An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy.

Background 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. Objectives (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. Search strategy 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. Selection criteria 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. Data collection and analysis 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. Main results 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. Authors' conclusions 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.

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

Definition: Lumbar disc herniation is a common condition that frequently affects the spine in young and middle-aged patients.1,5,11 The lumbar intervertebral disc is a complex structure composed of collagen, proteoglycans, and sparse fibrochondrocytic cells that serve to dissipate forces exerted on the spine. As part of the normal aging process, the disc fibrochondrocytes can undergo senescence, and proteoglycan production diminishes. This leads to a loss of hydration and disc collapse, which increases strain on the fibers of the annulus fibrosus surrounding the disc. Tears and fissures in the annulus can result, facilitating a herniation of disc material, should sufficient forces be placed on the disc. Alternatively, a large biomechanical force placed on a healthy, normal disc may lead to extrusion of disc material in the setting of catastrophic failure of the annular fibers.5

Regardless of etiology, herniations represent protrusions of disc material beyond the confines of the annular lining and into the spinal canal. Back pain may occur due to disc protrusions that do not enter the canal or compromise nerve roots.5 The more treatable condition of lumbar radiculopathy, however, arises when extruded disc material contacts, or exerts pressure, on the thecal sac or lumbar nerve roots.5,11 The pain associated with lumbar radiculopathy occurs due to a combination of nerve root ischemia and inflammation resulting from local pressure and neurochemical inflammatory factors present within the disc material.5,7,9,11

Incidence: Lumbar disc herniations exist on a continuum of degenerative spinal processes that include intervertebral disc degeneration and lumbar spondylosis.5 Many studies have demonstrated that lumbar herniations, protrusions, and annular tears are present in asymptomatic individuals and, in certain instances, can represent normal aging of the intervertebral disc. The incidence of lumbar disc herniations, albeit asymptomatic, within certain populations has been estimated to be greater than 50%.5 The true incidence of symptomatic lumbar disc herniations, however, has not been satisfactorily characterized due to a lack of consensus regarding what constitutes a symptomatic herniation (ie, back pain alone versus radicular pain versus back pain and radicular pain), as well as a lack of ability to quantify a specific at-risk population. Furthermore, the complete natural history of this disorder is inadequately described, although a variety of anecdotal as well as Level IV–V evidence exists, suggesting that 90% of patients with lumbar disc herniations will resolve their symptoms without substantial medical intervention.5,7

Economics: Disc disorders, back pain, and/or radiculopathy are often grouped together in terms of economic considerations, and a discrete estimation of the effect of symptomatic lumbar disc herniation on the economic system, in terms of days lost to work and reduced productivity, is hard to obtain. Nonetheless, back-related conditions are a common cause of disability, and the US health care system spends over $1 billion annually to redress these disorders. Recently, annual Medicare spending on lumbar discectomy procedures has been estimated to exceed $300 million.

Level of evidence: The evidence presented in this article is largely derived from recent prospective, randomized, controlled trials (RCTs) as well as prospective case-control studies. These include the Spine Patient Outcomes Research Trial (SPORT)19 as well as the Maine Lumbar Spine Study.2–4 Therefore, the evidence presented in this paper can be graded as Level I–II.

Search sources: Sources used in the preparation of this manuscript included PubMed, MedLine, and the Cochrane Library. An advanced search was performed using the PubMed database and key words, including “intervertebral disc herniation”, “lumbar disc herniation”, and “lumbar disc displacement”. The PubMed search revealed 2370 articles that were potential matches. A similar search method on the Cochrane database returned 6153 potential articles, and a like number was obtained with a search using MedLine. Articles with Level I or II evidence were selected for use in the preparation of this article, as well as other publications found to contain pertinent or unique information.

Outcomes: Outcomes considered in the preparation of this manuscript included the relief of radicular pain, resolution of associated motor and sensory deficits, and restoration of preinjury work-related status and level of function.

Consumer summary: Radicular pain in the lower extremities results from the herniation of disc material into the spinal canal and resultant pressure on a nerve root. The constellation of symptoms can include numbness and weakness, but most often consists solely of leg pain that radiates posterolaterally below the knee from nerves L5 and S1 (sciatica); or, less commonly, into the anterior thigh or groin from nerves L2, L3, and L4 (femoralgia). Sensory abnormalities in the genitals, anus, or perineum often coupled with loss of bladder control (cauda equina syndrome), as well as progressive loss of sensation or motor function in the legs, are ominous signs and warrant urgent evaluation and treatment. In situations where leg pain is the primary symptom, conservative management including physical therapy, judicious use of pain medication and epidural steroid injections, as well as surgical intervention (lumbar discectomy) have been shown to be effective.1–9,12–21 Most of the literature supports earlier relief of pain-related symptoms, and possibly earlier restoration of function, in patients who undergo surgery.1–5,8,17,18,20,21 The four-year as treated analysis of the SPORT trial, documented advantages for surgical intervention over conservative management that persist for up to four years following surgery.21 Additionally, if symptoms have already been present for an extended period of time, discectomy may be more likely to relieve symptoms than continued nonoperative management.12 While both conservative and surgical options are shown to be efficacious, the ultimate decision regarding initial and definitive management should be made by the patient based on their desires and individualized requirements, following a frank discussion regarding risks and benefits of the various treatments with their surgeon.7

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Treatment of lumbar disc herniation: Evidence-based practice

Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization. A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR. Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making. This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

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Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

Importance Low back pain (LBP) in children and adolescents is a common problem. The differential diagnosis of LBP in this population is broad and different from that seen in the adult population. Most causes of LBP are musculoskeletal and benign in their clinical course. Clinicians should have an understanding of the relevant anatomy and the most commonly encountered etiologic factors of LBP in children and adolescents to provide effective care. Observations Low back pain is rarely seen in youth before they reach school age. Subsequently, rates of LBP rise until age 18 years, at which age the prevalence of LBP is similar to that in adults. The differential diagnosis of LBP in this population is broad, and individual etiologic factors are most often associated with musculoskeletal overuse or trauma. Sinister etiologic factors are rare. The patient’s history and physical examination are the foundation of evaluating a child with LBP. The indication for and timing of specific imaging or other studies will vary depending on the etiologic factor of concern. Most treatment of LBP in this population is centered on relative rest, rehabilitation, and identification of predisposing risk factors. Pharmacologic treatment may be used but is typically a brief course. Orthopedic, rheumatologic, and other subspecialty referrals may be considered when indicated, but most of these patients can be managed by a general pediatrician with a good understanding of the principles described in this article. Conclusions and Relevance Low back pain in children and adolescents is a common problem. It is most often nonspecific, musculoskeletal, and self-limiting. Pediatricians should recognize the importance of a proper history, physical examination, and general knowledge of the lumbar spine and pelvic anatomy relevant to the child in their evaluation with this presenting symptom.

Musculoskeletal Low Back Pain in School-aged Children: A Review

Background:An accurate and specific diagnosis prevents the re- currences of low back pain and chronic spinal pain. The physical examination is the most useful tool to diagnosis. The examiner must aim to determine the exact tissue that pain arises from to make the specific diagnosis. Lumbar disc herniation is 1 disease that physical examination, symptoms, and findings on imaging technique do not always correlate with each other. The Straight Leg Raising (SLR) test has been used as the primary test to diagnosis lumbar disc herniations and found to have high correlation with findings on operation since its sensitivity is high in only disc herniations leading to root compression that may eventually need operation. More sensitive test, like the Slump, might be used in herniations in which the SLR is negative. The Slump test is really a variant of the SLR and the Lasegue's tests performed in the seated position and is a progressive series of maneuvers designed to place the sciatic nerve roots under increasing tension. At each step in the procedure, the patient informs the examiner what is being felt and whether radic- ular pain is produced. As a result, the Slump test applies traction to the nerve roots by incorporating spinal and hip joint flexion into the leg raising and would warn the examiner of the presence of nerve root compression when there is a negative SLR test. Objectives:This study measured the sensitivity and specificity of the Slump test and compare it with the SLR test in patients with and without lumbar disc herniations. Methods:A prospective case control study of 75 patients with complaints suggestive of lumbar disc herniation was carried out in the outpatient clinics of the neurosurgery department of a state teaching hospital. Seventy-five referred or self-admitted patients with low back, leg, or low back and leg pain who had results of magnetic resonance imaging (MRI) of the lumbar spine were in- cluded in the study. Thirty-eight patients had signs of herniation demonstrated by MRI. Control patients (n!37) had no disc bulges or herniations on MRI. Both the Slump and SLR tests were per- formed during the assessment of all the patients by the second author. The MRI results were assessed and recorded by the first author. Results:The Slump test was found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniations. How- ever, the SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83). Conclusion:The Slump test might be used more frequently as a sensitive physical examination tool in patients with symptoms of lumbar disc herniations. In contrast, owing to its higher specificity, the SLR test may especially help identify patients who have hernia- tions with root compression requiring surgery.

Javid Majlesi

Papers

The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation.