Use of lumbar extension, slump test, physical and neurological examination inthe evaluation of patients with suspected herniated nucleurs pulposus. A prospective clinical study

doi:10.1016/S1356-689X(99)80006-X

Manual Therapy

Volume 4, Issue 1, February 1999, Pages 25-32

https://doi.org/10.1016/S1356-689X(99)80006-X Get rights and content

Summary

This prospective and consecutive study was designed to evaluate the validity of different clinical tests, e.g. lumbar extension in lying and sulmp 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 everage 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 bulding discs and 12 patients without positive findings. The mean values with standard deviations of 25 variables of three dianostic groups were studied.

Multiple comparison adjustment according to Bonferroni showed significant differences for threevariables 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 hermination was accurete in 72 patients (69%). The diagnostic sensitivity for disc herniation was 82.6% and the specificity 54.7%.

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Cited by (37)

Inadequacies of the Lasègue test, and how the Slump and Bowstring tests are useful for the diagnosis of sciatica
2021, Joint Bone Spine
Diagnosis of sciatica mainly relies on pain reproduction by stretching of the lumbar roots since neurological examination and medical history are usually not sufficient to guarantee diagnosis. The Lasègue test is the most popular method, which starts with the straight leg-raising test (SLR). However it is not perfect, and is not always well performed or interpreted. Passive ankle dorsiflexion at the end of the SLR (Bragard test) is more sensitive, but can also remain normal in some cases of sciatica. Other stretching tests can help to recognise lumbar root damage in patients with poorly defined pain in a lower extremity: firstly, the Christodoulides test, i.e. reproduction of L5 sciatic pain by a femoral stretch test; secondly, the Slump test, performed on a patient in a sitting position, by slowly extending their painful leg then passively bending their neck (or the opposite); and thirdly, the Bowstring test, which requires, at the end of the Lasègue test, once the knee has been slightly flexed, pressing on the course of the peroneal and/or tibial nerves in the popliteal fossea to try and reproduce the exact pain felt by the patient. The combination of all these tests takes less than 2 minutes, and could improve both the sensitivity and specificity of the physical examination for the diagnosis of sciatica. This article is a review of the limitations of the Lasègue/SLR tests and of the efficacy of these other tests for stretching the lumbar roots.
Inadequacies of the Lasègue test, and how the Slump and Bowstring tests are useful for the diagnosis of sciatica
2020, Revue du Rhumatisme (Edition Francaise)
L’interrogatoire et l’examen neurologique ne suffisent souvent pas au diagnostic de sciatique radiculaire, sur lequel repose surtout la reproduction de la douleur par la mise en tension des racines. Celle-ci est réalisée d’ordinaire seulement par la manœuvre de Lasègue, dont le premier temps, jambe tendue, est dénommé straight-leg-raising (SLR). Le test de Lasègue n’est toutefois pas parfait, ni toujours bien réalisé et interprété. La dorsiflexion de la cheville en fin de test (test de Braggard) peut être plus sensible. Toutefois, ces deux tests peuvent être parfois faussement négatifs, si bien que d’autres tests de mise en tension radiculaire peuvent aider à poser le diagnostic positif d’une souffrance sciatique en présence de douleurs atypiques d’un membre inférieur. Il s’agit premièrement du signe de Christodoulides, qui correspond à la reproduction d’une douleur de topographie L5 lors de la réalisation d’un test de Léri (femoral stretch test) ; deuxièmement, du signe de Slump, qui consiste sur un patient assis, à étendre la jambe douloureuse à l’horizontale puis à fléchir passivement le cou (ou l’inverse) ; et troisièmement, du signe de la corde de l’arc, qui consiste lors de la manœuvre de Lasègue, une fois le genou un peu fléchi après avoir atteint le degré maximal d’élévation passive du membre douloureux, à appuyer sur le trajet des nerfs péroniers et tibiaux dans le creux poplité pour reproduire ou non la douleur connue du patient. La combinaison de tous ces tests pourrait beaucoup améliorer tant la sensibilité que la spécificité de l’examen clinique des sciatiques.
Neurodynamic test of the peroneal nerve: Study of the normal response in asymptomatic subjects
2019, Musculoskeletal Science and Practice
Citation Excerpt :
In the lower extremity, the straight leg raise test (SLR) is one of the most performed NDTs to examine for mechanosensitivity of mechanical function of the nervous system (B S Boyd et al., 2009a,b; Boyd and Villa, 2012; Capra et al., 2011; Herrington et al., 2008; Majlesi et al., 2008; Sierra-Silvestre et al., 2017). The SLR has shown to produce mechanical (Rade et al., 2016; Shacklock et al., 2016a, 2016b) and/or physiological changes (Kobayashi et al., 2003) on the neural tissues in the lumbar region and the leg (Capra et al., 2011; Kobayashi et al., 2003; Majlesi et al., 2008; Ridehalgh et al., 2005; Stankovic et al., 1999; Urban and MacNeil, 2015; Walsh et al., 2007). Normal values for the SLR have been previously analysed and widely described (B S Boyd et al., 2009a,b; Boyd and Villa, 2012; Capra et al., 2011; Herrington et al., 2008; Majlesi et al., 2008; Sierra-Silvestre et al., 2017).
Neurodynamic tests (NDTs) have shown to be useful in evaluating neural tissue involvement. Peroneal nerve reaches high importance in ankle injuries. However, up to date, no study has documented the normal responses for this nerve.
The objective of this study was to document normal responses of the peroneal neurodynamic test (NDT_PER) in asymptomatic subjects. Differences in sensory response depending on sex and leg dominance were also examined.
A cross-sectional study was designed.
Forty-four asymptomatic subjects with a total of 88 lower limbs were tested. The range of motion (ROM) at the point of first appearance of symptoms (S1) and the point of symptoms tolerance (S2), quality and distribution of sensory responses were recorded.
Hip flexion was significantly higher at S2 than S1 (mean difference, 27.22°; 95% CI: 25.29°, 29.14°; p < 0.001). However, it was not different between sex, nor dominance (p > 0.05). The descriptor of the quality of sensory responses more often used by subjects was stretching (90.9%) in the external foot (74.6%).
This study provides the normal hip flexion angle and quality and distribution of sensory responses to the NDT_PER in asymptomatic subjects. Responses were independent of the influence of sex or leg dominance.
Accuracy of Clinical Tests in Detecting Disk Herniation and Nerve Root Compression in Subjects With Lumbar Radicular Symptoms
2018, Archives of Physical Medicine and Rehabilitation
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).
Validity study.
Secondary care.
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).
Not applicable.
Accuracy of clinical tests in detecting MRI findings was evaluated using sensitivity, specificity, and receiver operating characteristics analysis with area under the curve (AUC).
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.
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.
Lumbar Discectomy
2016, Benzel's Spine Surgery: Techniques, Complication Avoidance and Management: Volume 1-2, Fourth Edition
Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: A systematic review and meta-analysis
2013, Spine Journal
Citation Excerpt :
Six studies with a total population of 849 patients used radiology as the reference standard to detect a lumbar disc herniation. Three studies evaluated the ability of these tests to diagnose disc herniation at any lumbar spine level [20,42,44], whereas the other three studies investigated neurological tests to diagnose specific levels of disc herniation [35,37,43]. In the former three studies, sensory testing data were only able to be pooled in a meta-analysis.
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.
To review the scientific literature to evaluate the diagnostic accuracy of the neurological examination to detect lumbar disc herniation with suspected radiculopathy.
A systematic review and meta-analysis of the literature.
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.
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.
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.

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Original articleUse of lumbar extension, slump test, physical and neurological examination inthe evaluation of patients with suspected herniated nucleurs pulposus. A prospective clinical study

Summary

Physiotherapy

Lancet

Australian Journal of Physiotherapy

Australian Journal of Physiotherapy

Australian Journal of Physiotherapy

Pain

Ruptured intervertebral disc and sciatic pain

Journal of Bone and Joinst Surgery

Reliability of attraction method for measuring lumbar spine backward bending

Physical Therapy

A study of computed assisted tomography II. Comparison of metrizamide myelography and computed tomography in the diagnosis of herniated lumbar discand spinal stenosis

Spine

Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects

Journal of Bone and Joint Surgery

A comparison of CT scanning and myelography in the diagnosis of lumbar disc herniation

Clinical Orthopaedics and Related Research

Biomechanics of the lumbosacral nerve roots

Acta Radiologica Diagnostica

The diagnosis of disc sequestration

Spine

Induced pain patterns on passive straight leg raising in the lower lumbar disc protrusion

Journal of Bone and Joint Surgery

Quantitative power measurements of extensor hallucis longus. A simple objective test in evaluatioin of low-back pain with neurological involvement

Spine

Biostatistics. A methodology for the health sciences

Contribution à l'étude clinique de la sciatique

Paris Thèse No. 33

Comparative study of abrodil myelogram and operative findings in low back pain and sciatica

Acta Orthopaedica Scandinavica

Computed tomography of herniated and extruded nucleus pulposus

Journal of Computer Assisted Tomography

Prognosis in sciatica

Acta Orthopadica Scandinavica Suppl

The comparative reliability of preoperative diagnostic methods in lumbar disc surgery

Acta Orthopaedica Scandinavica

MR imaging of the spine

Radiology

A prospective comparison of computed tomography and myelography in the diagnosis of hermiated lumbar discs

Radiology

The reliability of lumbar disc surgery

Clinical Orthopaedics and Related Research

Abnormal myelograns in asymptomatic patients

Journal of Neurosurgery

The question of lumbar discography

Journal of Bone and Joint Surgery

The crossed straight leg raising test

New England Journal of Medicine

The slump test: the effect of head and lower extremity position on knee extension

Journal of Orthopedic Sports Physiotherapy

Symptomas and signs in degeneration of the lumbar spine. A prospective, consecutive study of 300 operated patients

Journal of Bone and Joint Surgery

Epidemiology and impact of low-back pain

Spine

Comparative value of electromyelographic, myelographic and clinical-neurological examination in diagnosis of lumbar root compression syndrome

Acta Orthopaedica Scandinavica Supp 49

Original article
Use of lumbar extension, slump test, physical and neurological examination inthe evaluation of patients with suspected herniated nucleurs pulposus. A prospective clinical study