Abstract
Background context
Disc herniation is a common low back pain (LBP) disorder, and several clinical test
procedures are routinely employed in its diagnosis. The neurological examination that
assesses sensory neuron and motor responses has historically played a role in the
differential diagnosis of disc herniation, particularly when radiculopathy is suspected;
however, the diagnostic ability of this examination has not been explicitly investigated.
Purpose
To review the scientific literature to evaluate the diagnostic accuracy of the neurological
examination to detect lumbar disc herniation with suspected radiculopathy.
Study design
A systematic review and meta-analysis of the literature.
Methods
Six major electronic databases were searched with no date or language restrictions
for relevant articles up until March 2011. All diagnostic studies investigating neurological
impairments in LBP patients because of lumbar disc herniation were assessed for possible
inclusion. Retrieved studies were individually evaluated and assessed for quality
using the Quality Assessment of Diagnostic Accuracy Studies tool, and where appropriate,
a meta-analysis was performed.
Results
A total of 14 studies that investigated three standard neurological examination components,
sensory, motor, and reflexes, met the study criteria and were included. Eight distinct
meta-analyses were performed that compared the findings of the neurological examination
with the reference standard results from surgery, radiology (magnetic resonance imaging,
computed tomography, and myelography), and radiological findings at specific lumbar
levels of disc herniation. Pooled data for sensory testing demonstrated low diagnostic
sensitivity for surgically (0.40) and radiologically (0.32) confirmed disc herniation,
and identification of a specific level of disc herniation (0.35), with moderate specificity
achieved for all the three reference standards (0.59, 0.72, and 0.64, respectively).
Motor testing for paresis demonstrated similarly low pooled diagnostic sensitivities
(0.22 and 0.40) and moderate specificity values (0.79 and 0.62) for surgically and
radiologically determined disc herniation, whereas motor testing for muscle atrophy
resulted in a pooled sensitivity of 0.31 and the specificity was 0.76 for surgically
determined disc herniation. For reflex testing, the pooled sensitivities for surgically
and radiologically confirmed levels of disc herniation were 0.29 and 0.25, whereas
the specificity values were 0.78 and 0.75, respectively. The pooled positive likelihood
ratios for all neurological examination components ranged between 1.02 and 1.26.
Conclusions
This systematic review and meta-analysis demonstrate that neurological testing procedures
have limited overall diagnostic accuracy in detecting disc herniation with suspected
radiculopathy. Pooled diagnostic accuracy values of the tests were poor, whereby all
tests demonstrated low sensitivity, moderate specificity, and limited diagnostic accuracy
independent of the disc herniation reference standard or the specific level of herniation.
The lack of a standardized classification criterion for disc herniation, the variable
psychometric properties of the testing procedures, and the complex pathoetiology of
lumbar disc herniation with radiculopathy are suggested as possible reasons for these
findings.
Keywords
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Article info
Publication history
Published online: March 18, 2013
Accepted:
February 8,
2013
Received in revised form:
May 9,
2012
Received:
August 23,
2011
Footnotes
FDA device/drug status: Not applicable.
Author disclosures: NHAN: Nothing to disclose. AGS: Nothing to disclose. PAH: Nothing to disclose.
Institutional Review Board Approval—not applicable.
Identification
Copyright
© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
