Systematic review of diagnostic accuracy of patient history, clinical findings, and physical tests in the diagnosis of lumbar spinal stenosis

Abstract

Purpose

To update evidence of diagnostic potential for identification of lumbar spinal stenosis (LSS) based on demographic and patient history, clinical findings, and physical tests, and report posttest probabilities associated with test findings.

Methods

An electronic search of PubMed, CINAHL and Embase was conducted combining terms related to low back pain, stenosis and diagnostic accuracy. Prospective or retrospective studies investigating diagnostic accuracy of LSS using patient history, clinical findings and/or physical tests were included. The risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Diagnostic accuracy including sensitivities (SN), specificities (SP), likelihood ratios (+LR and −LR) and posttest probabilities (+PTP and −PTP) with 95% confidence intervals were summarized.

Results

Nine studies were included (pooled n = 36,228 participants) investigating 49 different index tests (30 demographic and patient history and 19 clinical findings/physical tests). Of the nine studies included, only two exhibited a low risk of bias and seven exhibited good applicability according to QUADAS 2. The demographic and patient history measures (self-reported history questionnaire, no pain when seated, numbness of perineal region) and the clinical findings/physical tests (two-stage treadmill test, symptoms after a March test and abnormal Romberg test) highly improved positive posttest probability by > 25% to diagnose LSS.

Conclusion

Outside of one study that was able to completely rule out LSS with no functional neurological changes none of the stand-alone findings were strong enough to rule in or rule out LSS.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

Appendices

Appendix 1: PRISMA-DTA checklist—based on blinded manuscript

1. Adapted From: McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, The PRISMA-DTA Group (2018). Preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies: The PRISMA-DTA statement. JAMA. 2018 Jan 23;319(4):388–396. https://doi.org/10.1001/jama.2017.19163
2. For more information, visit: www.prisma-statement.org

Appendix 2: AMSTAR-2 checklist

Appendix 3

PubMed search strategy

• 1. Population: low back pain

low back pain [ti/ab] OR lumbar paraspinal [ti/ab] OR pain [ti/ab] OR back-pain [ti/ab] OR back pain [ti/ab] OR backache [ti/ab] OR back ache [ti/ab] OR dorsalgia [ti/ab] OR lumbago [ti/ab] OR lumbar [ti/ab] OR lumbosacral [ti/ab] OR sciatic [ti/ab] OR radicular [ti/ab] OR lumbar vertebrae [ti/ab] OR spine [ti/ab] OR spinal [ti/ab]

• 2. Target condition: lumbar spinal stenosis

Stenosis [ti/ab] OR stenosis [ti/ab] OR canal stenosis [ti/ab] OR lumbar spinal stenosis [ti/ab] OR spinal stenosis [ti/ab] OR spine stenosis [ti/ab] OR lss [ti/ab] OR claudication [ti/ab] OR claudicant [ti/ab] OR neurogen* [ti/ab] OR canal compression [ti/ab] OR canal compressing [ti/ab]

• 3. Index test

Diagnostic [ti/ab] OR diagnosis [ti/ab]

• 4. Methodological filter

sensitivity [ti/ab] OR specificity [ti/ab] OR sensitive test [ti/ab] OR specific test [ti/ab] OR screening [ti/ab] OR false positive [ti/ab] OR false negative [ti/ab] OR accuracy [ti/ab] OR predictive value [ti/ab] OR predictive values [ti/ab] OR reference value [ti/ab] OR reference values [ti/ab] OR reference standard [ti/ab] OR roc [ti/ab] OR likelihood [ti/ab]

• Searches (combination): #1 AND #2 AND #3 AND 4

Embase search strategy

• 1. Population and target condition: lumbar spinal stenosis

‘low back pain’:ta,ab OR ’back’:ab,ta OR ’backache’:ab,ta OR ’lumbar spine’:ta,ab OR ’lumbosacral spine’:ab,ta AND ‘stenosis’:ta,ab OR ’vertebral canal’:ta,ab OR ’vertebral canal stenosis’:ta,ab OR ’claudication’:ta,ab OR ’spinal cord compression’:ta,ab)

• 2. Index test and methodological filter

(‘diagnosis’:ta,ab OR ’diagnostic procedure’:ta,ab) AND (‘sensitivity and specificity’:ta,ab OR ’screening’:ta,ab OR ’false positive result’:ta,ab OR ’false negative result’:ta,ab OR ’diagnostic accuracy’:ta,ab OR ’predictive value’:ta,ab OR ’reference value’:ta,ab OR ’standard’:ta,ab OR ’likelihood ratio’:ta,ab) AND [humans]/lim

• Searches (combination): #1 AND #2

CINAHL search strategy

• 1. Population and target condition: lumbar spinal stenosis

(low back pain OR back pain OR lumbar pain OR back OR backache OR back ache OR dorsalgia OR lumbago OR lumbar OR lumbosacral) AND (stenosis OR stenosis spinal OR canal stenosis OR spinal stenosis OR claudication OR claudicant)

• 2. Index test and methodological filter

(diagnostic OR diagnosis) AND (sensitivity OR specificity OR specificity and sensitivity OR screening OR false positive OR false negative OR accuracy OR predictive value OR reference values OR reference standards OR likelihood ratio)

• Searches (combination): #1 AND #2

Appendix 4: List of excluded studies/reasons for exclusion

• 1. Adachi S, Nakano A, Kin A, Baba I, Kurokawa Y, Neo M (2018) The tibial nerve compression test for the diagnosis of lumbar spinal canal stenosis—a simple and reliable physical examination for use by primary care physicians. Acta Orthop Traumatol Turc 52(1):12–16. https://doi.org/10.1016/j.aott.2017.04.007

Reason for exclusion: Included patients were pre-diagnosed with LSS.

• 2. Aizawa T, Tanaka Y, Yokoyama T, Shimada Y, Yamazaki K, Takei H, Konno S, Kawahara C, Itoi E, Kokubun S (2016) New diagnostic support tool for patients with leg symptoms caused by lumbar spinal stenosis and lumbar intervertebral disc herniation: a self-administered, self-reported history questionnaire. J Orthop Sci 21(5):579–585. https://doi.org/10.1016/j.jos.2016.07.012

Reason for exclusion: Included patients were pre-diagnosed with LSS.

• 3. Ando M, Tamaki T, Kawakami M, Minamide A, Nakagawa Y, Maio K, Enyo Y, Yoshida M (2013) Electrophysiological diagnosis using sensory nerve action potential for the intraforaminal and extraforaminal L5 nerve root entrapment. Eur Spine J 22(4):833–839. https://doi.org/10.1007/s00586-012-2592-5

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 4. Annunziata, CC, Lauerman, WC (1999). When back surgery fails: what’s the next step? Diagnostic findings must be interpreted within the clinical context. J. Musculosk Medicine

Reason for exclusion: Other study designs.

• 5. Arce D, Sass P, Abul-Khoudoud H (2001). Recognizing spinal cord emergencies. Am Fam Physician

Reason for exclusion: Other study designs.

• 6. Barz T, Staub LP, Melloh M, Hamann G, Lord SJ, Chatfield MD, Bossuyt PM, Lange J, Merk HR (2014) Clinical validity of the nerve root sedimentation sign in patients with suspected lumbar spinal stenosis. Spine J 14(4):667–674. https://doi.org/10.1016/j.spinee.2013.06.105

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 7. Bosscher HA, Heavner JE (2012) Diagnosis of the vertebral level from which low back or leg pain originates. A comparison of clinical evaluation, MRI and epiduroscopy. Pain Pract 12(7):506–512. https://doi.org/10.1111/j.1533-2500.2012.00549.x

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 8. Chien JJ, Bajwa ZH (2008). What is mechanical back pain and how best to treat it? Curr Pain Headache Rep

Reason for exclusion: Other study designs.

• 9. Dvonch V, Scarff T, Bunch WH, Smith D, Boscardin J, Lebarge H, Ibrahim K (1984) Dermatomal somatosensory evoked potentials: their use in lumbar radiculopathy. Spine (Phila Pa 1976) 9(3):291–293

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 10. Esmailiejah AA, Abbasian M, Bidar R, Esmailiejah N, Safdari F, Amirjamshidi A (2018) Diagnostic efficacy of clinical tests for lumbar spinal instability. Surg Neurol Int 9:17. https://doi.org/10.4103/sni.sni_359_17

Reason for exclusion: Included patients were pre-diagnosed with LSS.

• 11. Faciszewski T, Broste SK, Fardon D (1997) Quality of data regarding diagnoses of spinal disorders in administrative databases. A multicenter study. J Bone Joint Surg Am 79(10):1481–1488

Reason for exclusion: Included other causes of LBP.

• 12. Genevay S, Courvoisier DS, Konstantinou K, Kovacs FM, Marty M, Rainville J, Norberg M, Kaux JF, Cha TD, Katz JN, Atlas SJ (2018) Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. The N-CLASS criteria. Spine J 18(6):941–947. https://doi.org/10.1016/j.spinee.2017.10.003

Reason for exclusion: Included patients were pre-diagnosed with LSS.

• 13. Haig AJ, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, Chiodo A, Miner JA, Choksi VR, Geisser ME (2005) The sensitivity and specificity of electrodiagnostic testing for the clinical syndrome of lumbar spinal stenosis. Spine (Phila Pa 1976) 30(23):2667–2676

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 14. Hayashi H, Toribatake Y, Murakami H, Yoneyama T, Watanabe T, Tsuchiya H (2015) Gait analysis using a support vector machine for lumbar spinal stenosis. Orthopedics 38(11):e959–e964. https://doi.org/10.3928/01477447-20151020-02

Reason for exclusion: Included healthy volunteers.

• 15. Kato Y, Kawakami T, Kifune M, Kishimoto T, Nibu K, Oda H, Shirasawa K, Tominaga T, Toyoda K, Tsue K, Taguchi T (2009) Validation study of a clinical diagnosis support tool for lumbar spinal stenosis. J Orthop Sci 14(6):711–718. https://doi.org/10.1007/s00776-009-1391-2

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 16. Konno S, Kikuchi S, Tanaka Y, Yamazaki K, Shimada Y, Takei H, Yokoyama T, Okada M, Kokubun S (2007) A diagnostic support tool for lumbar spinal stenosis: a self-administered, self-reported history questionnaire. BMC Musculoskelet Disord 8:102. https://doi.org/10.1186/1471-2474-8-102

Reason for exclusion: Included other causes of LBP.

• 17. Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B (2005) Agreement between diagnoses reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskelet Disord 6:28. https://doi.org/10.1186/1471-2474-6-28

Reason for exclusion: Included other causes of LBP.

• 18. Lee JH, Lee SH (2012) Physical examination, magnetic resonance imaging, and electrodiagnostic study of patients with lumbosacral disc herniation or spinal stenosis. Journal of Rehabilitation Medicine 44(10):845–850

Reason for exclusion: Included other causes of LBP.

• 19. Leng GC, Fowkes FG (1992) The Edinburgh Claudication Questionnaire: an improved version of the WHO/Rose Questionnaire for use in epidemiological surveys. J Clin Epidemiol 45(10):1101–1109

Reason for exclusion: Included other causes of LBP.

• 20. Lin JH, Hsieh YC, Chen YC, Wang Y, Chen CC, Chiang YH (2017) Diagnostic accuracy of standardised qualitative sensory test in the detection of lumbar lateral stenosis involving the L5 nerve root. Sci Rep 7(1):10598. https://doi.org/10.1038/s41598-017-10641-2

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 21. Mann NH, 3rd, Brown MD, Enger I (1992) Expert performance in low-back disorder recognition using patient pain drawings. J Spinal Disord 5(3):254–259

Reason for exclusion: Included other causes of LBP.

• 22. Martin BI, Lurie JD, Tosteson AN, Deyo RA, Tosteson TD, Weinstein JN, Mirza SK (2014) Indications for spine surgery: validation of an administrative coding algorithm to classify degenerative diagnoses. Spine (Phila Pa 1976) 39(9):769–779. https://doi.org/10.1097/brs.0000000000000275

Reason for exclusion: Other study designs.

• 23. Nayeb Aghaei H, Azimi P, Shahzadi S, Azhari S, Mohammadi HR (2015) Role of the Self-Administered, Self-Reported History Questionnaire to identify types of Lumbar spinal stenosis: a sensitivity analysis. Asian Spine J 9(5):689–693. https://doi.org/10.4184/asj.2015.9.5.689

Reason for exclusion: Other study designs.

• 24. Ohtori S, Sekiguchi M, Yonemoto K, Kakuma T, Takahashi K, Konno S (2014) Awareness and use of diagnostic support tools for lumbar spinal stenosis in Japan. J Orthop Sci 19(3):412–417. https://doi.org/10.1007/s00776-014-0551-1

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 25. Papadakis NC, Christakis DG, Tzagarakis GN, Chlouverakis GI, Kampanis NA, Stergiopoulos KN, Katonis PG (2009) Gait variability measurements in lumbar spinal stenosis patients: part A. Comparison with healthy subjects. Physiol Meas 30(11):1171–1186. https://doi.org/10.1088/0967-3334/30/11/003

Reason for exclusion: Included healthy volunteers.

• 26. Shevelev IN, Konovalov NA, Cherkashov AM, Molodchenkov AA, Sharamko TG, Asiutin DS, Nazarenko AG (2013) [Virtual clinical diagnosis support system of degenerative stenosis of the lumbar spinal canal]. Zh Vopr Neirokhir Im N N Burdenko 77(5):38–43; discussion 43

Reason for exclusion: Other study designs.

• 27. Thomas SA (2003). Spinal stenosis: history and physical examination. Phys Med Rehabil Clin N Am

Reason for exclusion: Other study designs.

• 28. Tomkins-Lane CC, Quint DJ, Gabriel S, Melloh M, Haig AJ (2013) Nerve root sedimentation sign for the diagnosis of lumbar spinal stenosis: reliability, sensitivity, and specificity. Spine (Phila Pa 1976) 38(24):E1554–E1560. https://doi.org/10.1097/brs.0b013e3182a8c2da

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.

• 29. Yamada H, Oka H, Iwasaki H, Endo T, Kioka M, Ishimoto Y, Nagata K, Takiguchi N, Hashizume H, Minamide A, Nakagawa Y, Kawai M, Tsutsui S, Yoshida M (2015) Development of a support tool for the clinical diagnosis of symptomatic lumbar intra- and/or extra-foraminal stenosis. J Orthop Sci 20(5):811–817. https://doi.org/10.1007/s00776-015-0743-3

Reason for exclusion: Other study designs.

• 30. Zhang L, Chen R, Liu B, Zhang W, Zhu Y, Rong L (2017) The nerve root sedimentation sign for differential diagnosis of lumbar spinal stenosis: a retrospective, consecutive cohort study. Eur Spine J 26(10):2512–2519. https://doi.org/10.1007/s00586-016-4435-2

Reason for exclusion: Included diagnostic accuracy of tests not related to the scope of this review.