Liquid crystal thermography of the spine and extremities

Its value in the diagnosis of spinal root syndromes

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✓ Cholesteric liquid crystals are special compounds that display specific color changes in response to variations in temperature. Their responses can be graphically demonstrated by means of color thermography. A new color contact thermographic technique is described utilizing liquid crystals embedded in elastic flexible sheaths. These sheaths, when inflated, conform to the varied contours of the torso and extremities and, therefore, the new thermographic technique is especially well suited to the study of the skin dermatomes and myotomes. Typical heat patterns have been observed in root compression syndromes and particularly at the S-1, L-5, L-4, C-6, C-7, and C-8 levels. A high degree of anatomic accuracy can thus be achieved, comparable to or better than can be achieved by electromyography or myelography. Liquid crystal thermography can serve to screen patients for myelography and can complement myelography in identifying clinically significant abnormalities. The imaging technique correlates well with clinical and surgical findings, and constitutes one of the first attempts by means of a concomitant study of the body dermatomes to objectively document the subjective complaint of pain.

The liquid crystals used for liquid crystal thermography (LCT) are cholesterol derivatives that selectively reflect polarized light in a narrow region of wavelengths. They have strong molecular rotatory power and specific color-temperature responses that are utilized in color thermography.2,5 In the past, the adaptation of liquid crystals to thermography had been hampered by the necessity of skin preparation with black water-based paint in the form of a spray prior to the actual application of liquid crystals to the skin.2,16 Rigid plastic plates subsequently replaced skin preparation and spraying, but the unyielding plates precluded uniform contact between the liquid crystals and the skin, particularly when applied to the spine or extremities. The resultant thermograms were, therefore, inadequate.

Two of the current authors have previously reported a new thermographic technique for the examination of the breasts, utilizing liquid crystals embedded in elastomeric sheaths.18,19 The sheaths were individually contoured to the body by means of a vacuum. This method resulted in a good correlation with clinical and mammographic findings. A modification of this technique has been specifically adapted for contact thermography of the spine and extremities and is described in this paper. The currently reported adaptation also employs flexible, elastomeric “Flexi-Therm” sheaths containing thermally sensitive liquid crystals. However, they may now be contoured to the torso and extremities by means of a new device, an “air pillow.” Uniform skin contact and consistently reliable thermograms have been achieved.

Clinical Material and Methods
Case Material

Our series consists of 101 patients, all examined in a hospital setting. Of these 101 hospital patients, 61 also underwent myelography, and 38 were operated on.

Apparatus

The apparatus (Fig. 1) consists of a hermetically sealed 37 × 28 × 3.5-cm box, one side of which has a transparent plastic wall, while the other is composed of liquid crystals embedded in an elastomeric sheath. Air is pumped into the system by means of a foot pump, ballooning the liquid crystal sheaths, which then form a convex bulging surface (Fig. 2 left). The inflated air pillow is then ready to be used for contact thermography (Fig. 2 right).

Fig. 1.
Fig. 1.

Photograph of the apparatus. The liquid crystals are embedded in elastomeric sheaths (A), which are mounted on “air pillow” boxes (B), and can be inflated by a foot pump (C). Courtesy of Flexi-Therm, Inc.

Fig. 2.
Fig. 2.

Diagrams showing the inflated “air pillow” (left), and the air pillow in place with the area of contact thermography (cross hatching, right). Courtesy of Flexi-Therm, Inc.

Six or more air-pillow boxes are available which are progressively numbered 26 to 35 to correspond with the median Celsius temperature ranges of their incorporated liquid crystal “Flexi-Therm” sheaths.* Liquid crystals have accurate and reliable color responses to specific temperature changes (Table 1). The lowest temperature is displayed as a dark brown color, and changes with progressive temperature elevation to tan, reddish brown, yellow, green, light blue, and dark blue. The highest temperature is indicated by a dark blue color.

TABLE 1

Typical liquid crystal elastomeric sheet temperature calibrations (°C)*

1 Dark Brown2 Tan3 Reddish Brown4 Yellow5 Green6 Light Blue7 Dark Blue
31.231.631.932.232.433.235
3232.332.733.633.734.636
32.933.233.43434.235.336.4

These color-temperature calibrations permit simultaneous determinations of temperature differentials (ΔT°) in comparable regions of the spine and extremities.

An instant camera with an electronic flash system and cross-polarized filter records the color thermograms. A fixed-distance frame attached to the camera provides support for the air pillow and facilitates photography (Fig. 3).

Fig. 3.
Fig. 3.

Photograph showing the thermography system in use. Courtesy of Flexi-Therm, Inc.

Conduct of Examination

The examination should be performed in an air-conditioned, draft-free room. The skin temperature of the back is stabilized by sponging with water and cooling for 10 minutes. A hair drier set on “cool” can further expedite skin drying and cooling. Patients should refrain from smoking on the day of the examination since smoking may affect skin temperature.11

The air pillow box with the widest display for the patient's skin temperature is selected. A 30°C box is used initially. If brown colors predominate, the skin temperature is too cold for that particular box. A 28°C box is then used. If blue colors predominate, the skin temperature is too warm and a 32°C box is used. The appropriate box is then firmly pressed against the patient's back (Fig. 2 right). A colored image promptly appears on the liquid crystal sheath. The box is then lifted slightly from the skin surface to eliminate distortion and glare, and the image is immediately photographed (Fig. 3).

Routine views of the lumbosacral region and lower extremities consist of separate images of the lumbar region, buttocks, anterior, lateral, and posterior aspects of both thighs, the anterior, lateral, and posterior aspects of both lower legs including the ankles and the dorsal aspect of the feet, including the toes. Routine images of the cervical spine and upper extremities include posterior views of both shoulders and forearms, anterior views of the forearms, ulnar and radial aspects of the forearms, and the dorsal and palmar aspects of the hands and fingers. Abnormal thermographic images should be repeated at least three times in succession to confirm their reliability. Special attention is given to the body dermatomes and myotomes.14

Thermographic Results
Theoretical and Anatomical Bases for Thermographic Interpretation

A normal thermogram of the extremities shows symmetrical heat emission; root lesions of the spine have been associated with temperature changes in the corresponding dermatomes and myotomes (Figs. 4 to 8). The temperature changes may have been related to reflex sympathetic vasoconstriction within affected extremity dermatomes and metabolic changes or muscular spasm in corresponding paraspinal myotomes. As a rule, temperature changes appear as zones of hypothermia at the levels of the affected extremity dermatomes (Figs. 4 to 8).3,7,10,29,30 Frequently, however, and particularly in the hands and feet (for unknown reasons), hyperthermia occurs at the level of the affected dermatomes (Figs. 6 to 8). Both hypothermic and hyperthermic reactions are abnormal since there should be no significant temperature difference between the extremities in normal individuals. The only exception to this rule is the occasional increase in temperature in the dominant arm and posterior forearm in very muscular males. In the spine, root compression syndromes usually show lumbosacral hyperthermia (Fig. 6) and cervicothoracic hypothermia (Fig. 8) of the ipsilateral adjacent paraspinal myotomes. Musculoligamentous injuries of the spine and/or osseous lesions without root compression appear to cause thermographic changes localized to the spine.13 They are not necessarily associated with thermographic changes in the extremities.

Fig. 4.
Fig. 4.

Liquid crystal thermograms (A)-(D) and myelogram (E) showing right S-1 root compression syndrome in a 28-year-old man with backache and sciatica associated with exercise for several years. A: Gluteal regions. Note decreased heat emission (brown) from right gluteal region (arrow). This cold area extends inferomedially. B: Posterior aspect of the thighs. Note decreased heat emission (less green and blue) from lower aspect of the right thigh (arrow). C and D: Lateral aspect of the legs. The right leg (C) shows a generalized decreased heat emission (dark brown color) as compared to the left (D), which shows normal heat emission (green and blue, arrow) above the ankle. E: Myelogram showing a right L5-S1 defect (arrow). At surgery, a herniated disc compressed the right S-1 root. Comment: A cold gluteal region with inferior and medial extension and cold posterior thigh, lateral leg, and ankle are typical findings in S-1 root compression syndrome.

Fig. 6.
Fig. 6.

Liquid crystal thermograms showing a left L-5 root syndrome in a 49-year-old man with back pain radiating to the left leg. Left: Note hot (blue and green) zone (upper arrow) in left lower lumbar area, and cold (brown) zone (lower arrow) in left buttock and radiating laterally. Right: First, second, and third toes (arrow) of left foot are warmer (blue) than the right. Comment: This case demonstrates typical findings in L-5 syndromes: warm low lumbosacral area, cold midgluteal radiating laterally, and warm toes.

Fig. 8.
Fig. 8.

Liquid crystal thermograms (LCT's, A-D and G) and telethermograms (E and F) of a left C-7 root syndrome in a 33-year-old woman with cervical spine pain. Posterior oblique aspect of the left (L) shoulder (A) shows it to be colder (darker brown, arrow) than the right (R) (C). Both shoulders appear thermographically symmetrical on direct posterior view (B). The LCT of both dorsal forearms (D) shows the left is colder (less blue, arrow). Conventional telethermography shows almost indentical findings: the posterior view of the left shoulder (E) is colder (less pink, arrow) than the right and the dorsal aspect of the left forearm (F) is colder (less pink, arrow) than the right. The LCT of the dorsum of the hands (G) shows the second and third fingers (arrows) are slightly warmer on the left than on the right. Comment: These findings correspond to the dermatome distribution of the left C-7 root. Electromyography confirmed the presence of a left C-7 root dysfunction.

Although there are frequent minor variations and nerve fiber crossovers, temperature fluctuations at particular dermatomes and myotomes14 reflect a fairly accurate picture of referred pain in root compression syndromes.3,7,10,29 A normal thermogram of the spine is characterized by a central zone of decreased heat emanation in the region of the spinal processes from the cervical spine down to the lower lumbosacral spine. The intergluteal fold is also hypothermic, since it is not in contact with the liquid crystal sheaths. The sacroiliac joints may show symmetrically localized increased heat emission.8,21 A positive or abnormal thermogram will show evidence of asymmetrically increased heat production at myotomes in this zone (Fig. 6) or decreased heat production lateral to the midline along the cervical, thoracic, and upper lumbar spine (Fig. 8).

Comparison with Clinical Findings and Myelography

Liquid crystal thermography was performed on 101 patients who had clinical complaints relating to the back and extremities. Of these, 61 had myelography, which was usually performed after LCT. Most patients referred for myelography had one or more positive physical findings, which included localized muscle spasm, a positive straight-leg raising test, a positive Lasègue test, reflex and sensory changes, muscle atrophy, and/or a positive electromyogram. Of these 61 clinically positive patients, 48 (79%) had a positive LCT while only 38 (62%) had positive myelograms (Table 2); 23 patients had negative or questionable myelograms. Therefore, LCT correlated better with clinical findings than myelography. An analysis of surgically treated cases in which LCT and myelography disagreed is discussed below and summarized in Table 4. Nevertheless, both LCT and myelography were in agreement in 51 patients or 84% of cases (Table 2, Figs. 4 and 5). There were no definitively positive myelograms when the LCT was negative (Table 2). This suggests that the yield of myelography is likely to be low in the face of a normal LCT.

TABLE 2

Comparison of LCT with myelography in 61 patients*

LCT ResultsMyelogram Results
PositiveNegative 
positive3810
negative013

LCT = liquid crystal thermography.

TABLE 4

Comparison of LCT and myelography results in 38 operated patients*

ResultLCTMyelography
true positive3531
true negative11
false positive20
false negative06
total cases3838
accuracy (%)9584

LCT = liquid crystal thermography.

Fig. 5.
Fig. 5.

Left S-1 root syndrome in a 48-year-old man with back pain radiating to the left leg. Left: Liquid crystal thermogram of the posterior aspects of both thighs. Left (L) thigh (arrow) is colder (less blue) than right (R). Right: Myelogram showing left L5-S1 defect (arrow). Surgery disclosed metastasis at this level.

Comparison with Surgical Results

Liquid crystal thermography, myelography, and surgery were performed on 38 patients. There was good correlation of LCT with both myelography and surgical findings (Figs. 4 and 5, Tables 2 to 4). In our series, LCT showed no false negatives, whereas myelography was equivocal or falsely negative in six patients, all of whom had surgical evidence of root compression. Three of these six patients were found to have superior facet hypertrophy or lateral recess stenosis (Fig. 7), and three had hypertrophic spurs or herniated discs. Myelography on the other hand, showed no false positives.

Fig. 7.
Fig. 7.

Liquid crystal thermograms (LCT) of right L-4 and L-5 root syndromes in a 55-year-old man. He had suffered backache for 20 years, which had increased in severity with associated right sciatica and tingling in the right foot in the past 6 weeks. A and B: Lateral aspects of the thighs. Note the colder (less blue) right thigh (A) compared with the left thigh (B). C: Anterior aspect of the thighs. The lower anterior aspect of the right thigh (arrow) is cooler (less blue) than the left. D: Dorsum of the feet. The lower anterior aspect of the right leg, dorsum of the right foot (arrow), and all toes are warmer (more blue) than on the left. The findings in (A), (B), and (D) indicate a right L-5 root compression syndrome. The findings in (C) together with a warm first toe (D) represent a right L-4 foot compression syndrome. Myelography showed no definite abnormalities. Surgery, however, disclosed right lateral recess stenosis at the L-4 and L-5 levels, with signs of root compression at both locations. Comment: This is an example of a positive LCT showing lesions at two separate levels. The LCT showed a better correlation with clinical findings than the myelogram, which was falsely negative in this case.

In eight surgically treated cases in which LCT and myelography disagreed, LCT was fully correct in six cases (Fig. 7) and partially correct in one case. If only results completely proven at surgery were tabulated, the overall accuracy of LCT was 95% and that of myelography 84% (Table 4).

Surgery was performed on only one of 12 patients who had both a normal LCT and a normal myelogram. Although lateral spinal recess stenosis was found at the L-5 level, there was no evidence of root compression at surgery. This case is considered a true negative, although it may conceivably have caused intermittent root compression.

Comparison with Conventional Telethermography

Simultaneous LCT and conventional infrared telethermography were performed on over 50 patients by two of the authors in a private-practice setting. These patients were not included in the material presented in this paper, which was restricted to hospital patients. Results of this ongoing study will be the subject of a separate paper. Preliminary results, however, indicate good correlation between these two thermographic techniques (Fig. 8), which appear to complement each other.

Advantages of LCT over electronic infrared telethermography are the low price, simplicity of the apparatus, and the distinct color contrast it is able to achieve (Figs. 4 to 8). The chief advantages of telethermography include the fact that contact with the patient's skin is not required and that larger body areas can be encompassed on each view (Fig. 8).

Value of Thermography of the Spine

Uematsu and Long27 reviewed thermograms of 101 patients with chronic pain in a variety of locations in the body. There were 17 abnormal thermograms. All but one demonstrated coldness in the area of pain. Potanin, et al.,20 using liquid crystals, demonstrated coldness of the skin corresponding to the distribution of pain during attacks of experimentally stress-induced angina pectoris. Tichauer,25 in his series of patients with backache, found asymmetrical warm areas in the paralumbar area and cold gluteal patches in a high percentage of cases.

Thermography was found to be accurate in predicting disc herniation in 80% of a reported series of 29 surgically proven cases.8 Its accuracy was comparable to that of myelography. When both thermography and myelography were positive, the probability of negative findings at surgery became much smaller.8 Accordingly, in our series no false positives were found at surgery when LCT and myelography were in agreement (Table 4). Raskin, et al.,21 in a report based on 24 patients in whom herniated discs were found at surgery, noted that thermography was accurate in 71% and myelography in 88% of the series.

DePalma and Rothman6 estimated that the incidence of error in myelography ranges from 20% to 30%. This is due to the fact that herniated or extruded disc material may be small in volume and/or may lie far to the side in the lateral recess of the spinal canal without significant contact with the dural sac. Myelography may be unremarkable in cases with lateral recess stenosis or superior facet entrapment (Fig. 7).4,9 The fact that myelography may not detect all clinically significant lesions was illustrated in one case in our series in which LCT showed evidence of a left L-5 and a left S-1 root compression syndrome while myelography only demonstrated a left L4–5 defect. Surgery revealed spinal stenosis, a herniated disc at the L4–5 interspace, and an osteophyte impinging on and compressing the left S-1 root at the L5-S1 interspace. Myelography may, furthermore, be falsely negative (Fig. 7, Tables 3 and 4) or falsely positive in asymptomatic patients.6

TABLE 3

Surgical findings in 38 patients with root compression syndromes

Surgical Findings*No. of Cases
L-5 root compression due to herniated disc, facet entrapment, osteophyte impingement &/or spinal stenosis25
S-1 root compression due to herniated disc, facet entrapment, osteophyte impingement &/or spinal stenosis12
neurofibroma: S-1 root compression1
extradural metastasis: S-1 root compression2
ependymoma: L-3 root compression1
syringomyelia: C3–71
L-4 root compression due to spinal stenosis & facet entrapment3
neurofibroma: C6-T3 root compression1

In some patients two or more levels were involved.

Computerized tomography (CT) is highly useful in spinal canal stenosis4 and appears to show promise in the detection of herniated discs and other abnormalities as well. However, it may be misleadingly negative, especially in cases of musculoligamentous injuries which are positive on thermography.13 Both myelography and CT are more expensive examinations which also involve radiation exposure.

Wexler29,30 correlated the thermographic spine patterns and extremity dermatome changes, and standardized the thermographic examination of the spine to include the extremities as an integral part of the study. In his series of 86 patients, Wexler30 found that thermography of the spine and extremities was 92% accurate, as compared to physical findings, while electromyography was only 83% accurate.

Root Syndrome Patterns

Liquid crystal thermography appears to be particularly well suited for the diagnosis of root compression syndromes. The following recurrent, typical heat patterns have been observed in this preliminary study which serve to delineate and associate affected myotomes and dermatomes.

Involvement of the S-1 root is associated with localized increased heat emission from the affected side of the lumbosacral region. The posterior aspect of the ipsilateral thigh, and posterior and lateral aspects of the leg will, in most cases, show hypothermia, while concomitant hyperthermia or hypothermia will be seen along the lateral aspects of the foot and fifth toe. The ipsilateral buttock may also show hypothermia with inferomedial extension (Figs. 4 and 5).

Involvement of the L-5 root is usually characterized by hyperthermia of the ipsilateral lumbar spine, usually radiating laterally, hypothermia of the ipsilateral midgluteal region, also radiating laterally, hypothermia of the lateral thigh and anterior leg, and hyperthermia or hypothermia of the dorsum of the foot and first, second, third, and fourth toes (Figs. 6 and 7).

Involvement of the L-4 root is indicated by hyperthermia of the lateral aspect of the lumbar spine, hypothermia of the anterior aspect of the ipsilateral lower thigh, and medial aspects of the leg and ankle, and hyperthermia or hypothermia of the medial aspect of the foot including the first toe (Fig. 7).

Compression syndromes of the C-6 root are usually associated with hypothermia of the ipsilateral posterior cervical muscles, posterior aspect of the shoulder, radial side of the forearm, and a hot or cold thumb.

Involvement of the C-7 root is associated with hypothermia of the ipsilateral posterior cervical spine muscles, posterior aspect of the shoulder and dorsal aspect of the forearm. Hyperthermia or hypothermia of the ipsilateral second and third fingers is also seen in most cases (Fig. 8).

Involvement of the C-8 root is associated with hypothermia of the ipsilateral posterior cervical spine muscles, posterior aspect of the shoulder, and ulnar aspects of the forearms. Hyperthermia or hypothermia of the ipsilateral fourth and fifth fingers is frequently noted.

It is our opinion that thermographic accuracy in diagnosing spinal root compression syndromes was greatly improved when a study of extremity dermatomes was simultaneously included with the thermographic evaluation of the spine.

Discussion

Despite the fact that the current study is based on a limited number of cases, preliminary results indicate that a high degree of anatomic accuracy may be achieved with LCT that is comparable to or better than that realized by myelography (Tables 2 to 4). This is true with the proviso that the extremity dermatomes are simultaneously included in the basic LCT examination. Liquid crystal thermography is a noninvasive technique that appears to have great sensitivity and correlates well with clinical and surgical findings. This imaging technique is one of the first attempts to objectively document the subjective complaint of pain by charting the body and particularly the extremity dermatomes.

Indications

Thermography of the spine and extremities is useful in numerous conditions.1,12,15,17,22–24,26,28 Since LCT is a noninvasive technique that appears to be highly sensitive, it may play an important role in selecting those patients who require myelography, thereby improving the efficacy of the latter study. In the appropriate clinical setting, a negative LCT may, therefore, obviate an unnecessary myelogram. It may also be valuable in the evaluation of patients with negative or questionable myelograms, and may further complement myelography in helping to determine which abnormalities are clinically significant. Liquid crystal thermography helps confirm clinically suspected spinal root compression syndromes, as seen in association with herniated discs and osteophyte formation, spinal canal stenosis including lateral recess stenosis and subluxation, and hypertrophy of superior vertebral facets.4,9 It graphically documents pain in spinal musculoligamentous injuries in which roentgenographic studies may be normal. It is also positive in inflammatory, infectious, traumatic, and neoplastic diseases of the spine and extremities, as well as in peripheral arthropathies. It complements radiographic studies. It monitors treatment results, and documents remissions and relapses of diseases of the spine, extremities, and joints.1,26,30

Liquid crystal thermography may be useful in preemployment examinations in helping to identify and document occult or latent nerve root syndromes. Applicants may then be steered away from potentially hazardous occupations or strenuous athletic activities.13 It establishes a baseline pattern for future reference or comparison.30 It identifies and graphically demonstrates otherwise purely subjective pain patterns, and helps document and distinguish true somatic complaints from malingering.17 It aids in the evaluation and diagnosis of thrombophlebitis of the legs,22,23 as well as arterial insufficiency of the extremities.28

Differential Diagnosis

The thermographic differential diagnosis of spinal root compression syndromes includes deep venous thrombosis,22,23 ischemic arterial disease,28 local trauma, and arthropathies of extremity joints.26 These conditions can be distinguished from spinal root compression syndromes in most cases by their distinct clinical pictures and by the failure of thermographic findings to be confined to a definite skin dermatome distribution. Varicose veins can be distinguished by their serpiginous course on the thermograms.3,29

In the upper extremities, the differential diagnosis includes carpal tunnel syndrome with median nerve irritation and the ulnar nerve entrapment syndrome.15,24,30 In median nerve involvement, there may be temperature changes in the thumb, second and third fingers, and radial side of the fourth finger.30 The ulnar nerve entrapment syndrome is usually associated with a cold dorsal forearm and temperature changes in the fourth and fifth finger.30 In leprosy, hypothermic areas, as noted on thermography, are the sites of most marked sensory loss.24

Advantages

The entire apparatus for LCT costs only a small fraction of the price of a conventional thermographic unit, thus permitting its routine use in small hospitals and/or physicians' offices. It has demonstrated a high degree of accuracy and correlates well with clinical and surgical findings. There is no exposure to radiation. The liquid crystals dramatically accentuate thermal and vascular pathology with a rich, high-contrast, thermographically calibrated color display (Table 1).

Although this technique and the unit described above have been especially adapted for use with the spine and extremities, it can be adapted to virtually any region of the body. It can be used for thermography of the head and could be used in a screening program for stroke prevention.12 Its utilization for thermography of the breasts has been documented previously.18,19

Acknowledgment

The technical contribution of Mr. Seymour Katz is gratefully acknowledged.

References

Flexi-Therm sheaths manufactured by Flexi-Therm, Inc., 117 Magnolia Avenue, Westbury, New York.

Article Information

Address reprint requests to: Rubem Pochaczevsky, M.D., Department of Radiology, Long Island Jewish-Hillside Medical Center, New Hyde Park, New York 11042.

© AANS, except where prohibited by US copyright law."

Headings

Figures

  • View in gallery

    Photograph of the apparatus. The liquid crystals are embedded in elastomeric sheaths (A), which are mounted on “air pillow” boxes (B), and can be inflated by a foot pump (C). Courtesy of Flexi-Therm, Inc.

  • View in gallery

    Diagrams showing the inflated “air pillow” (left), and the air pillow in place with the area of contact thermography (cross hatching, right). Courtesy of Flexi-Therm, Inc.

  • View in gallery

    Photograph showing the thermography system in use. Courtesy of Flexi-Therm, Inc.

  • View in gallery

    Liquid crystal thermograms (A)-(D) and myelogram (E) showing right S-1 root compression syndrome in a 28-year-old man with backache and sciatica associated with exercise for several years. A: Gluteal regions. Note decreased heat emission (brown) from right gluteal region (arrow). This cold area extends inferomedially. B: Posterior aspect of the thighs. Note decreased heat emission (less green and blue) from lower aspect of the right thigh (arrow). C and D: Lateral aspect of the legs. The right leg (C) shows a generalized decreased heat emission (dark brown color) as compared to the left (D), which shows normal heat emission (green and blue, arrow) above the ankle. E: Myelogram showing a right L5-S1 defect (arrow). At surgery, a herniated disc compressed the right S-1 root. Comment: A cold gluteal region with inferior and medial extension and cold posterior thigh, lateral leg, and ankle are typical findings in S-1 root compression syndrome.

  • View in gallery

    Liquid crystal thermograms showing a left L-5 root syndrome in a 49-year-old man with back pain radiating to the left leg. Left: Note hot (blue and green) zone (upper arrow) in left lower lumbar area, and cold (brown) zone (lower arrow) in left buttock and radiating laterally. Right: First, second, and third toes (arrow) of left foot are warmer (blue) than the right. Comment: This case demonstrates typical findings in L-5 syndromes: warm low lumbosacral area, cold midgluteal radiating laterally, and warm toes.

  • View in gallery

    Liquid crystal thermograms (LCT's, A-D and G) and telethermograms (E and F) of a left C-7 root syndrome in a 33-year-old woman with cervical spine pain. Posterior oblique aspect of the left (L) shoulder (A) shows it to be colder (darker brown, arrow) than the right (R) (C). Both shoulders appear thermographically symmetrical on direct posterior view (B). The LCT of both dorsal forearms (D) shows the left is colder (less blue, arrow). Conventional telethermography shows almost indentical findings: the posterior view of the left shoulder (E) is colder (less pink, arrow) than the right and the dorsal aspect of the left forearm (F) is colder (less pink, arrow) than the right. The LCT of the dorsum of the hands (G) shows the second and third fingers (arrows) are slightly warmer on the left than on the right. Comment: These findings correspond to the dermatome distribution of the left C-7 root. Electromyography confirmed the presence of a left C-7 root dysfunction.

  • View in gallery

    Left S-1 root syndrome in a 48-year-old man with back pain radiating to the left leg. Left: Liquid crystal thermogram of the posterior aspects of both thighs. Left (L) thigh (arrow) is colder (less blue) than right (R). Right: Myelogram showing left L5-S1 defect (arrow). Surgery disclosed metastasis at this level.

  • View in gallery

    Liquid crystal thermograms (LCT) of right L-4 and L-5 root syndromes in a 55-year-old man. He had suffered backache for 20 years, which had increased in severity with associated right sciatica and tingling in the right foot in the past 6 weeks. A and B: Lateral aspects of the thighs. Note the colder (less blue) right thigh (A) compared with the left thigh (B). C: Anterior aspect of the thighs. The lower anterior aspect of the right thigh (arrow) is cooler (less blue) than the left. D: Dorsum of the feet. The lower anterior aspect of the right leg, dorsum of the right foot (arrow), and all toes are warmer (more blue) than on the left. The findings in (A), (B), and (D) indicate a right L-5 root compression syndrome. The findings in (C) together with a warm first toe (D) represent a right L-4 foot compression syndrome. Myelography showed no definite abnormalities. Surgery, however, disclosed right lateral recess stenosis at the L-4 and L-5 levels, with signs of root compression at both locations. Comment: This is an example of a positive LCT showing lesions at two separate levels. The LCT showed a better correlation with clinical findings than the myelogram, which was falsely negative in this case.

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