SPINE Volume 36, Number 11, pp E712–E719

©2011, Lippincott Williams & Wilkins

DIAGNOSTICS

Diagnostic Accuracy of the Clinical Examination

in Identifying the Level of Herniation in Patients
with Sciatica
Mark J. Hancock, PhD,* Bart Koes, PhD,† Raymond Ostelo, PhD,‡§ and Wilco Peul, PhD¶#

informative individual neurological test. The overall suspected level

Study Design. Cross sectional
of disc herniation rated by the neurologist after a full examination
Objective. To investigate the ability of the neurological examination
of the patient was more accurate than individual tests. At L4/5 and
to identify the specific level of a disc herniation in patients with
L5/S1 herniations the AUC for neurologist ratings was 0.79 and 0.80
sciatica and confirmed disc herniation.
respectively.
Summary of Background Data. Tests included in a neurological
Conclusion. The current study did not find evidence to support
examination theoretically provide accurate diagnostic information
the accuracy of individual tests from the neurological examination
about the level of the herniated disc. However, there is currently
in identifying the level of disc herniation demonstrated on MRI.
very little evidence about the diagnostic accuracy of individual tests
A neurologist’s overall impression was moderately accurate in
or combinations of tests.
identifying the level of disc herniation.
Methods. The study included 283 patients with sciatica and
Key words: low back pain, sciatica, clinical examination, disc
confirmed disc herniation from a previous randomized controlled trial.
herniation, MRI. Spine: 2011;36:E712-E719
The reference test for the current study was the MRI scan, reported for
level of disc herniation. Index tests investigated were a neurologist’s
overall impression of the level of disc herniation, individual

neurological tests (e.g., sensation testing) and multiple test findings (i.e.,
the number of positive tests). The index tests were performed blinded to
the MRI results. The diagnostic accuracy of the index tests in predicting
herniations at the lower three lumbar discs was investigated using area
under the curve (AUC), sensitivity and specificity.
Results. None of the individual neurological tests from the clinical
examination were highly accurate for identifying the level of disc
herniation (AUC ! 0.75). The outcome of multiple test findings
was slightly more accurate but did not produce high sensitivity and
specificity. The dermatomal pain location was generally the most
From the *Faculty of Health Sciences, University of Sydney, Australia;
†Department of General Practice, Erasmus Medical Centre, Rotterdam, The
Netherlands; ‡EMGO Institute VU University Medical Centre, Amsterdam,
Netherlands; §Department of Health Economics & Health Technology Assess-
ment, Institute of Health Sciences, VU University, Amsterdam, Netherlands;
¶Department of Neurosurgery, Leiden University Medical Center/Medical
Center Haaglanden, The Hague, The Netherlands; and #Department of
Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands.
Supported by a grant from the Netherlands Organisation for Health Research
and Development (ZonMW) and the Hoelen Foundation, The Hague.
Acknowledgement date: February 15, 2010. Revised date: May 19, 2010.
Accepted date: July 15, 2010.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any form have
been or will be received from a commercial party related directly or indirectly
to the subject of this manuscript.
Address correspondence and reprint requests to Mark Hancock, PhD,
University of Sydney PO Box 170, Lidcombe 1825, NSW, Australia;
E-mail: M.Hancock@usyd.edu.au
DOI: 10.1097/BRS.0b013e3181ee7f78
E712 www.spinejournal.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T
he typical clinical examination of a patient with sciatica
includes test procedures to determine if a disc herniation
is the likely source of symptoms.1,2 Some of the informa-
tion gathered during this clinical examination is nonspecific,
in that it may help indicate the likelihood of a disc herniation
but does not provide information about the spinal level of
the herniation or nerve root causing the symptoms.3 Common
examples of such tests include the straight leg raise (SLR) test,
and questions about pain with activities like coughing that
increase intra-abdominal pressure.4,5 Other tests commonly
included in the clinical examination potentially provide in-
formation about the specific level of the disc herniation likely
to be responsible for the symptoms.3,6 Examples of these tests
include dermatomal tests of sensation, myotomal tests of
muscle strength and reflex testing.
Magnetic resonance imaging (MRI) is widely used to assess
patients with sciatica to determine if a disc herniation exists.
An essential part of clinical decision-making for neurologists,
rheumatologists and spinal surgeons is to decide if the find-
ings from the clinical examination are likely to be the result
of a herniation observed on MRI. It is the combination and
correlation of the clinical examination findings and MRI find-
ings that is essential for successful selection of patients for
surgical management of sciatica. If a herniation seen on MRI
is not likely to be responsible for the patients symptoms (for
example, because the level of the herniated disc and com-
pressed nerve root do not correspond with the pain distri-
bution and/or neurologic deficit) then is not reasonable to
expect that surgical removal or other treatment aimed at
that disc will be beneficial to the patient. Even when surgical
May 2011

BRS204030.indd 712 21/04/11 3:33 AM

 DIAGNOSTICS
intervention is not being considered it is important for clini-
cians to know how accurately clinical findings predict pathol-
ogy on MRI scans. Only if clinical findings correlate strongly
with MRI findings can clinicians confidently provide patients
with a clear explanation of the source of leg pain including the
level of herniated disc.
Understanding the relationship between the specific level of
the disc herniation found on MRI and the clinical examina-
tion is therefore important to the clinical care of patients with
sciatica, especially those considered possible candidates for
surgery. However, surprisingly little is known about how ac-
curate the clinical examination is in predicting the level of disc
herniation found in patients with sciatica. It is unclear which
neurological tests are most accurate and how the accuracy of
individual tests compares to a clinicians overall impression.
Kortelainen et al3 investigated the accuracy of some clinical
tests in predicting the level of disc herniation at surgery. They
found the location of pain projection was the most useful find-
ing in identifying the spinal level of herniation. Limited other
evidence or validation of these initial findings when using MRI
as the reference standard exists. It is not clear how commonly
a disc herniation at a specific spinal level results in involvement
of nerve roots exiting at the same spinal level, or one or more
levels below, or even above. It is possible that the location of a
herniation as well as the spinal level impacts on the nerve root
involved and therefore the clinical presentation. Central her-
niations are considered more likely to effect nerve roots exit-
ing below the herniation whereas lateral herniations are more
likely to effect the nerve root exiting at the same level as the
herniation. Kortelainen et al3 found pain projection was most
common in the dermatome below the herniation. For example
L4/L5 herniations most commonly produced pain in an L5
distribution. They did not investigate the influence of the loca-
tion of the disc herniation on this finding.
There is a clear need to investigate the relationship between
the level and location of disc herniation identified on MRI and
findings from clinical examination tests which aim to identify
the specific level of clinical signs and symptoms. The aim of
this study was therefore to investigate the diagnostic accuracy
of individual neurologic tests, combinations of tests and a cli-
nicians overall impression in identifying the specific level of a
disc herniation, of the lower three lumbar levels, in patients
with sciatica and confirmed disc herniation. A secondary aim
was to determine how the location of the herniation (central
or lateral) influenced the diagnostic accuracy.
MATERIALS AND METHODS
Study Population and Flow
This study included 283 patients with sciatica from a pre-
viously published randomized controlled trial comparing
surgery versus prolonged conservative care.7,8 Patients were
included if they received a diagnosis from an neurologist of
lumbosacral radicular syndrome (dermatomal pain pattern
with signs of nerve root compression) that had lasted 6 to
12 weeks, were 18 to 65 years of age, and had a radiologi-
cally confirmed disc herniation. Patients were excluded if they
Spine
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS204030.indd 713
Diagnostic Accuracy of the Clinical • Hancock et al
presented with cauda equine syndrome, severe paresis (in-
sufficient strength to move against gravity), another episode
of symptoms similar to the current episode during the last
12 months, previous spine surgery, bony stenosis, spondylo-
listhesis, pregnancy, or severe coexisting disease.
Figure 1 presents the patient flow and the timing of the
index and reference tests. Patients with sciatica were identi-
fied by general practitioners and examined by a neurologist
for inclusion and exclusion criteria. All patients had an MRI
scan (reference test), which was reported for level of disc her-
niation. Patients also underwent a neurologic examination on
two occasions, one just before and one soon after the MRI.
The first neurologic examination was conducted by a neu-
rologist who rated the level of disc herniation, believed to be
responsible for the patient’s sciatica symptoms, on the basis
of an overall impression after the complete examination. The
second neurologic examination was performed by trained re-
search nurses who rated individual neurologic examination
findings including reflex, strength and sensation testing, and
dermatomal distribution of pain. The neurologist’s overall im-
pression, findings of individual neurologic tests, and combi-
nations of neurologic tests performed by the trained research
nurses were the index tests for this study and are described
in more detail below. All index tests were performed blinded
to the MRI results. All data used in this study was collected
prospectively.
Reference Test (MRI)
MRI scans were performed using a 1.5 Tesla and a standard-
ized protocol. All patients had a sagittal and axial T1 and
T2 scan. Scans were reported on independently by a neu-
rosurgeon and radiologist according to the combined task
force recommendations.9 If there was no consensus about the
presence or absence of a herniated disc the MRI study was
reviewed by the senior neurosurgeon (WP) and a University
Figure 1. Study flow.
www.spinejournal.com E713
21/04/11 3:33 AM
 DIAGNOSTICS Diagnostic Accuracy of the Clinical • Hancock et al

neuroradiologist. The neurosurgeons and radiologists were

blinded to the result of index tests (neurologist examination TABLE 1. Incidence of Positive Index and
and neurologic examination by research nurse). For the pur- Reference Tests
pose of this study MRI scans were rated for the presence or Index or Reference Test n Positive Percent
absence of disc herniation at L3/L4, L4/L5, and L5/S1. The
Pain dermatome/location
location of herniations was also classified as central, subartic-
ular, intraforaminal, and extraforaminal.9 We dichotomised L4 only 283 14 4.9
the location into central (central and subarticular) and lateral L5 only 283 45 15.9
(foraminal and extraforaminal). The rationale for this deci-
S1 only 283 39 13.8
sion is that central herniations and lateral herniations at the
same level may result in involvement of different nerve root L4 and L5 283 56 19.8
and therefore different clinical test results. L5 and S1 283 121 42.8
L4, L5, S1 283 8 2.8
Index Test (Neurologist Overall Impression)
One of 68 neurologists performed a clinical examination of Includes L4 283 78 27.6
patients before the MRI. The neurologist was free to perform Includes L5 283 222 78.4
whatever tests they felt were appropriate however, this typi-
cally involved a range of nonspecific tests to determine if a Includes S1 283 168 59.4
disc herniation was likely to be the cause of the sciatica and Reflex tests
specific neurologic level tests to identify the most likely level Knee reflex 275 73 26.5
of disc herniation. To include patients in the study the neu-
rologist needed some signs fitting with a clear clinical picture Ankle reflex 274 110 40.5
of sciatica. On the basis of this examination the neurologist Sensory loss testing
recorded whether they suspected the patient had a disc her-
L4 279 74 26.5
niation at each of L3/L4, L4/L5, and L5/S1 and the side of
any herniation. This examination and rating was performed L5 277 145 52.3
blinded from the MRI results. S1 277 143 51.6
Motor strength/weakness
Index Tests (Individual Neurologic Examination Tests)
The neurologic examination was performed by one of six Quadriceps 283 167 60.5
research nurses following a standardized protocol. These Tibialis anterior 283 102 36.8
research nurses were specifically trained by a neurologist
Peroneals 276 110 39.9
and neurosurgeon and started independently examining pa-
tients only after passing tests concordant with the training Extensor hallucis longus 277 121 43.7
of residents of neurology. The examination was performed Triceps surae/calf 273 90 33
blind to the results of the MRI. The examination included
tests of sensation, muscle strength and reflexes for lumbar Neurologist suspected level
dermatomes and myotomes. Sensation was dichotomized as L3/4 280 11 3.9
normal or abnormal (reduced or absent) for each derma- L4/5 280 126 45.0
tome. Muscle strength of Grade 5 was considered normal
whereas Grade 4 or less was rated abnormal. Reflexes were L5/S1 280 149 53.2
initially rated as normal, absent, or less than the other side, Disc herniation
on both the right and left. For the purpose of the current
L3/4 283 13 4.6
study we considered absent or less than the other side to be
an abnormal result. In our primary analysis patient’s who L4/5 283 127 44.9
had bilateral absent reflexes were rated as normal due to L5/S1 283 169 59.7
the high number of patients in whom no reflex (knee or
Central location 266 243 91.4
ankle) could be elicited bilaterally. We conducted a sensi-
tivity analysis where patients with bilateral absent reflexes Lateral location 266 23 8.6
were rated as abnormal. The dermatomal location of each
patient’s leg pain was assessed by asking patients to describe ANALYSIS
the exact location of their pain. Using this information the The diagnostic accuracy of each index test in predicting
area of pain was recorded as being localized to a specific herniations at the lower three lumbar discs was investigated
dermatome for L4, L5, S1, a combination of adjacent der- using area under the curve (AUC), sensitivity and specific-
matomes or including a dermatome either in isolation or ity. To investigate the influence of the location of the disc
combination with other dermatomes (Table 2). Table 1 lists herniation on the diagnostic accuracy of the index tests we
the index tests investigated in this study. divided herniations at each level into central and lateral
E714 www.spinejournal.com May 2011

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

BRS204030.indd 714 21/04/11 3:33 AM

 DIAGNOSTICS Diagnostic Accuracy of the Clinical • Hancock et al

herniations. Using these modified reference test standards we

0.50 (0.43–0.57)
0.44 (0.37–0.50)
0.60 (0.53–0.67)
0.38 (0.31–0.45)
0.60 (0.53–0.67)
0.49 (0.42–0.56)
0.36 (0.30–0.43)
0.42 (0.35–0.48)
0.69 (0.62–0.75)
repeated the analyses for the index test of neurologist suspect-
ed level of herniation using the same statistical approach.

AUC
To investigate if diagnostic accuracy improved by using a
combination of individual clinical findings we created a new
index test score using the results from the diagnostic accuracy

L5/S1 Disc Herniation

of individual tests in predicting the level of disc herniation.

0.95 (0.89–0.98)
0.76 (0.67–0.84)
0.98 (0.94–1.00)
0.66 (0.56–0.74)
0.69 (0.60–0.78)
0.96 (0.90–0.99)
0.56 (0.47–0.65)
0.11 (0.06–0.19)
063 (0.54–0.72)
The index test from each category (sensation, motor strength,
reflex and dermatome of pain) with the greatest AUC for

Spec
identifying a herniation at each of the lower three lumbar
discs was identified. If in a category no index test produced an
AUC greater than 0.55 then it was not included. The number
of positive index test results for each patient for each lumbar

0.05 (0.02–0.09)
0.11 (0.06–0.16)
0.22 (0.16–0.29)
0.10 (0.06–0.16)
0.51 (0.43–0.59)
0.02 (0.00–0.05)
0.17 (0.11–0.23)
0.72 (0.62–0.78)
0.75 (0.67–0.81)
level was summed. The diagnostic accuracy of the summed

Sens
score was then evaluated for increasing numbers of positive
tests (Table 6).

RESULTS

0.48 (0.42–0.55)
0.58 (0.52–0.65)
0.40 (0.34–0.47)
0.60 (0.53–0.67)
0.41 (0.35–0.48)
0.52 (0.45–0.59)
0.60 (0.53–0.67)
0.60 (0.53–0.66)
0.33 (0.27–0.40)
Participants in this study were recruited between November
2002 and February 2005. The mean age of patients was 42

AUC
(SD = 10) years and 66% were male. Mean duration of sci-
atica was 9 weeks (SD = 2) and the patients had moderate
to high levels of leg pain (65 on a 100 point visual analogue
L4/5 Disc Herniation

scale). Most disc herniations occurred at L5/S1 (59.6%) and

0.03 (0.01–0.08) 0.94 (0.89–0.97)
0.15 (0.02–0.45) 0.84 (0.79–0.88) 0.50 (0.34–0.66) 0.25 (0.18–0.34) 0.92 (0.86–0.96)
0.00 (0.00–0.25) 0.86 (0.81–0.90) 0.43 (0.29–0.57) 0.30 (0.01–0.08) 0.78 (0.70–0.84)
0.31 (0.09–0.61) 0.81 (0.76–0.85) 0.56 (0.39–0.73) 0.31 (0.23–0.40) 0.89 (0.83–0.94)
0.49 (0.41–0.58)
0.00 (0.00–0.25) 0.97 (0.94–0.99) 0.49 (0.33–0.64) 0.50 (0.02–0.10) 0.99 (0.95–1.00)
Pain includes L4 0.69 (0.39–0.91) 0.74 (0.69–0.80) 0.72 (0.57–0.87) 0.39 (0.30–0.48) 0.81 (0.74–0.87)
Pain includes L5 0.62 (0.32–0.86) 0.21 (0.16–0.26) 0.41 (0.24–0.58) 0.89 (0.82–0.94) 0.30 (0.23–0.38)
Pain includes S1 0.15 (0.02–0.45) 0.39 (0.33–0.45) 0.27 (0.15–0.39) 0.41 (0.32–0.50) 0.26 (0.19–0.33)
L4/L5 (44.6) with far fewer at L3/L4 (4.6%). The frequency
of positive index tests varied greatly between the tests (Table 1).
Spec

The side of the herniation correlated highly with the side of

the patient’s sciatica symptoms. Only five patients had pain
TABLE 2. Diagnostic Accuracy of Sciatic Dermatomal Pain Location

on a side that they had no herniation. Twenty-five patients

had bilateral herniations but unilateral sciatica and three pa-
tients had bilateral sciatica and only a single sided herniation. 0.33 (0.25–0.42)
None of the individual index tests from the clinical exami-
Sens

nation were highly accurate for identifying the level of disc

herniation (AUC < 0.75; Tables 2 and 3). Dermatomal pain
location (Table 2) was generally more informative than the
0.15 (0.19–0.45) 0.56 (0.50–0.62) 0.36 (0.22–0.49)

other (neurologic) individual index tests (Table 3). Pain loca-

0.68 (50–86)

tion scored as pain including a dermatome rather than pain

AUC

only in a single dermatome typically produced higher AUC al-

though specificity was reduced as expected. Pain including L4
Sens indicates sensitivity; spec, specificity, AUC, area under curve.

was the most useful individual test in differentiating patients

L3/4 Disc Herniation

Values in each cell are estimate and 95% confidence intervals.

with and without L3/L4 disc herniations (AUC = 0.72). The

0.39 (0.14–0.68) 0.97 (0.94–0.99)

best tests to identify L4/L5 and L5/S1 herniations were pain

including the L5 and S1 dermatomes, respectively. Sensitivity
Spec

analyses for the diagnostic accuracy of reflexes where patients

were scored as positive if they had bilateral absent reflexes
produced very similar AUC to the primary analysis where pa-
tients with bilateral absent reflexes were considered negative.
The suspected level of disc herniation rated by the neu-
Sens

rologist after examining the patient was more accurate than

individual tests (Table 4). At L4/L5 and L5/S1 herniations the
AUC was 0.79 and 0.80, respectively. The AUC for L3/L4
herniations was somewhat lower (0.72) due to the low sensi-
Pain Location)
(Dermatomal

L4 and L5 pain
L5 and S1 pain
L4, L5, S1 pain

tivity (0.46) although specificity was high (0.98).

L4 pain only
L5 pain only
S1 pain only

The influence on diagnostic accuracy of location of disc

Predictor

herniation was investigated at L4/L5 and L5/S1 but not at L3/

L4 due to the low number of herniations at this level. The lo-
cation of the disc herniation seemed to influence the accuracy
Spine www.spinejournal.com E715
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

BRS204030.indd 715 21/04/11 3:33 AM

BRS204030.indd 716

E716 www.spinejournal.com

TABLE 3. Diagnostic Accuracy of Individual Neurological Tests

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

L3/4 Disc Herniation L4/5 Disc Herniation L5/S1 Disc Herniation

DIAGNOSTICS
Predictor Sens Spec AUC Sens Spec AUC Sens Spec AUC
Knee reflex 0.50 (0.21–0.79) 0.83 (0.78–0.87) 0.64 (0.46–0.82) 0.19 (0.12–0.27) 0.82 (0.75–0.88) 0.49 (0.42–0.56) 0.16 (0.11–0.23) 0.787 (0.69–0.85) 0.48 (0.41–0.55)
Ankle reflex 0.27 (0.06–0.61) 0.64 (0.58–0.70) 0.46 (0.29–0.63) 0.16 (0.10–0.24) 0.49 (0.41–0.57) 0.34 (0.27–0.40) 0.48 (0.40–0.56) 0.83 (0.75–0.90) 0.66 (0.59–0.72)
Sensory loss L4 0.42 (0.15–0.72) 0.74 (0.69–0.79) 0.56 (0.38–74) 0.33 (0.25–0.42) 0.79 (0.72–0.85) 0.55 (0.48–0.62) 0.23 (0.17–0.30) 0.68 (0.59–0.77) 0.47 (0.40–0.54)
Sensory loss L5 0.50 (0.21–0.79) 0.48 (0.41–0.54) 0.47 (0.30–0.64) 0.60 (0.51–0.69) 0.54 (0.45–0.62) 0.57 (0.50–0.64) 0.48 (0.40–0.56) 0.40 (0.31–0.50) 0.44 (0.37–0.51)
Sensory loss S1 0.33 (0.10–0.65) 0.48 (0.41–0.54) 0.38 (0.22–0.54) 0.44 (0.35–0.54) 0.43 (0.35–0.50) 0.42 (0.36–0.50) 0.59 (0.51–0.66) 0.60 (0.50–0.69) 0.60 (0.53–0.67)
Quadriceps 0.67 (0.35–0.90) 0.40 (0.34–0.46) 0.52 (0.35–0.69) 0.64 (0.55–0.72) 0.42 (0.34–0.50) 0.52 (0.45–0.59) 0.61 (0.53–0.68) 0.39 (0.30–0.49) 0.51 (0.44–0.58)
weakness
Tibialis anterior 0.50 (0.21–0.79) 0.64 (0.58–0.70) 0.56 (0.38–0.73) 0.46 (0.37–0.55) 0.70 (0.63–0.77) 0.58 (0.51–0.65) 0.32 (0.25–0.40) 0.56 (0.46–0.66) 0.44 (0.37–0.51)
weakness
Peroneals 0.58 (0.28–0.85) 0.61 (0.55–0.67) 0.59 (0.41–0.76) 0.50 (0.41–0.59) 0.68 (0.60–0.75) 0.59 (0.52–0.66) 0.34 (0.27–0.42) 0.51 (0.42–0.61) 0.43 (0.36–0.50)
weakness
EHL weakness 0.50 (0.21–0.790) 0.57 (0.50–0.63) 0.52 (0.34–0.69) 0.54 (0.44–0.63) 0.64 (0.56–0.72) 0.59 (0.52–0.66) 0.38 (0.30–0.46) 0.47 (0.38–0.57) 0.43 (0.36–0.50)
Calf weakness 0.42 (0.15–0.72) 0.67 (0.61–0.73) 0.53 (0.35–0.70) 0.39 (0.30–0.48) 0.72 (0.64–0.79) 0.55 (0.48–0.62) 0.30 (0.23–0.38) 0.63 (0.53–0.72) 0.47 (0.40–0.54)
Shaded cells represent the optimal test in each category (reflex, sensation, and strength) for each lumbar disc if AUC is > 0.55.
Values in each cell are estimate and 95% confidence intervals.
Sens indicates sensitivity; spec, specificity; AUC, area under curve.

TABLE 4. Diagnostic Accuracy of Neurologist Examination Conclusion

L3/4 Disc Herniation L4/5 Disc Herniation L5/S1 Disc Herniation

Diagnostic Accuracy of the Clinical • Hancock et al

Predictor Sens Spec AUC Sens Spec AUC Sens Spec AUC
Neurologist concludes 0.46 0.98 0.72 0.04 0.96 0.50 0.02 0.93 0.47
L3/4 herniation (0.19–0.75) (0.96–0.99) (0.54–0.90) (0.01–0.09) (0.92–0.99) (0.43–0.57) (0.00–0.05) (0.86–0.97) (0.40–0.54)
Neurologist concludes 0.46 0.55 0.51 0.78 0.81 0.79 0.24 0.23 0.24
L4/5 herniation (0.19–0.75) (0.49–0.61) (0.35–0.67) (0.69–0.85) (0.74–0.87) (0.74–0.85) (0.18–0.31) (0.16–0.32) (0.18–0.29)
Neurologist concludes 0.08 0.45 0.26 0.20 0.20 0.20 0.77 0.83 0.80
L5/S1 herniation (0.00–0.36) (0.39–0.51) (0.15–0.37) (0.13–0.28) (0.14–0.27) (0.15–0.26) (0.70–0.84) (0.75–0.90) (0.75–0.86)
Shaded cells represent the diagnostic accuracy for the suspected level.
Values in each cell are estimate and 95% confidence intervals.
Sens indicates sensitivity; spec, specificity; AUC, area under curve.
May 2011
21/04/11 3:33 AM
 DIAGNOSTICS
of the neurologist in identifying L5/S1 herniations but not L4/
L5 herniations (Table 5). At L5/S1 the neurologist remained
relatively accurate in differentiating those with and without
central herniations (AUC = 0.81) however, the accuracy for
lateral herniations was much lower (AUC = 0.45).
The diagnostic accuracy of a combination of index tests
was slightly superior to the most informative individual test
(location of pain) and remained inferior to the rating of the
neurologist (Table 6). At L3/L4 the accuracy of up to four
positive tests (pain including L4, knee reflex, sensory loss in
L4, tibialis anterior weakness) was investigated whereas for
L4/L5 (pain including L5, sensory loss in L5, extensor hal-
lucis longus weakness) and L5/S1 (pain including S1, ankle
reflex and sensory loss S1) the maximal number of positive
tests was three because in one category there was no test with
AUC greater than 0.55. There was no threshold number of
positive tests that produced sensitivity and specificity values
over 80% for herniation at the lower three discs. When at
least 3 tests were positive the specificity for identifying a L3/
L4, L4/L5, and L5/S1 herniation was quite high (90, 83, and
94, respectively), however, sensitivity was poor.
DISCUSSION
The primary result of this study is that individual tests in the
clinical examination lack diagnostic accuracy for identifying
the level of disc herniation, of the lower three lumbar levels,
in patients who have sciatica and disc herniation on MRI. The
location of pain was typically more informative than weak-
ness, sensation or reflex testing. Using findings from a com-
bination of index tests (i.e., number of positive tests) slightly
increased the accuracy. No threshold number of positive tests
was found that produced both high sensitivity and specificity
for herniation at any of the three lower lumbar discs. The
suspected level of herniation as rated by a neurologist was
reasonably accurate and superior to any individual index test
or combination of tests investigated in this study.
The findings of the current study are similar to those of
Kortelainen et al.3 Both studies found pain location to be the
most accurate single clinical test in identifying the level of
disc herniation. The accuracy identified by Kortelainen et al3
seems somewhat higher than that found in the current study
although a direct comparison is no possible due to the dif-
ferent methods of analyzing and presenting the results. We
are not aware of any published study comparing the accuracy
of individual tests to the overall impression of a clinician or
investigating the influence of the location of the herniation.
An important finding of this study is the superior accu-
racy of the neurologist’s overall impression compared with
any individual index test or combination (number of positive
tests) of tests investigated. It is likely that the neurologist re-
lied on several pieces of information, explaining the superior
accuracy to individual tests but not to combinations of tests.
When interpreting several tests the neurologist may weigh the
importance given to individual tests or use information from
many tests both positive and negative in a manner that is very
difficult to analyses or investigate. Tests with highly positive
results may be relied more heavily on than other tests, which
Spine
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS204030.indd 717
Diagnostic Accuracy of the Clinical • Hancock et al
are only mildly positive. Clinical experience may be used to
rely more on some tests than others regardless of how positive
they are. It is possible that the inferior accuracy of the clinical
tests compared with the neurologist’s suspicion is because the
clinical tests were performed in this study by research nurses
who despite the rigorous training may not be as proficient at
performing the tests as a neurologist. Another possible expla-
nation is that the research nurses were forced to follow a strict
protocol whereas the neurologist may have used an examina-
tion based on a clinical reasoning approach. Future studies
would ideally compare individual index test results as part
of a neurologist’s (or other experienced spinal clinician) ex-
amination with the overall impression of the same clinician. It
may also be informative to add some qualitative investigation
asking the neurologist to indicate which piece of information
is decisive for indicating the level of disc herniation for each
patient. This may provide a greater understanding of which
test results are relied on most heavily in their overall clinical
judgment of the likely level of disc herniation.
Features of a disc herniation other than the level may ex-
plain why it is difficult based on a clinical examination to ac-
curately identify the level of herniation. The results of this
study demonstrated that the accuracy of clinical tests was dif-
ferent in identifying a central or lateral (foraminal) herniation
especially at L5/S1. The clinical presentation resulting in the
neurologist suspecting a L5/S1 herniation was more accurate
for central herniations than lateral herniations (Table 5). This
needs to be interpreted cautiously due to the small number
of lateral herniations in our sample. It is possible that lateral
herniations produce signs and symptoms more typical of a
central herniation at the level above. The data in this study
provides some preliminary evidence for this but a consistent
pattern is not identified.
The inclusion criteria for this study may have influenced the
accuracy of the clinical examination. Patients with less than
Grade 3 muscle strength were excluded. These excluded patients
with a more severe presentation would likely have clearer cut
findings for some of the index tests. It is possible the diagnos-
tic accuracy in these more severe cases would be better than in
the study population. Another factor potentially influencing the
accuracy of the neurologic examination is the presence of clini-
cally silent disc herniations, which are not responsible for the
patient’s symptoms. This could reduce both the sensitivity and
specificity of the neurologic examination. It is important that
the current results are interpreted as the accuracy of the neuro-
logic examination to predict a herniation on MRI regardless of
whether the herniation is responsible for producing symptoms.
Another factor, which may have reduced the accuracy of the
neurologic examination is the presence of six lumbar vertebrae
in a small number of patients (n = 8). Disc herniations are not
the only cause of sciatica. It is possible that the low accuracy
of the neurologic examination is partly due to other causes of
sciatica such as foraminal stenosis in a proportion of patients.
The SLR and reverse SLR are widely reported as tests to help
identify patients likely to have a disc herniation.4,10,11 Although
patients in the current study did undergo SLR testing the results of
these tests were not included as the tests have no logical basis for
www.spinejournal.com E717
21/04/11 3:33 AM
 DIAGNOSTICS Diagnostic Accuracy of the Clinical • Hancock et al

TABLE 5. Diagnostic Accuracy of Neurologist Exam Compared To Disc Level and Disc Location
L4/5 Disc Herniation
Central Lateral
Predictor Sens Spec AUC Sens Spec AUC
Neurologist concludes L3/4 0.03 0.96 0.49 0.13 0.97 0.55
herniation (0.01–0.08) (0.92–0.98) (0.42–0.57) (0.02–0.38) (0.94–0.98) (0.39–0.70)
Neurologist concludes L4/5 0.75 0.75 0.75 0.88 0.59 0.73
herniation (0.65–0.83) (0.68–0.81) (0.69–0.81) (0.62–0.98) (0.53–0.65) (0.62–0.84)
Neurologist concludes L5/S1 0.23 0.27 0.25 0.06 0.47 0.24
herniation (0.16–0.33) (0.20–0.34) (0.19–0.31) (0.00–0.30) (0.37–0.49) (0.15–0.34)
L5/S1 Disc Herniation
Central Lateral
Neurologist concludes L3/4 0.01 0.92 0.46 0.22 0.97 0.59
herniation (0.00–0.04) (0.85–0.96) (0.39–0.53) (0.03–0.60) (0.94–0.98) (0.38–0.81)
Neurologist concludes L4/5 0.21 0.26 0.23 0.56 0.56 0.56
herniation (0.15–0.29) (0.18–0.34) (0.18–0.29) (0.21–0.86) (0.49–0.61) (0.36–0.75)
Neurologist concludes L5/S1 0.81 0.81 0.81 0.44 0.46 0.45
herniation (0.74–0.87) (90.73–0.88) (0.76–0.86) (0.14–0.79) (0.40–0.53) (0.26–0.65)
Shaded cells represent the diagnostic accuracy for the suspected level.
Values in each cell are estimate and 95% confidence intervals.
Sens indicates sensitivity; spec, specificity; AUC, area under curve.

identifying the level of disc herniation as investigated in this study. The results of the study do not directly inform the deci-
It is possible that the location of pain produced during a SLR sion to perform surgery. The results demonstrate that based
test may be informative in identifying the level of disc herniation; on a clinical examination alone a clinician cannot be highly
however, this data was not collected in the current study. confident of the level of disc herniation. At present the level
of herniation identified on MRI presents the most valid infor-
TABLE 6. Diagnostic Accuracy of Multiple mation in guiding the level of surgery. As all patients had a
Test Findings confirmed disc herniation the results do not provide informa-
tion on the accuracy of neurological tests in identifying the
Predictor Sensitivity Specificity presence of a herniation.
L3/4 Disc Herniation In conclusion, the current study did not find evidence to
support the accuracy of individual tests from the neurological
No. of positive tests 1 1.00 (0.74–1.00) 0.33 (0.27–0.39)
examination in identifying the level of disc herniation (for the
for L3/4 tests
AUC = 2 0.75 (0.43–0.95) 0.65 (0.59–0.71) lower three discs) demonstrated on MRI. A neurologist was
0.79 (0.68–0.91) 3 0.50 (0.21–0.79) 0.90 (0.85–0.93) moderately accurate in identifying the level of disc herniation.
Further research may focus on determining which individual
4 0.08 (0.00–0.39) 0.99 (0.97–1.00) test or combination of tests is most informative in predicting
L4/5 Disc Herniation the level of disc herniation.
No. of positive tests 1 0.97 (0.92–0.99) 0.16 (0.10–0.22)
for L4/5 tests
AUC = 2 0.68 (0.59–0.76) 0.51 (0.43–0.59)
0.64 (0.58–0.71) 3 0.37 (0.28–0.46) 0.83 (0.76–0.88) ➢ Key Points
L5/S1 Disc Herniation Individual tests from the neurological examination
No. of positive tests 1 0.90 (0.85–0.94) 0.34 (0.25–0.43) did not accurately identifying the level of disc hernia-
for L5/S1 (AUC = tion demonstrated on MRI in patients with sciatica.
0.74 (0.67–0.79) 2 0.67 (0.59–0.74) 0.71 (0.62–0.79)
The outcome of multiple test findings was slightly
3 0.28 (0.21–0.35) 0.94 (0.88–0.98) more accurate but did not produce high sensitivity
Positive tests for each disc level include the index test from each category and specificity for level of disc herniation.
(sensation, motor strength, reflex, and dermatome of pain) with the greatest A neurologist’s overall impression was moderately
AUC for identifying a herniation at that disc providing the AUC was > 0.55.
Values in each cell are estimate and 95% confidence intervals.
accurate in identifying the level of disc herniation.
Sens indicates sensitivity; spec, specificity; AUC, area under curve.

E718 www.spinejournal.com May 2011

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

BRS204030.indd 718 21/04/11 3:33 AM

 DIAGNOSTICS
References
1. Deyo RA, Rainville J, Kent DL. What can the history and physical
examination tell us about low back pain? JAMA 1992;268:760–5.
2. Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of
sciatica. BMJ 2007;334:1313–7.
3. Kortelainen P, Puranen J, Koivisto E, et al. Symptoms and signs
of sciatica and their relation to the localization of the lumbar disc
herniation. Spine 1985;10:88–92.
4. Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of his-
tory and physical examination in patients suspected of sciatica due
to disc herniation: a systematic review. J Neurol 1999;246:899–906.
5. Vroomen PC, de Krom MC, Wilmink JT, et al. Diagnostic value of
history and physical examination in patients suspected of lumbosa-
cral nerve root compression. “see comment”. J Neurol Neurosurg
Psychiatry 2002;72:630–4.
6. Jensen OH. The level-diagnosis of a lower lumbar disc hernia-
tion: the value of sensibility and motor testing. Clin Rheumatol
1987;6:564–9.
Spine
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS204030.indd 719
Diagnostic Accuracy of the Clinical • Hancock et al
7. Peul WC, van Houwelingen HC, Van Den Hout WB, et al. Surgery
versus prolonged conservative treatment for sciatica. N Engl J Med
2007;356:2245–56.
8. Peul WC, van Houwelingen HC, Van Der Hout WB, et al. Pro-
longed conservative treatment or ‘early’ surgery in sciatica caused
by a lumbar disc herniation: rationale and design of a randomized
trial “ISRCT 26872154”. BMC Musculoskelet Disord 2005;6:8.
9. Fardon DF, Milette PC, et al., Combined Task Forces of the North
American Spine Society ASoSR, Nomenclature and classification of
lumbar disc pathology. Recommendations of the Combined task
Forces of the North American Spine Society, American Society of
Spine Radiology, and American Society of Neuroradiology. Spine
2001;26:E93–113.
10. Haldeman S, Shouka M, Robboy S. Computed tomography, elec-
trodiagnostic and clinical findings in chronic workers’ compensa-
tion patients with back and leg pain. Spine 1988;13:345–50.
11. Hudgins WR. The crossed straight leg raising test: a diagnostic sign
of herniated disc. J Occup Med 1979;21:407–8.
www.spinejournal.com E719
21/04/11 3:33 AM