***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Study Design . Cross sectional Objective . To investigate the ability of the neurological examination to identify the specific level of a disc herniation in patients with sciatica and confirmed disc herniation . Summary of Background Data . Tests included in a neurological examination theoretically provide accurate diagnostic information about the level of the herniated disc . However , there is currently very little evidence about the diagnostic accuracy of individual tests or combinations of tests . Methods . The study included 283 patients with sciatica and confirmed disc herniation from a previous r and omized controlled trial . 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 informative individual neurological test . The overall suspected level of disc herniation rated by the neurologist after a full examination of the patient was more accurate than individual tests . At L4/5 and L5/S1 herniations the AUC for neurologist ratings was 0.79 and 0.80 respectively . Conclusion . The current study did not find evidence to support the accuracy of individual tests from the neurological examination in identifying the level of disc herniation demonstrated on MRI . A neurologist 's overall impression was moderately accurate in identifying the level of disc herniation Summary The diagnostic power or clinical parameters in the diagnosis of lumbar disc herniation in patients with monoradicular pain was evaluated in a prospect i ve study with a 100 % verification of the diagnosis . Eighty patients with monoradicular pain corresponding to the fifth lumbar or the first sacral nerve root were included . Pre-operatively a number of clinical parameters were recorded and compared to the intra-operative finding of a disc herniation . The parameters were analysed by receiver operating characteristic ( ROC ) curves . Results from the available literature were analysed by ROC curves for comparison . In 76 % of the cases a disc herniation was discovered . The level of the disc herniation was correctly predicted in 93 % of these cases by the location of the pain alone or supplemented by neurological signs . Apart from radicularly distributed pain , all parameters in the present study and in the literature had no or low diagnostic accuracy . Thus , in patients with monoradicular sciatica further clinical parameters do not add to the diagnosis of lumbar disc herniation OBJECTIVE To establish the level of cardiorespiratory fitness and the rate of decrease in maximal aerobic capacity according to age in patients with chronic low back pain and compare these with normative data . DESIGN Prospect i ve case series with historical controls . SUBJECTS/ PATIENTS Seventy patients with chronic low back pain . METHODS A maximal cycle ergometer protocol was used to measure VO2max , heart rate , respiratory exchange ratio and blood lactate levels .  RESULTS Seventy patients achieved absolute and normalized for weight VO2max values of 2.17 ( st and ard deviation ( SD ) 0.65 ) l/min and 30.79 ( SD 7.77 ) ml/kg/min , respectively . Absolute VO2max was poorly related to age in both men and women with chronic low back pain ( r = -0.22 and r = -0.28 , respectively ) . VO2max normalized for weight was also inversely related to age in both men and women ( r = -0.36 and r = -0.42 , respectively ) . The rate of VO2max decline between 20 and 59 years was -3.3 ml/kg/min/decade for the entire population and -1.2 and -5.4 ml/kg/min/decade in men and women , respectively . CONCLUSION The level of physical fitness of patients with chronic low back pain is comparable to the physical fitness of healthy , but poorly conditioned subjects . Patients with chronic low back pain show a VO2max decline with ageing that is slower than of active subjects This prospect i ve and consecutive study was design ed to evaluate the validity of different clinical tests , e.g. lumbar extension in lying and slump test for patients with suspected herniated nucleus pulposus , in comparison with findings on computed tomography ( CT ) and /or magnetic resonance imaging ( MRI ) scan . There were 105 patients who were seen and examined by the senior author ( for the sake of the study ) at the Orthopaedic Physiotherapy Department , on an average of 5.5 days ( range 0 - 21 days ) before CT and /or MRI examination were carried out . There were 36 women and 69 men with an average age of 42.7 + /- 9.8 ( range 19 - 64 ) years . According to the radiological findings on CT and /or MRI , the patients were divided into three groups : 52 patients with disc hernia , 41 patients with bulging discs and 12 patients without positive findings . The mean values with st and ard deviations of 25 variables of three diagnostic groups were studied . Multiple comparison adjustment according to Bonferroni showed significant differences for three variables that were of diagnostic value ( lumbar range of motion for forward flexion , left side-bending in st and ing , and pain distribution during extension in st and ing ) . The agreement between clinical and radiological findings for type and level of diagnosis of disc herniation was accurate in 72 patients ( 69 % ) . The diagnostic sensitivity for disc herniation was 82.6 % and the specificity 54.7 % Summary In a prospect i ve , consecutive study of patients with lumbar back pain and sciatica , various clinical features and surgical findings were evaluated in order to analyse the predictive value regarding ( 1 ) level of diseased interspace ( 2 ) presence and type of lesion responsible for root compression ( 3 ) outcome after surgery . One hundred patients underwent surgery solely on clinical grounds . Fifty-eight had disc herniation . The level of disc herniation was correctly predicted in three quarters of patients with aprolapsed disc . The outcome after surgery was good in 77 patients .Only few clinical features , namely male sex and scoliosis were predictors of a good outcome . Lasegue 's sign was indicative of root compression in 90 % , but only two-thirds had disc herniation . Conversely one-third had disc herniation in spite of a “ negative ” test . Lasegue 's sign was not superior to other clinical tests in predicting outcome .The most important indicator of a good outcome was the presence of disc herniation at surgery .  Patients with disc pathology other than true disc herniation fared equally with patients , who had normal discs disclosed at surgery . Myelography was undertaken in all patients prior to surgery , the results of which are analysed in the following paper . ( Espersenet al. : Predictive value of radiculography in patients with lumbago-sciatica . A prospect i ve Currently , there are over 300,000 lumbar discectomies performed in the US annually without an objective st and ard for patient selection . A prospect i ve clinical outcome study of 200 cases with 5-year follow-up was used to develop and vali date an MRI-based classification scheme to eliminate as much ambiguity as possible . 100 consecutive lumbar microdiscectomies were performed between 1992 and 1995 based on the criteria for “ substantial ” herniation on  MRI .  This series was used to develop the MSU Classification  as an objective measure of lumbar disc herniation on MRI to define “ substantial ” . It simply classifies herniation size as 1 - 2 - 3 and location as A-B-C , with inter-examiner reliability of 98 % . A second prospect i ve series of 100 discectomies was performed between 2000 and 2002 , based on the new criteria , to vali date this classification scheme . All patients with size-1 lesions were electively excluded from surgical consideration in our study . The Oswestry Disability Index from both series was better than most published outcome norms for lumbar microdiscectomy . The two series reported 96 and 90 % good to excellent outcomes , respectively , at 1 year , and 84 and 80 % at 5 years . The most frequent types of herniation selected for surgery in each series were types 2-B and 2-AB , suggesting the combined importance of both size and location . The MSU Classification is a simple and reliable method to objective ly measure herniated lumbar disc . When used in correlation with appropriate clinical findings , the MSU Classification can provide objective criteria for surgery that may lead to a higher percentage of good to excellent outcomes Study Design . A cross-sectional study of interobserver variability in primary care patients . Objective . To investigate the consistency of signs and symptoms of nerve root compression in primary care patients with pain irradiating pain into the leg ( sciatica ) . Summary of Background Data . The literature does not report on all the clinical tests for nerve root compression . In previous studies , most patients had low back pain with no irradiation . Often , little information on examination technique , proportion of positive test results , or clinical patient characteristics was provided . Methods . A r and om selection of 91 patients was investigated by a neurologist-resident couple .  Agreement percentages , proportions of positive test results , and kappas were calculated . Results . The kappa of the overall conclusion after the history taking was 0.40 , increasing to 0.66 after physical examination . Kappas were good for decreased muscle strength and sensory loss ( 0.57–0.82 ) , intermediate for reflex changes ( 0.42–0.53 ) , and poor for the examination of the lumbar spine ( 0.16–0.33 ) . The straight leg raising , crossed straight leg raising , Bragard ’s sign , and Naffziger ’s sign were the most consistent nerve root tension signs ( > 0.66 ) . Conclusions . Two clinicians disagreed on the presence of nerve root involvement in one of four patients after history taking , and in one of five patients after physical examination . For a more consistent overall diagnosis , the physician probably should put more emphasis on the history of pain on coughing – straining – sneezing , a feeling of coldness in the legs , and urinary incontinence . The investigation of paresis , sensory loss , reflex changes , straight leg raising , and Bragard ’s sign provide the most consistent results OBJECTIVE To determine the extent to which the history and physical examination predict the outcome of the electrodiagnostic ( EDX ) evaluation in patients with suspected lumbosacral radiculopathy . DESIGN Data for 170 subjects referred for low-back and lower limb symptoms were prospect ively collected at five EDX laboratories . The sensitivity , specificity , positive and negative predictive values , and odds ratios were determined for symptoms and neurologic signs . RESULTS Symptoms were not significantly associated with an EDX study or a lumbosacral radiculopathy . The physical examination was better at predicting that an EDX study would be abnormal in general than it was at predicting a lumbosacral radiculopathy in particular . Of those subjects with normal physical examinations , 15%-18 % still had abnormal EDX findings . CONCLUSIONS In a population of patients referred for an EDX study , the history and physical examination alone can not reliably predict electrodiagnostic outcome & NA ; Chronic low back pain ( CLBP ) is a major clinical problem with a substantial socio‐economical impact . Today , diagnosis and therapy are insufficient , and knowledge concerning interaction between musculoskeletal pain and motor performance is lacking . Most studies in this field have been performed under static conditions which may not represent CLBP patients ' daily‐life routines . A st and ardized way to study the sensory‐motor interaction under controlled motor performance is to induce experimental muscle pain by i.m . injection of hypertonic saline . The aim of the present controlled study was to analyze and compare electromyographic ( EMG ) activity of and coordination between lumbar muscles ( 8 paraspinal recordings ) during gait in 10 patients with CLBP and in 10 volunteers exposed to experimental back muscle pain induced by bolus injection of 5 % hypertonic saline .  When the results are compared to sex‐ and age‐matched controls , the CLBP patients showed significantly increased EMG activity in the swing phase ; a phase where the lumbar muscles are normally silent . These changes correlated significantly to the intensity of the back pain . Similar EMG patterns were found in the experimental study together with a reduced peak EMG activity in the period during double stance where the back muscles are normally active . Generally , these changes were localized ipsilaterally to the site of pain induction . The clinical and experimental findings indicate that musculoskeletal pain modulates motor performance during gait probably via reflex pathways . Initially , these EMG changes may be interpreted as a functional adaptation to muscle pain , but the consequences of chronic altered muscle performance are not known . New possibilities to monitor and investigate altered motor performance may help to develop more rational therapies for CLBP patients In a prospect i ve study of 163 consecutive patients operated on because they were thought to have lumbar disc hernia , the authors investigated whether physical signs could predict the degree of hernia ( complete hernia , incomplete hernia , protruded disc , and normal disc ) found at surgery . Stepwise discriminant analysis showed that there were only 2 physical signs of diagnostic value :  lumbar range of motion  and crossed Lasegue sign . By these signs , 74 % of the uncontained hernias and 68 % of the contained hernias could be correctly classified . Discrimination also was made between intact annuli ( negative exploration and protruded disc ) versus ruptured annuli ( incomplete h 
    Output:
    
This systematic review and meta- analysis demonstrate that neurological testing procedures have limited overall diagnostic accuracy in detecting disc herniation with suspected radiculopathy .
Pooled diagnostic accuracy values of the tests were poor , whereby all tests demonstrated low sensitivity , moderate specificity , and limited diagnostic accuracy independent of the disc herniation reference st and ard or the specific level of herniation .