Clinical findings associated with diagnosing lumbar foraminal stenosis: systematic review

Purpose To determine the diagnostic value of history taking and clinical examination tests for diagnosing lumbar radicular pain due to foraminal stenosis (FS) as established using magnetic resonance imaging (MRI). Method An electronic search of PubMed, CINAHL, Embase and MEDLINE was conducted. Studies with diagnostic accuracy of FS using dichotomous index tests (patient history measures and clinical examination tests) were included. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS 2) tool. Diagnostic value of index test was analyzed using proportions of positive findings (sensitivity). Specificity was not obtained. The results of all patients with FS were compared with all patients of a different specific diagnosis, disc herniation (DH) or central spinal stenosis (CSS), by comparing the proportion of positive findings for each index test. Results A total of 2,491records were identified. After title and abstract screening, 1,951 records were excluded, and 84 full-text articles were assessed for eligibility. Finally, 15 studies were included. No study investigating accuracy of tests for patients with recess stenosis was found. In the included studies, 737 subjects had FS, and 10 different index tests were found (2 patient history measures and 8 clinical examination tests). Of the 15 included studies, overall risk of bias was judged as low in two studies, while remaining studies had some concerns primarily due to unclear risk in the index test and flow and timing domains. Applicability concerns were generally low across studies. The index tests with highest average proportion of positive findings in detecting FS were Leg pain at rest (74%; 4 studies, n = 190) and Lumbar extensions test (66%; 11 studies, n = 537); and the test with the lowest proportion of positive findings was Straight leg raise (SLR; 33%; 10 studies, n = 471). Conclusion This review concluded that SLR has the lowest ability to detect lumbar foraminal stenosis, whereas positive Lumbar extension test and Leg pain at rest have the highest ability to detect the diagnosis. These findings should be interpreted cautiously given methodological uncertainties and limited diagnostic accuracy evidence.