title: The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement.
abstract: METHODS
  Cross-sectional study with prospective recruitment. OBJECTIVE.: To determine the accuracy of the physical examination for the diagnosis of midlumbar nerve root impingement (L2, L3, or L4), low lumbar nerve root impingement (L5 or S1) and level-specific lumbar nerve root impingement on magnetic resonance imaging, using individual tests and combinations of tests.
  
  
  BACKGROUND
  The sensitivity and specificity of the physical examination for the localization of nerve root impingement has not been previously studied.
  
  
  METHODS
  Sensitivities, specificities, and likelihood ratios (LRs) were calculated for the ability of individual tests and test combinations to predict the presence or absence of nerve root impingement at midlumbar, low lumbar, and specific nerve root levels.
  
  
  RESULTS
  LRs ≥5.0 indicate moderate to large changes from pre-test probability of nerve root impingement to post-test probability. For the diagnosis of midlumbar impingement, the femoral stretch test (FST), crossed FST, medial ankle pinprick sensation, and patellar reflex testing demonstrated LRs ≥5.0 (LR ∞). LRs ≥5.0 were observed with the combinations of FST and either patellar reflex testing (LR 7.0; 95% confidence interval [CI] 2.3-21) or the sit-to-stand test (LR ∞). For the diagnosis of low lumbar impingement, the Achilles reflex test demonstrated an LR ≥5.0 (LR 7.1; 95% CI 0.96-53); test combinations did not increase LRs. For the diagnosis of level-specific impingement, LRs ≥5.0 were observed for anterior thigh sensation at L2 (LR 13; 95% CI 1.8-87); FST at L3 (LR 5.7; 95% CI 2.3-4.4); patellar reflex testing (LR 7.7; 95% CI 1.7-35), medial ankle sensation (LR ∞), or crossed FST (LR 13; 95% CI 1.8-87) at L4; and hip abductor strength at L5 (LR 11; 95% CI 1.3-84). Test combinations increased LRs for level-specific root impingement at the L4 level only.
  
  
  CONCLUSIONS
  Individual physical examination tests may provide clinical information that substantially alters the likelihood that midlumbar impingement, low lumbar impingement, or level-specific impingement is present. Test combinations improve diagnostic accuracy for midlum-bar impingement.
authors.affiliation: Division of Research, New England Baptist Hospital, Boston, MA, USA. psuri@caregroup.harvard.edu
authors.forename: Pradeep
authors.initials: P
authors.lastname: Suri
authors.forename: James
authors.initials: J
authors.lastname: Rainville
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Katz
authors.forename: Cristin
authors.initials: C
authors.lastname: Jouve
authors.forename: Carol
authors.initials: C
authors.lastname: Hartigan
authors.forename: Janet
authors.initials: J
authors.lastname: Limke
authors.forename: Enrique
authors.initials: E
authors.lastname: Pena
authors.forename: Ling
authors.initials: L
authors.lastname: Li
authors.forename: Bryan
authors.initials: B
authors.lastname: Swaim
authors.forename: David J
authors.initials: DJ
authors.lastname: Hunter
mesh_terms: D000328:Adult; D000368:Aged; D001900:Boston; D003430:Cross-Sectional Studies; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D016013:Likelihood Functions; D017116:Low Back Pain / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D035002:Lower Extremity / Q000294:innervation*; D008159:Lumbar Vertebrae; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D053580:Muscle Strength; D009408:Nerve Compression Syndromes / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology; D009460:Neurologic Examination; D010147:Pain Measurement; D010808:Physical Examination; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012018:Reflex; D012677:Sensation; D012680:Sensitivity and Specificity; D013126:Spinal Nerve Roots / Q000503:physiopathology*; D011795:Surveys and Questionnaires