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Results of the search for studies evaluating the diagnostic performance of physical examination in the diagnosis of lumbar disc herniation
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Figure 1

Results of the search for studies evaluating the diagnostic performance of physical examination in the diagnosis of lumbar disc herniation

Quality assessment summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Quality assessment summary: review authors' judgements about each risk of bias item for each included study.

Forest plot: SLR (leg pain at any angle) ‐ reference test: imaging
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Figure 3

Forest plot: SLR (leg pain at any angle) ‐ reference test: imaging

Forest plot: SLR (leg pain at any angle) ‐ reference test surgery
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Figure 4

Forest plot: SLR (leg pain at any angle) ‐ reference test surgery

Summary ROC Plo: SLR (leg pain at any angle) ‐ reference test surgeryNote: the case‐control study by Demircan et al (2002 ‐ upper left in ROC‐space) showed clear review bias and was excluded from the pooled analysis.
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Figure 5

Summary ROC Plo: SLR (leg pain at any angle) ‐ reference test surgery

Note: the case‐control study by Demircan et al (2002 ‐ upper left in ROC‐space) showed clear review bias and was excluded from the pooled analysis.

Forest plot:XSLR (leg pain at any angle) ‐ reference test surgery or imaging (study by Poiraudeau et al.)
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Figure 6

Forest plot:XSLR (leg pain at any angle) ‐ reference test surgery or imaging (study by Poiraudeau et al.)

Summary ROC Plot of X‐SLR (leg pain at any angle) ‐ reference test surgery or imaging.Note: The study by Kerr et al. (1988 ‐ highest sensitivity among the studies) was found to have a high risk of verification bias
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Figure 7

Summary ROC Plot of X‐SLR (leg pain at any angle) ‐ reference test surgery or imaging.

Note: The study by Kerr et al. (1988 ‐ highest sensitivity among the studies) was found to have a high risk of verification bias

Forest plot: Scoliosis (visual inspection) ‐ reference test surgery
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Figure 8

Forest plot: Scoliosis (visual inspection) ‐ reference test surgery

Forest plot: Paresis (dorsiflexion toe/ankle) ‐ reference test surgical findings or imaging (study by Vroomen et al.)
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Figure 9

Forest plot: Paresis (dorsiflexion toe/ankle) ‐ reference test surgical findings or imaging (study by Vroomen et al.)

Forest plot: Muscle wasting ‐ reference test surgical findings
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Figure 10

Forest plot: Muscle wasting ‐ reference test surgical findings

Forest plot: Impaired reflexes (Achilles tendon) ‐ reference test: surgical findings or imaging (study by Vroomen et al).
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Figure 11

Forest plot: Impaired reflexes (Achilles tendon) ‐ reference test: surgical findings or imaging (study by Vroomen et al).

Forest plot: Sensory deficits ‐ reference test: surgical findings or imaging (study by Vroomen et al.)
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Figure 12

Forest plot: Sensory deficits ‐ reference test: surgical findings or imaging (study by Vroomen et al.)

Forest plot of Forward flexion ‐ reference test surgery or imaging (study by Vroomen et al.)
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Figure 13

Forest plot of Forward flexion ‐ reference test surgery or imaging (study by Vroomen et al.)

SLR (leg pain at any angle) ‐ reference test: imaging.
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Test 1

SLR (leg pain at any angle) ‐ reference test: imaging.

SLR (leg pain at any angle) ‐ reference test surgery.
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Test 2

SLR (leg pain at any angle) ‐ reference test surgery.

X‐SLR (leg pain at any angle) ‐ reference test surgery or imaging.
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Test 3

X‐SLR (leg pain at any angle) ‐ reference test surgery or imaging.

Scoliosis (visual inspection) ‐ reference test: surgical findings.
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Test 4

Scoliosis (visual inspection) ‐ reference test: surgical findings.

Paresis (dorsiflexion toe/ankle) ‐ reference test:surgical findings or imaging.
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Test 5

Paresis (dorsiflexion toe/ankle) ‐ reference test:surgical findings or imaging.

Muscle wasting ‐ reference test: surgical findings.
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Test 6

Muscle wasting ‐ reference test: surgical findings.

Impaired reflexes (Achilles tendon) ‐ reference test: surgical findings or imaging.
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Test 7

Impaired reflexes (Achilles tendon) ‐ reference test: surgical findings or imaging.

Sensory deficits ‐ reference test surgical findings or imaging.
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Test 8

Sensory deficits ‐ reference test surgical findings or imaging.

Forward flexion ‐ reference test surgery or imaging.
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Test 9

Forward flexion ‐ reference test surgery or imaging.

Summary of findings Summary Table: performance of aspects of physical examination in the diagnosis of lumbar radiculopathy due to disc herniation in patients with low‐back pain

What is the performance of tests performed during physical examination to identify radiculopathy due to lower lumbar disc herniation in patients with low‐back pain and sciatica?

Population: Patients with LBP and sciatica in primary or secondary care

Prior testing:Variable or not described, imaging (X‐ray or myelography was reported for some surgical populations

Index tests: All relevant physical examination tests, including the straight leg raising test, crossed straight leg raising test, paresis or muscle weakness, sensory deficits, and impaired reflexes

Target condition: radiculopathy due to lumbar disc herniation

Reference standard: Diagnostic imaging (MRI, CT, myelography) or findings at surgery.

Studies: Cohort studies (16) or case‐control studies (n=3)

Diagnostic test

Setting / reference standard

Pooled estimate for sensitivity (95% CI)

or range of estimates

Pooled estimate for specificity (95% CI)

or range estimates

Mean prevalence disc herniation (range)**

Summary estimate

LR of positive test result (95% CI)

Summary estimate

LR negative test result (95% CI)

Population: patients with LBP in primary or secondary care

Index test: Straight leg raising test (SLR)

5 studies, no pooled analysis

Diagnostic imaging:

1 primary care / MRI:

4 sec care / CT‐MTI:

0.64 (0.56 to 0.71)*

range: 0.35 to 0.81

0.57 (0.47 to 0.66)*

range: 0.37 to 1.00

55%

40% (26 to 55%)

Population: patients with LBP referred for surgery

Index test: Straight leg raising test (SLR)

pooled estimate of 9 studies

Surgical findings

0.92 (0.87 to 0.95)

0.28 (0.18 to 0.40)

82% (58 to 98%)

1.3 (1.1 to 1.4)

0.30 (0.24 to 0.39)

Population: patients with LBP referred for surgery

Index test: Crossed straight leg raising test (XSLR)

pooled estimate of 5 studies

Surgical findings

0.28 (0.22 to 0.35)

0.90 (0.85 to 0.94)

77% (55 to 89%)

2.1 (1.6 to 2.8)

0.86 (0.83 to 0.89)

Population: patients with LBP referred for surgery

Index test: Scoliosis

5 studies, no pooled analysis

Surgical findings

range: 0.39 to 0.68

range: 0.62 to 0.89

66% (58 to 76%)

 

 

Population: patients with LBP in primary care or referred for surgery

Index test: Paresis or muscle weakness

7 studies, no pooled analysis

1 primary care / MRI:

6 surgical findings:

0.27 (0.20 to 0.37)*

range: 0.29 to 0.62

0.93 (0.88 to 0.97)*

range: 0.50 to 0.89

55%

74% (58 to 89%)

 

 

Population: patients with LBP referred for surgery

Index test: Muscle wasting

3 studies, no pooled analysis

surgical findings

range: 0.15 to 0.38

range: 0.50 to 0.94

83% (76 to 89%)

 

 

Population: patients with LBP in primary care or referred for surgery

Index test: Impaired reflexes

7 studies, no pooled analysis

1 primary care / MRI:

6 surgical findings:

0.15 (0.09 to 0.21)*

range: 0.31 to 0.62

0.93 (0.88 to 0.97)*

range: 0.60 ? 0.89

55%

82% (63 to 98%)

 

 

Population: patients with LBP in primary care or referred for surgery

Index test: Sensory deficits

6 studies, no pooled analysis

1 primary care / MRI:

5 surgical findings:

0.28 (0.21 to 0.36)*

range: 0.26 to 0.67

0.66 (0.56 to 0.74)*

range: 0.42 to 0.69

55%

72% (58 to 89%)

 

 

Population: patients with LBP in primary or referred for surgery

Index test: Forward flexion

3 studies, no pooled analysis

1 primary care / MRI:

2 surgical findings:

0.45 (0.37 to 0.53)*

range: 0.85 and 0.90

0.74 (0.65 to 0.81)*

range: 0.16 and 0.29

55%

range: 76 and 84%

 

 

Population: patients with LBP in secondary care

Index test: Extension test

2 studies, no pooled analysis

secondary care / MRI‐CT

range: 0.13 to 0.90, depending on cut‐point

range: 0.17 to 0.94, depending on cut‐point

range: 55 and 88%

 

 

Population: patients with LBP in secondary care

Index test: Slump test

2 studies, no pooled analysis

secondary care / MRI‐CT

range: 0.44 to 0.87, depending on cut‐point

range: 0.23 to 0.63, depending on cut‐point

88% and unclear (case control study)

 

 

Population: patients with LBP in secondary care

Indext test: Bell test

1 study

secondary care / MRI‐CT

0.49 (0.33 to 0.65)

0.63 (0.45 to 0.79)

55%

 

 

* Results from the single primary care study are presented separately. For surgical studies, range of estimates is given (no pooled analysis because of heterogeneity)

** Not weighted for sample size

Figuras y tablas -
Summary of findings Summary Table: performance of aspects of physical examination in the diagnosis of lumbar radiculopathy due to disc herniation in patients with low‐back pain
Table Tests. Data tables by test

Test

No. of studies

No. of participants

1 SLR (leg pain at any angle) ‐ reference test: imaging Show forest plot

5

672

2 SLR (leg pain at any angle) ‐ reference test surgery Show forest plot

10

6561

3 X‐SLR (leg pain at any angle) ‐ reference test surgery or imaging Show forest plot

5

2950

4 Scoliosis (visual inspection) ‐ reference test: surgical findings Show forest plot

4

479

5 Paresis (dorsiflexion toe/ankle) ‐ reference test:surgical findings or imaging Show forest plot

7

3419

6 Muscle wasting ‐ reference test: surgical findings Show forest plot

3

397

7 Impaired reflexes (Achilles tendon) ‐ reference test: surgical findings or imaging Show forest plot

7

4515

8 Sensory deficits ‐ reference test surgical findings or imaging Show forest plot

6

935

9 Forward flexion ‐ reference test surgery or imaging Show forest plot

3

442

Figuras y tablas -
Table Tests. Data tables by test