Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review

Accepted Manuscript

Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematicreview

Abdullah M. Alqarni, MPhty, Anthony G. Schneiders, PhD, Chad E. Cook, PhD,Doctor of Physical Therapy Program, Paul A. Hendrick, PhD

PII: S1466-853X(15)00002-4

DOI: 10.1016/j.ptsp.2014.12.005

Reference: YPTSP 648

To appear in: Physical Therapy in Sport

Received Date: 10 June 2014

Revised Date: 14 December 2014

Accepted Date: 31 December 2014

Please cite this article as: Alqarni, A.M., Schneiders, A.G., Cook, C.E., Hendrick, P.A., Clinical tests todiagnose lumbar spondylolysis and spondylolisthesis: A systematic review, Physical Therapy in Sports(2015), doi: 10.1016/j.ptsp.2014.12.005.

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Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review

Abdullah M. Alqarni (MPhty)

Department of Physiotherapy, King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia.

Anthony G. Schneiders (PhD)

School of Human, Health and Social Sciences, Central Queensland University, Branyan,

Australia.

Chad E. Cook (PhD) Doctor of Physical Therapy Program, Duke University, Durham, USA.

Paul A. Hendrick (PhD) Division of Physiotherapy Education, University of Nottingham,

Nottingham, UK.

Corresponding author: A.G. Schneiders, Central Queensland University, University Drive,

Branyan, Queensland, Australia, 4670.

Tel: +61 7 41507007; fax: +61 7 41507080

E-mail address: [email protected]

Keywords: Systematic review, Diagnosis, Lumbar spine, Validity

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Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic

review

ABSTRACT

The aim of this paper was to systematically review the diagnostic ability of clinical

tests to detect lumbar spondylolysis and spondylolisthesis.

A systematic literature search of six databases, with no language restrictions, from

1950 to 2014 was concluded on February 1, 2014. Clinical tests were required to be

compared against imaging reference standards and report, or allow computation, of

common diagnostic values.

The systematic search yielded a total of 5164 articles with 57 retained for full-text

examination, from which 4 met the full inclusion criteria for the review. Study

heterogeneity precluded a meta-analysis of included studies. Fifteen different clinical

tests were evaluated for their ability to diagnose lumbar spondylolisthesis and one

test for its ability to diagnose lumbar spondylolysis. The one-legged hyperextension

test demonstrated low to moderate sensitivity (50-73) and low specificity (17-32) to

diagnose lumbar spondylolysis, while the lumbar spinous process palpation test was

the optimal diagnostic test for lumbar spondylolisthesis; returning high specificity (87-

100) and mixed sensitivity (60-88) values.

Lumbar spondylolysis and spondylolisthesis are identifiable causes of LBP in athletes.

There appears to be utility to lumbar spinous process palpation for the diagnosis of

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lumbar spondylolisthesis, however the one-legged hyperextension test has virtually no

value in diagnosing patients with spondylolysis.

1. INTRODUCTION

Lumbar spondylolysis and spondylolisthesis are established conditions in both

adolescent and adult populations and an identifiable cause of low back pain (LBP) in

athletes (Garet et al., 2013). The prevalence of lumbar spondylolysis differs in the

literature but has been estimated to be approximately 6–8% in the general

population by some authors (Wiltse and Rothman, 1989; Brooks et al., 2010), and

as high as 63% in those engaging in specific sporting activities (Rossi, 1988);

while the reported incidence of spondylolisthesis is suggested to comprise

between 2% to 6% of LBP populations (Magora 1976; Osterman et al., 1993).

Spondylolysis is characterised by a defect in the pars interarticularis which is

proposed to be either developmental or an acquired stress fracture secondary to

chronic low-grade trauma or repetitive loading (Leone et al., 2011) such as that can

occur in sport. Over time, stress concentration and accumulation can lead to a physis

stress fracture at the vertebral body diminishing the stabilising ability of the posterior

elements in the spinal segment and can progress to an isthmic spondylolisthesis

(Sairyo et al., 2006). A spondylolisthesis occurs when there is a bilateral pars

interarticularis defect and is often hallmarked by a forward slip of the superior

vertebrae on the inferior vertebrae (McNeely et al., 2003;Cavalier et al., 2006).

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The Wiltse classification system (Wiltse et al., 1976) subdivides

spondylolisthesis into five aetiological categories; isthmic, dysplastic, degenerative,

traumatic, and pathological (Huijbregts, 2001). Of these categories, the degenerative

form is the most prevalent with isthmic spondylolisthesis more common in individuals

aged less than 50 years (Logroscino et al., 2001). Whereas the majority of individuals

with spondylolysis remain asymptomatic (Haun and Kettner, 2005), symptomatic

cases may present with considerable morbidity and result in focal low back pain.

Symptoms may radiate into the buttock or lower limb following incidental trauma or

intense athletic activities; most often associated with repeated extension and/or

rotation of the lumbar spine (Morita et al., 1994; Ralston, 1998; Standaert and

Herring, 2000; Standaert, 2002).

Other classification systems for spondylolisthesis define the grade of severity,

such as the commonly used Meyerding system (Ganju, 2002), which categorizes the

degree of vertebral slip using static lateral radiographs. Similar approaches, such as

the Boxall and Taillard method, use comparable slip assessment criteria (Taillard,

1954; Boxall et al, 1979). Each of these measures quantifies the severity of

spondylolisthesis and each implies the potential presence of instability.

A recent systematic review assessed the accuracy of tests to diagnose lumbar

instability and included tests utilised with both spondylolysis and spondylolisthesis

(Alqarni et al., 2011), however, these conditions do not always lead to lumbar

structural instability and current evidence suggests that translational instability

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(structural instability) and spondylolisthesis represent differing and separate

aetiologies (Axelsson et al., 2000; McGregor et al., 2002). Translational instability is

defined as abnormal translation and/or rotation around the x-, y-, and z-axes of the

three-dimensional coordinates of the spine (Panjabi and White, 1978). The reported

cutoff values for vertebral translatory motion employed to diagnose the presence of

translational instability (structural instability) also remain somewhat contentious and

very between 3 to 5 mm in the literature (Knutsson, 1944; Shaffer et al., 1990; Hayes

at al., 1989).

A variety of diagnostic imaging methods are used to identify the presence of

spondylolysis, including plain-film imaging, computed tomography (CT), magnetic

resonance imaging (MRI), single photon emission computed tomography (SPECT) and

bone scintigraphy. SPECT has demonstrated the greatest sensitivity of the measures

with 10-12 times more contrast than bone scintigraphy (Harvey et al., 1998; Standaert

and Herring, 2000). Further estimates of the incidence of spondylolysis in the general

population range from 5.9% in the general population to 30% in select populations

(Sakai et al., 2010) with a reported prevalence of 11.5% in populations with CLBP

(Leonid et al., 2009). Since imaging is an imperfect science, linking the symptom

severity and the degree of anatomical or radiographic changes is challenging (Gibson

and Waddell, 2005). We cannot yet therefore determine the link between the levels of

morbidity and radiographic features.

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Spondylolisthesis is diagnosed radiographically through bone scintigraphy,

computed tomography (CT), magnetic resonance imaging (MRI), and lateral

radiographs in order to demonstrate a pars interarticularis defect and establish the

percentage of vertebral slippage in the absence of translation instability (Standaert

and Herring, 2000; Campbell et al.,2005). The North American Spine Society Clinical

Guidelines for Multidisciplinary Spine Care report (2008) designated lateral plain-film

radiographs and MRI as the most effective tools for diagnosis of spondylolisthesis with

stenosis, with CT-scan demonstrating effectiveness for patients in which MRI is

contraindicated. However, as with diagnosis of other low back-related conditions, a

high degree of false positives (imaging findings with poor correlation to clinical

symptoms) are present (Lurie, 2005).

Clinical examination findings, including specific orthopaedic tests offer

advantages as initial diagnostic indicators as they may expedite diagnosis and guide

initial management, while limiting the exposure of patients to the associated risks and

further costs of radiology (Alqarni et al., 2011). At present, there are few pre-clinical

indications that are specific to degenerative and asymptomatic lumbar

spondylolisthesis, whereas patients who are symptomatic complain primarily of

radiculopathy or neurogenic intermittent claudication with or without concomitant

back pain. While seminal signs and symptoms that are suggested to be associated with

spondylolysis and spondylolisthesis have been described in the literature (Barash et

al., 1970), it is important to note that these are not unique to spondylolysis and

spondylolisthesis and therefore the clinical diagnosis of these conditions based on

these signs and symptoms currently remains challenging.

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To our knowledge there have been no systematic reviews to date that have

investigated the accuracy of clinical tests to diagnose spondylolysis and

spondylolisthesis. Therefore, the aim of this paper was to systematically search and

review the literature relating to clinical tests specifically for the detection of

spondylolysis and spondylolisthesis in order to establish which tests have the best

accuracy and utility to diagnose these conditions. We planned to qualitatively report

the diagnostic accuracy of the clinical tests and describe the risk of bias of each

included study.

2. METHODS

2.1 Study Design

This systematic review used the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) guidelines throughout the research and

reporting process (Moher et al., 2009). The study was exempt from Human Ethics

Committee review.

2.2 Study Inclusion Criteria

Type of Studies: Prospective and retrospective case control and case-based study

designs were included in this review.

Type of Participants: For inclusion, at least one group of participants in the studies was

required to have been diagnosed with either spondylolisthesis or spondylolysis with

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an acceptable reference standard. There were no restrictions with regards to age for

patients included in the studies.

Index Tests: The diagnostic accuracy of clinical tests associated with spondylolisthesis

or spondylolysis were required to be reported for inclusion in this review.

Targeted Conditions: At least one group of subjects in each study required a diagnosis

of the targeted conditions of spondylolisthesis or spondylolysis.

Reference Standard: The following reference standards were considered acceptable

for diagnosis of spondylolysis and/or spondylolisthesis; plain-film imaging, computed

tomography (CT), magnetic resonance imaging (MRI), single photon emission

computed tomography (SPECT) and bone scintigraphy.

Diagnostic Accuracy Measures: Each study was required to report or allow

computation of diagnostic values (sensitivity, specificity, positive & negative likelihood

ratios) for all clinical tests.

2.3 Search Strategy

Electronic Search: A comprehensive electronic search of the relevant literature was

concluded on February 1, 2014 in the following databases: CINHAL, PubMed,

MEDLINE, Scopus, AMED, and SPORTDiscus from 1950 to 2014. The following key

words/mesh terms were used in various combinations; lumbar spine,

spondylolisthesis, anterolisthesis, posterolisthesis, spondylolysis, validity, sensitivety,

specificity, diagnosis, clinical tests, provocation tests, and physical examination (Figure

1). No language restrictions were applied.

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Other Searches: The reference lists of all included articles were hand searched for

additional relevant references. Relevant grey literature was also accessed where

available as were references through review of the authors’ personal literature.

Selection of Studies: The first reviewer (A.M.A) evaluated the retrieved articles’ title

and abstract from the initial search, for possible inclusion. Two independent reviewers

(A.M.A & P.A.H) then assessed the retrieved titles for potential inclusion and retrieval

of the full text article. Full text articles were scrutinised independently for inclusion by

two reviewers (A.M.A & P.A.H). A third reviewer (A.G.S) was consulted if consensus

was unable to be reached. The reviewers were experienced Orthopaedic Manipulative

Physical Therapists, and as active researchers, were familiar with the literature and

therefore it was not possible to blind reviewers to the; authors, date of publication or,

journals in which the articles were published.

2.4 Data Extraction and Management

Data were extracted by one author (A.M.A) and was either placed in a 2 X 2

contingency table or, if the sensitivity, specificity and positive and negative likelihood

ratios (± LRs) were reported, the values were tabulated.

2.5 Quality Assessment

The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool,

developed by Whiting et al. (2003) was used to assess the methodological quality of

included articles. The QUADAS tool consists of 14 items which are scored as either yes,

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no or, unclear. Nine items specifically relate to bias, three items to the quality of

reporting, and two items relate to variability. To provide uniform interpretation of

each study and avoid quality assessment bias, the reviewers re-familiarised

themselves with the QUADAS prior to the evaluation, as all reviewers had

considerable experience in using the QUADAS, and a priori pre-piloting of the form for

calibration of assessors was not deemed necessary.Each of the 14 items were

independently scored either “yes”, “no” or, "unclear" by two reviewers (A.M.A &

A.G.S). In the case of any disagreement, a third reviewer (P.A.H) was consulted.

The original QUADAS tool did not initially incorporate a quality scoring system.

For this review, we used the methods proposed by the original developers (Whiting et

al.,2003). Quality was scored using item-weightings based and scaled for potential bias

or variation. Items 1, 5, 10, 11, and 12 were scored three points for “yes”, while items

3 and 6 were scored two for yes, and all other items (2, 4, 7, 8, 9, 13, and 14) scored

one point for yes. All items were scored zero if the response was “no”, or unable to be

determined (unclear); with a total possible score of 26. Studies were not stratified into

“high or low quality” using the QUADAS quality score, since it was estimated that the

number of articles retrieved during the review would be low, and as it is also

recognised that rating scores can potentially bias conclusions based on the quality of

diagnosis accuracy estimates and the weighting attributed to each item (Whiting et

al., 2005).

2.6 Statistical Analysis and Data Synthesis

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To determine the accuracy with which each physical examination test

identifies each pathology and subsequently its clinical usefulness, sensitivity and

specificity and positive and negative likelihood ratios were calculated. Sensitivity is the

probability of a positive test result in someone with the pathology, whereas specificity

is the probability of a negative test result in someone without the pathology. The

taxonomy for descriptively characterizing magnitudes of sensitivity and specificity as

described by Schneiders et al., (2012) was used for this study and were classified as;

low if 50% or less, low to moderate if between 51% and 64%, moderate if between

65% and 74%, moderate to high if between 75% and 84%, and high if 85% or greater.

Both positive likelihood ratios (LR+) and negative likelihood ratios (LR-) were

calculated from the data provided from the sensitivity and specificity findings.

Positive likelihood ratios (LR+) greater than one (1) increase the post-test probability

that the target condition is present, and the higher the positive likelihood ratio the

greater this increase. Negative likelihood ratios (LR-) closer to 0 decreases the

probability of the target disorder with a negative finding, and the smaller the negative

likelihood ratio, the greater the decrease in probability (McCarthy et al., 2008). A

positive finding with a test that has a LR+ >10 generates a large change in post-test

probability, whereas a LR+ of 5-10 moderately influences post-test probability. A

negative finding with a test that has a LR- <0.1 generates a large shift in post-test

probability, whereas a LR- of 0.1-0.2 moderately shifts the pre to post-test probability

(Jaeschke et al., 1994). This study did not endeavour to perform a meta-analysis.

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3. RESULTS

3.1 Study Selection Results

A total of 5164 articles resulted from the initial systematic literature search.

After title screening, 42 articles were selected for possible inclusion in the review and

after full text examination (Figure 1), 4 articles fulfilled all eligibility criteria.

3.2 Study Characteristics

Two studies (Collaer et al., 2006; Kalpakcioglu et al., 2009) used lateral

radiographs as the reference standard for the differential diagnosis of a

spondylolisthesis and two studies (Masci et al.,2006; Gregg et al., 2009) used MRI and

SPECT to diagnose the presence of spondylolysis. A total of 15 different clinical tests

were evaluated for their ability to diagnose lumbar spondylolisthesis, and 1 test for its

ability to diagnose lumbar spondylolysis.

3.3 Risk of Bias Scores

The quality scores using the QUADAS tool for each item, total score, and the

percentage agreement between the two reviewers are presented in Table 4. All items

had an initial reviewer agreement of 100%, except clarity of selection criteria and

patient withdrawal from studies, where agreement was 75%. A third reviewer (P.A.H)

was consulted where agreement was not initially reached, resulting in the final scores

reported in Table 4. All articles satisfied the criterion that subjects in the studies

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included the complete spectrum of patients representative of those whom would

normally be expected to receive the test in clinical practice (Whiting et al., 2003).

None of the included studies clarified whether the time period between the

performance of the reference standard and clinical test was short enough to be sure

that the target condition had not changed between the two tests (Whiting et al.,

2003). Subjects in all studies received the same diagnostic test regardless of the

clinical test result, and the diagnostic test was performed independent of the clinical

test results in all cases. Diagnostic and clinical tests were sufficiently described in all

included studies, except the study by Gregg et al. (2009) and all studies reported

uninterruptible test results. Blinding of assessors for the clinical testing procedures

and radiographic diagnosis of lumbar spondylolysis and spondylolisthesis was unclear

in all studies except the study by Collaer et al. (2006). None of the studies reported

whether interpretation of the radiological examination occurred without prior

knowledge of the clinical test results. Only one study (Collaer et al., 2006) did not

report on the reasons for patients’ withdrawal.

3.4 Tests for Spondylolysis

The one-legged hyperextension test was employed to diagnose lumbar

spondylolysis in a prospective cohort study of 71 patients with symptoms of recent

onset non-specific LBP recruited from a sports medicine clinic (Masci et al., 2006) and

a retrospective cohort of 82 patients with suspected spondylolysis recruited from a

medical facility that included a sports medicine centre and radiology clinic (Gregg et

al., 2009). The test was performed, as previously described by Jackson et al. (1981),

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with the patient standing, facing away from the tester and each subject was then

asked to stand on his/her left leg and to raise his/her right leg with right hip slightly

flexed and right knee flexed to 80 degrees. Subjects were then asked to actively

extend their lumbar spine. Subjects repeated the test on the opposite side to compare

and record the symptom response. A positive result occurred when the patient

reported pain during this procedure. Masci and colleagues (2006) reported low

sensitivity, specificity, and +LR values for both sided tests; left leg (50%, 32%, 0.7),

right leg (55%, 46%, 1.0) for the diagnosis of spondylolysis confirmed by scintigraphy

(SPECT). Gregg et al. (2009) reported a sensitivity of 73% and specificity of 17% with a

+LR of 0.9, however it is unclear from this study which leg was used. Full study results

are presented in Table 1.

3.5 Tests for Spondylolisthesis

Table 2 outlines the 15 tests evaluated for their association with lumbar

spondylolisthesis. Lumbar spinous process palpation was investigated by Collaer et al.

(2006) in 44 patients with LBP and/or radiculopathy (mean age 40 yrs). The palpation

was performed with the examiner seated whilst maintaining a lateral view of the

patient’s lumbar spine. The palpation examination consisted of applying and

maintaining firm contact on the lumbosacral spinous processes, while sliding the

examining finger tips from the upper lumbar region to the sacrum for the presence or

absence of a lumbar spinous process “step”. Sensitivity, specificity, and +LR were

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reported as 60%, 87%, and 4.6 respectively, for the diagnosis of lumbar

spondylolisthesis as confirmed on lateral radiographs.

Kalpakcioglu et al. (2009) compared the findings of lateral radiography and 15

clinical tests/signs within a cohort of 100 patients (mean age 54.8 yrs) with

radiologically confirmed lumbar spondylolisthesis and 30 patients (Table 3) without

radiological diagnosis of translational spondylolisthesis. The 15 tests (Table 2)

comprised; sign of slipping (inspection and palpation), contraction of the hamstring

muscles, lumbar flexion, extension, lateral flexion, and rotation, single and double leg

raise, femoral nerve stretch, Achilles and patellar reflexes, loss of strength of ankle

sagittal motion and first toe extension, sensorial change, and a walking distance <250

meters. Sensitivity values ranged from 1% for active lumbar rotation, active single leg

raise, lumbar spasm or pain on contraction of the hamstring muscles and, loss of

strength of ankle sagittal motion with first toe extension to 88% for a sign of slipping

on palpation. Specificity values ranged from 3% for active lumbar flexion to 100% for a

sign of slipping on inspection, a sign of slipping on palpation, and sensorial change.

Positive LRs were unable to be calculated from tests with 100% specificity (+LR = ∞).

4. DISCUSSION

The goals of this study were to investigate the diagnostic accuracy of clinical

tests to detect spondylolysis and spondylolisthesis. We evaluated studies that

investigated the clinical test’s diagnostic ability when compared to imaging reference

standards of bone scintigraphy (SPECT), computed tomography (CT), magnetic

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resonance imaging (MRI), and lateral radiographs which are capable of demonstrating

the presence of a pars interarticularis defect or establishing the percentage of

vertebra slippage in the absence of translational instability. The majority of clinical

tests (n = 16) reviewed were utilised to diagnose lumbar spondylolisthesis, with only

one test found that had been evaluated for its specific ability to diagnose lumbar

spondylolysis. The large number of clinical tests associated with the assessment of

spondylolisthesis is due to Kalpakcioglu et al. (2009) investigating the diagnostic ability

of common assessment procedures which are often evaluated in LBP patients but are

not necessarily specific to pathology associated with spondylolisthesis. Our findings

suggest there is utility to lumbar spinous process palpation for the diagnosis of lumbar

spondylolisthesis whereas there are no tests that demonstrate clinical value when

diagnosing spondylolysis.

This review differs from the previous review by Alqarni et al. (2011), which

focused purely on a reference standard of radiographic translational instability.

Despite this separate focus, it is worth noting that there is strong evidence that

spondylolysis can induce spinal instability (Leone et al., 2011) and that some of the

individuals included in this review might have also have been diagnosed with lumbar

instability based on current clinical criteria. Although current evidence suggests that

translational instability and spondylolisthesis represent differing conditions (Axelsson

et al., 2000; McGregor et al., 2002), there is potential for these conditions to co-exist

and/or represent a progression on a clinical spectrum, thus affecting the utility and

diagnostic ability of the testing procedures for each of these conditions. The relatively

low diagnostic ability of the clinical tests from the review may also reflect the fact that

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these conditions sit on a clinical spectrum with potential for a number of co-existing

pathologies dependent upon the aetiology of the condition and the age range of the

participants (Logroscino et al., 2001).

The one-legged hyperextension test was the single clinical test found which

was evaluated for its diagnostic ability to detect spondylolysis. The premise behind the

one-legged hyperextension test is that unilateral standing on the affected side and

hyperextension loads and stresses the posterior structures resulting in pain elicitation.

Based on low to high grading criteria for sensitivity and specificity conceived by

Schneiders et al. (2012); Gregg et al. (2009) reported moderate sensitivity but low

specificity, whereas, Masci et al. (2006) demonstrated low specificity, while sensitivity

for this test was low for the left leg, and low to moderate for the right leg. Differences

in selection criteria might have affected the sensitivity value in the study by Gregg et

al. (2009) which included patients who were already suspected of having lumbar

spondylolysis. Another possible factor for the higher sensitivity in the study by Gregg

et al. (2009) is the higher age range of participants. Masci and colleagues (2006)

included an age range of 10-30 years, excluding the potential for elderly patients with

possible degenerative lumbar spondylolysis. Despite these differences, and the

retrospective nature of Gregg et al.’s (2009) study, both studies reported similar and

very small +LRs (1.0), which suggests that one-legged hyperextension test has virtually

no value in diagnosing patients with spondylolysis.

Two studies evaluated a combined total of 16 clinical tests to diagnose lumbar

spondylolisthesis between them. Collaer et al. (2006) demonstrated the lowest risk of

bias of all the studies in this review and reported that the lumbar spinous process

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palpation test (with the presence of step) had high specificity (87%), low to moderate

sensitivity (60%), and a moderate +LR (4.7) for the diagnosis of lumbar

spondylolisthesis. It is however important to note that these authors reported poor

inter-rater reliability (K: 0.18, 0.39, 0.31) for the lumbar spinous process palpation test

among the three pairs of examiners. Kalpakcioglu et al. (2009) examined the palpation

test’s ability to detect spondylolisthesis in a cohort of 100 patients with confirmed

radiological lumbar spondylolisthesis and compared them to 30 controls. They

reported high specificity (100%) and sensitivity (88%), however, the inclusion of

patients with confirmed spondylolisthesis would have inflated the sensitivity value

and such spectrum bias would inflate other diagnostic accuracy values. Despite these

potential methodological reservations, the authors of both studies indicated that

lumbar spinous process palpation might be an effective clinical test to diagnose

lumbar spondylolisthesis. Further study in wider spectrums of LBP populations is

required to validate these findings.

Other tests evaluated by Kalpakcioglu et al. (2009) also demonstrated potential

utility. A visual sign of slipping on inspection and the presence of sensory changes

(sciatalgia) demonstrated low sensitivity (21% & 2% respectively) but high specificity

(100%) to diagnose spondylolisthesis. The active double leg raise test also provided

high sensitivity (87%), and moderate to high specificity (77%), and a small but

sometimes important +LR value (4) to diagnose lumbar spondylolisthesis.The femoral

nerve stretch test demonstrated low sensitivity (14%), but high specificity (97%), with

a +LR of 4, and this could be due to the movement of the femoral nerve and/or the

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movement in the spine during the testing procedure which stresses the lumbar spine

in extension.

Kalpakcioglu et al. (2009) also investigated a number of other active and

passive clinical tests that yielded poor utility in diagnosis of lumbar spondylolisthesis.

The lumbar extension test, lumbar lateral flexion test, and a test of walking distance

(<250m) all had respectively low to moderate/high sensitivities and specificities,

however, +LRs were small. The other common clinical tests (Table 2) had low

sensitivity, but high specificity and consequently small +LRs. Lumbar flexion also

showed no ability to diagnose lumbar spondylolisthesis with low sensitivity and

specificity, and very small +LR values.

It is acknowledged that the clinical tests evaluated in this review are routinely

performed in combination in clinical practice and also in conjunction with a thorough

subjective examination. However, the diagnostic capacity of combined clinical tests

has yet to be comprehensively evaluated and reported in the literature. It is also the

case that lumbar spondylolisthesis and spondylolysis often represent differing stages

of a progressive disorder and therefore symptomology and clinical signs may vary

dependent on where the patient sits on the clinical spectrum at a said point in time.

Further prospective research into the diagnostic ability of the clinical tests within

mixed cohorts of LBP patients is therefore warranted.

4.1 Limitations

The findings of this review are primarily limited by the small number of articles

that have reported on the accuracy of clinical tests to diagnose lumbar spondylolysis

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and spondylolisthesis. The study sample sizes were also relatively small ranging from

44 to 130 patients (Table 3) which also may have affected the internal validity and

diagnostic accuracy of included studies. For this review the weighted QUADAS

assessment tool was used to assess the quality of included articles; however, the

QUADAS tool is suggested to have a number of associated limitations. These include

the possibility that even well-conducted studies may score poorly if the methods and

results of the study are not reported in sufficient detail, and that the tool does not

include items that assess statistical power which can subsequently affect a study’s

internal validity. In our assessment of quality, only 1 of the 4 papers evaluated yielded

a low risk of bias score. The reference standards used for both targeted diagnoses

demonstrate weaknesses in that findings are not always corrected with clinical

symptoms. Additionally, as stated, we targeted papers that did not use a translational

instability measure for a reference standard for spondylolysis and spondylolisthesis.

Despite this, and as stated previously, there is a chance that patients could

demonstrate instability that was not captured in the study.

This review is also limited due to a meta-analysis not being performed due to

the clinical heterogeneity of the studies. While Masci et al. (2006) and Gregg et al.

(2009) did appear to perform the same test (one-legged hyperextension test), one

study was prospective and the other retrospective and although Masci et al. reported

adequate raw data (true/false-positive/negatives) to allow a meta-analysis, Gregg et

al. did not. Additionally Gregg et al. was working with a limited data set for the one-

legged hyperextension test with only 44 of the 82 patient reports having sufficient

detail to determine the outcome of this test. Additionally, Masci et al. reported data

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from both legs while Gregg reported only one set of data and it is therefore unclear

which leg contributed to the data set.

Limitations in test detail also retrospectively precluded meta-analysis of the

data for diagnosis of lumbar spondylolisthesis. While both Kalpakcioglu et al. (2009)

and Collaer et al. (2006) appeared to perform similar lumbar palpation techniques, the

test was not explained in sufficient detail in Kapakcioglu’s study to determine a

definite association. For instance, it is not clear if the test was performed in standing

or lying and what the outcome variable was (pain or displacement). An additional

problem when performing a metaanaylsis on these studies is that Kapakcioglu

reported 100% specificity as there were no true-negatives (0) in their cohort, which

meant a positive likelihood ratio approaching infinity. The resulting empty cell for

true-negatives poses additional problems for a meta-analysis where calculation is

impossible without inserting dummy variables into the equation. These clinical and

statistical heterogenity issues are suggested to limit the ability to confidently combine

the data of both tests in a meta-analysis. Future studies should be adequately

powered incorporating a broad spectrum of patients with and without the disorder

and a standardised and well-described clinical testing procedure. Additionally, a clear

and defined valid reference standard for diagnosis should be correlated independently

to the results of the clinical test. This would allow meta-synthesis of the results.

5. CONCLUSION

Spondylolysis and spondylolisthesis has a high prevalence in sporting and

athletic populations. This is the first systematic review to evaluate the accuracy of

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clinical tests to diagnose patients with lumbar spondylolysis and spondylolisthesis that

used reference standard mechanisms that were not associated with translational

instability. There appears to be utility to lumbar spinous process palpation for the

diagnosis of lumbar spondylolisthesis, however the one-legged hyperextension test

has virtually no value in diagnosing patients with spondylolysis. To ensure the

reliability, validity and diagnostic accuracy of included clinical tests, further studies are

required, which have larger sample sizes, lower risks of bias, differing age ranges, and

different examiners.

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FIGURE 1. Search history

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Table 1. Summary of diagnostic tests for Spondylolysis

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Table 2. Summary of diagnostic tests for spondylolisthesis

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Table 3. Study descriptors and subject demographics for each of the included studies

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Table 4. QUADAS scores for each of the included studies

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Table 1. Summary of diagnostic tests for Spondylolysis

Authors Tests Subjects Sensitivity

(95% CI)

Specificity

(95% CI)

+LR

(95% CI)

–LR

(95% CI)

QUADAS

Score (26/26)

Masci et al., 2006 One-legged

hyperextension test

(left)

71 50 (33 - 67) 32 (16 - 50) 0.74 (0.5 - 1.1) 1.5 (1 - 2.4) 13

One-legged

hyperextension test

(Right)

55 (38 - 71) 46(29 - 63) 1.0 (0.7 - 1.5) 1.0 (0.6 - 1.5)

Gregg et al., 2009 Single leg

hyperextension test

82 73 (52 - 88) 17 (9 - 31) 0.9 (0.7 - 1.1) 1.5 (0.7 - 3.0) 22

Abbreviations: CI, confidence interval; LR, likelihood ratio; QUADAS, Quality Assessment of Diagnostic Accuracy

Studies.

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Table 2. Summary of diagnostic tests for spondylolisthesis

Authors Tests Subjects Sensitivity

(95% CI)

Specificity

(95% CI)

+LR

(95% CI)

–LR

(95% CI)

QUADAS Score

(26/26)

Collaer et al.,

2006

Lumbar spinous

process

palpation

44 60 (17- 93) 87 (72 - 95) 4.7 (1.6 - 14) 0.5 (0.2 - 1.4) 16

Kalpakcioglu et

al., 2009

Sign of slipping

(inspection)

130 21 (14 - 31) 100 (86-100) ∞ 0.8 (0.7- 0.9) 16

Sign of slipping

(palpation)

88 (79 - 93) 100 (86-100) ∞ 0.1(0.07- 0.2)

Contraction of

Hamstring

muscles

1(0.05- 1.0) 90 (72- 97) 0.1(0.01-0.9) 1.1(1.0 - 1.1)

Lumbar flexion 19 (12- 28) 3(0.2 -19) 0.2 (0.1 - 0.3) 24 (3 - 178)

Lumbar

extension

79 (69- 86) 67 (47 - 82) 2.4(1.4 - 4) 0.3 (0.2 - 0.5)

Lumbar lateral

flexion

46 (36 - 56) 83 (65 - 94) 2.8 (1.2 - 6) 0.7 (0.5 - 0.8)

Lumbar rotation 1(0.05 - 2) 97 (80 - 100) 3 (0.4 - 22.5) 0.9 (0.9 - 1)

Single leg raise 1 (0.05 –1.0) 90 (72 - 97) 1 (0.3 - 3) 1 (0.9 - 1)

Double leg raise 87 (78 - 93) 77 (57 - 89) 4 (2 - 7) 0.2 (0.1 - 0.3)

Femoral nerve

stretch

14 (8 - 23) 97 (81 - 100) 4 (0.6 - 31) 0.9 (0.8 -1)

Achilles reflex 13 (7 - 22) 93 (76 - 99) 2 (0.5 - 8) 0.9 ( 0.9 -1)

Patellar reflex 8 (4 - 16) 97 (80 - 100) 2.4 (0.3 - 18) 1 (0.9 - 1)

Loss of strength

of ankle sagittal

motion and 1st

1 (0 - 6) 97 (80 - 100) 0.3 (0.2 - 5) 1 (1 - 1.04)

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Sensorial

change

2 (0 - 7) 100 (86 -100) ∞ 1 (0.9 - 1)

Walking

distance < 250m

74 (64 - 82) 60 (40 - 77) 2 (1.2 - 3) 0.4 (0.3 - 0.6)

Abbreviations: CI, confidence interval; LR, likelihood ratio; QUADAS, Quality Assessment of Diagnostic Accuracy

Studies.

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Table 3. Study descriptors and subject demographics for each of the included studies

Authors Index tests Subjects Examiners Reference

tests

Definition of the

positive index tests

Condition

Masci et al.,

(2006)

One-legged

hyperextension

test (left-right)

71 patients; age

10-30 years with

LBP (≤ 6 months)

One Sports Physician (details

of training)

SPECT bone

scan

Pain reproduction Spondylosis

Collaer et al.,

(2006)

Lumbar

spinous

process

palpation

44 patients; age

40 ± 15 yrs with

LBP or

radiculopathy

One Manual Therapist (15

yrs experience)

Lateral lumbar

radiograph

Presence of step

deformity

Spondylolisthesis

Gregg et al.,

(2009)

Single leg

hyperextension

test

82 patients; age

≤ 20 yrs with LBP

(≤ 3 months)

Sports Doctors/Orthopaedic

Surgeons

SPECT bone

scan

Pain reproduction Spondylolysis

Kalpakcioglu

et al., (2009)

All 15 tests

reported in

Table

100 patients

with radiological

spondylolisthesis

and 30 control

patients with

LBP; age 22 - 78

with an average

of 54.8 yrs.

Study was conducted in

Physical Therapy and

Rehabilitation department

Lateral lumbar

radiograph

Various Spondylolisthesis

Abbreviations: LBP, low back pain; SPECT, single photon emission computed tomography.

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Table 4. QUADAS scores for each of the included studies

Item

Study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total

Gregg et al., 2009 Y U Y U Y Y Y N N U U U Y Y

3 0 2 0 3 2 1 0 0 0 0 0 1 1 13

Masci et al., 2006 Y Y Y U Y Y Y Y Y U U U Y Y

3 1 2 0 3 2 1 1 1 0 0 0 1 1 16

Collaer et al., 2006 Y Y Y Y Y Y Y Y Y Y Y N Y U

3 1 2 1 3 2 1 1 1 3 3 0 1 0 22

Kalpakcioglu et al.,

2009

Y Y Y U Y Y Y Y Y U U U Y Y

3 1 2 0 3 2 1 1 1 0 0 0 1 1 16

% Agreementa 100 75 100 100 100 100 100 100 100 100 100 100 100 75

Item Criteria

1. Was the spectrum of patient’s representative of the patients who will receive the test in practice?

2. Were selection criteria clearly described?

3. Is the reference standard likely to correctly classify the target condition?

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did

not change between the 2 tests?

5. Did the whole sample or a random selection of the sample, receive verification using a reference standard of diagnosis?

6. Did patients receive the same reference standard regardless of the index text result?

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

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9. Was the execution of the reference standard described in sufficient detail to permit its replication?

10. Were the index test results interpreted without knowledge of the results of the reference standard?

11. Were the reference standard results interpreted without knowledge of the results of the index test?

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in

practice?

13. Were uninterpretable/intermediate test results reported?

14. Were withdrawals from the study explained?

Abbreviations: N, no; U, unclear; Y, yes.

aPercent agreement between initial two reviewers.

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FIGURE 1. Search history

Search strategy

1) “lumbar spine” OR “spondylolisthesis” OR “anterolisthesis “ OR “posterolisthesis” OR “spondylolysis”

2) “validity” OR “sensitivity,” OR

“specificity “ 3) “diagnosis “ OR “clinical tests”

OR “provocation tests” OR “physical examination”

4) (1 AND 2), (1 AND 3), (1 AND

2 AND 3)

Databases

1. CINAHL (n=204 )

2. MEDLINE (n=1100)

3. PubMed (n=1571)

4. Scopus (n=1733 )

5. SPORTDiscus (n=314)

6. AMED (n=242)

7. EMBASE (n=2427)

Electronic database Searched (n=5164)

Included after title screen (n=104)

Full abstracts (n=42)

Full texts (n=4)

Full texts (n=4)

Included in the review (n=4)

Quality assessment

Excluded after abstracts screen (n=38)

Hand search reference lists

Excluded after full text screen (n=4)

Duplications removed (n=62)

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• Lumbar spondylolysis and spondylolisthesis are identifiable causes of LBP in athletes

• This paper is the first to systematically review clinical tests to diagnose lumbar

spondylolysis and spondylolisthesis

• Fifteen clinical tests were retrieved that had been studied to diagnose lumbar

spondylolisthesis and lumbar spondylolysis

• The one-legged hyperextension test demonstrated low to moderate sensitivity and

low specificity to diagnose spondylolysis

• Lumbar spinous process palpation had high specificity and was the optimal

diagnostic test for lumbar spondylolisthesis

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Source of Support: No specific and/or direct funding was received for this study

Conflict of Interest: Dr A.G Schneiders, the second and corresponding author, is an associate

editor of the journal, Physical Therapy in Sport.