Accuracy of clinical neurological examination in diagnosing lumbo-sacral radiculopathy: a systematic literature review

Abstract

BackgroundLumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate treatment of patients resulting in poor health outcomes, exacerbating this already debilitating condition. This review evaluated 12 primary diagnostic accuracy studies that specifically assessed the performance of various individual and grouped clinical neurological tests in detecting nerve root impingement, as established in the current literature.MethodsEight electronic data bases were searched for relevant articles from inception until July 2016. All primary diagnostic studies which investigated the accuracy of clinical neurological test (s) in diagnosing lumbar radiculopathy among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the ‘Quality Assessment of Diagnostic tests Accuracy Studies’ criteria.ResultsA total of 12 studies which investigated standard components of clinical neurological examination of (sensory, motor, tendon reflex and neuro-dynamics) of the lumbo-sacral spine were included. The mean inter-observer agreement on quality assessment by two independent reviewers was fair (k = 0.3 – 0.7).The diagnostic performance of sensory testing using MR imaging as a reference standard demonstrated a sensitivity (confidence interval 95%) 0.61 (0.47-0.73) and a specificity of 0.63 (0.38-0.84). Motor tests sensitivity was poor to moderate, ranging from 0.13 (0.04-0.31) to 0.61 (0.36-0.83). Generally, the diagnostic performance of reflex testing was notably good with specificity ranging from (confidence interval 95%) 0.60 (0.51-0.69) to 0.93 (0.87-0.97) and sensitivity ranging from 0.14 (0.09-0.21) to 0.67 (0.21-0.94). Femoral nerve stretch test had a high sensitivity of (confidence interval 95%) 1.00 (0.40-1.00) and specificity of 0.83 (0.52-0.98) while SLR test recorded a mean sensitivity of 0.84 (0.72-0.92) and specificity of 0.78 (0.67-0.87).ConclusionsThere is a scarcity of studies on the diagnostic accuracy of clinical neurological examination testing. Furthermore there seem to be a disconnect among researchers regarding the diagnostic utility of lower limb neuro-dynamic tests which include the Straight Leg Raise and Femoral Nerve tests for sciatic and femoral nerve respectively. Whether these tests are able to detect the presence of disc herniation and subsequent nerve root compression or hyper-sensitivity of the sacral and femoral plexus due to mechanical irritation still remains debatable.

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations

“…The search process is summarized in Figure 2. Table 1 13,15,[22][23][24][25][26][27][28][29] displays the systematic reviews included in this review, including the diagnostic foci and quality ratings. Ten reviews met initial eligibility criteria; 2 were deemed unacceptable quality, leaving 8 included reviews.…”

The association between pelvic asymmetry and non-specific chronic low back pain as assessed by the global postural system

“…Participants were recruited from the staff and student populations of Sun Yat-sen University. The inclusion criteria for the NCLBP group were as follows: 1) age between 18 and 30; 2) diagnosis of NCLBP lasting more than 3 months; 3) pain score greater than 2 on the numerical rating scale (NRS) in both static (i.e., lying, sitting, or standing) and dynamic situations (i.e., moving or walking) was defined as the presence of LBP; 4) no referred symptoms of radiating pain below the knee, or paresthesia during straight-leg raise test [26]; and 5) no radiographic evidence of congenital anomalies of the lumbosacral region. The exclusion criteria for the NCLBP group were as follows: 1) presence of scoliosis as assessed by the Adam's forward bend test [27]; 2) history of fracture or surgery in the pelvic or spinal area; 3) history of a neurological disorder or on regular medications; 4) Montreal cognitive assessment (MoCA) score of < 26;and 5) pregnancy.…”

The association between pelvic asymmetry and non-specific chronic low back pain as assessed by the Global Postural System.

“…Participants were recruited from the staff and student populations of Sun Yat-sen University. The inclusion criteria for the NCLBP group were as follows: 1) age between 18 and 30; 2) diagnosis of NCLBP lasting more than 3 months; 3) pain score greater than 2 on the numerical rating scale (NRS) in both static (i.e., lying, sitting, or standing) and dynamic situations (i.e., moving or walking) was de ned as the presence of LBP; 4) no referral symptoms of radiating pain below the knee, or paresthesia sensation during straight-leg raise test (26); and 5) no radiographic evidence of congenital anomalies of the lumbosacral region. The exclusion criteria for the NCLBP group were as follows: 1) presence of scoliosis as assessed by the Adam's forward bend test (27) ; 2) history of fracture or surgery in the pelvic or spinal area;…”