By February 12, 2014 Read More →

Neurological Examination for Radiculopathy

I found this recent article regarding neurological examination for radiculopathy interesting.

Al Nezari et al (2013) conducted a systematic review and meta-analysis of the literature investigating the diagnostic accuracy of the neurological examination to detect lumbar disc herniation with suspected radiculopathy. The authors found 14 studies that investigated three standard neurological examination components (sensory, motor, and reflexes) met the study criteria and were included. These 14 studies were then meta-analysed in order to compare 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.

The authors results and conclusions were that:

  1. Neurological testing procedures have limited overall diagnostic accuracy in detecting disc herniation with suspected radiculopathy.
  2. 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.

In addition to the Al Nezari et al (2013) systematic review I subsequently found the following study by Iversen et al (2013). The aims of this study were to:

  1. Investigate the association between findings at clinical examination and nerve root impingement.
  2. Evaluate the accuracy of clinical index tests (see below) in a specialised care setting.
  3. See whether imaging clarifies the cause of chronic radicular pain.

The authors followed the following procedure:

  1. 116 patients with symptoms of lumbar radiculopathy lasting more than 12 weeks and with at least one positive index test were included. The tests were the straight leg raising test, and tests for motor muscle strength, dermatome sensory loss, and reflex impairment.
  2. Magnetic resonance imaging or computer tomography were the imaging reference standards. Images were analysed at the level of single nerve root(s), and nerve root impingement was classified as present or absent. Sensitivities, specificities, and positive and negative likelihood ratios (LR) for detection of nerve root impingement were calculated for each individual index test. An overall clinical evaluation, concluding on the level and side of the radiculopathy, was performed.

Results/Conclusions being:

  1. The accuracy of individual clinical index tests used to predict imaging findings of nerve root impingement in patients with chronic lumbar radiculopathy is low when applied in specialised care, but clinicians’ overall evaluation improves diagnostic accuracy slightly.
  2. The tests are not very helpful in clarifying the cause of radicular pain, and are therefore inaccurate for guidance in the diagnostic workup of the patients.
  3. The study population was highly selected and therefore the results from this study should not be generalised to unselected patient populations in primary care nor to even more selected surgical populations.

My Thoughts?

So the information above might seem to suggest that our neurological examinations are not particularly helpful. Maybe we should abandon the traditional neurological examination? A couple of things jump to mind regarding this.

Firstly, what is a radiculopathy? When we look more specifically into the research we see that the definition of radiating leg pain (radiculopathy) is not consistent. Lin et al (2013) conducted a systematic review investigating how radiating leg pain is defined in the research literature, specifically in randomised controlled trials of conservative treatments in primary care. What they found was:

  1. The included studies used multiple terms to describe radiating leg pain; the most commonly used terms were sciatica and disc herniation.
  2. Most studies that used the term sciatica included pain distribution in the eligibility criteria, but studies were inconsistent in including signs (e.g. neurological deficits) and imaging findings.
  3. Studies that used other terms to describe radiating leg pain used inconsistent eligibility criteria between studies and to the pain taxonomy, except that positive imaging findings were required for almost all studies that used disc herniation to describe radiating leg pain.
  4. In view of the varying terms to describe, and eligibility criteria to define, radiating leg pain, consensus needs to be reached for each of communication and comparison between studies.
Secondly, we only have to revisit my post on MRI Findings in Low Back Pain to see that we can, for example, see signs of nerve root compression on MRI in asymptomatic people. So MRI/Imaging findings are not always going to support clinical findings, and vice versa.

Thirdly, it would appear that patients can have different “causes” of “radiculopathy”. We need to be mindful that patients can have different pain “mechanisms” and contributing factors resulting in different signs and symptoms. Hence clinically it would appear that we need to ensure we sub classify patients with referred pain into different categories (as seen above the research also looks like it needs to do this better!). From a pain mechanisms perspective,  I use the classification system devised by Schafer et al. If interested please see the following post for information about this classification system.

My Final Thoughts?

So based on all of the above I  suggest we don’t forget about our neurological examinations!

I think it is a critical part of examining a patient with potential referring limb pain to ascertain if certain “patho-mechanisms” are occurring, or not, in the presentation. Findings from the examination then allow us to better direct treatment/management.

Thanks for reading.

References:

Al Nezari NH, Schneiders AG, Hendrick PA. Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review and meta-analysis. Spine J. 2013 Jun;13(6):657-74.

Iversen T, Solberg TK, Romner B, Wilsgaard T, Nygaard Ø, Waterloo K, Brox JI, Ingebrigtsen T. Accuracy of physical examination for chronic lumbar radiculopathy. BMC Musculoskelet Disord. 2013 Jul 9;14:206.

Lin CW, Verwoerd AJ, Maher CG, Verhagen AP, Pinto RZ, Luijsterburg PA, Hancock MJ. How is radiating leg pain defined in randomized controlled trials of conservative treatments in primary care? A systematic review. Eur J Pain. 2013 Aug 13. doi: 10.1002/j.1532-2149.

Posted in: Clinical Reasoning, Spinal and Pelvic Pain

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

2 Comments on "Neurological Examination for Radiculopathy"

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    May 26, 2014 at 5:18 am

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