Review Article| Volume 13, ISSUE 6, P657-674, June 2013

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Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review and meta-analysis


      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.


      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.


      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.


      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.


      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.


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        • Adams M.A.
        Biomechanics of back pain.
        Acupunct Med. 2004; 22: 178-188
        • Deyo R.A.
        Early diagnostic evaluation of low back pain.
        J Gen Intern Med. 1986; 1: 328-338
        • Shahbandar L.
        • Press J.
        Diagnosis and nonoperative management of lumbar disk herniation.
        Oper Tech Sports Med. 2005; 13: 114-121
        • Battié M.C.
        • Videman T.
        • Parent E.
        Lumbar disc degeneration: epidemiology and genetic influences.
        Spine. 2004; 29: 2679-2690
        • Boden S.D.
        • Davis D.O.
        • Dina T.S.
        • et al.
        Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.
        J Bone Joint Surg Am. 1990; 72: 403-408
        • Cheung K.M.C.
        • Karppinen J.
        • Chan D.
        • et al.
        Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals.
        Spine. 2009; 34: 934-940
        • Karamouzian S.
        • Eskandary H.
        • Faramarzee M.
        • et al.
        Frequency of lumbar intervertebral disc calcification and angiogenesis, and their correlation with clinical, surgical, and magnetic resonance imaging findings.
        Spine. 2010; 35: 881-886
        • Weber H.
        The natural history of disc herniation and the influence of intervention.
        Spine. 1994; 19: 2234-2238
        • Sembrano J.N.
        • Polly D.W.
        How often is low back pain not coming from the back?.
        Spine. 2009; 34: E27-E32
        • Miyoshi S.
        • Sekiguchi M.
        • Konno S.I.
        • et al.
        Increased expression of vascular endothelial growth factor protein in dorsal root ganglion exposed to nucleus pulposus on the nerve root in rats.
        Spine. 2011; 36: E1-E6
        • McCarron R.F.
        • Wimpee M.W.
        • Hudkins P.G.
        • Laros G.S.
        The inflammatory effect of nucleus pulposus. A possible element in the pathogenesis of low-back pain.
        Spine. 1987; 12: 760-764
      1. Merskey H. Bogduk N. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. IASP Press, Seattle, WA1994
        • Murphy D.R.
        • Hurwitz E.L.
        • Gerrard J.K.
        • Clary R.
        Pain patterns and descriptions in patients with radicular pain: does the pain necessarily follow a specific dermatome?.
        Chiropr Osteopat. 2009; 17: 9
        • Jarvik J.G.
        • Deyo R.A.
        Diagnostic evaluation of low back pain with emphasis on imaging.
        Ann Intern Med. 2002; 137: 586-597
        • Gurdjian E.S.
        • Webster J.E.
        • Ostrowski A.Z.
        • et al.
        Herniated lumbar intervertebral discs—an analysis of 1176 operated cases.
        J Trauma. 1961; 1: 158-176
        • Hakelius A.
        • Hindmarsh J.
        The comparative reliability of preoperative diagnostic methods in lumbar disc surgery.
        Acta Orthop Scand. 1972; 43: 234-238
        • Van Der Windt D.A.W.M.
        • Simons E.
        • Riphagen I.
        • et al.
        Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain.
        Cochrane Database Syst Rev. 2010; 2: CD007431
        • Humphreys S.C.
        • Eck J.C.
        • Tennessee C.
        Clinical evaluation and treatment options for herniated lumbar disc.
        Am Fam Physician. 1999; 59: 575-582
        • Knutsson B.
        Electromyographic studies in the diagnosis of lumbar disc herniations.
        Acta Orthop Scand. 1959; 28: 290-299
        • Weise M.D.
        • Garfin S.R.
        • Gelberman R.H.
        Lower-extremity sensibility testing in patients with herniated lumbar intervertebral discs.
        J Bone Joint Surg Am. 1985; 67: 1219-1224
        • Medical Research Council Grading System
        Aids to the investigation of peripheral nerve injuries.
        HMSO, London1976
        • Cook C.
        Orthopedic manual therapy. An evidence based approach.
        Pearson/Prentice Hall, Upper Saddle River, New Jersey2007
        • McCarthy C.J.
        • Gittins M.
        • Roberts C.
        • Oldham J.A.
        The reliability of the clinical tests and questions recommended in international guidelines for low back pain.
        Spine. 2007; 32: 921-926
        • Vroomen P.C.A.J.
        • De Krom M.C.T.F.M.
        • Knottnerus J.A.
        Consistency of history taking and physical examination in patients with suspected lumbar nerve root involvement.
        Spine. 2000; 25: 91-97
        • Deyo R.A.
        • Rainville J.
        • Kent D.L.
        What can the history and physical examination tell us about low back pain?.
        JAMA. 1992; 268: 760-765
        • Rubinstein S.M.
        • van Tulder M.
        A best-evidence review of diagnostic procedures for neck and low-back pain.
        Best Pract Res Clin Rheumatol. 2008; 22: 471-482
        • Van den Hoogen H.M.M.
        • Koes B.W.
        • Van Eijk J.T.M.
        • et al.
        On the accuracy of history, physical examination, and erythrocyte sedimentation rate in diagnosing low back pain in general practice: a criteria-based review of the literature.
        Spine. 1995; 20: 318-327
        • Vroomen P.C.A.J.
        • De Krom M.C.T.F.M.
        • Knottnerus J.A.
        Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review.
        J Neurol. 1999; 246: 899-906
        • Greenhalgh T.
        How to read a paper. Papers that report diagnostic or screening tests.
        Br Med J. 1997; 315: 540-543
        • Whiting P.
        • Rutjes A.W.S.
        • Reitsma J.B.
        • et al.
        The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.
        BMC Med Res Methodol. 2003; 3: 1-13
        • Whiting P.
        • Harbord R.
        • Kleijnen J.
        No role for quality scores in systematic reviews of diagnostic accuracy studies.
        BMC Med Res Methodol. 2005; 5: 19
        • Irwig L.
        • Tosteson A.N.A.
        • Gatsonis C.
        • et al.
        Guidelines for meta-analyses evaluating diagnostic tests.
        Ann Intern Med. 1994; 120: 667-676
        • Zamora J.
        • Abraira V.
        • Muriel A.
        • et al.
        Meta-DiSc: a software for meta-analysis of test accuracy data.
        BMC Med Res Methodol. 2006; 6: 31
        • Albeck M.J.
        A critical assessment of clinical diagnosis of disc herniation in patients with monoradicular sciatica.
        Acta Neurochir (Wien). 1996; 138: 40-44
        • Bertilson B.C.
        • Brosjö E.
        • Billing H.
        • Strender L.E.
        Assessment of nerve involvement in the lumbar spine: agreement between magnetic resonance imaging, physical examination and pain drawing findings.
        BMC Musculoskelet Disord. 2010; 11: 202
        • Hakelius A.
        • Hindmarsh J.
        The significance of neurological signs and myelographic findings in the diagnosis of lumbar root compression.
        Acta Orthop Scand. 1972; 43: 239-246
        • Hancock M.J.
        • Koes B.
        • Ostelo R.
        • Peul W.
        Diagnostic accuracy of the clinical examination in identifying the level of herniation in patients with sciatica.
        Spine. 2011; 36: E712-E719
        • Kerr R.S.C.
        • Cadoux-Hudson T.A.
        • Adams C.B.T.
        The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion.
        J Neurol Neurosurg Psychiatry. 1988; 51: 169-173
        • Knutsson B.
        Comparative value of electromyographic, myelographic and clinical-neurological examinations in diagnosis of lumbar root compression syndrome.
        Acta Orthop Scand Suppl. 1961; 49: 1-135
        • Kosteljanetz M.
        • Espersen J.O.
        • Halaburt H.
        • Miletic T.
        Predictive value of clinical and surgical findings in patients with lumbago-sciatica. A prospective study (Part I).
        Acta Neurochir (Wien). 1984; 73: 67-76
        • Spangfort E.V.
        The lumbar disc herniation. A computer-aided analysis of 2,504 operations.
        Acta Orthop Scand Suppl. 1972; 142: 1-95
        • Stankovic R.
        • Johnell O.
        • Maly P.
        • Willner S.
        Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus. A prospective clinical study.
        Man Ther. 1999; 4: 25-32
        • Suri P.
        • Rainville J.
        • Katz J.N.
        • et al.
        The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement.
        Spine. 2011; 36: 63-73
        • Vroomen P.C.A.J.
        • De Krom M.C.T.F.M.
        • Wilmink J.T.
        • et al.
        Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression.
        J Neurol Neurosurg Psychiatry. 2002; 72: 630-634
        • Vucetic N.
        • Svensson O.
        Physical signs in lumbar disc hernia.
        Clin Orthop Relat Res. 1996; 333: 192-201
        • Jaeschke R.
        • Guyatt G.
        • Sackett D.L.
        Users' guides to the medical literature: III. How to use an article about a diagnostic test. A. Are the results of the study valid?.
        JAMA. 1994; 271: 389-391
        • Haig A.J.
        The need versus the choice for treatment of spinal disorders: does our science help us to differentiate?.
        Spine J. 2006; 6: 355-356
        • Davidson M.
        The interpretation of diagnostic tests: a primer for physiotherapists.
        Aust J Physiother. 2002; 48: 227-232
        • Fardon D.F.
        • Milette P.C.
        Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined Task Forces of the North American spine Society, American Society of Spine Radiology, and American Society of Neuroradiology.
        Spine. 2001; 26: E93-E113
        • Mysliwiec L.W.
        • Cholewicki J.
        • Winkelpleck M.D.
        • Eis G.P.
        MSU classification for herniated lumbar discs on MRI: toward developing objective criteria for surgical selection.
        Eur Spine J. 2010; 19: 1087-1093
        • Valat J.P.
        • Genevay S.
        • Marty M.
        • et al.
        Best Pract Res Clin Rheumatol. 2010; 24: 241-252
        • Bogduk N.
        On the definitions and physiology of back pain, referred pain, and radicular pain.
        Pain. 2009; 147: 17-19
        • Schäfer A.
        • Hall T.
        • Briffa K.
        Classification of low back-related leg pain—a proposed patho-mechanism-based approach.
        Man Ther. 2009; 14: 222-230
        • Foerster O.
        The dermatomes in man.
        Brain. 1933; 56: 1-39
        • Marzo J.M.
        • Simmons E.H.
        • Kallen F.
        Intradural connections between adjacent cervical spinal roots.
        Spine. 1987; 12: 964-968
        • Lauder T.D.
        • Dillingham T.R.
        • Andary M.
        • et al.
        Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy.
        Am J Phys Med Rehabil. 2000; 79: 60-68
        • De Luigi A.J.
        • Fitzpatrick K.F.
        Physical examination in radiculopathy.
        Phys Med Rehabil Clin N Am. 2011; 22: 7-40
        • Levin K.H.
        Electrodiagnostic approach to the patient with suspected radiculopathy.
        Neurol Clin. 2002; 20: 397-421
        • Freynhagen R.
        • Rolke R.
        • Baron R.
        • et al.
        Pseudoradicular and radicular low-back pain—a disease continuum rather than different entities? Answers from quantitative sensory testing.
        Pain. 2008; 135: 65-74
        • Dworkin R.H.
        • Backonja M.
        • Rowbotham M.C.
        • et al.
        Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations.
        Arch Neurol. 2003; 60: 1524-1534
        • Finnerup N.B.
        • Otto M.
        • McQuay H.J.
        • et al.
        Algorithm for neuropathic pain treatment: an evidence based proposal.
        Pain. 2005; 118: 289-305
        • Plastaras C.T.
        • Joshi A.B.
        The electrodiagnostic evaluation of radiculopathy.
        Phys Med Rehabil Clin N Am. 2011; 22: 59-74
        • Rubinstein S.M.
        • Pool J.J.M.
        • Van Tulder M.W.
        • et al.
        A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.
        Eur Spine J. 2007; 16: 307-319
        • Arendt-Nielsen L.
        • Graven-Nielsen T.
        • Svarrer H.
        • Svensson P.
        The influence of low back pain on muscle activity and coordination during gait: a clinical and experimental study.
        Pain. 1996; 64: 231-240
        • Lafond D.
        • Champagne A.
        • Descarreaux M.
        • et al.
        Postural control during prolonged standing in persons with chronic low back pain.
        Gait Posture. 2009; 29: 421-427
        • Popa T.
        • Bonifazi M.
        • Della Volpe R.
        • et al.
        Adaptive changes in postural strategy selection in chronic low back pain.
        Exp Brain Res. 2007; 177: 411-418
        • Bousema E.J.
        • Verbunt J.A.
        • Seelen H.A.M.
        • et al.
        Disuse and physical deconditioning in the first year after the onset of back pain.
        Pain. 2007; 130: 279-286
        • Duque I.
        • Parra J.H.
        • Duvallet A.
        Physical deconditioning in chronic low back pain.
        J Rehabil Med. 2009; 41: 262-266
        • Smeets R.J.E.M.
        • Wade D.
        • Hidding A.
        • et al.
        The association of physical deconditioning and chronic low back pain: a hypothesis-oriented systematic review.
        Disabil Rehabil. 2006; 28: 673-693
        • Haneline M.
        • Cooperstein R.
        Weighing the reliability and validity of clinical tests.
        J Amer Chiropr Assoc. 2006; 43: 19-22
        • Bertilson B.C.
        • Bring J.
        • Sjöblom A.
        • et al.
        Inter-examiner reliability in the assessment of low back pain (LBP) using the Kirkaldy-Willis classification (KWC).
        Eur Spine J. 2006; 15: 1695-1703
        • Lurie J.D.
        • Doman D.M.
        • Spratt K.F.
        • et al.
        Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations: comparison of clinician and radiologist readings.
        Spine. 2009; 34: 701-705