Background
Objective
Methods
Eligibility criteria
Types of studies
Participants
Interventions
Physical prognostic factors
Outcomes
Inclusion criteria | |
Population | 16 years or older, male and female |
Intervention | Lumbar and lumbosacral standard open discectomy or microdiscectomy Single one level Primary operation with no previous history of other lumbar spine surgery |
Prognostic factors | Intensity of back/leg pain Pre-operative duration of back/leg pain Healh related quality of life Range of movement Motor deficit Sensory deficit SLR Walking distance Disability |
Study design | Prospective cohort studies ≥1 year follow up |
Exclusion criteria | |
Population | History of previous back operation Extraspinal cause of low back and/or leg pain Trauma, vertebral fractures, arthritis or metabolic bone disease, scoliosis, spondylolysis, spondlylolisthesis, spinal stenosis or any other notable non-intervertebral disc abnormalities, trauma, rapid progressive motor deficit, cauda equina syndrome |
Intervention | Any other lumbar surgical management Lumbar discectomy combined with other surgery |
Study design | Studies not published in English language |
Information sources
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CINAHL, EMBASE, MEDLINE, PEDro and ZETOC.
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Hand searches of key journals [Spine, European Spine Journal, The Spine Journal].
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Pubmed
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Screening reference lists by hand in papers that match the eligibility criteria.
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Unpublished research: British National Bibliography for Report Literature, Dissertation Abstracts, Index to Scientific and Technical Proceedings, National Technical Information Service, System for Information on Grey Literature.
Search
Searches | Results |
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1 | incidence.sh. |
2 | follow-up studies.sh. |
3 | prognos*.tw. |
4 | predict*.tw. |
5 | course*.tw. |
6 | 1 or 2 or 3 or 4 or 5 |
7 | Lumbar Vertebrae/ or lumbar.mp. |
8 | Lumbosacral.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary word, unique identifier] |
9 | Intervertebral Disc/ or low back.mp. |
10 | 7 or 8 or 9 |
11 | sciatica.mp. or exp. Sciatica/ |
12 | radicular pain.mp. or Radiculopathy/ |
13 | Intervertebral Disc Degeneration/ or Intervertebral Disc Displacement/ or degenerative disc disease.mp. |
14 | Low back pain.mp. or Low Back Pain/ |
15 | 11 or 12 or 13 or 14 |
16 | Discectomy.mp. or exp. Discectomy/ |
17 | Discectomy.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary word, unique identifier] |
18 | Microsurgery/ or microdiscectomy.mp. or Discectomy, Percutaneous/ |
19 | Laminectomy.mp. or Laminectomy/ |
20 | 16 or 17 or 18 or 19 |
21 | 6 and 10 and 15 and 20 |
Study selection
Data collection process
Data items
Risk of Bias in individual studies
Planned method of analysis
Risk of Bias across studies
Results
Study selection
Study characteristics
Study | Country | Characteristics of Participants | Follow-up | Physical Prognostic factors | Outcome measures |
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Divecha et al., 2014 | United Kingdom | n = 89 Age: 25–79, mean 48.6 Gender: Male n = 46 [51.7%] Female n = 43 [48.3%] | 1 year n = 32 [35%] | • Pre-operative leg pain [% of pain that was radicular, calculated from the Core Outcome Measures Index [COMI] | • COMI score – patient completed assessment through Spine Tango. Includes questions on the severity of leg and back pain. • Definition of outcome unclear for multivariate analyses |
Fisher et al., 2004 | Canada | n = 82 Age: 17–83, mean 42.2 Gender: Male n = 52 [63.4%] Female n = 30 [36.6%] | 1 year n = 71 [87%] | • Pre-operative duration of leg pain in months | • Health Related Quality Of Life [HRQOL] outcome comprising: a. North American Spine Society instruments: Neurogenic Symptom Score and Pain/Disability Score b. Short Form-36 [SF-36] questionnaire |
Lewis et al., 1987 (and Weir, 1979) | Canada | n = 100 Agea: Mean [SD] 41.7 [1] Gender: Male 75% Female 25% | 1 year N = 91 [91%] 5–10 years n = 81 [81%] | • Pre-operative duration of leg pain in months • Ipsilateral straight leg raise (detail of measurement not reported) • Forward bend (detail of measurement tool not reported) | • Relief of back pain • Relief of leg pain • No multivariate analyses |
Nygaard et al., 2000 | Norway | n = 132 Agea: > 18 Gender: Not reported | 1 year n = 132 [100%] | • Pre-operative duration of leg pain in months • Pre-operative duration of back pain in months | • Clinical Overall Score, calculated from 40% weighting pain, 20% clinical examination, 20% functional status [Oswestry Disability Index, ODI] and 20% analgesia |
Silverplats et al., 2010 | Sweden | n = 171 Agea: Mean[SD] 39 [11] Gender: Male n = 95 [55.6%] Female n = 76 [44.4%] | 2 years n = 154 [90%] Mean[SD] long term 7.3 [1.0] years Range 5.1–9.3 years n = 140 [81%] | • Pre-operative leg pain - recorded with three 0–100 Visual Analogue Scale [VAS] representing ‘pain when as worst’, ‘pain when as least’ and ‘pain right now’. Mean value of the three scales recorded • Pre-operative back pain - recorded with three 0–100 VAS representing ‘pain when as worst’, ‘pain when as least’ and ‘pain right now’. Mean value of the three scales recorded • Pre-operative duration of leg pain in months • Pre-operative ODI- self complete questionnaire 0–100 | Primary outcomes: • MacNab classification of post-operative outcome [at 2 years] with 4 categories of outcome – excellent, good, fair, poor but unclear how applied as dichotomized outcome in multivariate analyses • Satisfaction with treatment [satisfied, partly, not satisfied, both follow up points] Secondary outcomes: • Change in leg pain [improved, no improvement, worse] • Change in back pain [improved, no improvement, worse] |
Silverplats et al., 2011 | Sweden | n = 117 Age: 18–66, mean 39 Gender: Male n = 63 [54%] Female n = 54 [46%] | Range 5–8 years 2 years 82% 7 years 76% | • Pre-operative duration of leg pain in months • Pre-operative leg pain [detail of measurement not reported] • Pre-operative back pain [detail of measurement not reported] • Pre-operative EuroQol-5 Dimension [EQ-5D] score for HRQOL self-completion questionnaire 0–100 | • Change in EQ- 5D score |
Solberg et al., 2005 | Norway | n = 228 Age: Mean[SD] 41 [11] Gender: Male n = 114 [63.3%] Female n = 66 [36.7%] | 1 year n = 180 [78.9%] | • Pre-operative ODI score - self complete questionnaire 0–100 • Pre-operative duration of leg pain in months • Pre-operative duration of back pain in months • Pre-operative leg pain 0–100 VAS no pain to worst conceivable pain • Pre-operative back pain 0–100 VAS no pain to worst conceivable pain | Primary outcome: • ODI score classified as: a. deterioration [increased ODI] or no deterioration [decreased/unchanged ODI] b. poor [ODI > 39] or good [ODI < 40] Secondary outcomes: • VAS back pain • VAS leg pain |
Methods
Participants
Physical prognostic factors
Outcome measures
Risk of Bias within studies
Study [n = 6] | Study Participation | Study Attrition [Follow-up] | Prognostic Factor | Outcome | Confounding Factor | Analysis | Overall Risk of Bias |
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Divecha et al., 2014 | High | High | Moderate | Low | Moderate | Low | High |
Fischer et al., 2004 | Moderate | High | Moderate | Low | Low | Moderate | High |
Lewis et al., 1987 and Weir 1979 | High | High | Moderate | Low | High | High | High |
Nygaard et al., 2000 | High | High | Moderate | Low | High | High | High |
Silverplats et al., 2010 and Silverplats et al., 2011 | Moderate | Moderate | Low | Low | Low | Low | Low |
Solberg et al., 2005 | Moderate | High | Low | Low | High | Moderate | High |
Results per physical prognostic factor
Physical prognostic factors | Study and risk of bias | Results | Summary of study findings [based on multivariate analyses; where significant, direction of effect is reported] | gy9 | Summary of findings across studies |
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Oswestry Disability Index [ODI] | Silverplats et al., 2010 LOW risk of bias | Bivariate analyses: ● Patients with worse pre-operative ODI scores were more likely to report improvement in leg pain [dichotomized as improvement versus no improvement / worse]. Patients with improved leg pain had pre-operative mean ODI 52 compared to 42 in no improvement/worse group [p = 0.040]. ● Patients with worse pre-operative ODI scores were more likely to report improvement in back pain [dichotomized as improvement versus no improvement / worse]. Patients with improved back pain had pre-operative mean of 52 compared to 44 in no improvement/worse group [p = 0.040]. Multivariable analyses: ● ODI was not a significant predictor when using the full model of potential predictors [no measure of association reported] at 2 years or long term follow up. | Pre-operative ODI was not significant as a prognostic factor for leg pain or for back pain at 2 years or long term follow up [mean 7.3 ± 1.0 years]. | + Very low | Using GRADE, there is very low level evidence that ODI is not associated with patient outcome. |
Solberg et al., 2005 HIGH risk of bias | Multivariable analyses: ● Using change in ODI score as a dichotomous variable (deterioration or no deterioration of score) in binary stepwise logistic regression analyses, a low pre-operative ODI score was an independent risk factor for ‘deterioration’ [β [age adjusted] 0.087, p = 0.011; β [independent risk factor] –0.216, p = 0.013]. ● Using ODI raw score at 12 months as a dichotomous variable [“good” ODI score > 39, or “poor” outcome] pre-operative ODI was not an independent risk factor for a “poor” outcome [no measure of association reported]. Lower ODI score [β = − 0.0442, p < 0.001] pre-operatively was a predictor of less improvement in ODI score. | Pre-operative ODI was significant as a prognostic factor for post-operative disability [ODI] at 12 months.
Higher pre-operative ODI predicts better outcome [lower ODI] at 12 months.
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Duration of back pain | Nygaard et al., 2000 HIGH risk of bias | ● Multivariable analyses: Multiple linear regression analysis demonstrated that pre-operative duration of back pain was not predictive of clinical overall score [COS]; coefficient β [Standard error] = − 0.26 [0.16], t test − 1.65, p = 0.100. | Pre-operative duration of back pain was not significant as a prognostic factor for COS at 12 months. | + Very low | Using GRADE, there is very low level evidence that duration of back pain is not associated with patient outcome. |
Solberg et al., 2005 HIGH risk of bias | Multivariable analyses: ● Using change in ODI score as a dichotomous outcome variable in binary stepwise logistic regression analyses, duration of back pain was not an independent risk factor for ‘deterioration’ [β [age adjusted] 0.001, p = 0.304]. ● Using ODI raw score at 12 months as a dichotomous variable [“good” ODI score > 39, or “poor” outcome] in multivariate analyses, duration of back pain was not an independent risk factor for a “poor” outcome [no measure of association reported]. | Pre-operative duration of back pain was not significant as a prognostic factor for disability [ODI] at 12 months. | |||
Duration of leg pain | Fischer et al., 2004 HIGH risk of bias | Multivariable analyses: Patients with longer pre-operative duration of leg pain were more likely to report less improvement in Pain Disability Score [PDS] [p = 0.026] after adjustment for gender, age and pre-operative PDS. Mean change PDS 24.4 for duration 0–3 months, 20.0 for duration 3.1–9 months, 13.1 for duration > 9 months [no measures of association reported]. | Pre-operative duration of leg pain was significant as a prognostic factor for PDS at 12 months.
Shorter pre-operative duration of leg pain predicts better outcome [lower PDS] at 12 months.
| a | am |
Lewis et al., 1987 and Weir et al., 1979 HIGH risk of bias | Bivariate analyses: ● Duration leg pain < 17 months associated with complete relief of back pain in 43/71 cases [61%] at 1 year; 39/65 cases [60%] at 5–10 years. ● Duration leg pain ≥17 months associated with complete relief of back pain in 12/19 cases [63%] at 1 year; 9/15 cases [60%] at 5–10 years. ● Duration leg pain < 17 months associated with complete relief of leg pain in 54/71 cases [76%] at 1 year; 43/65 cases [66%] at 5–10 years. ● Duration leg pain ≥17 months associated with complete relief of leg pain in 12/19 cases [63%] at 1 year; 6/15 cases [40%] at 5–10 years. ● Significant association [chi-square of Fisher’s exact test] at 1-year follow-up review between duration leg pain and relief of back or leg pain [above]. Shorter duration of leg pain before surgery is associated with relief of leg pain following surgery. Not significant at 5–10 years [results not reported]. | Pre-operative duration of leg pain was not significant as a prognostic factor for leg pain and for back pain at 12 months [no multivariable analyses]. | |||
Nygaard et al., 2000 HIGH risk of bias | Multivariable analyses: ● Patients with longer pre-operative duration of leg pain were more likely to report less improvement in COS. Multiple linear regression analysis, coefficient β [Standard error] = 0.98 [0.3], t test 3.23, p = 0.0016. | Pre-operative duration of leg pain was significant as a prognostic factor for COS at 12 months.
Shorter pre-operative duration of leg pain predicts better outcome [lower COS] at 12 months.
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Silverplats et al., 2010 LOW risk of bias | Bivariate analyses: ● Patients with longer pre-operative duration of leg pain were more likely to report improvement in leg pain. Pre-operative short duration [< 6 months] of leg pain predicts good outcome on MacNab [dichotomized outcome] classification [p = 0.039] at 2-year follow up and predicts patient satisfaction with treatment [p = 0.019] at long term follow-up [mean 7.3 ± 1.0 years]. Multivariable analyses: ● Duration of leg pain was not a significant predictor when using the full model of potential predictors [no measure of association reported]. | Pre-operative duration of leg pain was not significant as a prognostic factor for leg pain or health-related quality of life [EQ-5D] at 2 year and long term follow up [mean 7.3 ± 1.0 years]. | |||
Silverplats et al., 2011 LOW risk of bias | Multivariable analyses: ● Duration of leg pain was not a significant predictor for EuroQol-5 Dimension, EQ-5D at 2 years [no measure of association reported]. | ||||
Solberg et al., 2005 HIGH risk of bias | Multivariable analyses: ● Duration of leg pain was not an independent risk factor for ‘deterioration’ [β [age adjusted] 0.008, p = 0.006; β [independent risk factor] 0.005, p = 0.572]; using change in ODI score as a dichotomous outcome variable (deterioration or no deterioration). ● Using ODI raw score at 12 months as a dichotomous outcome variable [“good” ODI score > 39, or “poor” outcome] duration of leg pain was not an independent risk factor for a “poor” outcome [no measure of association reported]. | Pre-operative duration of leg pain was not significant as a prognostic factor for disability [ODI] at 12 months. | |||
Severity leg pain | Divecha et al., 2014 HIGH risk of bias | Bivariate analyses: ● Patients with worse pre-operative leg pain were more likely to report improvement in functional outcome. Pearson’s correlation coefficient between pre-operative leg pain [%] and Core Outcome Measures Index [COMI] score at 12 months was −0.394 (95% CI -0.653, − 0.053; p = 0.0256]. Multivariable analyses: ● Patients with higher pre-operative leg pain had significantly lower COMI [R2 = 0.155, p = 0.03] at 12 months. | Pre-operative severity of leg pain was significant as a prognostic factor for functional outcome [COMI] at 12 months.
Higher severity pre-operative leg pain predicts better outcome [lower COMI] at 12 months.
| ++ Low | Using GRADE, there is low level evidence that higher severity of pre-operative leg pain predicts better Core Outcome Measures Index at 12 months and better post-operative leg pain at 2 and 7 years. |
Silverplats et al., 2010 LOW risk of bias | Bivariate analyses: ● Patients with higher pre-operative leg pain were more likely to report improvement in leg pain. Patients with improved leg pain had higher leg pain pre-operatively on VAS [60 versus 47, p = 0.008] Multivariable analyses: ● For improvement in leg pain the only significant predictor among all potential predictors was pre-operative VAS leg pain (p = 0.039). Pre-operative VAS leg pain was also the first and only predictor selected by the stepwise procedure [no measure of association reported]. | Pre-operative severity of leg pain was significant as a prognostic factor for leg pain at 2 years and long term follow up [mean 7.3 ± 1.0 years]. Pre-operative severity of leg pain was not significant as a prognostic factor for EQ-5D at 2 years or long term follow up [mean 7.3 ± 1.0 years].
Higher severity pre-operative leg pain predicts better outcome [lower leg pain] at 2 years and long term follow up [mean 7.3 ± 1.0 years].
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Silverplats et al., 2011 LOW risk of bias | Bivariate analyses: Patients with higher pre-operative leg pain were more likely to report improvement in health-related quality of life. Pre-operative VAS leg pain was correlated with change in EQ-5D at 2-year follow-up [r = 0.33, p = 0.002] and at 7-year follow up [r = 0.23, p = 0.04]. Multivariable analyses: VAS leg pain was not identified as a significant predictor of EQ-5D [no measure of association reported]. | ||||
Solberg et al., 2005 HIGH risk of bias | Bivariate analyses: Patients with higher pre-operative leg pain were more likely to report improvement in disability. Pre-operative VAS leg pain mean [SD; 95%CI] was 63.4 [27.5; 59.3 to 67.4], and at 12 months was 16.8 [21.1; 13.7 to 20.0]. Improvement was 46.5 [33.4, 41.6 to 51.4]. Multivariable analyses: Using change in ODI score as a dichotomous outcome variable, VAS leg pain was not an independent risk factor for ‘deterioration’ [β [age adjusted] -0.009, p = 0.481] at 12 months. Using ODI raw score at 12 months as a dichotomous outcome variable [“good” ODI score > 39, or “poor” outcome] VAS leg pain was not an independent risk factor for a “poor” outcome [no measure of association reported]. | Pre-operative severity of leg pain was not significant as a prognostic factor for disability [ODI] at 12 months. | |||
Severity back pain | Silverplats et al., 2010 LOW risk of bias | Bivariate analyses: Patients with higher pre-operative back pain were more likely to report improvement in back pain. Patients with improved back pain had higher VAS back pain pre-operatively [53 versus 36, p = 0.001]. Multivariable analyses: Pre-operative back pain was not a significant predictor when [no measure of association reported] at 2 years or long term follow up [mean 7.3 ± 1.0 years]. | Pre-operative severity of back pain was not significant as a prognostic factor for back pain or EQ-5D at 2 years or long term follow up [mean 7.3 ± 1.0 years]. | + Very low | Using GRADE, there is very low level evidence that severity of back pain is not associated with patient outcome. |
Silverplats et al., 2011 LOW risk of bias | Bivariate analyses: Back pain at baseline was not significantly correlated with change in EQ-5D at any follow-up. Multivariable analyses: Back pain was not identified as a significant predictor of EQ-5D at 2 years follow up [no measure of association reported]. | ||||
Solberg et al., 2005 HIGH risk of bias | Bivariate analyses: Baseline VAS back pain (0–100 points) mean [SD; 95%CI] = 51.7 [29.3; 47.4, 56.0]. 12 months 21.3 [22.6; 18.0, 24.6]. Improvement 31.4 [35.6, 25.2–35.6]. VAS back pain pre-operatively not predictive of follow up ODI score at 12 months. Multivariable analyses: VAS back pain was not an independent risk factor for ‘deterioration’ [β–[age adjusted] 0.003, p = 0.800]; using change in ODI score as a dichotomous variable [deterioration or no deterioration]. Using ODI raw score at 12 months as a dichotomous variable [“good” ODI score > 39, or “poor” outcome], VAS back pain was not an independent risk factor for a “poor” outcome [no measure of association reported]. | Pre-operative severity of back pain was not significant as a prognostic factor for disability [ODI] at 12 months. | |||
Health-related quality of life [EuroQol-5 Dimension, EQ-5D] | Silverplats et al., 2011 LOW risk of bias | Bivariate analyses: Patients with lower pre-operative EQ-5D were more likely to report improvement in health-related quality of life [EQ-5D]. Pre-operative EQ-5D was correlated with change in EQ-5D at 2-year or 7-year follow-ups [r = −0.70, p < 0.001 and r = − 0.71, p < 0.001]. Multivariable analyses: The only significant predictor of outcome was pre-operative EQ-5D score. The influence of baseline EQ-5D score was estimated [β = − 1.0, 95% CI: − 1.2, − 0.8] at 2 years. | Pre-operative EQ-5D was significant as a prognostic factor for health-related quality of life [EQ-5D] at 2 years.
Lower pre-operative EQ-5D predicts better outcome [lower EQ-5D] at 2 years.
| + Very low | Using GRADE, there is very low level evidence that a lower pre-operative EQ-5D predicts better EQ-5D at 2 years. |
Ipsilateral Straight Leg Raise [SLR] | Lewis et al., 1987 and Weir, 1979 HIGH risk of bias | Bivariate analyses: Positive ipsilateral SLR associated with complete relief of back pain in 47/75 cases [63%] at 1 year; 41/69 cases [59%] at 5–10 years. Negative ipsilateral SLR associated with complete relief of back pain in 9/16 cases [56%] at 1 year; 8/12 cases [67%] at 5–10 years. Positive ipsilateral SLR associated with complete relief of leg pain in 59/75 cases [79%] at 1 year; 42/69 cases [61%] at 5–10 years. Negative ipsilateral SLR associated with complete relief of leg pain in 8/16 cases [50%] at 1 year; 8/12 cases [67%] at 5–10 years. Significant association [chi-square of Fisher’s exact test] at 1-year follow-up review between ipsilateral SLR and relief of back or leg pain [above]. Positive ipsilateral SLR before surgery is associated with relief of back and leg pain following surgery. Not significant at 5–10 years [results not reported]. | Pre-operative ipsilateral SLR was not significant as a prognostic factor for back pain or leg pain at 5–10 years [no multivariable analyses]. | + Very low | Using GRADE, there is very low level evidence that straight leg raise is not associated with patient outcome. |
Forward bend | Lewis et al., 1987 and Weir, 1979 HIGH risk of bias | Bivariate analyses: Forward bend to knee associated with complete relief of back pain in 41/58 cases [71%] at 1 year; 33/50 cases [66%] at 5–10 years. Forward bend to mid tibia or floor associated with complete relief of back pain in 15/33 cases [45%] at 1 year; 16/31 cases [52%] at 5–10 years. Forward bend to knee associated with complete relief of leg pain in 48/58 cases [83%] at 1 year; 34/50 cases [68%] at 5–10 years. Forward bend to mid tibia or floor associated with complete relief of leg pain in 19/33 cases [58%] at 1 year; 13/31 cases [42%] at 5–10 years. Significant association [chi-square of Fisher’s exact test] at 1-year follow-up review between forward bend and relief of back or leg pain [above]. Positive forward bend to knee before surgery is associated with relief of back and leg pain following surgery. Not significant at 5–10 years [results not reported]. | Pre-operative forward flexion was not significant as a prognostic factor for back pain or leg pain at 5–10 years [no multivariable analyses]. | + Very low | Using GRADE, there is very low level evidence that forward bend is not associated with patient outcome. |
GRADE factor | |||||||||||||
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Factors that may reduce the quality | Factors that may increase the quality | ||||||||||||
Prognostic factor [pre-operative measures] | Number of participants | Number of studies | Number of cohorts | Estimated effect size [95% CI] | Phase (design) | Study limitations | Inconsistency | Indirectness | Imprecision | Publication bias | Moderate/ large effect size | Dose effect | Overall quality |
Oswestry Disability Index [ODI] | 399 | 2 | 2 | Unclear | 1 | ✓ | x | ✓ | x | x | x | x | + Very low |
Duration of back pain | 360 | 2 | 2 | Unclear | 1 | x | ✓ | ✓ | x | x | ✓ | x | + Very low |
Duration of leg pain | 713 | 5 | 5 | Unclear | 1 | ✓ | x | ✓ | ✓ | ✓ | x | x | ++ Low |
Severity leg pain | 488 | 3 | 3 | Unclear | 1 | ✓ | x | ✓ | ✓ | ✓ | x | x | ++ Low |
Severity back pain | 399 | 2 | 2 | Unclear | 1 | ✓ | x | ✓ | x | x | ✓ | x | + Very low |
EuroQol-5 Dimension [EQ-5D] | 140 | 1 | 1 | Unclear | 1 | ✓ | x | ✓ | ✓ | x | x | x | + Very low |
Ipsilateral Straight Leg Raise [SLR] | 100 | 1 | 1 | Unclear | 1 | x | x | ✓ | x | x | x | x | + Very low |
Forward bend | 100 | 1 | 1 | Unclear | 1 | x | x | ✓ | x | X | x | x | + Very low |