Extending the straight leg raise test for improved clinical evaluation of sciatica: validity and diagnostic performance with reference to the magnetic resonance imaging

Janne Pesonen, Michael Shacklock, Juha-Sampo Suomalainen, Lauri Karttunen, Jussi Mäki, Olavi Airaksinen, Marinko Rade, Janne Pesonen, Michael Shacklock, Juha-Sampo Suomalainen, Lauri Karttunen, Jussi Mäki, Olavi Airaksinen, Marinko Rade

Abstract

Background: The straight leg raise test (SLR) is one of the most utilized and studied physical tests in patients with low back pain (LBP) for the detection of lumbar disc herniation (LDH), showing high sensitivity and heterogeneous or low specificity. The high incidence of asymptomatic 'pathologic' findings in the magnetic resonance imaging (MRI) scans may cause verification bias to these results. We studied an extended SLR (ESLR) by adding location-specific structural differentiation movements (hip internal rotation or ankle dorsiflexion) to the traditional SLR for it to better differentiate neural symptoms from musculoskeletal. Previously, the ESLR has shown almost perfect interrater reliability between examiners and ability to detect sciatic patients. In this study, we investigated whether a 'positive' ESLR finding is associated with pathology seen on MRI.

Methods: Forty subjects comprised the study population, 20 in sciatic group and 20 in control group. The ESLR was performed 'blinded' to the subjects. After the ESLR, each subject's lumbar MRI was evaluated. The MRIs were analyzed independently by 2 senior radiologists and a spine specialist clinician. The ESLR and MRI results were cross-tabulated. To obtain the odds ratio (OR) with positive ESLR or SLR results for LDH or nerve root compression (NC), a binary logistic regression analysis with subjects' age, gender, height and weight was performed. ESLR's validity was assessed by combination of interrater agreement and percentage prevalence of both LDH and NC.

Results: Of sciatic (ESLR+) patients, 85 % had LDH and 75 % NC in the MRI. Not surprisingly, MRI showed a very high incidence of 'false-positive' findings with the ESLR negative group. The ESLR showed 0.85 sensitivity and 0.45 specificity for LDH and 0.75 sensitivity and 0.50 specificity for NC. A positive result in the ESLR was found to be strongly associated with for both LDH and NC: the OR was 8.0 (p = 0.028) and 5.6 (p = 0.041), respectively.

Conclusions: The ESLR shows high validity in detecting neural symptoms and is strongly associated with pathology seen in the MRI when judged positive. We suggest the use of ESLR in clinical practice as a part of clinical examination, where it may prove to be a valuable tool in detecting patients with sciatic symptoms.

Conflict of interest statement

The authors declare they have no competing or conflict of interest.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Proximal structural differentiation for distal symptoms with hip internal rotation. Published earlier by Pesonen et al., BMC Musculoskeletal Disorders 2021 [14]
Fig. 2
Fig. 2
Distal structural differentiation for proximal symptoms with ankle dorsiflexion (also known as Bragard test). Published earlier by Pesonen et al., BMC Musculoskeletal Disorders 2021 [14]
Fig. 3
Fig. 3
MRI showing lumbar disc herniation on L5-S1 disc with neural compression on right S1 nerve root (T2-weighted sagittal and axial views)
Fig. 4
Fig. 4
Crosstabulations between ESLR, traditional SLR and MRI findings for lumbar disc herniation. ESLR = Extended straight leg raise test; MRI = Magnetic resonance imaging; Trad. SLR = Traditional straight leg raise test
Fig. 5
Fig. 5
Crosstabulations between ESLR, traditional SLR and MRI findings for neural compression. ESLR = Extended straight leg raise test; MRI = Magnetic resonance imaging; Trad. SLR = Traditional straight leg raise test
Fig. 6
Fig. 6
Crosstabulations between ESLR and traditional SLR results. ESLR = Extended straight leg raise test, Trad. SLR = Traditional straight leg raise test

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