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01-10-2007 | Review Article

Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain

Authors: M. J. Hancock, C. G. Maher, J. Latimer, M. F. Spindler, J. H. McAuley, M. Laslett, N. Bogduk

Published in: European Spine Journal | Issue 10/2007

Abstract

Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR) > 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR (> 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4–5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: −LR = 0.21 (95%CI 0.12–0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3–4.4) and −LR of 0.29 (95%CI 0.12–0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.

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Airaksinen O, Brox JI, Cedraschi C et al. (2006) Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15(Suppl 2):S192–S300PubMedCrossRef

Aprill C, Bogduk N (1992) High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol 65:361–369PubMedCrossRef

Bogduk N (1995) The anatomical basis for spinal pain syndromes. J Manipulative Physiol Ther 18:603–605PubMed

Bogduk N (2005) Low Back Pain. In: Clinical anatomy of the lumbar spine and sacrum. 4th edn. Elsevier, Sydney pp 183–216

Braithwaite I, White J, Saifuddin A et al. (1998) Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur J Radiol 7:363–368

Carragee EJ, Alamin TF, Miller J et al. (2002) Provocative discography in volunteer subjects with mild persistent low back pain. Spine J 2:25–34PubMedCrossRef

Carragee EJ, Alamin TF, Carragee JM (2006) Low-pressure positive Discography in subjects asymptomatic of significant low back pain illness. Spine 31:505–509PubMedCrossRef

Carragee EJ, Lincoln T, Parmar VS et al. (2006) A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine 31:2115–2123PubMedCrossRef

Carrera GF (1980) Lumbar facet joint injection in low back pain and sciatica: preliminary results. Radiology 137:665–667PubMed

10.

Derby R, Kim B-J, Lee S-H et al. (2005) Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? Spine J 5:389–394PubMedCrossRef

11.

Deville WL, Buntinx F, Bouter LM et al. (2002) Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol 2:9PubMedCrossRef

12.

Donelson R, Aprill C, Medcalf R et al. (1997) A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine 22:1115–1122PubMedCrossRef

13.

Dreyfuss P, Michaelsen M, Pauza K et al. (1996) The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 21:2594–2602PubMedCrossRef

14.

Dreyfuss PH, Dreyer SJ, Nass (2003) Lumbar zygapophysial (facet) joint injections. Spine J 3:50S–59S

15.

Fritz JM, George S (2000) The use of a classification approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine 25:106–114PubMedCrossRef

16.

Holt EP Jr. (1968) The question of lumbar discography. J Bone Joint Surg Am 50:720–726PubMed

17.

Horton WC, Daftari TK (1992) Which disc as visualized by magnetic resonance imaging is actually a source of pain? A correlation between magnetic resonance imaging and discography. Spine 17:S164–S171PubMedCrossRef

18.

Ito M, Incorvaia KM, Yu SF et al. (1998) Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine 23:1252–1258PubMedCrossRef

19.

Kent P, Keating J (2004) Do primary-care clinicians think that nonspecific low back pain is one condition? Spine 29:1022–1031PubMedCrossRef

20.

Kokkonen S-M, Kurunlahti M, Tervonen O et al. (2002) Endplate degeneration observed on magnetic resonance imaging of the lumbar spine: correlation with pain provocation and disc changes observed on computed tomography diskography. Spine 27:2274–8PubMedCrossRef

21.

Lam KS, Carlin D, Mulholland RC (2000) Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source. Eur Spine J 9:36–41PubMedCrossRef

22.

Laslett M, Young SB, Aprill CN et al. (2003) Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother 49:89–97PubMed

23.

Laslett M, Oberg B, Aprill CN et al. (2004) Zygapophysial joint blocks in chronic low back pain: a test of Revel’s model as a screening test. BMC Musculoskeletal Disorders 5:43PubMedCrossRef

24.

Laslett M, Aprill CN, McDonald B et al. (2005) Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 10:207–218PubMedCrossRef

25.

Laslett M, Oberg B, Aprill CN et al. (2005) Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J 5:370–380PubMedCrossRef

26.

Laslett M, Oberg B, Aprill CN et al. (2006) A study of clincal predictors of lumbar discogenic pain as determined by provocation discography. Eur Spine J 15:1473–1484

27.

Laslett M, McDonald B, Aprill CN et al. (2006) Clinical predictors of screening lumbar zygapophysial joint blocks: Development of clinical prediction rules. Spine J 6:370–379PubMedCrossRef

28.

Lim C-H, Jee W-H, Son BC et al. (2005) Discogenic lumbar pain: association with MR imaging and CT discography. Eur J Radiol 54:431–437PubMedCrossRef

29.

Maigne JY, Boulahdour H, Chatellier G (1998) Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain. Eur Spine J 7:328–331PubMedCrossRef

30.

Manchikanti L, Pampati V, Fellows B et al. (1999) Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician 2:59–64PubMed

31.

Manchikanti L, Pampati V, Fellows B et al. (2000) The inability of the clinical picture to characterize pain from facet joints. Pain Physician 3:158–166PubMed

32.

McKenzie RA, May S (2003) The lumbar spine: mechanical diagnosis and therapy. 2nd edn. Spinal Publications New Zealand Ltd, Waikanae

33.

Merskey H, Bogduk N (1994) Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. IASP Press, Seattle

34.

Milette PC, Raymond J, Fontaine S (1990) Comparison of high-resolution computed tomography with discography in the evaluation of lumbar disc herniations. Spine 15:525–33PubMedCrossRef

35.

Ohnmeiss DD, Vanharanta H, Ekholm J (1999) Relationship of pain drawings to invasive tests assessing intervertebral disc pathology. Eur Spine J 8:126–131PubMedCrossRef

36.

Osti OL, Fraser RD (1992) MRI and discography of annular tears and intervertebral disc degeneration: A prospective clinical comparison. J Bone Joint Surg Ser B 74:431–435

37.

Parker LM, Murrell SE, Boden SD et al. (1996) The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine 21:1909–1916PubMedCrossRef

38.

Revel M, Poiraudeau S, Auleley GR et al. (1998) Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine 23:1972–1976PubMedCrossRef

39.

Revel ME, Listrat VM, Chevalier XJ et al. (1992) Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil 73:824–8PubMed

40.

Ricketson R, Simmons JW, Hauser BO (1996) The prolapsed intervertebral disc. The high-intensity zone with discography correlation. (see comment). Spine 21:2758–2562PubMedCrossRef

41.

Saal JS (2002) General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques... including commentary by Prager J, Saal J, Slosar P, Straus B, Turk D, Wetzel FT et al. Spine 27:2538–2546PubMedCrossRef

42.

Saifuddin A, Braithwaite I, White J et al. (1998) The value of lumbar spine magnetic resonance imaging in the demonstration of anular tears. Spine 23:453–457PubMedCrossRef

43.

Schellhas KP, Pollei SR, Gundry CR et al. (1996) Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine 21:79–86PubMedCrossRef

44.

Schwarzer AC, Aprill CN, Derby R et al. (1994) Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 19:1132–1137PubMed

45.

Schwarzer AC, Aprill CN, Derby R et al. (1994) The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 58:195–200PubMedCrossRef

46.

Schwarzer AC, Aprill CN, Bogduk N (1995) The sacroiliac joint in chronic low back pain. Spine 20:31–37PubMed

47.

Schwarzer AC, Aprill CN, Derby R et al. (1995) The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 20:1878–1883PubMedCrossRef

48.

Simmons JW, Emery SF, McMillin JN et al. (1991) Awake discography. A comparison study with magnetic resonance imaging. Spine 16:S216–S221PubMedCrossRef

49.

Slipman CW, Sterenfeld EB, Chou LH et al. (1996) The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome. Spine 21:2251–2254PubMedCrossRef

50.

Smith BM, Hurwitz EL, Solsberg D et al. (1998) Interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on magnetic resonance imaging and association of high-intensity zone with pain and anular disruption. Spine 23:2074–2080PubMedCrossRef

51.

Spitzer WO (1987) Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the quebec task force on spinal disorders. Spine 12:S16–S19

52.

Van Der Wurff P, Buijs EJ, Groen GJ (2006) A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil 87:10–14CrossRef

53.

Vanharanta H, Sachs BL, Spivey M et al. (1988) A comparison of CT/discography, pain response and radiographic disc height. Spine 13:321–324PubMedCrossRef

54.

Vanharanta H, Ohnmeiss DD, Aprill CN (1998) Vibration pain provocation can improve the specificity of MRI in the diagnosis of symptomatic lumbar disc rupture. Clin J Pain 14:239–247PubMedCrossRef

55.

Walsh TR, Weinstein JN, Spratt KF et al. (1990) Lumbar discography in normal subjects. A controlled, prospective study. J Bone Joint Surg Am 72:1081–1088PubMed

56.

Weishaupt D, Zanetti M, Hodler J et al. (2001) Painful lumbar disk derangement: relevance of endplate abnormalities at MR imaging. Radiology 218:420–427PubMed

57.

Whiting P, Rutjes AWS, Reitsma JB et al. (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25PubMedCrossRef

58.

Wilczynski NL, Haynes RB, Hedges T (2005) EMBASE search strategies for identifying methodologically sound diagnostic studies for use by clinicians and researchers. BMC Med 3:7PubMedCrossRef

59.

Yoshida H, Fujiwara A, Tamai K et al. (2002) Diagnosis of symptomatic disc by magnetic resonance imaging: T2-weighted and gadolinium-DTPA-enhanced T1-weighted magnetic resonance imaging. J Spinal Disord Tech 15:193–198PubMed

60.

Young S, Aprill C, Laslett M (2003) Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 3:460–465PubMedCrossRef

61.

Yrjama M, Vanharanta H (1994) Bony vibration stimulation: a new, non-invasive method for examining intradiscal pain. Eur Spine J 3:233–235PubMedCrossRef

62.

Yrjama M, Tervonen O, Vanharanta H (1996) Ultrasonic imaging of lumbar discs combined with vibration pain provocation compared with discography in the diagnosis of internal anular fissures of the lumbar spine. Spine 21:571–575PubMedCrossRef

63.

Yrjama M, Tervonen O, Kurunlahti M et al. (1997) Bony vibration stimulation test combined with magnetic resonance imaging. Can discography be replaced? Spine 22:808–813PubMedCrossRef

64.

Zamora J, Abraira V, Muriel A et al. (2006) Meta-DiSc: a software for meta-analysis of test accuracy data. BMC Med Res Methodol 6

Title: Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain
Authors: M. J. Hancock
C. G. Maher
J. Latimer
M. F. Spindler
J. H. McAuley
M. Laslett
N. Bogduk
Publication date: 01-10-2007
Publisher: Springer-Verlag
Published in: European Spine Journal / Issue 10/2007
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-007-0391-1

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Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain

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