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Accuracy of the clinical examination to predict radiographic instability of the lumbar spine

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Abstract

Forty-nine patients with low-back pain referred for flexion-extension radiographs due to suspicion of lumbar instability were studied to examine the relationship between the clinical presentation and the presence of radiographic instability of the lumbar spine. Patients had a mean age of 39.2 (±11.3) years, with a mean Oswestry score of 20.4% (±13.3). The median duration of symptoms was 78 days. All patients underwent both a radiographic and clinical examination. The reliability of the radiographic variables was high, while the reliability of clinical variables ranged from moderate to good. Twenty-eight patients (57%) had radiographic instability based on published norms. Clinical variables related to the presence of radiographic instability were age, lumbar flexion range of motion, total extension range of motion, the Beighton scale for general ligamentous laxity, and segmental intervertebral motion testing. The presence of at least 53° of lumbar flexion or a lack of hypomobility with intervertebral motion testing resulted in a positive likelihood ratio of 4.3 (95% CI: 1.8, 10.6), for predicting radiographic instability. The results of this study indicate that various factors from the clinical examination are useful for predicting radiographic instability. If the findings of this study can be replicated, these clinical factors could be used to inform treatment decision-making without a sole reliance on radiographic assessment.

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References

  1. Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P, Scott S (1995) The prognostic consequences in the making of the initial medical diagnosis of work-related back injuries. Spine 20:791–795

    PubMed  Google Scholar 

  2. Bednar DA (2001) Failure of external spinal skeletal fixation to improve predictability of lumbar arthrodesis. J Bone Joint Surg Am 83-A:1656–1659

    PubMed  Google Scholar 

  3. Beighton P, Horan F (1969) Orthopedic aspects of Ehlers-Danlos syndrome. J Bone Joint Surg Br 51:444–453

    PubMed  Google Scholar 

  4. Berlemann U, Jeszenszky DJ, Buhler DW, Harms J (1998) Facet joint remodeling in degenerative spondylolisthesis: an investigation of joint orientation and tropism. Eur Spine J 7:376–380

    Article  PubMed  Google Scholar 

  5. Boden SD, Wiesel SW (1991) Lumbosacral segmental motion in normal individuals. Have we been measuring instability properly? Spine 15:571–575

    Google Scholar 

  6. Borkan JM, Cherkin DC (1996) An agenda for primary care research on low back pain. Spine 21:2880–2884

    Article  PubMed  Google Scholar 

  7. Borkan JM, Koes B, Reis S, Cherkin DC (1998) A report from the second international forum for primary care research on low back pain: reexamining priorities. Spine 23:1992–1996

    Article  PubMed  Google Scholar 

  8. Brown MD, Wehman KF, Heiner AD (2002) The clinical usefulness of intraoperative spinal stiffness measurements. Spine 27:959–961

    Article  PubMed  Google Scholar 

  9. Bouter LM, van Tulder MW, Koes BW (1998) Methodologic issues in low back pain research in primary care. Spine 23:2014–2020

    Article  PubMed  Google Scholar 

  10. Buttermann GR, Garvey TA, Hunt TF et al (1998) Lumbar fusion results related to diagnosis. Spine 23:116–127

    Article  PubMed  Google Scholar 

  11. Cohen J (1960) A coefficient of agreement for nominal scales. Educ Psychol Meas 20:37–46

    Google Scholar 

  12. Coste J, Paolaggi J, Spira A (1992) Classification of non-specific low back pain II. Clinical diversity of organic forms. Spine 17:1038–1042

    PubMed  Google Scholar 

  13. Davidson M, Keating JL (2002) A comparison of five low back disability questionnaires: reliability and responsiveness. Phys Ther 82:8–24

    PubMed  Google Scholar 

  14. Delitto A, Erhard RE, Bowling RW (1995) A treatment based classification approach to low back syndrome: Identifying and staging patients for conservative treatment. Phys Ther 75:470–489

    PubMed  Google Scholar 

  15. Dupuis PR, Yong-Hing K, Kassidy JD, Kirkaldy-Willis WH (1985) Radiographic diagnosis of degenerative lumbar spinal instability. Spine 10:262–276

    PubMed  Google Scholar 

  16. Dvorak J, Panjabi M, Novotny JE, Chang DG, Grob D (1991) Clinical validation of functional flexion extension roentgenograms of the lumbar spine. Spine 16:943–950

    PubMed  Google Scholar 

  17. Fairbank JC, Couper J, Davies JB, O’Brien JP (1980) The Oswestry low back pain disability questionnaire. Physiotherapy 66:271–273

    PubMed  Google Scholar 

  18. Flynn T, Fritz J, Whitman J et al (2002) A clinical prediction rule for classifying patients with low back pain who demonstrate short term improvement with spinal manipulation. Spine 27:2835–2843

    Article  PubMed  Google Scholar 

  19. Fritz JM, Erhard RE, Hagen BF (1998) Segmental instability of the lumbar spine. Phys Ther 78:889–96

    PubMed  Google Scholar 

  20. Fritz JM, George S (2000) The use of a classification approach to identify subgroups of patients with acute low back pain: inter-rater reliability and short-term treatment outcomes. Spine 25:114–121

    Google Scholar 

  21. Fritz JM, Irrgang JJ (2001) A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther 81:776–788

    PubMed  Google Scholar 

  22. Fritz JM, George SZ, Delitto A (2001) The role of fear avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain 94:7–15

    Article  PubMed  Google Scholar 

  23. Frymoyer JW, Selby DK (1985) Segmental instability. Rationale for treatment. Spine 10:280–286

    PubMed  Google Scholar 

  24. Harreby M, Nygaard B, Jessen T et al (1999) Risk factors for low back pain in a cohort of 1389 Danish school children: an epidemiologic study. Eur Spine J 8:444–450

    Article  PubMed  Google Scholar 

  25. Hayes MA, Howard TC, Gruel CR, Kopta JA (1989) Roentgenographic evaluation of the lumbar spine flexion-extension in asymptomatic individuals. Spine 14:327–331

    PubMed  Google Scholar 

  26. Hides JA, Jull GA, Richardson CA (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 26:E243–E248

    Article  PubMed  Google Scholar 

  27. Hides JA, Richardson CA, Jull GA (1996) Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine 21:2763–2769

    Article  PubMed  Google Scholar 

  28. Jackson RP, Phipps T, Hales C, Surber J (2003) Pelvic lordosis and alignment in spondylolisthesis. Spine 28:151–160

    Article  PubMed  Google Scholar 

  29. Jull GA, Richardson CA (2000) Motor control problems in patients with spinal pain: a new direction for therapeutic exercise. J Manipulative Physiol Ther 23:115–117

    Article  PubMed  Google Scholar 

  30. Kirkaldy-Willis WH, Farfan HF (1982) Instability of the lumbar spine. Clin Orthop 165:110–123

    PubMed  Google Scholar 

  31. Klenerman L, Slade PD, Stanley IM et al (1995) The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting. Spine 20:478–484

    PubMed  Google Scholar 

  32. Knutsson F (1944) The instability associated with disk degeneration in the lumbar spine. Acta Radiol 25:593–609

    Google Scholar 

  33. Larsson LG, Mudholkar GS, Baum J, Srivastava DK (1995) Benefits and liabilities of hypermobility in the back pain disorders of industrial workers. J Indust Med 238:461–467

    Google Scholar 

  34. Lund T, Nydegger T, Schlenzka D et al (2002) Three-dimensional motion patterns during active bending in patients with chronic low-back pain. Spine 27:1865–1874

    Article  PubMed  Google Scholar 

  35. Lundberg G, Gerdle B (1999) The relationships between spinal sagittal configuration, joint mobility, general low back mobility and segmental mobility in female homecare personnel. Scand J Rehabil Med 31:197–206

    Article  PubMed  Google Scholar 

  36. Lundberg G, Gerdle B (2000) Correlations between joint and spinal mobility, spinal sagittal configuration, segmental mobility, segmental pain, and disabilities in female homecare personnel. Scand J Rehabil Med 32:124–133

    Article  PubMed  Google Scholar 

  37. MacNab I (1986) Disc degeneration and low back pain. Clin Orthop 208:3–14

    PubMed  Google Scholar 

  38. Magee DJ (1997) Orthopaedic physical assessment, 3rd edn. Saunders, Philadelphia, p 399

    Google Scholar 

  39. Magnusson SP, Julsgaard C, Aagaard P et al (2001) Viscoelastic properties and flexibility of the human muscle-tendon unit in benign joint hypermobility syndrome. J Rheumatol 28:2720–2725

    PubMed  Google Scholar 

  40. Nizard RS, Wybier M, Laredo J (2001) Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis. Radiol Clin North Am 39:55–71

    Article  PubMed  Google Scholar 

  41. Ogon M, Bender BR, Hooper DM et al (1997) A dynamic approach to spinal instability. Part I. Sensitization of intersegmental motion profiles to motion direction and load condition by instability. Spine 22:2841–2858

    Article  PubMed  Google Scholar 

  42. Ogon M, Bender BR, Hooper DM et al (1997) A dynamic approach to spinal instability. Part II. Hesitation and giving-way during interspinal motion. Spine 22:2859–2866

    Article  PubMed  Google Scholar 

  43. O’Sullivan PB (2000) Lumbar segmental “instability”; clinical presentation and specific stabilizing exercise management. Man Ther 5:2–12

    Article  Google Scholar 

  44. Panjabi MM, Lydon C, Vasavada A, Grob D, Crisco JJ, Dvorak J (1994) On the understanding of clinical instability. Spine 19:2642–2650

    PubMed  Google Scholar 

  45. Paris SV (1985) Physical signs of instability. Spine 10:277–279

    PubMed  Google Scholar 

  46. Pearcy M, Portek I, Shepard J (1984) Three-dimensional x-ray analysis of normal movement in the lumbar spine. Spine 9:294–297

    PubMed  Google Scholar 

  47. Posner I, White AA, Edwards WT, Hayes WC (1982) A biomechanical analysis of the clinical stability of the lumbar and lumbosacral spine. Spine 7:389–392

    Google Scholar 

  48. Putto E, Tallroth K (1990) Extension-flexion radiographs for motion studies of the lumbar spine: a comparison of two methods. Spine 15:107–110

    PubMed  Google Scholar 

  49. Sackett DL (1992) A primer on the precision and accuracy of the clinical examination. JAMA 267:2638–2644

    Article  PubMed  Google Scholar 

  50. Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86:420–426

    Article  Google Scholar 

  51. Simel DL, Samba GL, Matchar DB (1991) Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol 44:763–770

    Article  PubMed  Google Scholar 

  52. Slosar PJ (2002) Indications and outcomes of reconstructive surgery in chronic pain of spinal origin. Spine 27:2555–2562

    Article  PubMed  Google Scholar 

  53. Soini J, Antti-Poika I, Tallroth K et al (1991) Disc degeneration and angular movement of the lumbar spine: comparative study using plain and flexion-extension radiography and discography. J Spinal Dis 4:183–187

    Google Scholar 

  54. Suarez-Almazor ME, Kendall C, Johnson JA, Skeith K, Vincent D (2000) Use of health status measures in patients with low back pain in clinical settings: comparison of specific, generic and preference-based instruments. Rheumatology (Oxford) 39:783–790

    Article  Google Scholar 

  55. Tokuhashi Y, Matsuzaki H, Sano S (1993) Evaluation of clinical lumbar instability using the treadmill. Spine 18:2321–2324

    PubMed  Google Scholar 

  56. Vlaeyen JWS, Linton SJ (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85:317–332

    Article  PubMed  Google Scholar 

  57. Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G (2002) The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clin J Pain 18:251–261

    Article  PubMed  Google Scholar 

  58. Waddell G, Somerville D, Henderson I, Newton M (1992) Objective clinical evaluation of physical impairment in chronic low back pain. Spine 17:617–628

    PubMed  Google Scholar 

  59. Waddell G, Newton M, Henderson I, Somerville D, Main CJ (1993) A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 52:157–168

    Article  PubMed  Google Scholar 

  60. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S (2003) Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine 28:52–62

    Article  PubMed  Google Scholar 

  61. White AA, Panjabi MM (1990) Clinical biomechanics of the spine, 2nd edn. Lippincott, Philadelphia, pp 23–45

    Google Scholar 

  62. Yone K, Sakou T (1999) Usefulness of Posner’s definition of spinal instability for selection of surgical treatment for lumbar spinal stenosis. J Spinal Dis 12:40–44

    Google Scholar 

  63. Zdeblick TA (1993) A prospective, randomized study of lumbar fusion: preliminary results. Spine 18:983–991

    PubMed  Google Scholar 

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Acknowledgements

This work was supported by Central Research Development Grant, University of Pittsburgh

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Authors and Affiliations

  1. Division of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT, USA

    Julie M. Fritz

  2. Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, Pennsylvania, USA

    Sara R. Piva

  3. Wilford Hall Air Force Base, Lackland, Texas, USA

    John D. Childs

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  1. Julie M. Fritz
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  2. Sara R. Piva
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Correspondence to Julie M. Fritz.

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The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Air Force or the Department of Defense

A comment to this article can be found at http://dx.doi.org/10.1007/s00586-004-0828-8

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Fritz, J.M., Piva, S.R. & Childs, J.D. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J 14, 743–750 (2005). https://doi.org/10.1007/s00586-004-0803-4

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