Diagnostic accuracy of the clinical examination in identifying the level of herniation in patients with sciatica.
Clinical examination of patients with “sciatica” (lumbar radiculopathy) includes tests to determine the presence of a disc herniation and its specific level. The aim of this study was to measure the accuracy of neurologic tests individually or in combination and of clinical overall impression, to determine the specific level of a disc herniation.
283 patients with confirmed disc herniation (at L3/L4, L4/L5 or L5/S1) and associated sciatica were recruited. They all received a clinical examination by a neurologist, an MRI (gold standard), and a formal neurological examination (dermatomal pain and sensation, myotomal strength, reflexes). All examinations were blinded from the MRI conclusions.
- Dermatomal pain (on L4, L5 or S1 dermatomes) was the most informative individual test to identify the level of a disc herniation, compared to dermatomal sensation, myotomal strength and reflexes.
- When combined, at least 3 positive tests were required to identify the level with high specificity (83-94%), but poor sensitivity.
- The neurologist overall impression was moderately accurate, although superior to individual or combined tests. It is likely that neurologists weigh and interpret their examination findings based on their clinical experience and clinical reasoning.
Future studies should examine which combination of tests are most accurate, and should clarify the clinical decision-making processes used by neurologists. > From: Hancock et al., Spine 36 (2011) 712-719. All rights reserved to Lippincott Williams & Wilkins.
The Pubmed summary of the article can be found here.