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

1 MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY NGUYEN TUAN LUONG STUDY ON CLINICAL CHARACTERISTICS AND ELECTRICAL DIAGNOSTICS AND MAGNETIC RESONANCE IMAGING IN HERNIATED DISC OF THE SACRUM LUMBAR SPINE PATIENTS Major: Neurology Code: 62720147 SUMMARY OF MEDICAL DOCTORAL DISSERTATION HA NOI – 2022 THE THESIS WAS FULFILLED AT HANOI MEDICAL UNIVERSITY Supervisors: Assoc Prof Nguyen Huu Cong Assoc Prof Nguyen Van Lieu Reviewer 1: Reviewer 2: Reviewer 3: The dissertation is defended before the Committee of Hanoi Medical University At room………, A1 Building, HMU: For further detail of the dissertation, please search at: - The national library - The library of Hanoi Medical University on / /2022 THESIS RELATED PUBLICATIONS Nguyen Tuan Luong, Nguyen Thi Thu Huyen (2019).” Study on the characteristics of the H reflex recorded in the soleus muscle in patients with sacrum lumbar disc herniation”, Vietnam Medical Journal, vol 484, p 590 – 596 Nguyen Tuan Luong, Nguyen Huu Cong, Nguyen Van Lieu (2020) “Investigation of nerve conduction characteristics in patients with lumbar disc herniation and spinal stenosis”, Vietnam Medical Journal, vol 492, p 235 – 240 INTRODUCTION Low back pain is a common clinical manifestation In 2009, it was estimated that the annual cost of this disease in the US was about $90 billion Sacrum lumbar disc herniation is always a topical problem because it is one of the common causes of low back pain This pathology is the displacement of the intervertebral disc nucleus beyond the physiological limit of the annulus, causing compression on adjacent components (such as spinal cord, nerve roots, etc.), the main manifestation is low back pain and manifestations of compression in the respective nerve roots The diagnosis of this disease is based on: clinical examination, magnetic resonance imaging is not difficult with lumbar disc herniation, the same level But in fact, this lesion is often multi-layered with many forms and levels of damage to the nerve root, so it is difficult to diagnose the affected nerve root The method of electrodiagnostic support for magnetic resonance is able to assess nerve root function damage, damaged location, disease progression, etc In Vietnam, there are no studies on the coordination Combination of clinical examination, functional diagnosis and imaging to accurately assess the location of nerve root damage due to disc herniation in this region For the above reasons, we conduct the thesis: "Study on clinical characteristics and magnetic resonance imaging in herniated disc of the sacrum lumber spine patients" with the follwing objectives: Describe clinical characteristics, nerve conduction indices and electromyography in patients with disc herniation in the sacrum lumbar spine Evaluation of the compatibility between nerve conduction index, electromyography and magnetic resonance imaging in patients with disc herniation in the sacrum lumbar spine NEW CONTRIBUTIONS OF THE DISSERTATION Describe in detail and comprehensively the clinical features, nerve conduction indices and electromyography in patients with lumbar disc herniation Research has shown that when examining the F wave of the deep peroneal nerve and the H reflex can help localize the location of the damaged L5, S1 nerve roots When examining the electromyogram, the most common spontaneous potentials are muscle fiber twitches and positive spikes, which helps in early diagnosis of this disease The study evaluated the concordance between nerve conduction index, electromyography and magnetic resonance imaging in patients with lumbar disc herniation, the same mainly common in L4, L5 and S1 nerve roots The study also showed that for early diagnosis of this disease, electromyography of the paravertebral muscle group should be performed at the position of the multifidus muscle, which will help to accurately identify L3, L4 and L5 nerve root damage The study recommends that in patients with lumbar disc herniation, the combination of clinical examination, electrodiagnostic investigation and magnetic resonance imaging should be combined in the diagnosis of this pathology The results and recommendations of the thesis have contributed to improving the quality of diagnosis and treatment of herniated discs in the lumbar spine, a very common group of diseases in clinical practice LAYOUT OF THE DISSERTATION Dissertation include 148 pages, with main parts: - Introduction pages - Chapter I: Literature review 40 pages - Chapter II: Methodology 31 pages - Chapter II: Results 44 pages - Chapter IV: Discussion 39 pages - Conclusion pages - Recommendation page The dissertation includes 48 tables, 27 pictures, figures and 116 references (in which, 31 Vietnamese references, 85 English references), journal articles related to the dissertation CHAPTER LITERATURE REVIEW 1.1 Clinically herniated disc in the sacrum lumbar spine Clinically herniated disc in the sacrum lumbar spine has been clearly described by the authors Nguyen Van Thong, Ho Huu Luong, Nguyen Van Chuong, Greenberg M.S, Martin Merkle The clinical condition of herniated disc is diverse and rich, depending on the degree and stage of the disc herniation, etc including: * Spine syndrome: - Lumbar spine pain: dull, sometimes sharp, pain increases when moving, pain relief when lying down - Change in spine shape: scoliosis, loss of spinal physiological curvature - Limit movement of the lumbar spine to all sides - Schober index < 14/10 cm - Spasticity of paravertebral muscle mass - There is pain in the lumbar spine * Nerve root syndrome: - Pain along the great sciatic nerve - Signs of nerve root tension: signs of Lasègue, Valleix, ringing bells depending on the severity of the disease - Root type sensory disturbances; There may be sensory disturbances in the form of decreased, lost, increased, paresthesia or dysesthesia - Movement disorders: manifested as decreased muscle strength along the nerve roots Make it difficult for the patient to perform: walking on the tip of the foot or walking on the heel - Disorders of tendon reflexes: decrease or loss of knee or heel tendon reflexes - Nutritional disorders manifest: muscle atrophy, dry skin, hair loss, - If severe disc herniation completely compresses the nerve root cover, it can cause cauda equina syndrome: sphincter disorders, nutritional disorders, premature muscle atrophy, sensory disturbances, etc 1.2 Electrodiagnostic survey techniques used in the diagnosis of herniated disc in the sacrum lumbar spine Steps to perform an electrical diagnosis, including: - Clinical neurologic examination - Measurement of nerve conduction: survey of motor conduction and F waves of the tibial nerve, deep peroneal nerve Investigation of sensory conduction of calf nerve, superficial peroneal nerve H reflex test - Electromechanical recording with needle electrodes: L2, L3, L4, L5 Pelvic (lumbar) muscle, adductor long, rectus femoris, lateral wide, medial broad, anterior tibialis, posterior tibialis, semi-tendon, big toe extensor, gluteus medlar, biceps thighs, inner leg muscles, soleus muscles - Synthesize data to guide diagnosis and conclusions 1.2.1 Nerve conduction measurement method Nerve conduction survey method aims to study the conduction capacity of peripheral nerves, it includes: determination of peripheral motor potential time; nerve conduction velocity, including motor and sensory conduction rates; the latent time of the F wave and the H reflection Picture 1.1 Diagram of electrodes recording motor conduction of deep peroneal nerve 1.2.2 ELectromyography method 1.2.2.1 Electromyography making techniques Electromyography is a method of examining the action potential of skeletal muscle with a needle electrode to evaluate the function of skeletal muscle and nerve conduction function In this study, we used a 75 mm coaxial needle electrode, following these steps: - Leave the patient relax the muscle to be examined, then insert the needle electrode through the skin into the target muscle, surveying the electrical activity of that muscle - Leave the needle in place in a fully relaxed muscle (no muscle contraction) to find out the spontaneous electrical activity of that muscle (if any) - Have the patient contract gently so that the motor units emit discrete pulses, and examine the images of each motor unit potential - Ask the patient to gradually increase muscle contraction to investigate the phenomenon of aggregation of motor units Picture 1.2 Electromyography survey steps 1.2.2.2 Electromyography muscle groups Electromyography is important in the investigation of nerve root injuries Each muscle is innervated by one or more nerve roots Evaluation of muscle damage can determine whether the nerve root is damaged The distribution of nerve roots by the main muscle group: L2, L3 due to the lumbosacral, iliac, and long adductor muscles; L3, L4 due to rectus thigh muscle, inner wide muscle, outer wide muscle, Examination of the paraspinal muscles: electromyography of the paraspinal muscles (position of the multifidus muscles) is very important in the investigation of root lesions, based on the loss of nerve distribution in the examined paravertebral muscles According to the American Society of Electrodiagnostic and Neuromuscular Disease (2017) 1.3 MRI technique used in the diagnosis of herniated disc in the sacrum lumbar spine The patients underwent magnetic resonance imaging of the lumbar spine at the Department of Diagnostic Imaging - Viet Tiep Friendship Hospital, Hai Phong using a Phillips Achieva 1.5T machine placed in an air-conditioned room (average temperature from 24-260C), diagnosed with lumbar disc herniation, position and type of disc herniation Specifications: T1W pulse sequence: TR 500 ms, TE 5ms; mm thick, FOV: 300, voxel: 1x1x4 mm T2W pulse sequence: TR 5000 ms, TE 550ms; mm thick, FOV: 300, voxel: 1x1x4 mm Results analysis method: based on T1, T2 and cross-sectional images to diagnose lumbar disc herniation, and describe herniated disc morphology In addition, depending on the medical condition, we can perform other pulse sequences such as: STIR, T2*, T2 FAT SAT or T2 Myelo pulses CHAPTER METHOGOLOGY 2.1 Study subjects All patients diagnosed with sacrum lumbar disc herniation were inpatient treatment at Viet Tiep Friendship Hospital from January 2017 to November 2019 which eligibility to participate in the study 2.1.1 Criteria for selecting patients According to the standards of the North American Spine Association (2012) The patient was diagnosed as herniated disc when there were criteria: * About clinical: - Sensory disturbances along the nerve roots - Positive Lasègue sign - Positive buzzer sign - Decreased muscle strength due to damaged nerve roots * About subclinical: The patient was confirmed by MRI of the lumbar spine Diagnostic criteria for disc herniation on magnetic resonance imaging include: - Narrow the height of the combustion chamber - Decreased disc signal on T2W pulse - The nucleus pulposus of the disc is displaced from its normal position: backward or laterally, The patient underwent electrodiagnosis, including: - Measurement of nerve conduction: survey of deep peroneal, tibial nerve; sensory survey of superficial peroneal nerve, calf nerve; F waves and H reflections - Electromyography using needle electrodes (electromyography) of the muscles: paraspinal muscles, quadriceps, adductor muscles, anterior tibialis, posterior tibialis and inner leg abdominal muscles, 10 CHAPTER STUDY RESULTS Our study collected 108 patients who met the sampling criteria After collecting and processing the data, the results obtained are as follows: 3.1 General characteristics of patients with sacrum lumbar disc herniation 3.1.1 Epidemiology characteristics Table 3.1: Age, gender, occupation distribution of patients with sacrum lumbar disc herniation (n=108) Charisteristics < 60 y.o 60 – 69 y.o Group of age ≥ 70 y.o Mean age ± SD Nam Gender Nữ Manual work Occupation Intellectual work No patients Rate (%) 51 47,2 30 27,8 27 25,0 60,2 ± 13,7 50 46,3 58 53,7 95 88,0 13 12,0 Comment: Among 108 patients participating in the study, the majority of patients were of working age (36%), the common direction of spreading was along the nerve roots meridians L5 (88.9%), roots S1 (60.2%), and L4 (58.3%) The pain scale has an average score of 4.72 ± 1.14 points, in which the pain level accounts for 76.9% and 74.1% of patients have continuous pain during the day This is also difficult for clinical diagnosis and treatment 12 3.2 Clinical characteristics of patients with sacrum lumbar disc herniation 3.2.1 Spine syndromes Table 3.3: Location of sacrum lumbar spine pain along with the number of disc floors (n=108) Single-layer Multi-layer Pain position Thorns L1/L2/L3 Thorns L4 Thorns L5 Thorns S1 layers layers ≥ layers No.patients 13 57 28 Rate (%) 0,9 12,3 0,9 52,8 25,9 6,5 Comment: In the group of patients studied, the majority of patients showed multi-stage pain: floors (52.8%); floors (25.8%) and or more floors (6.5%) When clinical examination shows that the location of pain is multilayered, there is a possibility of damage to many nerve roots, so the diagnosis will be more difficult 3.2.2 Nerve roots syndromes Table 3.4: Sensory disorders along the nerve roots (n=108) Signs Decreased sensation Normal Increased sensation Unusual sensation Disorders sensation No.patients 93 Rate (%) 86,1 4,6 1,9 5,5 Comment: Most of the patients clinically had decreased sensation (86.1%) Besides, some other disorders such as dysesthesia (5.5%), hyperesthesia (4.6%); paresthesia (1.85%) 13 Table 3.5: Classification of clinical severity according to the Oswestry scale (n=108) ODI Classifiaction Level (ODI từ – 20%) Level (ODI từ 21 – 40%) Level (ODI từ 41 – 60%) Level (ODI từ 61 – 80%) Level (ODI từ 81 – 100%) Mean ± SD (max point of 50) No patients Rate (%) 0,9 8,3 83 76,9 15 13,9 0,0 25,4 ± 4,6 (10 – 38) Comment: The above table shows the classification of clinical severity according to the Oswestry scale (ODI), with 76.9% of patients at level (ODI from 41 to 60%), the level of functional loss greatly affects the quality of life of the patient If calculating the score as a percentage, it is ODI = 54.1 ± 9.4 (the lowest is 20.0 and the highest is 77.8) 3.3 Magnetic resonance imaging on patients with herniated discs in the lumbar spine 3.3.1 Location of herniated disc Table 3.6: Location of disc herniation on magnetic resonance imaging Layer location of disc herniation L1 – L2 L2 – L3 L3 – L4 L4 – L5 L5 – S1 No.patients 26 85 60 Rate (%) 1,9 5,6 24,1 78,7 55,6 Comment: On magnetic resonance imaging, the most common position of lumbar disc herniation is L4 – L5 (78.7%); then L5 – S1 (55.6%); next to L3 – L4 (24.1%) L1 – L2 disc location (1.9%), has the lowest rate 14 3.3.2 Number of disc herniation layer Table 3.7: Number of disc hermination on MRI (n=108) No layer layer layer layer layer No patients 52 42 12 Rate (%) 48,2 38,9 12,0 0,9 Comment: The majority of herniated discs (51.8%), which is difficult in clinical practice to determine the exact location of the damaged nerve root 3.4 Results of nerve conduction in patients with sacrum lumbar disc herniation Table 3.8: Mean motor conduction of the deep peroneal and tibial nerves (n=108) Mean ± SD (Min – Max) Deep peroneal nerves Tibial nerves Time of distal motor latency - DML (ms) Left side 3,88 ± 0,46 (3,2 – 5,5) 5,11 ± 0,66 (3,3 – 6,0) Right side 3,85 ± 0,52 (3,0 – 5,4) 5,21 ± 0,68 (3,4 – 6,5) p 0,48 0,46 Motor Conduction velocity speed – MCV (m/s) Left side 46,70 ± 3,37 (40,8 – 57,5) 46,10 ± 3,88 (39,0 – 66,0) Right side 46,70 ± 3,2 (40,1 – 56,7) 45,84 ± 3,86 (38,4 – 67,4) p 0,41 0,32 Amplitude M (mV) Left side 3,62 ± 1,64 (1 – 8,1) 11,49 ± 3,76 (6,0 – 22,4) Right side 3,48 ± 1,37 (1 – 8,4) 11,71 ± 4,42 (5,6 – 26,5) p 0,41 0,49 Comment: Based on the analytical T-test in 108 patients, there is no statistically significant difference between the two sides 15 3.5 Concordance in diagnosis between clinical, MRI and electromyography 3.5.1 Concordance of diagnosing the location of disc herniation Table 3.9: Concordance of diagnosis of damaged nerve roots between clinical, magnetic resonance and electrodiagnostic Clinical Injure location No patient 1 11 71 103 66 Root L1 Root L2 Root L3 Root L4 Root L5 Rễ S1 Rate % 0,9 0,9 10,2 65,7 95,4 61,1 MRI No patient 21 65 77 24 Electrodiagnostic Rate % 1,9 3,7 19,4 60,2 71,3 22,2 No patient 13 72 101 61 Rate % 1,9 12 66,7 93,5 56,5 Comment: All three methods give results to diagnose the location of lesions, focusing mainly on three nerve roots L4, L5 and S1 However, there is a difference between these three methods 55% 45% 31% 14% MRI, ED similar to clinical MRI, ED different to clinical MRI, ED different MRI, ED similar Figure 3.1: The compatibility of foot lesions diagnosis between clinical, magnetic resonance imaging (MRI) and electrical diagnosis (ED) 16 Comment: In the study group, 55% of patients had similar diagnostic results between the methods There are 14% of patients with similar diagnostic results on magnetic resonance imaging and electrodiagnosis but different clinical and 31% of patients with different diagnostic results between the methods 3.5.2 Concordance of the results of conduction measurements with the diagnosis of disc herniation on magnetic resonance When analyzing nerve conduction in the entire study sample (108 patients), we found no difference between the two sides Therefore, we analyzed separately in the group of unilateral nocturnal disc herniation, we received 32 patients This group conducted a nerve conduction study to evaluate the statistically significant difference between the healthy side and the diseased side Table 3.10: Results of F wave investigation on deep tibial and peroneal nerves (n=32) Mean ± SD (Min – Max) tibial nerve Deep peroneal nerve F (ms) Normal side 42,05 ± 7,60 (4,6 – 48,6) Disease side 42,19 ± 8,12 (4,4 – 51,8) P 0,43 Frequency of appearance of F waves (%) Normal side 95,56 ± 14,32 (25 – 100) Disease side 97,91 ± 6,30 (70 – 100) p 0,36 42,93 ± 4,55 (27,3 – 48,2) 43,29 ± 5,11 (27,6 – 52,0) 0,04 74,81 ± 15,30 (19 – 100) 75,69 ± 13,90 (31 – 100) 0,03 Comment: Based on the Mann-Whitney test, there is no statistically significant difference between the average F wave survey results of the tibial nerve However, there was a statistically significant difference in the deep peroneal nerve 17 Table 3.11: Reflection survey results H (n=32) Mean ± SD (Min – Max) Normal Disease side Time of distal motor latency H 28,49 ± 2,1 28,96 ± 2,39 (ms) (24,9 – 33,7) (25,4 – 34,3) 3,11 ± 1,61 2,70 ± 1,56 Amplitude H (mV) (1 – 7,2) (0,7 – 6,4) 35,12 ± 12,94 31,92 ± 12,77 Rate of H/M (13,1 – 66,7) (8,1 – 57,4) p 0,01 0,03 0,02 Comment: Based on the Mann - Whitney test analyzed in 32 patients diagnosed with disc herniation on one side on magnetic resonance, there was a statistically significant difference (p < 0.05) between the mean H wave survey results 3.5.4 Concordance in clinical features, electrodiagnostic and magnetic resonance In 108 patients, we diagnosed herniated disc with damage to 284 nerve roots on magnetic resonance and electrical diagnosis Table 3.12: Sensitivity, specificity of some muscle groups on electrodiagnosis compared with magnetic resonance results (disc herniation root L5) Disc hermination L5 Sensitively Disc hermination side (n=81) Paravertebral muscle group L5 90.4 Semi-tendom muscle 78,2 Long big toe stretch 79,2 Distal muscle group Anterior tibial 80,2 Posterior tibial 79,2 Disc herniation sides (n=203x2) Paravertebral muscle group L5 94,5 Semi-tendom muscle 69,2 Long big toe stretch 73,9 Distal muscle group Anterior tibial 78,3 Posterior tibial 73,5 Specificity 75,2 80,4 73,5 69,7 74,5 70,5 77,3 98,1 67,5 69,2 18 Comment: The L5 paravertebral muscle group showed high sensitivity in diagnosing L5 root damage However, the specificity is not high When analyzed on 51 patients, the diagnostic results were similar between clinical and magnetic resonance Because of current clinical practice, this similarity criterion is often used to lead to intervention conclusions if surgical treatment is required In 51 patients with a diagnostic match between clinical and magnetic resonance, we diagnosed herniated disc with damage to 130 nerve roots on magnetic resonance and electrical diagnosis, we found that the results were sensitive The diagnosis between electrodiagnostic and magnetic resonance imaging has been improved Especially in the case of diagnosis of disc herniation with L5 root damage (sensitivity 96.7%) Table 3.13: Sensitivity, specificity of some muscle groups on electrodiagnosis compared with magnetic resonance results (Disc herniation root L5) Disc herniation L5 Sensitively Disc hermination side (n=30) Paravertebral muscle group L5 94,4 Semi-tendom muscle 79,4 Long big toe stretch 78,4 Distal muscle group Anterior tibial 85,2 Posterior tibial 80,1 Disc hermination sides (n=102x2) Paravertebral muscle group L5 95,4 Semi-tendom muscle 72,4 Long big toe stretch 69,8 Distal muscle group Anterior tibial 86,5 Posterior tibial 85,4 Specificity 79,1 77,4 73,2 73,9 75,4 74,2 70,2 71,4 72,7 69,3 Comment: Sensitivity and specificity of L5 paraspinal muscle group is higher than that of distal muscle group in diagnosing disc herniation with L5 root lesion However, the specificity is not high 19 CHAPTER DISCUSSION 4.1 Clinical characteristics, nerve conduction index and electromyography in patients with sacrum lumbar disc herniation 4.1.1 Clinical characteristics In our study, the average age of the disease was 60.2 ± 13.7 years old The proportion of working age accounts for the largest proportion (47.2%), this can be explained because one of the causes of disc herniation is related to manual labor, the bearing movements of sacral spine This rate is similar to the study of authors Phan Viet Nga (63.4%), Nguyen Van Chuong, Nhu Dinh Son, Alexandros Tsarouhas (79.3%) Regarding the sex ratio, we find that the male/female ratio is 1/1.16; quite balanced (male accounted for 46.3%) Our study is in contrast to the study of Nguyen Van Chuong and Nguyen Minh Hien (2.03/1) However, similar to the study of M Mondelli, A Aretini (male 55%) Our study found pain perception according to the L4 nerve root (accounting for 58.3%); nerve root L5 (88.9%) and nerve root S1 (60.2%) Anatomically, L4, L5 is the largest structure among lumbar vertebrae group, S1 is the weak position between the lumbar position and the sacrum Therefore, it is possible to explain the location of the lesion here or occurring in relation to the anatomical structure According to many authors, the rate of pain in one location is often greater than in another To assess pain, in the study we used the VAS scale because it is easy to use and has been widely applied nationally and internationally The results obtained: the degree of pain accounted for the majority (76.9%), the VAS score was 4.72 ± 1.14 points Compared with some studies, this result is low, such as Pham Van Thach's study, the mean preoperative VAS score is 6.3 ± 1.19 points Most of the patients in our study had severe pain (76.9%) with continuous pain (74.1%) 20 The characteristics of spinal syndrome in the studied patients showed that the majority of patients had multi-layered pain: floors (52.8%); floors (25.8%) and or more floors (6.5%) When clinical examination shows that the location of pain is multi-layered, there is a possibility of damage to many nerve roots, so the definitive diagnosis will be more difficult The clinical severity rating scale (Oswestry scale (ODI)) showed the highest proportion of level expression (76.9%) with the mean score of the Oswestry scale of 54.1 ± 9.4 percentage points When analyzing the appropriateness of diagnosis of damaged roots between magnetic resonance and electrodiagnostic, the results of lesions in the L5 roots accounted for the highest percentage (>72%) The results of this study are similar to many studies by other authors such as Nguyen Van Chuong (67.10 ± 0.50), Stefan Endres (53.43 ± 10.12), etc Thus, the clinical characteristics of our study group with many characteristics such as age, gender, background of onset, pain symptoms, sensory disturbances, nerve root syndrome and sacral spine, VAS scale, Oswestry scale have similar results with studies of many domestic and foreign authors 4.1.2 Characterization of nerve conduction index and electromyography Nerve conduction survey method aims to study the conduction ability of peripheral nerves; At the foot, we choose positions that have diagnostic value and practical clinical applications The locations of nerve conduction measurements are the deep peroneal nerve, the tibial nerve, the superficial peroneal nerve, and the calf nerve Among 108 study patients, who were diagnosed with disc herniation on magnetic resonance imaging, including hernia on one side and hernia on both sides, we conducted a meta-analysis and found that: when investigating the time of external motor potential micro, motor conduction velocity, amplitude of the deep peroneal and tibial nerves; sensory conduction of the calf and 21 superficial peroneal nerves; There was no statistically significant difference between the left and right side of F wave and H reflection Our research is quite similar to the authors Le Van Son, J Kimura Regarding the electromyographic characteristics, in our study, we investigated the damage to the lumbar nerve root due to herniated disc in this region based on the paraspinal and distal muscle groups The results obtained, when surveying the needle according to the position of the dominant nerve root, was that in 852 sites of electromyography, the normal needle puncture potential was 39.91%, the increased needle puncture potential accounted for 45 percent ,65% Spontaneous potential: positive spike wave is 38.85%, the highest is muscle fiber convulsion accounting for 50.7% Motor unit potential we only conduct evaluation in the distal muscle group High amplitude accounted for the highest rate 301/568 (52.99%), wide interval accounted for 45.07%, polyphasic accounted for 43.13%, so these characteristics are very important in assessing root damage nerve Many studies, there are similarities with our results 4.2 Concordance between nerve conduction index, electromyography and MRI in patients with sacrum lumbar disc herniation We conducted a separate analysis in the group of unilateral disc herniation, we received 32 patients, when studying the F wave in this group of patients, found: there was no statistically significant difference between the median F wave results in the tibial nerve but significant in the deep peroneal nerve F wave in the deep peroneal nerve with difference between diseased and healthy side can help evaluate L5 nerve root damage due to disc herniation in this region Similarly, when analyzing the H reflex in this group of 32 patients, we found: there is a statistically significant difference (p 75%) The compatibility of diagnosis of lesion location between clinical, magnetic resonance imaging and electromyography: 55% of patients have the same conclusion and 45% have differences in lesion location between the methods In clinical practice, it is necessary to pay attention to the combination of methods to properly assess the lesion and distinguish it from other pathological groups In the diagnosis of patients with lumbar disc herniation, the electromyography evaluation of the paraspinal muscle group (at the position of the multi-leg muscle) plays an important role in the assessment of lumbar nerve root damage (especially in the early stages of injury) RECOMMENDATION The Oswestry scale should be used to assess the degree of limitation of lumbar spine mobility, along with a herniated disc in this position Should combine clinical examination, electrodiagnostic investigation and magnetic resonance imaging in the diagnosis of lumbar disc herniation pathology In the early stages of lumbar disc herniation, the same should be investigated by electromyography of the paravertebral muscle group at the multifidus position to assess nerve root damage at this location ... Oswestry scale (n=108) ODI Classifiaction Level (ODI từ – 20%) Level (ODI từ 21 – 40%) Level (ODI từ 41 – 60%) Level (ODI từ 61 – 80%) Level (ODI từ 81 – 100%) Mean ± SD (max point of 50) No patients... Nguyen Van Lieu Reviewer 1: Reviewer 2: Reviewer 3: The dissertation is defended before the Committee of Hanoi Medical University At room………, A1 Building, HMU: For further detail of the dissertation,... Thus, up to 45% of patients have differences between the methods, so clinical practice should pay attention to coordinate with each other to avoid mistakes in diagnosing the exact location of the