Accuracy of Clinical Tests in Detecting Disk Herniation and Nerve Root Compression in Subjects With Lumbar Radicular Symptoms.

OBJECTIVES: To investigate the accuracy of 3 commonly used neurodynamic tests (slump test, straight-leg raise [SLR] test, femoral neurodynamic test) and 2 clinical assessments to determine radiculopathy (radiculopathy I, 1 neurologic sign; radiculopathy II, 2 neurologic signs corresponding to 1 specific nerve root) in detecting magnetic resonance imaging (MRI) findings (extrusion, subarticular nerve root compression, and foraminal nerve root compression). DESIGN: Validity study. SETTING: Secondary care. PARTICIPANTS: We included subjects (N=99; mean age, 58y; 54% women) referred for epidural steroid injection because of lumbar radicular symptoms who had positive clinical and MRI findings. Positive clinical findings included the slump test (n=67), SLR test (n=50), femoral neurodynamic test (n=7), radiculopathy I (n=70), and radiculopathy II (n=33). Positive MRI findings included extrusion (n=27), subarticular nerve compression (n=14), and foraminal nerve compression (n=25). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Accuracy of clinical tests in detecting MRI findings was evaluated using sensitivity, specificity, and receiver operating characteristics analysis with area under the curve (AUC). RESULTS: The slump test had the highest sensitivity in detecting extrusion (.78) and subarticular nerve compression (1.00), but the respective specificity was low (.36 and .38). Radiculopathy I was most sensitive in detecting foraminal nerve compression (.80) but with low specificity (.34). Only 1 assessment had a concurrent high sensitivity and specificity (ie, radiculopathy II) in detecting subarticular nerve compression (.71 and .73, respectively). The AUC for all tests in detecting extrusion, subarticular nerve compression, and foraminal nerve compression showed ranges of .48 to .60, .63 to .82, and .33 to .57, respectively. CONCLUSIONS: In general, the investigated neurodynamic tests or assessments for radiculopathy lacked diagnostic accuracy. The slump test was the most sensitive test, while radiculopathy II was the most specific test. Most interestingly, no relationship was found between any neurodynamic test and foraminal nerve compression (foraminal stenosis) as visualized on MRI.

The 1-Year Results of Lumbar Transforaminal Epidural Steroid Injection in Patients with Chronic Unilateral Radicular Pain: The Relation to MRI Findings and Clinical Features.

OBJECTIVE: In patients with chronic radicular pain, we aimed to evaluate subgroup differences in 1-yr response to transforaminal epidural steroid injection. DESIGN: In this longitudinal cohort study of 100 subjects, 170 transforaminal epidural steroid injections were performed for 1 yr. The sample was stratified by type of disc herniation (protrusion n = 57, extrusion n = 27), by location of disc herniation (central/subarticular n = 60, foraminal n = 24), by grade of nerve root compression (low-grade compression n = 61, high-grade subarticular nerve compression n = 14, high-grade foraminal nerve compression n = 25), and by positive Slump test (n = 67). Treatment response was evaluated by visual analogue scale leg pain and self-reported disability (Oswestry Disability Index). Logistic regression was used to analyze the predictive value of baseline characteristics including the stratified subgroups. RESULTS: High-grade subarticular nerve compression predicted the 1-yr improvement in both visual analogue scale leg pain (P = 0.046) and Oswestry Disability Index (P = 0.027). Low age (P < 0.001), short duration of leg pain (P = 0.015), and central/subarticular disc herniation (P = 0.017) predicted improvement in Oswestry Disability Index. CONCLUSIONS: In patients treated with one or several transforaminal epidural steroid injections due to chronic lumbar radicular pain, clinical findings failed to predict the 1-yr treatment response. Low age, short duration of leg pain, central/subarticular disc herniation, and high-grade subarticular nerve compression predicted a favorable 1-yr response to transforaminal epidural steroid injection.

Three week results of transforaminal epidural steroid injection in patients with chronic unilateral low back related leg pain: The relation to MRI findings and clinical features.

BACKGROUND: Transforaminal epidural steroid injection (TESI) is a frequently used intervention for lumbar radicular pain. OBJECTIVE: To evaluate the value of MRI findings, neurologic assessment and the Slump test (neurodynamic test) as predictors of treatment response to TESI. METHOD: One hundred subjects (mean age 58 [SD13], 54% females) were included in this trial. The sample was stratified by location of disc herniaton, grade of nerve root compression, clinically assessed neurologic deficit and positive Slump test.Treatment response was primarily evaluated by Visual Analogue Scale for leg pain after three weeks. Predictive value for each stratum was analyzed using logistic regression after the sample was dichotomized into definite treatment response (≥ 50% reduction of pain) and negative response (≤ 0% reduction) to TESI (the 1-49% reduction group was excluded). RESULTS: The overall definite treatment response rate was 27%. The Slump test was the only predictor of the response to TESI (p= 0.031). The definite treatment response rates for subjects with positive and negative Slump test were 33% and 15%, respectively. CONCLUSION: In patients with chronic low back related leg pain, MRI findings and neurologic assessment results failed to predict treatment response, whereas a positive Slump test predicted the best 3-week response to TESI.

Fingertip-to-floor test and straight leg raising test: validity, responsiveness, and predictive value in patients with acute/subacute low back pain.

OBJECTIVES: To investigate the validity over time of the fingertip-to-floor test (FTF) and the straight leg raising test (SLR) using the Roland Morris Disability Questionnaire (RMDQ) and correlation coefficient (r), and to assess the predictive value of factors related to the change in RMDQ over 12 months using multivariate regression analysis. DESIGN: Longitudinal study. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Subjects (N=65) with acute/subacute low back pain (≤13 wk of symptoms). Thirty-eight (58%) had radicular pain as determined by the slump test. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported disability was used as a reference variable and was measured using the RMDQ at baseline and after 1 and 12 months. The FTF and SLR were measured at baseline and after 1 month. Responsiveness and imprecision were assessed by using effect size (ES) and minimal detectable change (MDC). The sample was stratified by the presence or absence of radicular pain (categorized by the slump test). RESULTS: The change in FTF results was significantly correlated to the 1-month change in RMDQ, both in the entire sample (r=.63) and in the group with radicular pain (r=.66). Similar analysis for the SLR showed a weak relationship to RMDQ. FTF showed adequate responsiveness (ES range, 0.8-0.9) in contrast to SLR (ES range, 0.2-0.5). The MDC for FTF and SLR were 4.5 cm and 5.7°, respectively. The change in FTF results over 1 month was independently more strongly associated with the 12-month (R(2)=.27-.31) change in RMDQ than any of the other variables and multivariate combinations. CONCLUSIONS: Our results suggest that the FTF has good validity in patients with acute/subacute low back pain and even better validity in those with radicular pain. The change in FTF results over the first month was a valid predictor of the change in self-reported disability over 1 year. In contrast, the validity of SLR can be questioned in the present group of patients.