Patrick C.A.J. Vroomen

Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression

Objective: To evaluate patient characteristics, symptoms, and examination findings in the clinical diagnosis of lumbosacral nerve root compression causing sciatica. Methods: The study involved 274 patients with pain radiating into the leg. All had a standardised clinical assessment and magnetic resonance (MR) imaging. The associations between patient characteristics, clinical findings, and lumbosacral nerve root compression on MR imaging were analysed. Results: Nerve root compression was associated with three patient characteristics, three symptoms, and four physical examination findings (paresis, absence of tendon reflexes, a positive straight leg raising test, and increased finger-floor distance). Multivariate analysis, analysing the independent diagnostic value of the tests, showed that nerve root compression was predicted by two patient characteristics, four symptoms, and two signs (increased finger-floor distance and paresis). The straight leg raise test was not predictive. The area under the curve of the receiver-operating characteristic was 0.80 for the history items. It increased to 0.83 when the physical examination items were added. Conclusions: Various clinical findings were found to be associated with nerve root compression on MR imaging. While this set of findings agrees well with those commonly used in daily practice, the tests tended to have lower sensitivity and specificity than previously reported. Stepwise multivariate analysis showed that most of the diagnostic information revealed by physical examination findings had already been revealed by the history items.

Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review.

Abstract We conducted a systematic review of the literature from 1965–1994 to assess the value of history and physical examination in the diagnosis of sciatica due to disc herniation; we also included population characteristics and features of the study design affecting diagnostic value. Studies on the diagnostic value of history and physical examination in the diagnosis of sciatica due to disc herniation are subject to important biases, and information on numerous signs and symptoms is scarce or absent. Our search revealed 37 studies meeting the selection criteria; these were systematically and independently read by three readers to determine diagnostic test properties using a standard scoring list to determine the methodological quality of the diagnostic information. A meta-analysis was performed when study results allowed statistical pooling. Few studies investigated the value of the history. Pain distribution seemed to be the only useful history item. Of the physical examination signs the straight leg raising test was the only sign consistently reported to be sensitive for sciatica due to disc herniation. However, the sensitivity values varied greatly, the pooled sensitivity and specificity values being 0.85 and 0.52, respectively. The crossed straight leg raising test was the only sign shown to be specific; the pooled sensitivity and specificity values were 0.30 and 0.84, respectively. There was considerable disagreement on the specificity of the other neurological signs (paresis, sensory loss, reflex loss). Several types of bias and other methodological drawbacks were encountered in the studies limiting the validity of the study results. As a result of these drawbacks it is probable that test sensitivity was overestimated and test specificity underestimated.

Consistency of history taking and physical examination in patients with suspected lumbar nerve root involvement

Study Design. A cross-sectional study of interobserver variability in primary care patients. Objective. To investigate the consistency of signs and symptoms of nerve root compression in primary care patients with pain irradiating pain into the leg (sciatica). Summary of Background Data. The literature does not report on all the clinical tests for nerve root compression. In previous studies, most patients had low back pain with no irradiation. Often, little information on examination technique, proportion of positive test results, or clinical patient characteristics was provided. Methods. A random selection of 91 patients was investigated by a neurologist-resident couple. Agreement percentages, proportions of positive test results, and kappas were calculated. Results. The kappa of the overall conclusion after the history taking was 0.40, increasing to 0.66 after physical examination. Kappas were good for decreased muscle strength and sensory loss (0.57–0.82), intermediate for reflex changes (0.42–0.53), and poor for the examination of the lumbar spine (0.16–0.33). The straight leg raising, crossed straight leg raising, Bragard’s sign, and Naffziger’s sign were the most consistent nerve root tension signs (> 0.66). Conclusions. Two clinicians disagreed on the presence of nerve root involvement in one of four patients after history taking, and in one of five patients after physical examination. For a more consistent overall diagnosis, the physician probably should put more emphasis on the history of pain on coughing–straining–sneezing, a feeling of coldness in the legs, and urinary incontinence. The investigation of paresis, sensory loss, reflex changes, straight leg raising, and Bragard’s sign provide the most consistent results.

When does the patient with a disc herniation undergo lumbosacral discectomy

OBJECTIVES To design a model that could accurately predict eventual lumbar disc surgery in the patient initially presenting with clinical findings of nerve root compression. METHODS Prospective study in 183 patients with nerve root compression sampled from a primary care population. All patients underwent a standardised history, physical examination, and MRI. Surgery carried out in the next 6 months was recorded. Models were constructed to predict whether patients eventually received surgery. RESULTS Two models were constructed. Reduced model A was based on baseline findings, only, and contained six variables. Model B incorporated change over time as well and contained 10 variables. The area under the curve (in a receiver operating characteristic) for these models was 0.86 and 0.92, respectively. It was shown that at a probability cut off of 0.60, model B predicted eventual surgery with a sensitivity of 57% and a specificity of 100%. CONCLUSIONS Given the requirement of a high specificity, eventual operation could be adequately predicted in a sample of 183 patients with clinical nerve root compression. The application of the model in patients with nerve root compression might lead to earlier operation in a subset of patients resulting in a reduction of duration of illness and associated indirect costs. An important prerequisite for future application would be the validation of the prediction rule in another population.