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Spine Apr 2013Systematic review of diagnostic studies. (Review)
Review
STUDY DESIGN
Systematic review of diagnostic studies.
OBJECTIVE
To update our previous systematic review on the diagnostic accuracy of tests used to diagnose lumbar spinal stenosis.
SUMMARY OF BACKGROUND DATA
A wide range of clinical, radiological, and electrodiagnostic tests are used to diagnose lumbar spinal stenosis. An accurate diagnosis is vital, because lumbar spinal stenosis may require specific medical advice and treatment. Therefore, it is important to know the accuracy of these diagnostic tests currently available.
METHODS
A comprehensive literature search was conducted for original diagnostic studies on lumbar spinal stenosis, in which one or more diagnostic tests were evaluated with a reference standard, and diagnostic accuracy was reported or could be calculated. Our previous systematic review included studies up to March 2004; this review is current up to March 2011. Included studies were assessed for their methodological quality using the QUADAS tool. Study characteristics and reported diagnostic accuracy were extracted.
RESULTS
Twenty-two additional articles in addition to the 24 included in the previous review met the inclusion criteria. Combined, this resulted in 20 articles concerning imaging tests, 11 articles evaluating electrodiagnostic tests, and 15 articles evaluating clinical tests. Estimates of the diagnostic accuracy of the tests differed considerably.
CONCLUSION
There is a need for a consensus on criteria to define and classify lumbar spinal stenosis. At present, the most promising imaging test for lumbar spinal stenosis is magnetic resonance imaging, avoiding myelography because of its invasiveness and lack of superior accuracy. Electrodiagnostic studies showed no superior accuracy for conventional electrodiagnostic testing compared with magnetic resonance imaging. These tests should be considered in the context of those presenting symptoms with the highest diagnostic value, including radiating leg pain that is exacerbated while standing up, the absence of pain when seated, the improvement of symptoms when bending forward, and a wide-based gait.
Topics: Diagnostic Imaging; Diagnostic Techniques and Procedures; Electrodiagnosis; Humans; Lumbar Vertebrae; Reproducibility of Results; Sensitivity and Specificity; Spinal Stenosis
PubMed: 23385136
DOI: 10.1097/BRS.0b013e31828935ac -
European Spine Journal : Official... May 2013In this article, we review the English literature of calcified pseudomeningoceles in the lumbar region. (Review)
Review
PURPOSE
In this article, we review the English literature of calcified pseudomeningoceles in the lumbar region.
METHODS
A systematic review using the Medline Database using the varied nomenclature for pseudomeningoceles, as well as reviewing the reference lists of relevant article found.
RESULTS
We discuss the different pathological theories on formation of a pseudomeningocele, the formation of a calcified wall and the optimal management for this entity. To date, 17 cases have been described, of which 13 are reviewed here. Calcification of pseudomeningocele is a rare entity and in the lumbar spine this occurs postsurgically. The only predisposing factor is prior surgery to the lumbar spine. Computer tomography, magnetic resonance imaging (MRI) and MRI myelography in combination are the preoperative investigations of choice. The radiological work-up can be preoperatively diagnostic and is important in the surgical planning.
CONCLUSIONS
The treatment is surgicel removal and the decision to treat is based on patient symptoms and correlating these with imaging. There is an average reported follow-up of 1.7 years postoperatively for these patients and the reported outcome after surgery is good.
Topics: Calcinosis; Female; Humans; Lumbar Vertebrae; Meningocele; Middle Aged; Orthopedic Procedures
PubMed: 23233216
DOI: 10.1007/s00586-012-2610-7 -
Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain.The Cochrane Database of Systematic... Feb 2010Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative... (Review)
Review
BACKGROUND
Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative treatment, but in carefully selected patients, surgical discectomy may provide faster relief of symptoms. Primary care clinicians use patient history and physical examination to evaluate the likelihood of disc herniation and select patients for further imaging and possible surgery.
OBJECTIVES
(1) To assess the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica;(2) To assess the influence of sources of heterogeneity on diagnostic performance.
SEARCH STRATEGY
We searched electronic databases for primary studies: PubMed (includes MEDLINE), EMBASE, and CINAHL, and (systematic) reviews: PubMed and Medion (all from earliest until 30 April 2008), and checked references of retrieved articles.
SELECTION CRITERIA
We considered studies if they compared the results of tests performed during physical examination on patients with back pain with those of diagnostic imaging (MRI, CT, myelography) or findings at surgery.
DATA COLLECTION AND ANALYSIS
Two review authors assessed the quality of each publication with the QUADAS tool, and extracted details on patient and study design characteristics, index tests and reference standard, and the diagnostic two-by-two table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for all aspects of physical examination. Pooled estimates of sensitivity and specificity were computed for subsets of studies showing sufficient clinical and statistical homogeneity.
MAIN RESULTS
We included 16 cohort studies (median N = 126, range 71 to 2504) and three case control studies (38 to100 cases). Only one study was carried out in a primary care population. When used in isolation, diagnostic performance of most physical tests (scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits) was poor. Some tests (forward flexion, hyper-extension test, and slump test) performed slightly better, but the number of studies was small. In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings.Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35).Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations.
AUTHORS' CONCLUSIONS
When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.
Topics: Humans; Intervertebral Disc Displacement; Low Back Pain; Lumbosacral Region; Physical Examination; Radiculopathy; Sciatica
PubMed: 20166095
DOI: 10.1002/14651858.CD007431.pub2 -
Journal of Neurosurgery. Spine Aug 2009The objective of this systematic review was to use evidence-based medicine to assess whether preoperative imaging or electromyography (EMG) predicts surgical outcomes in...
OBJECT
The objective of this systematic review was to use evidence-based medicine to assess whether preoperative imaging or electromyography (EMG) predicts surgical outcomes in patients undergoing cervical surgery.
METHODS
The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the preoperative imaging and EMG. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.
RESULTS
Preoperative MR imaging and CT myelography are successful in confirming clinical radiculopathy (Class II). Multilevel T2 hyperintensity, T1 focal hypointensity combined with T2 focal hyperintensity, and spinal cord atrophy each convey a poor prognosis (Class III). There is conflicting data concerning whether focal T2 hyperintensity or cervical stenosis are associated with a worse outcome. Electromyography has mixed utility in predicting outcome (Class III).
CONCLUSIONS
Magnetic resonance imaging or CT myelography are important for preoperative assessment. Magnetic resonance imaging may be helpful in assessing prognosis, whereas EMG has mixed utility in assessing outcome.
Topics: Cervical Vertebrae; Electroencephalography; Electromyography; Humans; Magnetic Resonance Imaging; Patient Selection; Prognosis; Radiculopathy; Spinal Cord; Spinal Cord Diseases; Spinal Stenosis; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 19769491
DOI: 10.3171/2009.3.SPINE08717 -
Spine May 2006Systematic review of diagnostic studies. (Review)
Review
STUDY DESIGN
Systematic review of diagnostic studies.
OBJECTIVE
To investigate the diagnostic performance of tests used to detect lumbar spinal stenosis.
SUMMARY OF BACKGROUND DATA
Little is known about the diagnostic accuracy of tests in detecting lumbar spinal stenosis. A systematic review will provide more insight in this topic.
METHODS
We performed a literature search in Medline (PubMed) and Embase for original diagnostic studies on lumbar spinal stenosis, in which one or more different tests were evaluated with a reference standard, and diagnostic values were reported or could be calculated. Two reviewers independently checked all abstracts and full text articles for inclusion criteria. Included articles were assessed for their quality using the Quadas tool. Study features and diagnostic values were extracted from the included studies.
RESULTS
Of the 24 articles included in this review, 15 concerned imaging tests, 7 evaluated "clinical tests," and 2 reported on other diagnostic tests. The overall quality was poor; only 5 studies scored positive on more than 50% of the quality items. Estimates of the diagnostic value of the tests differed considerably. The imaging studies showed no superior accuracy for myelography compared with CT or MRI. Overall, there is considerable variation in the clinical tests; some studies show high sensitivity, whereas others show high specificity.
CONCLUSIONS
Because of heterogeneity and overall poor quality, no firm conclusions about the diagnostic performance of the different tests can be drawn. Better-designed studies exploring the accuracy of diagnostic tests are needed to improve the diagnostic policy.
Topics: Diagnostic Tests, Routine; Humans; Lumbar Vertebrae; MEDLINE; Reproducibility of Results; Sensitivity and Specificity; Spinal Stenosis
PubMed: 16648755
DOI: 10.1097/01.brs.0000216463.32136.7b -
Journal of Clinical Oncology : Official... Mar 2005This systematic review describes the diagnosis and management of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression... (Review)
Review
Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group.
PURPOSE
This systematic review describes the diagnosis and management of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MSCC).
METHODS
MEDLINE, CANCERLIT, and the Cochrane Library databases were searched to January 2004 using the following terms: spinal cord compression, nerve compression syndromes, spinal cord neoplasms, clinical trial, meta-analysis, and systematic review.
RESULTS
Symptoms for MSCC include sensory changes, autonomic dysfunction, and back pain; however, back pain was not predictive of MSCC. The sensitivity and specificity for magnetic resonance imaging (MRI) range from 0.44 to 0.93 and 0.90 to 0.98, respectively, in the diagnosis of MSCC. The sensitivity and specificity for myelography range from 0.71 to 0.97 and 0.88 to 1.00, respectively. A randomized study detected higher ambulation rates in patients with MSCC who received high-dose dexamethasone before radiotherapy (RT) compared with patients who did not receive corticosteroids before RT (81% v 63% at 3 months, respectively; P = .046). There is no direct evidence that supports or refutes the type of surgery patients should have for the treatment of MSCC, whether surgical salvage should be attempted if patient is progressing on or shortly after RT, and whether patients with spinal instability should be treated with surgery.
CONCLUSION
Patients with symptoms of MSCC should be managed to minimize treatment delay. MRI is the preferred imaging technique. Treatment for patients with MSCC should consider pretreatment ambulatory status, comorbidities, technical surgical factors, the presence of bony compression and spinal instability, potential surgical complications, potential RT reactions, and patient preferences.
Topics: Adrenal Cortex Hormones; Humans; Ontario; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Spinal Cord Compression; Spinal Neoplasms
PubMed: 15774794
DOI: 10.1200/JCO.2005.00.067 -
CMAJ : Canadian Medical Association... Nov 2001Headache after cervical or lumbar puncture has long been attributed to early mobilization; however, there is little evidence for this. We performed a systematic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Headache after cervical or lumbar puncture has long been attributed to early mobilization; however, there is little evidence for this. We performed a systematic literature review and meta-analysis of randomized controlled trials to assess whether longer bed rest is better than immediate mobilization or short bed rest in preventing headache.
METHODS
We searched EMBASE (1988 to March 2001), MEDLINE (1966 to May 2001), Pascal Biomed (1996 to February 2001), Current Contents (1997 to September 1999), PsycINFO (1966 to May 2001), the Cochrane Controlled Trial Register (last search May 15, 2001), textbooks and references of the papers selected. Studies were eligible if patients underwent cervical or lumbar puncture for any reason and were randomly assigned to either a long or a short period of bed rest. Data were abstracted independently by 2 investigators to a predefined form.
RESULTS
We found 16 randomized controlled trials involving 1083 patients assigned to immediate mobilization or a short period of bed rest (up to 8 hours) and 1128 patients assigned to a longer period of bed rest (0.5 to 24 hours). Puncture was performed for anesthesia (5 trials), myelography (6 trials) and diagnostic reasons (5 trials). None of the trials showed that longer bed rest was superior to immediate mobilization or short bed rest for preventing headache after puncture. When pooling the results of the trials in the myelography group and the diagnostic group, the relative risks of headache after puncture were 0.93 (95% confidence interval [CI] 0.81-1.08) and 0.97 (95% CI 0.79-1.19) respectively. We did not pool the results from the trials in the anesthesia group because of clinical heterogeneity, but shorter bed rest appeared to be superior.
INTERPRETATION
There was no evidence that longer bed rest after cervical or lumbar puncture was better than immediate mobilization or short bed rest in reducing the incidence of headache.
Topics: Bed Rest; Cervical Vertebrae; Headache; Humans; Randomized Controlled Trials as Topic; Spinal Puncture; Time Factors
PubMed: 11760976
DOI: No ID Found