Clinical classification criteria for radicular pain caused by lumbar disc herniation: the RAPIDH criteria (RAdicular PaIn caused by Disc Herniation)

Publication date: Available online 5 May 2017
Source:The Spine Journal
Author(s): Stéphane Genevay, Delphine S. Courvoisier, Kika Konstantinou, Francisco M. Kovacs, Marc Marty, James Rainville, Michael Norberg, Jean-François Kaux, Thomas D. Cha, Jeffrey N. Katz, Steven J. Atlas
ContextClassification criteria are recommended for diseases that lack specific biomarkers in order to improve homogeneity in clinical research studies. Since imaging evidence of lumbar disc herniations (LDH) may not be associated with symptoms, clinical classification criteria based upon patient symptoms and physical examination findings are required.PurposeThis study aimed to produce clinical classification criteria to identify patients with radicular pain caused by LDH.Study DesignTwo stage process. Phase 1: Delphi process; Phase 2 cohort study.Patient sampleOutpatients recruited from spine clinics in 5 countriesOutcome MeasuresItems from history and physical examinationMethodsIn Phase 1: Seventeen spine experts participated in a Delphi process to select symptoms and signs suggesting radicular pain caused by LDH. In Phase 2: Nineteen different clinical experts identified patients they confidently classified as presenting with: 1) Radicular pain caused by LDH, 2) neurogenic claudication (NC) caused by lumbar spinal stenosis (LSS), or 3) non-specific low back pain (NSLBP) with referred leg pain. Patients completed survey items and specialists documented examination signs. A score to predict radicular pain caused by LDH was developed based on the coefficients of the multivariate model. An unrestricted grant of less than 15000 USD was received from MSD: It was used to support the conception of the Delphi, data management and statistical analysis. No fees were allocated to participating spine specialists.ResultsPhase 1 generated a final list of 74 potential symptoms and signs. In phase 2, 209 patients with pain caused by LDH (89), neurogenic claudication (63), or NSLBP (57) were included. Items predicting radicular pain caused by LDH (p<0.05) were: monoradicular leg pain distribution, patient-reported unilateral leg pain, positive straight leg raise test <60° (or femoral stretch test), unilateral motor weakness and asymmetric ankle reflex. The score had an AUC of 0.91. An easy to use weighted set of criteria with similar psychometric characteristics is proposed (specificity 90.4%, sensitivity 70.6%).ConclusionClassification criteria for identifying patients with radicular pain caused by LDH are proposed. Their use could improve the homogeneity of patients enrolled in clinical research studies.



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