title: Development of a support tool for the clinical diagnosis of symptomatic lumbar intra- and/or extra-foraminal stenosis.
abstract: BACKGROUND
  Not all lumbar intra- and/or extra-foraminal stenosis (LIEFS) on MRI is symptomatic. Therefore, the establishment of clinical diagnostic tools that can identify patients with symptomatic LIEFS is crucial in the clinical setting. The aim of this study was to develop a support tool for clinical diagnosis of LIEFS.
  
  
  METHODS
  Patients with L5 radiculopathy alone were prospectively enrolled. Fifty-one patients with lumbar spinal canal stenosis only at the L4-5 level and 49 patients with LIEFS only at the L5-S1 level were extracted from this cohort. We compared the two groups with regard to 12 variables--three subjective and three objective items from the Japanese Orthopaedic Association (JOA) score; Kemp's sign; results of the lumbar flexion test, Bonnet test, and Freiberg test; pain on sitting; and pain when recumbent--to determine which factors were associated with a high index of clinical suspicion of LIEFS.
  
  
  RESULTS
  The significant predictors of a final diagnosis of LIEFS were identified as follows: pain when recumbent, Freiberg and Bonnet test results, and pain on sitting. To develop a diagnostic tool, a scoring system (0-20 points) was formulated on the basis of the contribution ratios of these risk factors. To determine the contribution ratio, an integer score was assigned to the identified risk factors as follows: pain when recumbent = 9 points, Freiberg = 5 points, Bonnet = 3 points, and pain on sitting = 3 points. The Hosmer-Lemeshow statistic for this scoring system was p = 0.063, and confirmed that it was a good model. Receiver operating characteristic (ROC) curve analysis demonstrated a cut-off value of 5 points, an area under the ROC curve of 0.87435, sensitivity of 75.5 %, and specificity of 82.3 %.
  
  
  CONCLUSIONS
  We believe that the use of this tool in the clinical setting will improve the accuracy of diagnosing symptomatic LIEFS, which will lead to improved quality of patient care.
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan. yamacha@wakayama-med.ac.jp.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Yamada
authors.affiliation: Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Oka
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Iwasaki
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Toru
authors.initials: T
authors.lastname: Endo
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Masahiko
authors.initials: M
authors.lastname: Kioka
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Yuyu
authors.initials: Y
authors.lastname: Ishimoto
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Keiji
authors.initials: K
authors.lastname: Nagata
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Noboru
authors.initials: N
authors.lastname: Takiguchi
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Hashizume
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Akihito
authors.initials: A
authors.lastname: Minamide
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Yukihiro
authors.initials: Y
authors.lastname: Nakagawa
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Masaki
authors.initials: M
authors.lastname: Kawai
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Shunji
authors.initials: S
authors.lastname: Tsutsui
authors.affiliation: Department of Orthopedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
authors.forename: Munehito
authors.initials: M
authors.lastname: Yoshida
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008159:Lumbar Vertebrae / Q000473:pathology*; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D012372:ROC Curve; D011843:Radiculopathy / Q000175:diagnosis* / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D013123:Spinal Fusion / Q000379:methods; D013130:Spinal Stenosis / Q000150:complications / Q000175:diagnosis* / Q000601:surgery