Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviewsReportar como inadecuado

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BMC Musculoskeletal Disorders

, 18:188

Orthopedics and biomechanics


BackgroundClinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules CDR for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.

MethodsA sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.

ResultsSixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.

ConclusionsThis is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

KeywordsDiagnostic accuracy Sensitivity and specificity Clinical examination Low back pain classification Clinical decision making AbbreviationsCDRClinical diagnostic rule

CSCentral sensitization

CTX-ray computed tomography

FJFacet joint

IDLumbar intervertebral disc

LBPLow back pain

LRLikelihood ratio

MRIMagnetic resonance imaging

NRILumbar nerve root involvement

QUADASQuality Assessment of Diagnostic Accuracy Studies

ROMRange of movement

SIJSacroiliac joint

SLRStraight leg raise

SSLumbar spinal stenosis

TrPMyofascial trigger point

Electronic supplementary materialThe online version of this article doi:10.1186-s12891-017-1549-6 contains supplementary material, which is available to authorized users.

Autor: Tom Petersen - Mark Laslett - Carsten Juhl


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