Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back related leg pain: a systematic review and narrative synthesis

Abstract

Background: Low back-related leg pain (LBLP) is a challenge for healthcare providers to manage. Neuropathic pain (NP) is highly prevalent in presentations of LBLP and an accurate diagnosis of NP in LBLP is essential to ensure appropriate intervention. In the absence of a gold standard, the objective of this systematic review was to evaluate the diagnostic utility of patient history, clinical examination and screening tool data for identifying NP in LBLP. Methods: This systematic review is reported in line with PRISMA and followed a pre-defined and published protocol. CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro and PubMed databases, key journals and the grey literature were searched from inception to 31 July 2019. Eligible studies included any study design reporting primary diagnostic data on the diagnostic utility of patient history, clinical examination or screening tool data to identify NP in LBLP, in an adult population. Two independent reviewers searched information sources, assessed risk of bias (QUADAS-2) and used GRADE to assess overall quality of evidence. Results: From 762 studies, 11 studies were included. Nine studies out of the 11 were at risk of bias. Moderate level evidence supports a cluster of eight signs (age, duration of disease, paroxysmal pain, pain worse in leg than back, typical dermatomal distribution, worse on coughing/sneezing/straining, finger to floor distance and paresis) for diagnosing lumbosacral nerve root compression, demonstrating moderate/high sensitivity (72%) and specificity (80%) values. Moderate level evidence supports the use of the StEP tool for diagnosing lumbar radicular pain, demonstrating high sensitivity (92%) and specificity (97%) values.

Clinical indicators to identify neuropathic pain in low back related leg pain: A modified Delphi study

“…The use of pain descriptors and descriptors of dysesthesia are commonly used in NP screening tools; such as the Leeds Assessment of Neuropathic Symptoms and Signs (LANS S) [30], PainDETECT [31] and the StEP tool [32]. Despite being a key feature of many screening tools, evidence supporting the use of pain/dysesthesia descriptors in identifying NP in low back related leg pain is limited [17]. There is moderate level evidence to support the use of the StEP tool, which encompasses the aforementioned descriptors, in diagnosing lumbar radicular pain, demonstrating high sensitivity (92%) and specificity (97%) values [17].…”

“…Furthermore, the list has been generated through a similar designed study and therefore easily compared to the current study. Specific screening tools were not used as there is no consensus regarding superiority of one over the other, and furthermore none are validated in identifying NP in low back related leg pain [17]. The 2016 NeuPSIG recommendations for diagnosing NP were not used in this study.…”

“…Despite the vast interest surrounding NP there is no accepted gold standard for diagnosing NP in low back related leg pain [16]. Our recent systematic review investigated the diagnostic utility of clinical indicators to identify NP in low back related leg pain [17], finding a lack of uniformity across included studies for reference standards and terminology relating to NP in low back related leg pain. The review's conclusion was a need for consensus regarding a reference standard to enable evaluation of diagnostic utility of clinical indicators for NP in low back related leg pain.…”

“…The clinical classification accuracy of these indicators were investigated in low back pain patients with and without leg pain [22], finding that a cluster of two symptoms and one sign demonstrated a high level of classification accuracy. However, this study has been highlighted as being at risk of bias, due to clinicians not being blinded to the results of the reference standard before conducting the index test, therefore the results must be observed with caution [17]. Smart et al's original list of clinical indicators to identify NP in musculoskeletal pain serves as a useful starting point, however an update of this list is required.…”

Axially Loaded Magnetic Resonance Imaging Identification of the Factors Associated with Low Back-Related Leg Pain

“…Low back-related leg pain (LBLP) refers to neuropathic pain when the lower back nerves are compromised and is often manifested by sciatic or lumbar radicular pain [1]. LBLP may not be neuropathic and can manifest as a result of non-neuronal structure involvement (e.g., the muscles, ligaments, and disc) in the lumbar spine.…”