Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. Diagnosis and prognosis in lumbar disc herniation. Computed tomography, electrodiagnostic and clinical findings in chronic workers' compensation patients with back and leg pain. Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus. A prospective clinical study. Physical signs in lumbar disc hernia. Cramp finding: can it be used as a new diagnostic and prognostic factor in lumbar disc surgery? The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. Predictive value of clinical and surgical findings in patients with lumbago-sciatica. A prospective study (Part I). [A comparative study of EMG and CAT scan in the lumbo-ischial syndrome. II: Pain in the lumbo-ischial syndrome and the diagnostic value of clinical examination, EMG and CAT scan]. The lumbar disc herniation. A computer-aided analysis of 2,504 operations. The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. Herniated lumbar intervertebral discs -- an analysis of 1176 operated cases. Comparative value of electromyographic, myelographic and clinical-neurological examinations in diagnosis of lumbar root compression syndrome. The significance of neurological signs and myelographic findings in the diagnosis of lumbar root compression. Value of the bell test and the hyperextension test for diagnosis in sciatica associated with disc herniation: comparison with Lasègue's sign and the crossed Lasègue's sign. The clinical significance of straight-leg raising (Lasègue's sign) in the diagnosis of prolapsed lumbar disc. Interobserver variation and correlation with surgical finding. The clinical significance of gadolinium enhancement of lumbar disc herniations and nerve roots on preoperative MRI. A critical assessment of clinical diagnosis of disc herniation in patients with monoradicular sciatica. The crossed straight leg raising test: a diagnostic sign of herniated disc.
To evaluate patient characteristics, symptoms, and examination findings in the clinical diagnosis of lumbosacral nerve root compression causing sciatica.
                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.
                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.
                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. In a prospective 2-year followup study of 160 consecutive patients undergoing primary surgery for suspected lumbar disc herniation, the authors studied the diagnostic and prognostic factors by using stepwise logistic regression analysis. When the different factors were entered in the same order as presented clinically, history and pain analysis contained most of the predictive information available. When all factors were entered simultaneously in the computations, the following factors (in order of relative importance) predicted relief of sciatica after 2 years: rupture of the anulus (as opposed to bulging disc or negative exploration), no preoperative comorbidity, and male gender. The following factors predicted return to work at 2 years: no preoperative comorbidity, duration of sciatica less than 7 months, education or vocational training in addition to compulsory school, age younger than 41 years, male gender, and no previous nonspinal surgery. Return to work does not seem to be a valid result parameter in lumbar disc surgery. The most important physical signs were root tension tests and lumbar range of motion, whereas neurologic signs were of secondary importance. Many people have asymptomatic herniations, and today supersensitive diagnostic imaging is widely available. Thus, the importance of clinical evaluation has increased, and most of the relevant information can be obtained by listening to the patient. A simple anamnesis apparently is a good alternative to psychologic tests in surgical triage. One hundred patients with complaints of low-back pain and leg pain, consistent with a diagnosis of sciatica, were evaluated. All patients had complaints for longer than 6 months and had recently undergone electrodiagnostic testing and computed tomography (CT). Correlation was made between symptoms, straight leg raising, clinical neurological deficits, electrodiagnostic and CT findings. The radiation of pain above or below the knee and pain on straight leg raising did not show a high correlation with each other or with neurological deficits or CT findings. Electrodiagnostic studies often defined a radiculopathy in patients with equivocal clinical signs. CT findings did not predict the nature of symptoms or clinical and electrodiagnostic findings. Electrodiagnostic abnormalities showed the greatest ability to predict CT abnormalities. It is concluded that in chronic sciatica patients, no single diagnostic parameter is conclusive and a combination of clinical and laboratory findings is necessary to reach a diagnosis. In addition, many assumptions, valid in patients with acute pain cannot be extrapolated to patients with chronic sciatica. This prospective and consecutive study was designed to evaluate the validity of different clinical tests, e.g. lumbar extension in lying and slump test for patients with suspected herniated nucleus pulposus, in comparison with findings on computed tomography (CT) and/or magnetic resonance imaging (MRI) scan. There were 105 patients who were seen and examined by the senior author (for the sake of the study) at the Orthopaedic Physiotherapy Department, on an average of 5.5 days (range 0-21 days) before CT and/or MRI examination were carried out. There were 36 women and 69 men with an average age of 42.7 +/- 9.8 (range 19-64) years. According to the radiological findings on CT and/or MRI, the patients were divided into three groups: 52 patients with disc hernia, 41 patients with bulging discs and 12 patients without positive findings. The mean values with standard deviations of 25 variables of three diagnostic groups were studied. Multiple comparison adjustment according to Bonferroni showed significant differences for three variables that were of diagnostic value (lumbar range of motion for forward flexion, left side-bending in standing, and pain distribution during extension in standing). The agreement between clinical and radiological findings for type and level of diagnosis of disc herniation was accurate in 72 patients (69%). The diagnostic sensitivity for disc herniation was 82.6% and the specificity 54.7%. In a prospective study of 163 consecutive patients operated on because they were thought to have lumbar disc hernia, the authors investigated whether physical signs could predict the degree of hernia (complete hernia, incomplete hernia, protruded disc, and normal disc) found at surgery. Stepwise discriminant analysis showed that there were only 2 physical signs of diagnostic value: lumbar range of motion and crossed Lasegue sign. By these signs, 74% of the uncontained hernias and 68% of the contained hernias could be correctly classified. Discrimination also was made between intact annuli (negative exploration and protruded disc) versus ruptured annuli (incomplete hernias and complete hernias). Again, lumbar range of motion and crossed Lasègue sign were the only significant parameters, predicting 71% of the ruptured annuli and 80% of the intact annuli. These 2 physical signs are important because the degree of the hernia is the most important prognostic factor for the outcome of lumbar disc surgery. The degree of the hernia also has an impact on the choice of invasive therapy: open surgery, percutaneous surgery, or enzymatic nucleolysis. Neurologic signs often were absent, showed low correlation to the degree of the hernia, and had a limited value for predicting the level of the hernia. However, they are important for the differential diagnosis in distinguishing between radicular and referred pain. In this prospective study, the validity and the importance of a new finding (cramp finding) in the diagnosis and outcome after lumbar disc surgery were tested. The test is performed with the person in prone position. Against a forceful knee flexion, the examiner holds the leg with one hand and applies a force to overcome the knee flexion. The finding is positive if the examined person feels a disturbing cramp in the leg or thigh. The study was performed between October 1997 and December 1999. Besides the cramp finding, the classical disc herniation examination, including mechanical and neurological findings, magnetic resonance (MR) imaging tests, and laboratory findings were checked pre- and postoperatively. The positive cramp finding in the operated group was 72% (n=133) preoperatively and straight leg raising (SLR) test was positive in all of them. Cramp finding was positive in 70%, 52%, 34%, and 8% of patients postoperatively in the first, 3rd, 12th and 24th months, respectively. The presented finding appears to be as valuable as the SLR, and especially contralateral SLR, tests in lumbar disc surgery. Cramp finding is also important in outcome evaluation. One hundred patients with lumbar disc protrusions were studied. Thirty six "control" patients were admitted in the same time period with low back pain and sciatica but with subsequently "normal" myelograms and no surgery. The aim of this paper was to relate history and clinical signs to the myelograms and surgical findings. Ninety nine per cent of our patients presented with sciatica (controls 94%). The most frequently found sign in patients with a disc protrusion was reduction of ipsilateral straight leg raising (98%). However, 55% of controls also showed this sign. There were three signs that, when present, particularly indicated a disc protrusion; "crossed straight leg raising" (pain on contralateral straight leg raising), measured calf wasting and impaired ankle reflex: the latter being especially indicative of an L5-S1 disc protrusion. There were two further important signs, weakness of dorsiflexion of the foot and scoliosis of the lumbar spine. However, such signs occurred in about half the patients and so clinical diagnosis in the remaining half depended on obtaining a good history of sciatica, and paying due regard to severity of the pain, the mobility of the patient, the ability and desire to work and the overall personality. Satisfactory results of surgery simply depend on finding and removing a definite disc protrusion. Using these methods of selection, 98% have returned to their original employment, 86% within 3 months of the operation. For a patient with no abnormal signs and a normal myelogram, surgical treatment should not be advised. In a prospective, consecutive study of patients with lumbar back pain and sciatica, various clinical features and surgical findings were evaluated in order to analyse the predictive value regarding (1) level of diseased interspace (2) presence and type of lesion responsible for root compression (3) outcome after surgery. One hundred patients underwent surgery solely on clinical grounds. Fifty-eight had disc herniation. The level of disc herniation was correctly predicted in three quarters of patients with a prolapsed disc. The outcome after surgery was good in 77 patients. Only few clinical features, namely male sex and scoliosis were predictors of a good outcome. Lasegue's sign was indicative of root compression in 90%, but only two-thirds had disc herniation. Conversely one-third had disc herniation in spite of a "negative" test. Lasegue's sign was not superior to other clinical tests in predicting outcome. The most important indicator of a good outcome was the presence of disc herniation at surgery. Patients with disc pathology other than true disc herniation fared equally with patients, who had normal discs disclosed at surgery. Myelography was undertaken in all patients prior to surgery, the results of which are analysed in the following paper. (Espersen et al.: Predictive value of radiculography in patients with lumbago-sciatica. A prospective study (Part II, Acta Neurochirurgica 73 (1984), 213-221. nan nan An accurate and specific diagnosis prevents the recurrences of low back pain and chronic spinal pain. The physical examination is the most useful tool to diagnosis. The examiner must aim to determine the exact tissue that pain arises from to make the specific diagnosis. Lumbar disc herniation is 1 disease that physical examination, symptoms, and findings on imaging technique do not always correlate with each other. The Straight Leg Raising (SLR) test has been used as the primary test to diagnosis lumbar disc herniations and found to have high correlation with findings on operation since its sensitivity is high in only disc herniations leading to root compression that may eventually need operation. More sensitive test, like the Slump, might be used in herniations in which the SLR is negative. The Slump test is really a variant of the SLR and the Lasègue's tests performed in the seated position and is a progressive series of maneuvers designed to place the sciatic nerve roots under increasing tension. At each step in the procedure, the patient informs the examiner what is being felt and whether radicular pain is produced. As a result, the Slump test applies traction to the nerve roots by incorporating spinal and hip joint flexion into the leg raising and would warn the examiner of the presence of nerve root compression when there is a negative SLR test.
                This study measured the sensitivity and specificity of the Slump test and compare it with the SLR test in patients with and without lumbar disc herniations.
                A prospective case control study of 75 patients with complaints suggestive of lumbar disc herniation was carried out in the outpatient clinics of the neurosurgery department of a state teaching hospital. Seventy-five referred or self-admitted patients with low back, leg, or low back and leg pain who had results of magnetic resonance imaging (MRI) of the lumbar spine were included in the study. Thirty-eight patients had signs of herniation demonstrated by MRI. Control patients (n = 37) had no disc bulges or herniations on MRI. Both the Slump and SLR tests were performed during the assessment of all the patients by the second author. The MRI results were assessed and recorded by the first author.
                The Slump test was found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniations. However, the SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83).
                The Slump test might be used more frequently as a sensitive physical examination tool in patients with symptoms of lumbar disc herniations. In contrast, owing to its higher specificity, the SLR test may especially help identify patients who have herniations with root compression requiring surgery. nan nan nan To evaluate the reliability, sensitivity, specificity and positive (PPV) and negative (NPV) predictive values for the diagnosis of sciatica associated with disc herniation of the bell test (BT) and the hyperextension test (HT).
                According to magnetic resonance imaging, computed tomography scanning or myelography findings, patients were classified as having sciatica associated with disc herniation (group A) or sciatica without disc herniation or sciatica of other mechanical origin (group B). Four clinical manoeuvres [bell test (BT), hyperextension test (HT), Lasègue's sign (LS) and the crossed Lasègue's sign (CL)] were tested by three investigators. Intra- and interobserver reliabilities were calculated using the kappa correlation coefficient or the intraclass correlation coefficient (ICC). The sensitivity, specificity, PPV and NPV of the four manoeuvres were calculated. Stepwise logistic regression analysis was performed to determine the best set of variables predicting sciatica caused by disc herniation.
                Seventy-eight patients (43 in group A, 35 in group B; 33 males) with a mean age of 50+/-16 yr were included. Interobserver reliabilities ranged from 0.58 to 0.64 for the BT, 0.35 to 0.50 for the HT, 0.27 to 0.47 for LS and 0.43 to 0.72 for CL. LS had the best sensitivity (0.77-0.83) and CL the best specificity (0.74-0.89), while PPV and NPV were equivalent for the four manoeuvres (0.55-0.75 for PPV and 0.45-0.59 for NPV). The best PPV was observed for the association of HT with CL (0.67-0.85). Stepwise logistic regression analysis did not allow us to propose a set of variables predicting sciatica caused by disc herniation.
                This study suggests that clinical values of the BT and HT are of interest, and are similar to those of LS and CL. Limitation of straight-leg raising (SLR) (Lasègue's sign) is considered an important test in the diagnosis of herniated lumbar disc disease. In a prospective study of 55 patients suffering from unilateral sciatica this sign was evaluated. Two aspects were investigated: 1) the interobserver variation, and 2) the correlation between the result of the test and the surgical finding. There was considerable interobserver variation among three observers concerning the measured angle at which pain was elicited. However, in 2/3 to 3/4 of the cases the variation amounted to 10 degrees or less. There was also some discordance in the classification of the type of pain that was elicited. Fifty-two patients underwent surgery; 45 had a prolapsed disc. SLR was "positive" in 49 cases, 43 of whom harbored a prolapsed disc. Crossed SLR was noted in 20, 19 of whom had a prolapsed disc at surgery. Absence of SLR limitation does not preclude the presence of a herniated lumbar disc. The clinical significance of preoperative gadolinium DPTA enhancement around disc herniations and in the epidural space on MRI is not clear. The relation of nerve root enhancement to dysfunction also remains controversial. To investigate the clinical significance of contrast enhancement we looked at the symptoms and signs and gadolinium DPTA-enhanced images of 71 consecutive surgical candidates in a standardised fashion. Annular rupture and disc enhancement were found to be closely related, and correlated with sensory loss and paresis, respectively. Nerve root enhancement was found to be related to neurological deficits in general and sensory impairment in particular. The diagnostic power or clinical parameters in the diagnosis of lumbar disc herniation in patients with monoradicular pain was evaluated in a prospective study with a 100% verification of the diagnosis. Eighty patients with monoradicular pain corresponding to the fifth lumbar or the first sacral nerve root were included. Pre-operatively a number of clinical parameters were recorded and compared to the intra-operative finding of a disc herniation. The parameters were analysed by receiver operating characteristic (ROC) curves. Results from the available literature were analysed by ROC curves for comparison. In 76% of the cases a disc herniation was discovered. The level of the disc herniation was correctly predicted in 93% of these cases by the location of the pain alone or supplemented by neurological signs. Apart from radicularly distributed pain, all parameters in the present study and in the literature had no or low diagnostic accuracy. Thus, in patients with monoradicular sciatica further clinical parameters do not add to the diagnosis of lumbar disc herniation. Increased sciatica on raising the opposite or "well" leg, the crossed straight leg raising (XSLR) sign, is associated with a herniated lumbar disc in 97% of patients. Although XSLR predicts poor response to conservative management, the results of laminectomy are usually good, with 91% of patients returning to work. Myelography is unnecessary for the diagnosis of disc herniation in patients with XSLR. It is possible for patients with this sign to have a normal myelogram, but 90% of them will prove nevertheless to have a herniated disc.
When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.