714 Letters to the editor / The Spine Journal 18 (2018) 712–715
involvement. AJNR Am J Neuroradiol 2011;32:639–42. doi:10.3174/
Figure. Contrast-enhanced T1 weighted imaging sagittal (Left) and axial
(Right) series showing bilateral symmetrical thickening and enhancement
along the cauda equina ventral nerve roots (white arrows), sparing the dorsal
roots.
15) showed after gadolinium thickening and selective CE of
the ventral cauda equina roots, with sparing of the dorsal roots
and in the absence of parenchymal lesions (Figure). Intra-
venous immunoglobulins (0.4 g/kg/daily) were administered
from days 12 to 16 with benefit. The boy slowly recovered
within 5 weeks. In conclusion, our patient had a monopha-
sic GBS, which could be defined as an acute, reversible motor
axonal neuropathy (AMAN), with selective CE of ventral roots
[2,3].Previous studies demonstrated that CE of intrathecal
spinal roots and ventral rami of spinal nerves is constant feature
of AMAN [3], where the early pathologic events consisted
of inflammatory endoneurial edema and perivenular infiltra-
tion, resulting in focal nerve conduction failure [3]. Zuccoli
et al [4], redefining the GBS spectrum in children, stated that
thickening and CE of the ventral roots on MRI, although non-
specific, are characteristic of patients with typical GBS [3,4].
Although prominent anterior spinal root enhancement has been
observed, along with increased severity of leg weakness, the
correlation between the degree of CE and the clinical outcome
is poorly established [4]; in fact, in early AMAN, outstand-
ing MRI changes in the anterior roots might be, to some
degree, subclinical [3].
References
[1] Resorlu M, Guven M, Aylanc H, Karatag O. Lumbar MRI findings in
Guillain-Barré syndrome. Spine J 2016;16:e709–10. doi:10.1016/
j.spinee.2016.03.034.
[2] Yuki N, Hartung HP. Guillain-Barré syndrome. N Engl J Med
2012;366:2294–304. doi:10.1056/NEJMra1114525.
[3] Berciano J, Sedano MJ, Pelayo-Negro AL, Garcia A, Orizaola P,
Gallardo E, et al. Proximal nerve lesions in early Guillain–Barré
syndrome: implications for pathogenesis and disease classification. J
Neurol 2017;264:221–36. doi:10.1007/s00415-016-8204-2.
[4] Zuccoli G, Panigraphy A, Bailey A, Pitz C. Redefining the Guillain-
Barré spectrum in children: neuroimaging findings of cranial nerve
ajnr.A2358.
Giuliana Galassia
Maurilio Genoveseb
Alessandra Ariattia
Marcella Malagolib
a
Department of Biomedical, Metabolic and Neural Sci-
ences, University Hospitals of Modena and Reggio Emilia,
Modena, Italy
b
Neuroradiology Unit, University Hospitals of Modena
and Reggio Emilia, Modena, Italy
“Text-neck”: an epidemic of the modern era
of cell phones?
To the Editor:
We would like to thank the authors of the article “ ‘Text-
neck’: an epidemic of the modern era of cell phones?” for
highlighting a new behavior that is hypothesized to cause mus-
culoskeletal consequences. We agree that there has been a
potentially harmful increased use of, and addiction to, mobile
phones for texting combined with the growing prevalence of
neck pain [1–4].
However, some claims and recommendations of the authors
need further discussion. The authors stated that the findings
of Hansraj are quite alarming because the estimated load in
the cervical spine during mobile phone texting is 49 lb while
the neck is at 45 degrees, and 60 lb while the neck is at 60
degrees [5]. Nevertheless, the average compression force at
which the cervical disc-vertebral body units reach their elastic
limit in cadaveric samples is 540 lb [6]. Furthermore, Przybyla
et al stated that living people might be able to resist and adapt
to higher loads than cadaveric specimens [6].
Some studies claim that the increased stresses upon the
cervical spine can result in accelerated disc degeneration. We
consider that it is not as plausible as it seems. There is evi-
dence of longitudinal studies with twins that the strongest factor
associated with disc degeneration is genetics and the second
one is aging [7,8]. It is also very important to consider that
disc degeneration is very common in asymptomatic people,
and neck pain is very common in people with no disc de-
generation [9–11].
Regarding the longitudinal study of Gustafsson et al, the
authors emphasized the association between persistent neck
pain and upper back pain with time spent text messaging [12].
However, the main finding of the study was that among par-
ticipants who were symptom-free at baseline, prospective
associations were found between text messaging and new cases
FDA device/drug status: Not applicable.
Author disclosures: NMF: Nothing to disclose. ADSF: Nothing to dis-
close. LACN: Nothing to disclose. FJJR: Nothing to disclose.
https://doi.org/10.1016/j.spinee.2017.11.022
 Letters to the editor / The Spine Journal 18 (2018) 712–715
of reported symptoms in the hand-fingers only at 1-year follow-
up. Therefore, time texting on the mobile phone was not a
risk factor to developing neck pain. Moreover, the study did
not assess the neck posture of the participants.
The authors recommended their patients to hold their cell
phone up at or near eye level while texting. Even if we accept
text-neck as a risk factor to developing neck pain, it is not
known if this recommendation would prevent neck pain. It
may be possible that this recommendation does not provide
a decrease in the risk of neck pain or even increase the risk
of developing shoulder-elbow or hand-fingers pain [12,13].
However, prophylactic trials would be necessary to answer
this question.
There is a prevailing reasoning among health profession-
als that the main cause of spinal pain is structural vulnerability,
such that posture correction plays a major role in avoiding
tissue damage [14]. The belief of pain as a synonym of tissue
damage may contribute to a lack of patient reassurance during
the first consultations. Moreover, this behavior is a possible
cause of the excess of low-value health care, such as excess
magnetic resonance imaging scan prescriptions and early phys-
iotherapy interventions, for spinal pain [15].
References
[1] Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. The global
burden of neck pain: estimates from the global burden of disease 2010
study. Ann Rheum Dis 2014;73:1309–15. doi:10.1136/annrheumdis-
2013-204431.
[2] Nordicom. The Swedish Media Barometer 2009. Univ Gothenbg Nord
Inf Cent Media Commun Res; 2010.
[3] IBGE. National Household Survey, PNAD. Brazilian Inst Geogr Stat;
2016.
[4] Lin Y-H, Lin Y-C, Lee Y-H, Lin P-H, Lin S-H, Chang L-R, et al. Time
distortion associated with smartphone addiction: identifying smartphone
addiction via a mobile application (App). J Psychiatr Res 2015;65:139–
45. doi:10.1016/j.jpsychires.2015.04.003.
[5] Hansraj KK. Assessment of stresses in the cervical spine caused by
posture and position of the head. Surg Technol Int 2014;25:277–9.
[6] Przybyla AS, Skrzypiec D, Pollintine P, Dolan P, Adams MA. Strength
of the cervical spine in compression and bending. Spine 2007;32:1612–
20. doi:10.1097/BRS.0b013e318074c40b.
715
[7] Battié MC, Videman T, Kaprio J, Gibbons LE, Gill K, Manninen H,
et al. The Twin Spine Study: contributions to a changing view of disc
degeneration. Spine J 2009;9:47–59. doi:10.1016/j.spinee.2008.11.011.
[8] Näkki A, Battié MC, Kaprio J. Genetics of disc-related disorders: current
findings and lessons from other complex diseases. Eur Spine J
2014;23:354–63. doi:10.1007/s00586-013-2878-2.
[9] Lee TH, Kim SJ, Lim SM. Prevalence of disc degeneration in
asymptomatic Korean subjects. Part 2: cervical spine. J Korean
Neurosurg Soc 2013;53:89–95. doi:10.3340/jkns.2013.53.2.89.
[10] Binder AI. Neck pain. BMJ Clin Evid 2008;2008.
[11] Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo
RA, et al. Systematic literature review of imaging features of spinal
degeneration in asymptomatic populations. AJNR Am J Neuroradiol
2015;36:811–16. doi:10.3174/ajnr.A4173.
[12] Gustafsson E, Thomée S, Grimby-Ekman A, Hagberg M. Texting on
mobile phones and musculoskeletal disorders in young adults: a
five-year cohort study. Appl Ergon 2017;58:208–14. doi:10.1016/
j.apergo.2016.06.012.
[13] Toh SH, Coenen P, Howie EK, Straker LM. The associations of mobile
touch screen device use with musculoskeletal symptoms and exposures:
a systematic review. PLoS ONE 2017;12:e0181220. doi:10.1371/
journal.pone.0181220.
[14] O’Sullivan P, Caneiro JP, O’Keeffe M, O’Sullivan K. Unraveling the
complexity of low back pain. J Orthop Sport Phys Ther 2016;46:932–7.
doi:10.2519/jospt.2016.0609.
[15] Traeger AC, Moynihan R, Maher CG. Wise choices: making
physiotherapy care more valuable. J Physiother 2017;2–4. doi:10.1016/
j.jphys.2017.02.003.
Ney Meziat-Filho, PhDa
Arthur Sá Ferreira, PhDa
Leandro Alberto Calazans Nogueira, PhDb
Felipe José Jandre Reis, PhDc
a
Postgratuate Program in Rehabilitation Sciences, Centro
Universitário Augusto Motta, UNISUAM, Praça das
Nações 34, Bonsucesso, 21041-010, Rio de Janeiro, Brazil
b
Postgraduate Program in Rehabilitation Sciences, Centro
Universitário Augusto Motta, UNISUAM; Instituto
Federal do Rio de Janeiro, Rua Professor Carlos
Wenceslau, Realengo, 21710-240, Rio de Janeiro, Brazil
c
Instituto Federal do Rio de Janeiro, Department of Clini-
cal Medicine, Universidade Federal do Rio de Janeiro, Av
Brigadeiro Trompowsky s/n, andar 11, 21941-590, Ilha do
Fundão, Rio de Janeiro, Brazil