Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain

Abstract

Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative treatment, but in carefully selected patients, surgical discectomy may provide faster relief of symptoms. Primary care clinicians use patient history and physical examination to evaluate the likelihood of disc herniation and select patients for further imaging and possible surgery. (1) To assess the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica; (2) To assess the influence of sources of heterogeneity on diagnostic performance. We searched electronic databases for primary studies: PubMed (includes MEDLINE), EMBASE, and CINAHL, and (systematic) reviews: PubMed and Medion (all from earliest until 30 April 2008), and checked references of retrieved articles. We considered studies if they compared the results of tests performed during physical examination on patients with back pain with those of diagnostic imaging (MRI, CT, myelography) or findings at surgery. Two review authors assessed the quality of each publication with the QUADAS tool, and extracted details on patient and study design characteristics, index tests and reference standard, and the diagnostic two-by-two table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for all aspects of physical examination. Pooled estimates of sensitivity and specificity were computed for subsets of studies showing sufficient clinical and statistical homogeneity. We included 16 cohort studies (median N = 126, range 71 to 2504) and three case control studies (38 to100 cases). Only one study was carried out in a primary care population. When used in isolation, diagnostic performance of most physical tests (scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits) was poor. Some tests (forward flexion, hyper-extension test, and slump test) performed slightly better, but the number of studies was small. In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings. Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35). Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations. When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined. 腰痛がある患者における椎間板ヘルニアに起因する腰髄神経根障害に対する理学的検査 脚部痛（坐骨神経痛）を伴う腰痛が、神経根圧迫を生じる椎間板脱出により引き起こされることがある。多くの患者で保存療法が奏効するが、外科的椎間板切除術はより迅速な症状の緩和をもたらす可能性がある。プライマリ・ケア医は、椎間板ヘルニアの可能性を評価し、更なる画像診断や場合によっては手術に患者を選択するため、患者病歴や身体的検査を用いる。 （1）腰痛や坐骨神経痛がある患者において診察中に行われる検査（単独または併用）が椎間板ヘルニアによる神経根障害を同定する診断能を評価する。（2）異質性がある情報源が診断能に与える影響を評価する。 PubMed（MEDLINEを含む）、EMBASE、CINAHL、および、（システマティック）レビュー：PubMedおよびMedion（すべて最も初期から2008年4月30日まで）を主要な研究を同定するため電子データベースを検索し、検索した論文の参考文献をチェックした。 腰痛患者に対して診察中に行われた検査の結果を、画像診断（MRI、CT、脊髄造影）の結果や手術時所見と比較した研究を考慮した。 2人のレビューアが、QUADASツールを用いて各々の発表の質を評価し、患者や研究デザイン特性、インデックス検査と参照基準、および、2×2診断表についての詳細を抽出した。身体的検査のすべての面に対する感度と特異度と95％信頼区間（95％CI）に関する情報を提示する。感度と特異度のプールした推定値を、十分な臨床的および統計的同質性を示している研究サブセットに対して計算した。...