Hancock M J, Maher C G, Latimer J, Spindler M F, McAuley J H, Laslett M, Bogduk N
Back Pain Research Group, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, 1825, Sydney, NSW, Australia.
Eur Spine J. 2007 Oct;16(10):1539-50. doi: 10.1007/s00586-007-0391-1. Epub 2007 Jun 14.
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.
临床实践指南指出，大多数腰痛患者的组织来源无法明确。然而，对于用于确定腰痛来源的诊断测试的准确性，尚未进行系统评价。因此，本系统评价的目的是确定临床医生可用的测试对于识别椎间盘、小关节或骶髂关节（SIJ）作为腰痛来源的诊断准确性。检索了截至2006年2月的MEDLINE、EMBASE和CINAHL数据库，并对符合条件的研究进行了引文追踪。符合条件的研究在腰痛患者中将索引测试与适当的参考测试（椎间盘造影、小关节或SIJ阻滞或内侧支阻滞）进行了比较。阳性似然比（+LR）>2或阴性似然比（-LR）<0.5被认为具有信息量。纳入了41项中等质量的研究；28项研究调查了椎间盘，8项研究了小关节，7项研究了骶髂关节。在大多数研究中，MRI上观察到的各种特征（高强度区、终板改变和椎间盘退变）产生了具有信息量的+LR（>2），增加了椎间盘是腰痛来源的可能性。然而，数据的异质性妨碍了合并分析。高强度区、椎间盘退变和终板改变的+LR分别为1.5至5.9、1.6至4.0和0.6至5.9。中央化是唯一被发现增加椎间盘作为疼痛来源可能性的临床特征：+LR = 2.8（95%CI 1.4 - 5.3）。MRI上无退变是唯一被发现降低椎间盘作为疼痛来源可能性的测试：-LR = 0.21（95%CI 0.12 - 0.35）。虽然单独的SIJ手法测试无信息量，但联合使用时具有信息量，+LR为3.2（95%CI 2.3 - 4.4），-LR为0.29（95%CI 0.12 - 0.35）。未发现任何小关节疼痛测试具有信息量。本评价结果表明，确实存在一些测试可以改变椎间盘或SIJ（而非小关节）作为腰痛来源的概率。然而，概率变化通常较小，充其量为中等程度。这些测试在临床实践中的实用性，特别是对于指导治疗选择，仍不明确。
