MSAT 6502 Takeshi Kitamura February 3, 2014

Accuracy of 4 Diagnostic Tests for Lumbar Neural Tension

Anatomy The lumbar spine consists of five moveable lumbar vertebral bodies L1 to L5. And there is a pair of neural foramina with the same number designation located just below the each lumber vertebral body. Those neural foramina are bounded superiorly and inferiorly by pedicles, anteriorly by the intervertebral disc and vertebral body, and posteriorly by fact joints.2 The nerve root, just distal to the neural foramen, is divided in the dorsal and ventral primary rami. The small dorsal primary ramus supplies motor innervation to the paraspinal muscles and cutaneous innervation to the skin of the trunk and back.2 The large ventral primary ramus supplies motor and sensory innervation to the legs and trunk, including abdominal wall muscles.2 The lumbar nerves consist of five pairs of nerve roots and the lumbar plexus includes T12 nerve and L1-5 nerve roots. Lower part of the lumbar plexus merges with the sacral plexus, whereas the posterior branches of L2-4 nerve roots converge to form the femoral nerve and the anterior branches merge to form the obturator nerve.2 Along these skeletal and neurologic structures, there are intrinsic and extrinsic muscles to support the lumbar spinal column. Intrinsic muscles such as erector spinae muscles are located close to the spinal column and directly influence lumbar motion and postural control.2 Extrinsic muscles provide more dynamic control such as respiration movement related to the upper extremity and support lumbar motion (e.g. rectus abdominus, internal/external obliques, transverse abdominus).2

Mechanisms of Injury The most common mechanisms of lumbar neural tension is nerve rot compression caused by any of following etiologies: disc herniation, spondylosis, spinal stenosis, facet joint degeneration, or other intervertebral space-occupying conditions.1,2,4,7 The lumbar spine, in general, is susceptible to these pathologies above, especially L4-5, because of its mobility and compression loading.1,2,7 However, nerve roots may be injured at any disc level from the L1-2 level to the level of their exit into their neural foramina, depending on the nature and location of compression.7 And there is increased likelihood of multiple and/or bilateral simultaneous nerve root compressions due to their multiple because of the presence of multiple spinal nerve roots in the cauda equina.1,7 Congenital narrowing of the canal such as spinal stenosis and spina bifida is also not uncommon that may result in traction of the nerve

roots.1 Other possible mechanisms include but not limited to infection, inflammation, neoplasm, and vascular disease.1

Evaluation The findings of the lumbar neural tension vary according to the nature of injury and level of nerve root or roots involved. As mentioned previously, the L5 nerve roots are most commonly involved and prone to radiculopathies. The L5 nerve roots exit via the neural foramina at the L5/S1 disc space level, and it usually gets compressed by posterolateral disc herniation of the L4/L5.2 The L5 lesion often presents with back pain that radiates down the lateral aspect of the leg into the foot.3,7 Typical chief complaints include but not limited to muscle weakness in particular myotome (e.g. difficulty getting up from a chair, buckling of the knee, dragging of the toe), sensory changes in lower extremities, and radicular pain with particular activities such as lifting and bending.1,3,7 Objective findings vary according to specific nerve root levels of involvement. The L5 lesion typically affects muscle strength and reduces ankle dorsiflexion, inversion, and eversion, toe extension, and gluteus minimus and medius.3,7 Atrophy could also be present in the extensor digitorum brevis and tibialis anterior. Sensory loss may also be present in the lateral aspect of the lower leg and dorsum of the foot, especially in the web space between the first and second digits.3,7 Deep tendon reflexes are usually found intact. If these L1-4 nerve roots are involved, on the other hand, acute back pain with radiating pain in the anterior aspect of the leg down into the knee and medial aspect of the lower leg as far as the arch of the foot are typically present as a chief complaint.3 There may be muscle weakness in hip flexion and knee extension present as well as sensory loss over the anterior thigh down to the medial aspect of the lower leg.3,7, And knee reflex is typically reduced on the affected side. Severity of condition may vary upon underlying pathologies.3 The lumbar neural tension may be misdiagnosed in case of low back pain caused by injury of non-neurologic structures such as muscles, tendons, ligaments, or fascia without affecting the nerve roots.1,3,7

Gold Standard Test Magnetic resonance imaging (MRI) is considered as the gold standard diagnostic test to identify the cause of lumbar neural tension, compared to other imaging studies such as radiography and computed tomography (CT). The sensitivity and specificity of MRI in detecting the changes in lumbar neural structure has been reported at 0.83 and 0.78, respectively.4,6 The CT scan is helpful to assess osseous structures but cannot visualize nerve 2

roots. And plain radiographs are only useful to identify osseous deficits such as fracture, spondylolisthesis, and degenerative changes. Although the MRI is the gold standard test for lumbar neural tension, there are some false positive findings with MRI in asymptomatic individuals who have MRI evidence of disc herniation but no back pain.4-6 A combination of electromyography (EMG) and nerve conduction studies (NCS) can also give a high diagnostic information of spinal nerve roots and their connection with the muscles they innervate.4-7 These tests are commonly considered if neurologic weakness persists for at least three weeks and neuroimaging findings are not consistent with the clinical presentation.

Straight Leg Raise Test The straight leg raise (SLR) test is performed with a patient in a supine position. The examiner raises the patients extended leg on the symptomatic side with passive ankle dorsiflexion. The patient may report the presence or worsening of radicular pain as the examiner raises the leg. The examiner then flexes the knee while maintaining the degree of hip flexion. A positive SLR test refers to the relief of radicular pain when the knee is flexed. It usually occurs between 30 and 60 degrees of hip flexion, indicating the presence of disc pathologies such as disc herniation with nerve root compression.8,9 However, individuals with tight hamstrings may present with similar symptoms but no lumbar pain.8 In the literature, the diagnostic accuracy of the SLR seems limited due to its low specificity. Rabin et al found that the supine SLR test has higher sensitivity (0.67) than seated SLR test (0.41) among individuals with consistent signs and symptoms of lumbar radiculopathy and MRI evidence of nerve root compression.10 Neither the specificity nor likelihood ratio was reported in this study because of their patients who presented with positive MRI findings and an insufficient sample size of patients with negative MIR findings to the rate of a negative SLR test result.10 Majlesi et al reported the SLR test have a high specificity (0.89) with low sensitivity (0.52) and relatively high positive likelihood ratio (4.73) and negative likelihood ratio (0.54) in patients with and without lumbar disc herniation.11 They also found a higher validity of the SLR test when the MRI confirmed nerve root compression (sensitivity=0.84, specificity=0.88, LR+ =7, LR- =0.18), L4/5 disc herniation (sensitivity=0.78, specificity=0.86, LR+=5.57, LR=0.26), and L5/S1 disc herniation (sensitivity=0.75, specificity=0.95, LR+=15, LR- =0.26).11 Capra et al, on the other hand, pointed out the low accuracy and limited usefulness of the SLR in identifying L4/5 and L5/S1 lumbar disc herniation if compared with MRI findings.12 Sensitivity and specificity were 0.36 and 0.74, whereas positive and negative likelihood were 1.38 and 0.87 for the SLR test in patients with sciatic pain with and without lumbar pain.12 3

There has been an inconsistency of findings in the diagnostic accuracy of SLR test depending on the study design (e.g. population, testing procedures, comparison with imaging studies), and therefore it is still inconclusive in diagnosis of lumbar neural tension.

Slump Test The Slump test is performed with a patient in a short-sitting position with hands behind his/her back. The testing procedure is divided into four steps. The patient is first asked to actively flex (slump) cervical/thoracic spine followed by neck flexion, and the examiner places his/her hand on top of head to maintain the slump position. The patient then actively extend the knee until full extension is reached and dorsiflex the ankle while maintaining the slump position. The examiner then remove his/her hand from the patients head and the patient extend the neck to neutral position. The slump test is considered positive if symptoms are reproduced or increased in the slumped position and decreased as the patient is released from the neck flexion.13-16 In the literature, the diagnostic accuracy of the Slump test also seems limited. Walsh et al suggest that sensory responses elicited during the Slump test are not necessarily indicative of pathologies but may be suggestive of lumbar neural pathology.13 Davis et al found that the Slump test has a high false positive rate (33%) with specificity of 0.67.14 They suspect the effects of full knee extension in its testing procedure on the diagnostic validity of the test and suggest that a positive test should only be considered when peripheral symptoms are reproduced before 22 degrees of knee extension.14 Majlesi et al also investigated the correlation between the Slump test and the SLR test in the patients with lumbar disc herniation and nerve root compression.15 Sensitivity and specificity of the Slump test were 0.84 and 0.83 (LR+=4.94, LR-=0.19), whereas 0.52 and 0.89 for the SLR test.15 They also found a higher validity of the Slump test when the MRI confirmed nerve root compression (sensitivity=0.84, specificity=0.90, LR+ =8.4, LR- =0.18), L4/5 disc herniation (sensitivity=0.78, specificity=0.88, LR+=6.5, LR- =0.25), and L5/S1 disc herniation (sensitivity=0.91, specificity=0.90, LR+=9.1, LR- =0.1).15 The findings indicate that the Slump test may be more accurate than the SLR test for ruling out the condition, whereas the SLR is slightly more accurate in ruling in the condition. Walsh et al later found that the SLR test and the Slump test have a good correlation in individual with peripheral symptoms.16 And they suggest that a combination of these two tests may be appropriate tests to identify the lumber neural tension, but only when the Slump test is interpreted as positive in the event of reproduction of presenting leg pain elicited by ankle dorsiflexion.16 Thus, the diagnostic accuracy of the Slump test is still inconclusive, but these findings of the Slump tests high 4

validity would support its use as part of physical examination of lumbar neural pathology.

Brudzinski & Kernig Tests The Brudzinski and Kernig tests are typically used to assess for inflammation of the meninges associated with certain pathologies including meningitis, disc pathology, or other conditions causing inflammation in the spinal canal.17 Both of these tests are performed with the patient in supine. In clinical settings, these tests are performed in slightly different maneuvers depending on the patient population and their suspected pathologies. The most typically performed maneuver of the Kernig test is described as the patient supine with hips and knees in flexion. The inability of knee extension beyond 135 degrees without causing pain is considered as a positive test.17 The Brudzinski test is also described as the patient supine with active cervical flexion. A positive test consists of an increase in pain with active cervical and hip flexion (straight leg raise) and reduction of pain followed by active knee flexion.17 Thomas et al investigated the diagnostic accuracy of Brudzinski and Kernig sings for identifying individuals with suspected meningitis. For both of these tests, they found the same sensitivity (0.05), specificity (0.95), positive likelihood ratio (0.07), and negative likelihood ratio (1.0).17 According to the results of both low sensitivity and poor negative likelihood, neither tests seem accurate in ruling out the condition when tests are negative. In addition, high specificity and poor positive likelihood ratio of the tests indicate that positive results of these tests may be false positive and do not accurately identify those individuals with meningitis. Therefore, the Brudzinski test and Kernig test are not valid tests either ruling in or out the condition, and should not be relied on identifying with meningitis. Further prospective studies are needed to thoroughly evaluate the validity of these tests in a wide variety of populations with meningitis lumber pathologies.

Clinical Recommendations Despite a widespread use of the Straight Leg Raise (SLR) test, Slump test, and Brudzinski and Kernig tests in a diagnosis of lumbar neural tension, there have been little research in relation to the accuracy of these tests conducted and their findings have not been consistent. In a thorough literature review, the SLR test was found without a consistent validity or likelihood ratio, but it could still be a helpful on-field tool as one of the basic components of physical examination of the lumbar neural pathology. When the SLR is combined with the Slump test, especially, it should become more informative and increase a total diagnostic accuracy by ruling out the condition with the negative Slump test and ruling in the condition 5

with the positive SLR test. In addition to these two tests, the Brudzinski and Kernig signs may provide a clinician with supplemental information of inflammation in meninges. In conclusion, the clinician should not solely rely on one of these tests because they are not very accurate or helpful in clarifying the cause of lumbar neural tension. A combination of the SLR test and Slump test may be considered in order to obtain a fairly reasonable idea of the lumbar neural status. Further imaging studies such as MRI are essential to investigate the cause of lumbar neural tension and make an accurate diagnosis followed by proper treatment and rehabilitation.

Reference
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12. Capra F, Vanti C, Donati R, Tombetti S, O'reilly C, Pillastrini P. Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. J Manipulative Physiol Ther. 2011;34(4):231-8. 13. Walsh J, Flatley M, Johnston N, Bennett K. Slump test: sensory responses in asymptomatic subjects. J Man Manip Ther. 2007;15(4):231-8. 14. Davis DS, Anderson IB, Carson MG, Elkins CL, Stuckey LB. Upper Limb Neural Tension and Seated Slump Tests: The False Positive Rate among Healthy Young Adults without Cervical or Lumbar Symptoms. J Man Manip Ther. 2008;16(3):136-41. 15. Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008;14(2):87-91. 16. Walsh J, Hall T. Agreement and correlation between the straight leg raise and slump tests in subjects with leg pain. J Manipulative Physiol Ther. 2009;32(3):184-92. 17. Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis. 2002;35(1):46-52.