Enrique Pena

The Accuracy of the Physical Examination for the Diagnosis of Midlumbar and Low Lumbar Nerve Root Impingement

Study Design. Cross-sectional study with prospective recruitment. Objective. To determine the accuracy of the physical examination for the diagnosis of midlumbar nerve root impingement (L2, L3, or L4), low lumbar nerve root impingement (L5 or S1) and level-specific lumbar nerve root impingement on magnetic resonance imaging, using individual tests and combinations of tests. Summary of Background Data. The sensitivity and specificity of the physical examination for the localization of nerve root impingement has not been previously studied. Methods. Sensitivities, specificities, and likelihood ratios (LRs) were calculated for the ability of individual tests and test combinations to predict the presence or absence of nerve root impingement at midlumbar, low lumbar, and specific nerve root levels. Results. LRs ≥5.0 indicate moderate to large changes from pre-test probability of nerve root impingement to post-test probability. For the diagnosis of midlumbar impingement, the femoral stretch test (FST), crossed FST, medial ankle pinprick sensation, and patellar reflex testing demonstrated LRs ≥5.0 (LR ∞). LRs ≥5.0 were observed with the combinations of FST and either patellar reflex testing (LR 7.0; 95% confidence interval [CI] 2.3–21) or the sit-to-stand test (LR ∞). For the diagnosis of low lumbar impingement, the Achilles reflex test demonstrated an LR ≥5.0 (LR 7.1; 95% CI 0.96–53); test combinations did not increase LRs. For the diagnosis of level-specific impingement, LRs ≥5.0 were observed for anterior thigh sensation at L2 (LR 13; 95% CI 1.8–87); FST at L3 (LR 5.7; 95% CI 2.3–4.4); patellar reflex testing (LR 7.7; 95% CI 1.7–35), medial ankle sensation (LR ∞), or crossed FST (LR 13; 95% CI 1.8–87) at L4; and hip abductor strength at L5 (LR 11; 95% CI 1.3–84). Test combinations increased LRs for level-specific root impingement at the L4 level only. Conclusion. Individual physical examination tests may provide clinical information that substantially alters the likelihood that midlumbar impingement, low lumbar impingement, or level-specific impingement is present. Test combinations improve diagnostic accuracy for midlum-bar impingement.

Quantification of walking ability in subjects with neurogenic claudication from lumbar spinal stenosis—a comparative study

BACKGROUND CONTEXT Walking limitations caused by neurogenic claudication (NC) are typically assessed with self-reported measures, although objective evaluation of walking using motorized treadmill test (MTT) or self-paced walking test (SPWT) has periodically appeared in the lumbar spinal stenosis (LSS) literature. PURPOSE This study compared the validity and responsiveness of MTT and SPWT for assessing walking ability before and after common treatments for NC. STUDY DESIGN Prospective observational cohort study. PATIENT SAMPLE Fifty adults were recruited from an urban spine center if they had LSS and substantial walking limitations from NC and were scheduled to undergo surgery (20%) or conservative treatment (80%). OUTCOME MEASURES Walking times, distances, and speeds along with the characteristics of NC symptoms were recorded for MTT and SPWT. Self-reported measures included back and leg pain intensity assessed with 0 to 10 numeric pain scales, disability assessed with Oswestry Disability Index, walking ability assessed with estimated walking times and distances, and NC symptoms assessed with the subscales from the Spinal Stenosis Questionnaires. METHODS Motorized treadmill test used a level track, and SPWT was conducted in a rectangular hallway. Walking speeds were self-selected, and test end points were NC, fatigue, or completion of the 30-minute test protocol. Results from MTT and SPWT were compared with each other and self-reported measures. Internal responsiveness was assessed by comparing changes in the initial results with the posttreatment results and external responsiveness by comparing walking test results that improved with those that did not improve by self-reported criteria. RESULTS Mean age of the participants was 68 years, and 58% were male. Neurogenic claudication included leg pain (88%) and buttock(s) pain (12%). Five participants could not safely perform MTT. Walking speeds were faster and distances were greater with SPWT, although the results from both tests correlated with each other and self-reported measures. Of the participants, 72% reported improvement after treatment, which was confirmed by significant mean differences in self-reported measures. Motorized treadmill test results did not demonstrate internal responsiveness to change in clinical status after treatment but SPWT results did, with increased mean walking times (6 minutes) and distances (387 m). When responsiveness was assessed against external criterion, both SPWT and MTT demonstrated substantial divergence with self-reported changes in clinical status and alternative outcome measures. CONCLUSIONS Both MTT and SPWT can quantify walking abilities in NC. As outcome tools, SPWT demonstrated better internal responsiveness than MTT, but neither test demonstrated adequate external responsiveness. Neither test should be considered as a meaningful substitution for disease-specific measures of function.

Nonsurgical Treatment of Lumbar Disk Herniation: Are Outcomes Different in Older Adults?

OBJECTIVES: To determine whether older adults (aged ≥60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60).

Inciting events associated with lumbar disc herniation.

BACKGROUND CONTEXT No prior study has investigated the frequency of patient-identified inciting events in lumbar disc herniation (LDH) or their clinical significance. PURPOSE To examine the clinical frequency of patient-identified inciting events in LDH, and to identify associations between the presence of inciting events and the severity of the clinical presentation. STUDY DESIGN/SETTING Cross-sectional analysis of data from a cohort study with prospective recruitment, with retrospective data collection on inciting events. The setting was a hospital-based specialty spine clinic. PATIENT SAMPLE One hundred fifty-four adults with lumbosacral radicular pain and LDH confirmed by magnetic resonance imaging. OUTCOME MEASURES Self-report measures of disability measured by the Oswestry Disability Index (ODI), the visual analog scale (VAS) for leg pain, and the VAS for back pain. METHODS Dependent variables included the presence of a patient-identified inciting event, which were categorized as spontaneous onset, nonlifting physical activity, heavy lifting (>35 lbs), light lifting (<35 lbs), nonexertional occurrence, or physical trauma. We examined the association of an inciting event, or a lifting-related event, with each outcome, first using univariate analyses, and second using multivariate modeling, accounting for important adjustment variables. RESULTS Sixty-two percent of LDH did not have a specific patient-identified event associated with onset of symptoms. Nonlifting activities were the most common inciting event, comprising 26% of all LDH. Heavy lifting (6.5%), light lifting (2%), nonexertional occurrences (2%), and physical trauma (1.3%) accounted for relatively small proportions of all LDH. Patient-identified inciting events were not significantly associated with a more severe clinical presentation in crude analyses. Spontaneous LDH was significantly associated with higher baseline ODI scores in multivariate analysis, although the magnitude of this effect was small. There were no significant associations (p< or =.05) between the presence of a lifting-associated event and the outcomes of ODI, VAS leg pain, or VAS back pain. CONCLUSIONS The majority of LDH occurred without specific inciting events. A history of an inciting event was not significantly associated with a more severe clinical presentation. There was no significant association between the occurrence of a lifting-related event and the severity of the clinical presentation. This information may be useful in the counseling of patients recovering from acute LDH.

Exploration of sensory impairments associated with C6 and C7 radiculopathies

BACKGROUND CONTEXT Cervical radiculopathy is a common disorder caused by compression of the cervical nerve roots and is characterized by arm pain and altered sensory-motor function. Incongruity in the locations of C6 and C7 dermatomes in competing versions of historical dermatome maps has plagued interpretation of impaired sensation associated with C6 and C7 radiculopathies. Magnetic resonance imaging (MRI) allows accurate identification of the C6 or C7 nerve root compression and therefore makes it possible to explore sensory findings that are associated with compression of specific nerve root. PURPOSE This study compared the locations of impaired sensation in subjects with cervical radiculopathy from MRI-confirmed C6 and C7 nerve root compression. STUDY DESIGN Case series was used for this study. PATIENT SAMPLE A total of 122 subjects with symptoms suggestive of cervical radiculopathy were recruited by 11 spine specialist from 5 practice locations. Of these, 30 subjects had MRI-confirmed C6 and 40 subjects C7 radiculopathy. OUTCOME MEASURES Standardized pinprick sensory examination of the forearm and hand of every subject was performed, and the locations of sensory impairments were recorded. METHODS Sensory examination was performed before reviewing MRI results or performing motor or reflex examination. Areas of impaired sensation were recorded on drawings of the palmar and dorsal forearm and hand, and translated using a grid into 36 specific areas for analysis. Chi-square was used to compare frequencies of findings for each grid area for C6 and C7 radiculopathies. Power analysis suggested that a minimum of 27 subjects in each group were needed to detect a 30 percentage point difference in frequency of sensory impairments. Significance was set at ≤.05. RESULTS Approximately 80% of subjects had impaired sensation in at least 1 grid area, most often in the distal forearm and hand, and many had findings in multiple areas. There was nearly complete overlap for locations of impaired sensation for C6 and C7 radiculopathy, and the frequencies of impaired sensation differed only in the dorsal aspect of the distal radial forearm where it was twice as common in C6 radiculopathy (p=.02). CONCLUSIONS The location of sensory impairments associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting compression of either the C6 or C7 nerve roots based on locations of impaired sensation. Impaired sensation in the radial aspect of the distal forearm is more common in C6 radiculopathies.

Nonsurgical Treatment of Lumbar Disk Herniation: Are Outcomes Different in Older Adults?: LUMBAR DISK HERNIATION IN OLDER ADULTS

OBJECTIVES: To determine whether older adults (aged ≥60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60).

Nonsurgical treatment of lumbar disk herniation

OBJECTIVES: To determine whether older adults (aged ≥60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60).