A best-evidence review of diagnostic procedures for neck and low-back pain

This chapter aims to present an overview of the best available evidence on diagnostic procedures for neck and low-back pain. Relatively little is known about the accuracy of such procedures. Although most spinal conditions are benign and self-limiting, the real challenge to the clinician is to distinguish serious spinal pathology or nerve-root pain from non-specific neck and low-back pain. The use of valid procedures can assist the clinician in this aim. A search was conducted in PubMed to identify relevant systematic reviews and primary studies on diagnostic procedures for the neck and low back. A systematic review was included if at least two independent reviewers were used; a systematic procedure was followed for identifying the literature; and a methodological assessment was conducted. In the absence of systematic reviews, primary studies are reported. Systematic reviews were identified which evaluated evidence for diagnostic procedures in the following categories: history, physical examination, and special studies, including diagnostic imaging, diagnostic blocks, and facet and sacroiliac joint injections. In general, there is much more evidence on diagnostic procedures for the low back than there is for the neck. With regard to the history, a number of factors can be identified which can assist the clinician in identifying sciatica due to disc herniation or serious pathology. With regard to the physical examination, the straight-leg raise is the only sign consistently reported to be sensitive for sciatica due to disc herniation, but is limited by its low specificity. The diagnostic accuracy of other neurological signs and tests is unclear. Orthopaedic tests of the neck, such as Spurling's or the upper-limb tension test, are useful to rule a radiculopathy in or rule out, respectively. In patients 50 years of age or older, plain spinal radiography together with standard laboratory tests are highly accurate in identifying underlying systemic disease; however, plain spinal radiography is not a valuable tool for non-specific neck or low-back pain. There is strong evidence for the diagnostic accuracy of facet joint blocks in evaluating spinal pain, and moderate evidence for transforaminal epidural injections, as well as sacroiliac joint injections for diagnostic purposes. In conclusion, during the history, the clinician can accurately identify sciatica due to disc herniation, as well as serious pathology. There is sufficient evidence regarding the accuracy of specific tests for identifying sciatica or radiculopathy (such as the straight-leg raise) or certain orthopaedic tests of the neck. Plain spinal radiography in combination with standard laboratory tests is useful for identifying pathology, but is not advisable for non-specific neck or low-back pain.