Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy

A systematic review and meta-analysis

Nezar H. Al Nezari, PT
The Spine Journal
Volume 13, Issue 6 , Pages 657-674, June 2013

Abstract
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.

Purpose
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.

Methods
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.

Results
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.

Conclusions
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.

Journal Abstract:  http://www.thespinejournalonline.com/article/PIIS1529943013001642/abstract