the lesion.\\u003c/p\\u003e \\u003cp\\u003eSelecting an appropriate puncture target and imaging guidance is critical for the successful implementation of RPT. Based on varying risks of nerve compression, the cervical intervertebral foramen can be divided into the entrance zone, middle zone, and exit zone, with each area contributing differently to nerve compression. In the entrance zone, nerve root compression is typically caused by disc herniation or uncovertebral joint osteophytes. Due to its smaller diameter, this area is a high-risk zone for nerve root compression [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. Therefore, to simulate effective stimulation of the lesion, the injection target should be positioned as close as possible to the entrance zone of the intervertebral foramen.\\u003c/p\\u003e \\u003cp\\u003eWith the advancement of ultrasound technology, ultrasound-guided cervical intervertebral foramen puncture has become increasingly refined. Real-time visualization under ultrasound guidance allows for effective avoidance of structures such as blood vessels and nerves during the procedure. Furthermore, ultrasound is radiation-free, cost-effective, and convenient, making it more acceptable to patients compared to X-ray or CT imaging. In this study, cervical intervertebral foramen puncture was performed under ultrasound guidance using an anterolateral approach. Compared to the traditional posterior approach, the anterolateral puncture route better conforms to the anatomical structure of the cervical intervertebral foramen. The puncture needle can directly reach the intervertebral foramen along the surface of the facet joint, bringing the target closer to the region of nerve pathology. Additionally, the anterolateral approach effectively avoids critical structures such as the spinal cord and vertebral artery, thereby reducing the risk of direct injury to these vital anatomical structures [\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. However, the anterolateral puncture route is adjacent to important structures such as the trachea, esophagus, and carotid artery. This proximity poses risks of complications such as tracheal or esophageal injury, which can lead to dysphagia or pneumothorax [\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e]. In this study, strict control of the puncture angle was maintained during ultrasound-guided anterolateral intervertebral foramen puncture. Using the transverse process facet joint as a safe landmark, the needle was advanced to the facet bone surface and then slid inward along the joint surface into the intervertebral foramen. No severe complications, such as tracheal, esophageal, or arterial injuries, occurred during the procedures, effectively preventing adverse events. Although no significant adverse events or additional puncture-related injuries occurred in this study, the risks and technical challenges associated with ultrasound-guided anterolateral cervical intervertebral foramen puncture remain high. The procedure requires the operator to possess substantial experience and advanced skills to ensure safety and success.\\u003c/p\\u003e \\u003cp\\u003eAdditionally, to verify the accuracy of ultrasound-guided anterolateral cervical intervertebral foramen puncture, CT scans were performed after the needle was positioned under ultrasound guidance to confirm whether the puncture needle reached the target location. If discrepancies were found, the needle was further adjusted under CT guidance to ensure accurate placement within the intervertebral foramen, allowing the injected medication to exert an effective provocative effect. For the mechanical stimulation to effectively target the affected nerve root, the injected solution must disperse around the target nerve root. In a study by Wu et al.[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]fluoroscopic imaging demonstrated that contrast agents injected during ultrasound-guided anterolateral cervical intervertebral foramen puncture successfully diffused around the cervical nerve root. Similarly, in this study, a small amount of contrast agent was mixed with the injected solution during the US-guided RPT procedure. The dispersion of the contrast agent was observed under CT imaging, revealing that the solution surrounded the nerve root, thereby confirming precise localization of the medication at the target site. This observation indicates that the US-guided RPT procedure can deliver mechanical stimulation effectively to the target nerve root.\\u003c/p\\u003e \\u003cp\\u003eThis study utilized US-guided RPT to provoke patients\\u0026rsquo; pre-existing symptoms and combined the findings with surgical outcomes to generate an ROC curve. The ROC curve analysis indicated that the optimal cutoff value for diagnosing responsible lesions in multi-segmental suspected lesions of cervical radiculopathy using US-guided RPT was a pain intensity at the original symptom site of \\u0026ge;\\u0026thinsp;60%. The sensitivity was 91.1%, specificity was 75.9%, accuracy was 83.3%, PPV was 78.5%, NPV was 89.8%, and the AUC was 0.874. The high sensitivity and NPV suggest that US-guided RPT is effective in identifying responsible lesions, reducing the likelihood of missed diagnoses. Meanwhile, the specificity and PPV demonstrate moderate accuracy in ruling out non-responsible lesions, albeit with some risk of misdiagnosis. An AUC of 0.874 indicates that US-guided RPT has high diagnostic efficacy and robust discriminatory capability in differentiating between responsible and non-responsible lesions. These results support the reliability of US-guided RPT as a diagnostic tool for identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy, especially in scenarios where high sensitivity is crucial. Furthermore, given the lack of standardized assessments for sensitivity, specificity, and other key diagnostic metrics in current methods for multi-segmental suspected lesions of cervical radiculopathy, US-guided RPT fills this critical gap by providing quantifiable diagnostic data. The relatively lower specificity and PPV in this study may be attributed to the inclusion of patients with multi-segmental cervical disc protrusions or foraminal degenerative changes, where multiple sites had the potential for nerve compression. Additionally, during US-guided RPT, subjective factors from patients might have led to positive responses at non-responsible lesions, contributing to false-positive results.\\u003c/p\\u003e \\u003cp\\u003eIn this study, there was a significant difference in the intensity of provoked symptoms between responsible and non-responsible lesions using US-guided RPT. The pain intensity induced by US-guided RPT at responsible lesions was notably higher compared to non-responsible lesions, suggesting that US-guided RPT has the potential to reflect the pathophysiological state of the lesions and assess the severity of the pathological changes. The strong consistency between the provoked responses and patients\\u0026rsquo; actual symptoms further validates the clinical value of US-guided RPT. Additionally, this study demonstrates that by directly comparing the pain intensity induced at different lesion sites, US-guided RPT provides a more intuitive and quantitative measure to identify responsible lesions. This approach minimizes errors caused by variability in patients\\u0026rsquo; pain perception, nerve function, or symptoms over time, and eliminates the discomfort associated with repeated testing. Moreover, US-guided RPT addresses the limitations of SNRB, which often requires multiple tests at different times to identify responsible lesions. By offering a reliable and efficient diagnostic method, US-guided RPT reduces patient burden and enhances diagnostic accuracy.\\u003c/p\\u003e \\u003cp\\u003eMI-PCF, as a minimally invasive method for treating cervical radiculopathy, has become increasingly popular due to its advantages of minimal postoperative trauma and rapid recovery. Compared to traditional anterior cervical discectomy and fusion (ACDF), it achieves similar postoperative outcomes [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Moreover, MI-PCF has several unique advantages: first, it preserves cervical spine mobility, reducing the risk of adjacent segment degeneration; second, it excels in alleviating postoperative pain and improving functionality, with a lower complication rate and shorter recovery time for patients [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Additionally, MI-PCF avoids the necessity of cervical fusion, thereby minimizing its impact on cervical stability. The recurrence risk after MI-PCF is also relatively low compared to other surgical methods [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e]. Among the various MI-PCF techniques, PECF stands out as an innovative approach with unique benefits. By utilizing endoscopy for high-definition visualization, PECF ensures minimal trauma and greater precision, effectively removing pathological tissue compressing the nerves while reducing surgical time and intraoperative risks [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. Compared to other minimally invasive procedures, PECF offers faster recovery, fewer complications, and lower recurrence rates, making it particularly suitable for multilevel compression or complex cases [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. In this study, CT-guided PECF was employed as the \\u0026ldquo;gold standard\\u0026rdquo; procedure due to its superior performance in postoperative pain relief and functional improvement. Performing the procedure on a single segment at a time allowed for a more direct and effective determination of whether the operated segment was the responsible lesion.\\u003c/p\\u003e \\u003cp\\u003eAll patients in this study successfully underwent CT-guided PECF, with significant postoperative pain relief and short recovery times. At 1 and 3 months postoperatively, patients\\u0026rsquo; VAS and NDI scores showed further improvement. The favorable postoperative outcomes indicate that all operated lesion sites were responsible lesions, with no adverse events related to misjudgment of the responsible segments. These findings demonstrate the high effectiveness of US-guided RPT in identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy, providing accurate localization for subsequent surgical treatment.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations of the Study\\u003c/h2\\u003e \\u003cp\\u003eThis study is limited to cervical radiculopathy patients with multilevel radiological lesions, with a relatively small sample size and a short follow-up period.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eUS-guided RPT demonstrates diagnostic value in identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy. Additionally, following the diagnosis of responsible lesions by US-guided RPT, patients with multi-segmental cervical radiculopathy showed high efficacy when treated with CT-guided PECF.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eConceptualization: [J, W.]; Methodology: [T, S. X, D.]; Formal analysis and investigation: [T, S., R, R.]; Writing\\u0026mdash;original draft preparation: [T, S.]; Writing\\u0026mdash;review and editing: [T, S.]; Resources: [T, S., C, L., J, Z., S, Q.]; Supervision: [J, W.]. X, D. made significant contributions to the research process and is listed as a co-first author. All authors have reviewed the manuscript content and approved it for publication.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eBono CM, Ghiselli G, Gilbert TJ et al (2011) An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J 11(1):64\\u0026ndash;72. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.spinee.2010.10.023\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.spinee.2010.10.023\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRadhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT (1994) Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. 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Spine (Phila Pa 1976) 47(4):324\\u0026ndash;330. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/BRS.0000000000004140\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/BRS.0000000000004140\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZou T, Wang PC, Chen H, Feng XM, Sun HH (2022) Minimally invasive posterior cervical foraminotomy versus anterior cervical discectomy and fusion for cervical radiculopathy: a meta-analysis. 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J Neurosurg Spine 21(5):727\\u0026ndash;731. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3171/2014.7.SPINE131110\\u003c/span\\u003e\\u003cspan address=\\\"10.3171/2014.7.SPINE131110\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Cervical Radiculopathy, Radicular Provocation Test, Responsible Lesions, Ultrasound Guidance, Diagnosis\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5716936/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5716936/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eAccurately identifying responsible lesions in multi-segmental cervical radiculopathy is challenging due to the lack of reliable diagnostic methods. While selective nerve root block (SNRB) is commonly used, its specificity remains suboptimal.\\u003c/p\\u003e\\u003ch2\\u003eObjective\\u003c/h2\\u003e \\u003cp\\u003eThis study aims to evaluate the clinical diagnostic value of the ultrasound-guided radicular provocation test (US-guided RPT) in localizing responsible lesions in multi-segmental cervical radiculopathy.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThis study included patients diagnosed with cervical radiculopathy (with unclear responsible lesions) who visited the Department of Pain Medicine at the First Affiliated Hospital of GanNan Medical University between December 2023 and August 2024. All patients underwent US-guided RPT for suspected lesions before surgery. The pain intensity [Visual Analog Scale (VAS) score] of the original symptoms at the site of pain provoked during US-guided RPT was recorded. Based on US-guided RPT results, patients received single-segment computed tomography (CT)-guided percutaneous endoscopic cervical foraminoplasty (CT-guided PECF). Postoperative follow-up assessed pain relief and functional improvement, with \\u0026ge;\\u0026thinsp;50% improvement in pain symptoms (VAS score) at 3 days post-surgery used as the standard for surgical effectiveness. Lesions confirmed to be responsible based on effective pain relief were considered responsible lesions, while other suspected lesions were deemed non-responsible. By analyzing the provocation data of responsible and non-responsible lesions obtained from US-guided RPT and correlating these findings with clinical outcomes, a receiver operating characteristic (ROC) curve was generated to determine the area under the curve (AUC) and the optimal cutoff value. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of US-guided RPT were then calculated.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eA total of 56 patients (114 US-guided RPT procedures) with cervical radiculopathy meeting the inclusion criteria were included in this study. ROC analysis yielded an AUC of 0.874. A pain intensity\\u0026thinsp;\\u0026ge;\\u0026thinsp;60% at the original symptom site was identified as the optimal cutoff, with sensitivity of 91.1%, specificity of 75.9%, accuracy of 83.3%, PPV of 78.5%, and NPV of 89.8%. Pain intensity at responsible lesions [6 (5, 7.75)] was significantly higher than at non-responsible lesions [0 (0, 3.25)] (\\u003cem\\u003eP\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001\\u003c/em\\u003e). Postoperative VAS scores significantly decreased from 6.59\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.11 preoperatively to 1.57\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.20 at 3 days, 0.59\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.65 at 1 month, and 0.38\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.62 at 3 months. Neck Disability Index (NDI) scores similarly improved from 27.86\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.05 preoperatively to 11.34\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.87 at 3 days, 4.38\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.21 at 1 month, and 1.43\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.29 at 3 months.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eUS-guided RPT demonstrates diagnostic value in identifying responsible lesions in multi-segmental suspected lesions of cervical radiculopathy. Additionally, following the diagnosis of responsible lesions by US-guided RPT, patients with multi-segmental cervical radiculopathy showed high efficacy when treated with CT-guided PECF.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Evaluation of the Diagnostic Value of Ultrasound-guided Radicular Provocation Test in Identifying Responsible Lesions in Cervical Radiculopathy\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-12-30 16:41:43\",\"doi\":\"10.21203/rs.3.rs-5716936/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"82adc687-23a2-4594-9d38-6694376c1f76\",\"owner\":[],\"postedDate\":\"December 30th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-05-11T10:53:28+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-12-30 16:41:43\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5716936\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5716936\",\"identity\":\"rs-5716936\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}