Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review

Abstract

We conducted a systematic review of the literature from 1965-1994 to assess the value of history and physical examination in the diagnosis of sciatica due to disc herniation; we also included population characteristics and features of the study design affecting diagnostic value. Studies on the diagnostic value of history and physical examination in the diagnosis of sciatica due to disc herniation are subject to important biases, and information on numerous signs and symptoms is scarce or absent. Our search revealed 37 studies meeting the selection criteria; these were systematically and independently read by three readers to determine diagnostic test properties using a standard scoring list to determine the methodological quality of the diagnostic information. A meta-analysis was performed when study results allowed statistical pooling. Few studies investigated the value of the history. Pain distribution seemed to be the only useful history item. Of the physical examination signs the straight leg raising test was the only sign consistently reported to be sensitive for sciatica due to disc herniation. However, the sensitivity values varied greatly, the pooled sensitivity and specificity values being 0.85 and 0.52, respectively. The crossed straight leg raising test was the only sign shown to be specific; the pooled sensitivity and specificity values were 0.30 and 0.84, respectively. There was considerable disagreement on the specificity of the other neurological signs (paresis, sensory loss, reflex loss). Several types of bias and other methodological drawbacks were encountered in the studies limiting the validity of the study results. As a result of these drawbacks it is probable that test sensitivity was overestimated and test specificity underestimated.

Mechanisms-based classifications of musculoskeletal pain: Part 2 of 3: Symptoms and signs of peripheral neuropathic pain in patients with low back (±leg) pain

“…Additional clinical evidence supports the SLR test as an indicator of radicular LBP ) and as a diagnostic test for lumbar disc herniation and radiculopathy, and again by extension we assume PNP, in predominantly surgical populations (Devillé et al 2000;Vroomen et al 1999) and its inclusion within the clinical examination of LBP has been similarly recommended (Chou et al 2007).…”

“…During the development and preliminary validation of the painDETECT (Freynhagen et al 2006) 'radiating pain' emerged as an important predictor of PNP. A systematic review evaluating the diagnostic value of the history and physical examination in patients suspected of sciatica secondary to disc herniation, from which we infer the presence if not dominance of PNP, found pain extending below the knee to be the only useful diagnostic item from the clinical history (Vroomen et al 1999). A subsequent study investigating the diagnostic value of the history and physical examination in 274 patients suspected of lumbosacral nerve root compression found further evidence supporting a 'dermatomal distribution' of pain as a predictor of nerve root compression, as determined against a 'gold' standard of magnetic resonance imaging (adjusted DOR 3.2; 95% CI 2.2-4.7) (Vroomen et al 2002).…”

Reliability among clinicians diagnosing low back-related leg pain

“…Despite consensus that a comprehensive clinical assessment is the cornerstones to a sound diagnostic process for LBLP [2,25] inconsistencies are evident in studies when it comes to defining the specific criteria for diagnosing NRI [26]. Although diagnostic accuracy of individual items in clinical assessment of NRI is poor [5,6] clinicians most likely give more weight to certain positive signs when making a confident diagnosis. To improve reliability of this study, fulfilling predefined criteria to make a NRI diagnosis as opposed to giving an overall clinical impression could have been specified.…”

“…Items from history [5] and physical examination [6] in patients with nerve root symptoms due to disc herniation have mostly shown poor individual diagnostic performance. Many of the studies have been carried out in secondary care and have often used magnetic resonance imaging (MRI) as the reference standard [6].…”

Quadriceps muscle rupture mimicking lumbar radiculopathy

“…However, there is no standard diagnostic tool for lumbar spinal stenosis and discrepancies between clinical symptoms and imaging findings are common [8]. A patient's complaints about the pain distribution may be the only meaningful parameter [9,10]. Thus, it is important but difficult to diagnose the ''true clinical stenosis patient.''…”