Modified Omar sign for the clinical diagnosis of unilateral foraminal stenosis associated with disc prolapse.

Modified Omar sign for the clinical diagnosis of unilateral foraminal stenosis associated with disc prolapse. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Modified Omar sign for the clinical diagnosis of unilateral foraminal stenosis associated with disc prolapse. OMAR ELDANASORY This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1704214/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: A retrospective study analyses the validity of Modified Omar's Sign for the diagnosis of unilateral lumbar foraminal stenosis with disc prolapse. Methods: This study analyses 250 patients with unilateral sciatic pain, between 2011 and 2020.All the data obtained from the data base collected from our institution and our private clinics. All patients had a standardized neurological clinical assessment by applying the modified Omar test during their clinical examination, then comparing the clinical findings with the (MRI) imaging findings and comparing the preoperative clinical findings with the postoperative clinical findings. Results: As the modified Omar test was applied during the physical examination, the test was positive for all patients with positive MRI with unilateral lumbar disc prolapse with foraminal stenosis on the same side. The clinical findings also confirmed by the absence of the test after surgical intervention and after nerve root block. Conclusions: The modified Omar test is a test applied during the physical examination for specific diagnosis of lumbar foraminal stenosis of patients having unilateral lumbar disc prolapse. The correlation between clinical and radiological findings confirms the test availability. The absence of the omar sign during the test after surgical intervention, and after nerve root block is considered a sure sign of high sensitivity and specificity of the test. So, the test is a more reliable diagnostic tool for the clinical diagnosis of foraminal stenosis that can be added to the clinical examination sheet. And, for the clinical identification of the efficacy of the surgical treatment and follow-up. Signs of nerve root compression Modified Omar sign Clinical test for unilateral nerve root compression. Foraminal stenosis sign omar sign for foraminal stenosis Figures Figure 1 Figure 2 Key Points It is new clinical diagnostic test for lumbar foraminal stenosis diagnosis Introduction Lumbar disc herniation is one of the most common medical and surgical problems all over the world. The natural history of degenerative disc disease (DDD) is largely unknown. The lifetime prevalence of symptomatic lumbar disc herniation in the adult population is approximately 2%. [ 1 ] and is believed to result from annular degeneration that leads to a weakening of the annulus fibrosus, leaving the disc susceptible to annular fissuring and tearing. [ 2 ] Among patients with radiculopathy secondary to lumbar disc herniation, approximately 10–25% experience a persistent symptom where the L4–L5 and L5–S1 levels are the most common sites (90%). The L3–L4 level is the next most common level.[ 3 ] Most lumbosacral radiculopathies are caused by paracentral, lateral, and foraminal disc herniations and are diagnosed by Magnetic Resonance Imaging (MRI). [ 4 ] An accurate initial clinical diagnosis of nerve root compression is highly desirable for both physicians and patients, [ 5 ] and the proper management decisions should be based on the clinical findings corroborated by diagnostic test findings. [ 6 ] Methods Lumbar foraminal neuropathy is a pathologic condition of the neurovascular contents in the foramen causing radicular symptoms, which is associated with a narrowed foramen [ 7 ]. Anatomically, the foraminal stenosis may be anteroposterior (transverse), craniocaudal (vertical), or circumferential. The anteroposterior stenosis results from the superior articular process (SAP) and posterior vertebral body transversely, and the craniocaudal stenosis results from osteophytes of the posterolateral vertebral endplate and a laterally bulging or herniated disc compressing the nerve root against the superior pedicle vertically. [ 8 ] Dynamic foraminal stenosis implies position-dependent provocation of foraminal volume with intermittent lumbar extension-provoked nerve root impingement. [ 9 ] This study involved 250 patients having foraminal stenosis due to disc prolapse between 2011 and 2020. All patients had a standardized clinical assessment followed by Magnetic Resonance Imaging (MRI). Searching method During a physical examination for all patients who presented to our neurosurgical outpatient clinic with complaints of unilateral lower limb radicular pain with or without lower back pain, looking for the presence or absence of a new sign known as the (Omar sign) for the diagnosis of foraminal stenosis using a new clinical test known as the modified Omar test Selection criteria The test was performed on patients having unilateral acute or chronic lower limb radicular pain, with the exclusion of all patients having lower back pain only without radicular pain, or having bilateral radicular pain, or patients with scoliosis deformity, central canal stenosis, multilevel facet arthropathy, previous spinal surgery, spinal tumors, or spinal infection. Reference standards The test (Omar test) is applied to all selected patients during their physical examination, searching for a modified Omar sign. The clinical findings during physical examinations were compared to the findings obtained from the Magnetic Resonance Imaging (MRI) of the lumbar spine. Also, the clinical findings before and after surgery or before and after nerve root block were compared. Test description Prior to starting the test, the patient is informed to describe the location and distribution of any radiating pain along her /his lower limb and if associated with numbness during the test and after finishing the test. In a standing position with a straight spine and a neutral hip joint position, the palm of the left hand was placed on the front of the lower abdomen for support. While the thumb of the right hand is used to push against the spinous process and the interspinous space from the back for about 10 seconds. The patient during the test is advised to hold his breath. Then ask the patient to describe his leg pain, its distribution, its intensity, and other associations. The pressure on the spinous process and the lower abdominal wall is released, then the patient is asked (after 5 seconds) if he still has pain after releasing the pressure or not. The same technique is performed by asking the patient to cough, bending forward, and bending backward to detect the prevalence of the sign in different positions. The test was positive in both directions, but it was more reliable when the patient was standing in a straight position. Coughing, sneezing, or straining aggravates the testing effect. [Fig. 1]. Theoretical explanation of the test In the case of unilateral foraminal stenosis, as with disc prolapse, the nerve root is very sensitive to any movement of the spinal foramen, especially during walking or bending. In a standing position with a straight spine, pushing the spinous process and the interspinous space anteriorly against the anterior abdominal wall leads to movement and compression of the posterior foraminal parts against its anterior parts, causing more narrowing of the intervertebral foramen and more compression of the nerve root. This leads to radicular pain sensation, which could be due to direct mechanical nerve root compression, with neuronal nerve root transmission interruption. When the patient bends forward, we need to apply more compression forces during the test because of the stretching of the muscles and ligaments in the back. Results Degenerative narrowing of the lumbar foramen is a gradual process. However, it is generally understood that foraminal narrowing increases the risk of developing radicular pain and root compression. Many patients can remain asymptomatic or experience only mild discomfort if no foraminal stenosis, but if the patient has foraminal stenosis with an inflamed nerve, the nerve produces pain. The symptoms progress within a short time and the most common symptoms are pain radiating down the leg, tingling, and numbness when standing or walking. During the physical examination, the straight leg raising test and the femoral nerve stretching test are usually non-specific for foraminal stenosis. Therefore, the idea of the modified Omar test and the modified Omar sign” was developed for proper clinical diagnosis of nerve root compression and foraminal stenosis. During the physical examination, all patients showed positive tests at the following levels L5-S1, L4-L5, L3-L4, L2-L3 levels, and less significant at the L1-L2 level, so all patients having L1-2 discs with foraminal stenosis were excluded from this research. During the examination, the radiating leg pain explained by the patients follows the course of the nerve root affected in the MRI findings in all cases (250 patients, 100%). Bed rest, nonsteroidal anti-inflammatory drugs, and physiotherapy started after clinical and radiological diagnosis for about 2 to 3 months. Some patients had microdiscectomy before this time. The exact time for doing surgery or doing nerve root block was variable depending on the response of the patients to the medical treatment. 160 (64%) patients from the 250 patients underwent minimally invasive surgery, (unilateral laminectomy or laminotomy with microdiscectomy). 70 patients (28%) underwent nerve root block with the improvement of the radicular pain for a few weeks or months, then a recurrence of the pain and underwent surgical microdiscectomy. 20 patients (8%) were refusing surgery because they were afraid of having surgery, so they underwent repeated steroid injections. All patients were observed after surgery, and after nerve root block in an outpatient neurosurgical clinic for 1, 2, 3, 6, 9, and 12 months, searching for the Modified Omar sign during their clinical examinations. When comparing the clinical findings after surgery and after nerve root block, all patients were negative of this sign (100%) during the period of follow-up. The most common level in this study were L5-S1 (161 (64.4%)) patients, L4-L5 level (78 (31.2%) patients, L3-4 level 9 (3.6%)) patients, and L2-3 level 2 (0.8%) patients. [ Table 1]. [Fig. 2]. Discussion Acquired foraminal stenosis is found secondary to degenerative changes in the spine, such as hypertrophy of the facet joint, ligament, and bone, disc disorders, and osteophyte formation. [ 10 ] The normal intervertebral foramen has a teardrop-like shape, and its form changes significantly in flexion extension motions as well as in lateral-bending and axial rotation. [ 11 ] The foraminal height in the lumbar spine ranges between 19 and 21 mm and the superior–inferior sagittal diameter ranges between 7 and 8 mm. (3–4 mm in diameter is considered foraminal stenosis). Instead of measuring the dimensions, Wildermuth et al. introduced a qualitative scoring system for foraminal stenosis. [ 9 ], whoever’s direct measurement of the bony canal on a radiographic image does not provide an accurate assessment of the degree of stenosis.[ 12 ] Back pain and radicular pain can originate from several anatomic structures within the spine, making it difficult for the patient and the physician to localize. Localization of the anatomical pain generator in patients with leg pain is important for clinical diagnosis, for surgical planning, and for follow-up. [ 13 ] The incidence of foraminal stenosis and nerve root impingement increases in the lower lumbar levels due to the increased diameter of the dorsal root ganglia (DRG) and the commonly involved nerves are the fifth lumbar nerve root (75%), the fourth nerve root (15%), the third nerve root (5.3%), and the second nerve root (4%) respectively. [ 14 ] The sensory nerve root elicits nociceptive pain that includes deep aching and throbbing with heaviness and a squeezing sensation associated with tingling and numbness. As the DRG becomes inflamed and entrapped in the foramen, the pain changes to neuropathic pain, which is characterized by sharp, shooting, burning, stabbing, and lancinating sensations [ 15 ], which may become intolerable [ 16 ]. Boden et al. [ 17 ] noted abnormal findings in 57% of asymptomatic patients on magnetic resonance imaging (MRI) scans. Ishimoto et al. [ 18 ] reported that 9.9% of the patients with moderate radiographic stenosis obliterating one-third to two-thirds of the spinal canal showed symptoms and 17.5% of the patients with severe radiographic stenosis obliterating more than two-thirds of the spinal canal had symptoms, so the diagnosis of the foraminal stenosis is not based solely on the radiographic findings. Therefore, the clinical examination must include a specific test for the proper diagnosis of foraminal stenosis. Looking through the literature, demonstrating the movement of the facet joint against the nerve root and the movement of anterior parts of the intervertebral foramen against its posterior part in normal patients, suggested the idea of the test. So, the proposal for the Omar test and sign were developed, and the research was published in a local journal in 2015. [ 19 ] After that, some modifications were added to the test in this research to increase its specificity and selectivity, such as holding the patient’s breath, upright straight position, and duration of performing the test from 5 to 10 seconds. Some researchers found that the amount of movement observed at the intervertebral foramen is generally consistent throughout the literature. Goddard and Reid described an average movement of 4 millimeters at the intervertebral foramen [ 20 ]. This range of movement is out of the scope of this research. Many systematic reviews showed that the clinical diagnosis of disc prolapse and most of the physical tests known had a poor specificity and low sensitivity. But no research was found in the literature searched for the clinical diagnosis of foraminal stenosis. This study (the modified Omar test and sign) shows high sensitivity (100%) of the test for the diagnosis of foraminal stenosis, but variable selectivity for specific nerve root compression (70–80%%) due to the non-educated patients involved in this research and the associated symptoms from other different sources such as sacroiliac joint pain and hip joint pain. Conclusion The modified Omar test is a test applied during the physical examination for the specific diagnosis in lumbar foraminal stenosis of patients having unilateral lumbar disc prolapse. The absence of the omar sign during the test after surgical intervention and after nerve root block is considered a sure sign of high sensitivity and specificity of the test. So, the test is a more reliable diagnostic tool for the clinical diagnosis of foraminal stenosis and can be added to the clinical examination sheet and, for the clinical identification of the efficacy of the surgical treatment and follow-up. Abbreviations MRI= Magnetic Resonance Imaging. CT= Computerized Tomography. SAP=superior articular process. DRG= dorsal root ganglia. Statements And Declarations Acknowledgements: for my mother, my father, and the rest of my family, I acknowledge their help and support. Conflict of Interest: there is no conflict of interest Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests : The authors have no relevant financial or non-financial interests to disclose. Author Contributions: I’m the only author (Omar Abdelhay Eldanasory) l read and approved the final manuscript. Ethics approval: This is a descriptive new clinical examination test study no ethical approval is required. Human and Animal ethics: not applicable Consent to participate not applicable Availability for supporting data: not applicable Consent to publish not applicable Author information: Omar Abdelhay Eldanasory, MD, PhD. FACS. ASCD . Lecturer of Neurosurgery, Al-Azhar University Faculty of Medicine for Girls, Cairo, Egypt . Cell phone: +201205115256 Email: [email protected] [email protected] ORCID 0000-0001-5289-7452 The manuscript has not been previously published, in whole or in part, or submitted elsewhere for review References -Carragee E, Paragioudakis S, Khurana S. (2000) Lumbar high-intensity zone, and discography in subjects without low back problems. Spine. 25(23): 2987–2992. -Saal JA. Natural history and nonoperative treatment of lumbar disc herniation. Spine. 1996;21(24 suppl):2S–9S. -Koebbe CJ, et al. (2002) Lumbar microdiscectomy: a historical perspective and current technical considerations. Neurosurg Focus. 13: E3. -Hoffman RM, Wheeler KJ, Deyo RA. (1993) Surgery for herniated discs: a literature synthesis. J Gen Intern Med. 8:487–96. -Knutsson B. 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Table [Table 1] shows the results of the clinical findings before and after surgical intervention, and MRI findings for the whole patient. Level of stenosis L5-S1 L4-L5 L3-L4 L2-L3 Number of cases 161 78 9 2 Modified omar sign before intervention 100% positive 100% positive 100% positive 100% positive Modified omar sign after surgery and after nerve root block 100% negative 100% negative 100% negative 100% negative Period of follow up 1, 2, 3 ,6 ,9 ,12 months MRI finding preoperative All cases were positive for foraminal stenosis with disc prolapse Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1704214","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":110020525,"identity":"7743c77f-7e9f-482e-8a40-f0fa0dfeb32b","order_by":0,"name":"OMAR ELDANASORY","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYFAD9gYgYWBBihaeAyAtEqRokUgAk4QV8osdfva5oOJwPr/k86sbfhRIMPC3dyfg1SI5O8149owzhy1nzs4pu9kDdJjEmbMb8GoxuJ1gzMzbdtjA4HZO2g0eoBYDiVxCWtI/M/P+A2q5eSbt5h/itOQAbWkAarnBfuw2UbZIzs4pZuY5lm4g2ZPDdlvGQIKHoF/4pdM3M/PUWBvwsx9/dvPNHxs5/vZe/FqQAI8BmCRWOQiwPyBF9SgYBaNgFIwgAACc9EKakqGwcQAAAABJRU5ErkJggg==","orcid":"","institution":"Al Azhar University","correspondingAuthor":true,"prefix":"","firstName":"OMAR","middleName":"","lastName":"ELDANASORY","suffix":""}],"badges":[],"createdAt":"2022-05-29 07:44:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1704214/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1704214/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":22191161,"identity":"1caa50e0-f384-4a51-bacc-2bb7320bb3f7","added_by":"auto","created_at":"2022-06-02 16:08:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":225818,"visible":true,"origin":"","legend":"\u003cp\u003eAn illustration describes the technique of the test: in a standing position with the patient holding his breath. The left palm of the hand of the examiner pressing against the anterior abdominal wall anteriorly, and the thumb of the right hand pressing against the spinous process from the back.\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1704214/v1/22cf8b1d6a0196b95251b623.png"},{"id":22190732,"identity":"ad52b11a-e2d6-4fca-8202-9e72232a1676","added_by":"auto","created_at":"2022-06-02 16:03:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":343724,"visible":true,"origin":"","legend":"\u003cp\u003eMRI lumbar spine sagittal and axial views of a patient with right L5-S1 radicular pain for three weeks, and positive Modified Omar sign on physical examination. The MRI lumbar spine shows L5-S1 moderate broad-based paracentral disc herniation lateralizing to the right and impingement of the right neural foramen.\u0026nbsp;The patient underwent nerve root block with the dramatic improvement of his leg pain, after a while about two months, he had a recurrence of his leg pain. He was advised to have surgery (Minimal Invasive Microdiscectomy) and after surgery, he had a dramatic improvement in his leg pain for 12 months of follow-up with a negative Modified Omar sign during his clinical examination.\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1704214/v1/daebf4417984a297098a63f2.png"},{"id":22519441,"identity":"3f19fe97-56cf-4486-a378-e15fa183bf2d","added_by":"auto","created_at":"2022-06-10 18:59:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":787594,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1704214/v1/1a9660b2-90b2-45c8-90cf-700b90f39aa9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Modified Omar sign for the clinical diagnosis of unilateral foraminal stenosis associated with disc prolapse.","fulltext":[{"header":"Key Points","content":"\u003cp\u003e\u003cstrong\u003eIt is new clinical diagnostic test for lumbar foraminal stenosis diagnosis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eLumbar disc herniation is one of the most common medical and surgical problems all over the world. The natural history of degenerative disc disease (DDD) is largely unknown. The lifetime prevalence of symptomatic lumbar disc herniation in the adult population is approximately 2%. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and is believed to result from annular degeneration that leads to a weakening of the annulus fibrosus, leaving the disc susceptible to annular fissuring and tearing. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Among patients with radiculopathy secondary to lumbar disc herniation, approximately 10\u0026ndash;25% experience a persistent symptom where the L4\u0026ndash;L5 and L5\u0026ndash;S1 levels are the most common sites (90%). The L3\u0026ndash;L4 level is the next most common level.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eMost lumbosacral radiculopathies are caused by paracentral, lateral, and foraminal disc herniations and are diagnosed by Magnetic Resonance Imaging (MRI). [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] An accurate initial clinical diagnosis of nerve root compression is highly desirable for both physicians and patients, [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and the proper management decisions should be based on the clinical findings corroborated by diagnostic test findings. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eLumbar foraminal neuropathy is a pathologic condition of the neurovascular contents in the foramen causing radicular symptoms, which is associated with a narrowed foramen [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Anatomically, the foraminal stenosis may be anteroposterior (transverse), craniocaudal (vertical), or circumferential. The anteroposterior stenosis results from the superior articular process (SAP) and posterior vertebral body transversely, and the craniocaudal stenosis results from osteophytes of the posterolateral vertebral endplate and a laterally bulging or herniated disc compressing the nerve root against the superior pedicle vertically. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDynamic foraminal stenosis implies position-dependent provocation of foraminal volume with intermittent lumbar extension-provoked nerve root impingement. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This study involved 250 patients having foraminal stenosis due to disc prolapse between 2011 and 2020. All patients had a standardized clinical assessment followed by Magnetic Resonance Imaging (MRI).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearching method\u003c/h2\u003e \u003cp\u003eDuring a physical examination for all patients who presented to our neurosurgical outpatient clinic with complaints of unilateral lower limb radicular pain with or without lower back pain, looking for the presence or absence of a new sign known as the (Omar sign) for the diagnosis of foraminal stenosis using a new clinical test known as the modified Omar test\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSelection criteria\u003c/h2\u003e \u003cp\u003eThe test was performed on patients having unilateral acute or chronic lower limb radicular pain, with the exclusion of all patients having lower back pain only without radicular pain, or having bilateral radicular pain, or patients with scoliosis deformity, central canal stenosis, multilevel facet arthropathy, previous spinal surgery, spinal tumors, or spinal infection.\u003c/p\u003e \u003cp\u003e \u003cb\u003eReference standards\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe test (Omar test) is applied to all selected patients during their physical examination, searching for a modified Omar sign. The clinical findings during physical examinations were compared to the findings obtained from the Magnetic Resonance Imaging (MRI) of the lumbar spine. Also, the clinical findings before and after surgery or before and after nerve root block were compared.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTest description\u003c/h2\u003e \u003cp\u003ePrior to starting the test, the patient is informed to describe the location and distribution of any radiating pain along her /his lower limb and if associated with numbness during the test and after finishing the test.\u003c/p\u003e \u003cp\u003eIn a standing position with a straight spine and a neutral hip joint position, the palm of the left hand was placed on the front of the lower abdomen for support. While the thumb of the right hand is used to push against the spinous process and the interspinous space from the back for about 10 seconds. The patient during the test is advised to hold his breath. Then ask the patient to describe his leg pain, its distribution, its intensity, and other associations. The pressure on the spinous process and the lower abdominal wall is released, then the patient is asked (after 5 seconds) if he still has pain after releasing the pressure or not. The same technique is performed by asking the patient to cough, bending forward, and bending backward to detect the prevalence of the sign in different positions. The test was positive in both directions, but it was more reliable when the patient was standing in a straight position. Coughing, sneezing, or straining aggravates the testing effect. \u003cem\u003e[Fig.\u0026nbsp;1].\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eTheoretical explanation of the test\u003c/h2\u003e \u003cp\u003eIn the case of unilateral foraminal stenosis, as with disc prolapse, the nerve root is very sensitive to any movement of the spinal foramen, especially during walking or bending. In a standing position with a straight spine, pushing the spinous process and the interspinous space anteriorly against the anterior abdominal wall leads to movement and compression of the posterior foraminal parts against its anterior parts, causing more narrowing of the intervertebral foramen and more compression of the nerve root. This leads to radicular pain sensation, which could be due to direct mechanical nerve root compression, with neuronal nerve root transmission interruption. When the patient bends forward, we need to apply more compression forces during the test because of the stretching of the muscles and ligaments in the back.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDegenerative narrowing of the lumbar foramen is a gradual process. However, it is generally understood that foraminal narrowing increases the risk of developing radicular pain and root compression. Many patients can remain asymptomatic or experience only mild discomfort if no foraminal stenosis, but if the patient has foraminal stenosis with an inflamed nerve, the nerve produces pain. The symptoms progress within a short time and the most common symptoms are pain radiating down the leg, tingling, and numbness when standing or walking.\u003c/p\u003e \u003cp\u003eDuring the physical examination, the straight leg raising test and the femoral nerve stretching test are usually non-specific for foraminal stenosis. Therefore, the idea of the modified Omar test and the modified Omar sign\u0026rdquo; was developed for proper clinical diagnosis of nerve root compression and foraminal stenosis.\u003c/p\u003e \u003cp\u003eDuring the physical examination, all patients showed positive tests at the following levels L5-S1, L4-L5, L3-L4, L2-L3 levels, and less significant at the L1-L2 level, so all patients having L1-2 discs with foraminal stenosis were excluded from this research. During the examination, the radiating leg pain explained by the patients follows the course of the nerve root affected in the MRI findings in all cases (250 patients, 100%).\u003c/p\u003e \u003cp\u003eBed rest, nonsteroidal anti-inflammatory drugs, and physiotherapy started after clinical and radiological diagnosis for about 2 to 3 months. Some patients had microdiscectomy before this time. The exact time for doing surgery or doing nerve root block was variable depending on the response of the patients to the medical treatment. 160 (64%) patients from the 250 patients underwent minimally invasive surgery, (unilateral laminectomy or laminotomy with microdiscectomy). 70 patients (28%) underwent nerve root block with the improvement of the radicular pain for a few weeks or months, then a recurrence of the pain and underwent surgical microdiscectomy. 20 patients (8%) were refusing surgery because they were afraid of having surgery, so they underwent repeated steroid injections.\u003c/p\u003e \u003cp\u003eAll patients were observed after surgery, and after nerve root block in an outpatient neurosurgical clinic for 1, 2, 3, 6, 9, and 12 months, searching for the Modified Omar sign during their clinical examinations. When comparing the clinical findings after surgery and after nerve root block, all patients were negative of this sign (100%) during the period of follow-up. The most common level in this study were L5-S1 (161 (64.4%)) patients, L4-L5 level (78 (31.2%) patients, L3-4 level 9 (3.6%)) patients, and L2-3 level 2 (0.8%) patients. \u003cem\u003e[\u003c/em\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eTable\u0026nbsp;1]. [Fig.\u0026nbsp;2].\u003c/span\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAcquired foraminal stenosis is found secondary to degenerative changes in the spine, such as hypertrophy of the facet joint, ligament, and bone, disc disorders, and osteophyte formation. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The normal intervertebral foramen has a teardrop-like shape, and its form changes significantly in flexion extension motions as well as in lateral-bending and axial rotation. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The foraminal height in the lumbar spine ranges between 19 and 21 mm and the superior\u0026ndash;inferior sagittal diameter ranges between \u003cb\u003e7\u003c/b\u003e and 8 mm. (3\u0026ndash;4 mm in diameter is considered foraminal stenosis). Instead of measuring the dimensions, Wildermuth et al. introduced a qualitative scoring system for foraminal stenosis. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], whoever\u0026rsquo;s direct measurement of the bony canal on a radiographic image does not provide an accurate assessment of the degree of stenosis.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBack pain and radicular pain can originate from several anatomic structures within the spine, making it difficult for the patient and the physician to localize. Localization of the anatomical pain generator in patients with leg pain is important for clinical diagnosis, for surgical planning, and for follow-up. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The incidence of foraminal stenosis and nerve root impingement increases in the lower lumbar levels due to the increased diameter of the dorsal root ganglia (DRG) and the commonly involved nerves are the fifth lumbar nerve root (75%), the fourth nerve root (15%), the third nerve root (5.3%), and the second nerve root (4%) respectively. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe sensory nerve root elicits nociceptive pain that includes deep aching and throbbing with heaviness and a squeezing sensation associated with tingling and numbness. As the DRG becomes inflamed and entrapped in the foramen, the pain changes to neuropathic pain, which is characterized by sharp, shooting, burning, stabbing, and lancinating sensations [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which may become intolerable [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoden et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] noted abnormal findings in 57% of asymptomatic patients on magnetic resonance imaging (MRI) scans. Ishimoto et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported that 9.9% of the patients with moderate radiographic stenosis obliterating one-third to two-thirds of the spinal canal showed symptoms and 17.5% of the patients with severe radiographic stenosis obliterating more than two-thirds of the spinal canal had symptoms, so the diagnosis of the foraminal stenosis is not based solely on the radiographic findings. Therefore, the clinical examination must include a specific test for the proper diagnosis of foraminal stenosis.\u003c/p\u003e \u003cp\u003eLooking through the literature, demonstrating the movement of the facet joint against the nerve root and the movement of anterior parts of the intervertebral foramen against its posterior part in normal patients, suggested the idea of the test. So, the proposal for the Omar test and sign were developed, and the research was published in a local journal in 2015. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] After that, some modifications were added to the test in this research to increase its specificity and selectivity, such as holding the patient\u0026rsquo;s breath, upright straight position, and duration of performing the test from 5 to 10 seconds. Some researchers found that the amount of movement observed at the intervertebral foramen is generally consistent throughout the literature. Goddard and Reid described an average movement of 4 millimeters at the intervertebral foramen [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This range of movement is out of the scope of this research.\u003c/p\u003e \u003cp\u003eMany systematic reviews showed that the clinical diagnosis of disc prolapse and most of the physical tests known had a poor specificity and low sensitivity. But no research was found in the literature searched for the clinical diagnosis of foraminal stenosis. This study (the modified Omar test and sign) shows high sensitivity (100%) of the test for the diagnosis of foraminal stenosis, but variable selectivity for specific nerve root compression (70\u0026ndash;80%%) due to the non-educated patients involved in this research and the associated symptoms from other different sources such as sacroiliac joint pain and hip joint pain.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe modified Omar test is a test applied during the physical examination for the specific diagnosis in lumbar foraminal stenosis of patients having unilateral lumbar disc prolapse. The absence of the omar sign during the test after surgical intervention and after nerve root block is considered a sure sign of high sensitivity and specificity of the test. So, the test is a more reliable diagnostic tool for the clinical diagnosis of foraminal stenosis and can be added to the clinical examination sheet and, for the clinical identification of the efficacy of the surgical treatment and follow-up.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eMRI= Magnetic Resonance Imaging. CT= Computerized Tomography. SAP=superior articular process. DRG= dorsal root ganglia.\u003c/p\u003e\n"},{"header":"Statements And Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003efor my mother, my father, and the rest of my family, I acknowledge their help and support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003ethere is\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eno conflict of interest\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e: The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eI\u0026rsquo;m the only author (Omar Abdelhay Eldanasory) l read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThis is a descriptive new clinical examination test study no ethical approval is required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman and Animal ethics:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability for supporting data:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003eAuthor information: Omar Abdelhay Eldanasory, MD, PhD. FACS. ASCD\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eLecturer of Neurosurgery, Al-Azhar University Faculty of Medicine for Girls, Cairo, Egypt\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eCell phone: +201205115256\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eORCID 0000-0001-5289-7452\u003c/p\u003e\n\u003cp\u003eThe manuscript has not been previously published, in whole or in part, or submitted elsewhere for review\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003e-Carragee E, Paragioudakis S, Khurana S. (2000) Lumbar high-intensity zone, and discography in subjects without low back problems. Spine. 25(23): 2987\u0026ndash;2992.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e-Saal JA. 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(2015) AAMJ, VOL 13, NO 3, JULY 2015 \u0026ndash; suppl 2. 459\u0026ndash;463.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e-Goddard MD. Reid JD: (1965) Movements induced by straight-leg raising in the lumbosacral roots, nerves, and plexus, and in the intrapelvic section of the sciatic nerve. J Neurol Neurosurg Psychiatry. 28:12\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e[Table 1] shows the results of the clinical findings before and after surgical intervention, and MRI findings for the whole patient.\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eLevel of stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eL5-S1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eL4-L5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eL3-L4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eL2-L3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eNumber of cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eModified omar sign before intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003eModified omar sign after surgery and after nerve root block\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e100% negative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.033112582781456%\"\u003e\n \u003cp\u003ePeriod of follow up\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"79.96688741721854%\"\u003e\n \u003cp\u003e1, 2, 3 ,6 ,9 ,12 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.033112582781456%\"\u003e\n \u003cp\u003eMRI finding preoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"79.96688741721854%\"\u003e\n \u003cp\u003eAll cases were positive for foraminal stenosis with disc prolapse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Signs of nerve root compression, Modified Omar sign, Clinical test for unilateral nerve root compression. Foraminal stenosis sign, omar sign for foraminal stenosis","lastPublishedDoi":"10.21203/rs.3.rs-1704214/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1704214/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e A retrospective study analyses the validity of Modified Omar's Sign for the diagnosis of unilateral lumbar foraminal stenosis with disc prolapse.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study analyses 250 patients with unilateral sciatic pain, between 2011 and 2020.All the data obtained from the data base collected from our institution and our private clinics. All patients had a standardized neurological clinical assessment by applying the modified Omar test during their clinical examination, then comparing the clinical findings with the (MRI) imaging findings and comparing the preoperative clinical findings with the postoperative clinical findings. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e As the modified Omar test was applied during the physical examination, the test was positive for all patients with positive MRI with unilateral lumbar disc prolapse with foraminal stenosis on the same side. The clinical findings also confirmed by the absence of the test after surgical intervention and after nerve root block.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The modified Omar test is a test applied during the physical examination for specific diagnosis of lumbar foraminal stenosis of patients having unilateral lumbar disc prolapse. The correlation between clinical and radiological findings confirms the test availability. The absence of the omar sign during the test after surgical intervention, and after nerve root block is considered a sure sign of high sensitivity and specificity of the test. So, the test is a more reliable diagnostic tool for the clinical diagnosis of foraminal stenosis that can be added to the clinical examination sheet. And, for the clinical identification of the efficacy of the surgical treatment and follow-up.\u003c/p\u003e","manuscriptTitle":"Modified Omar sign for the clinical diagnosis of unilateral foraminal stenosis associated with disc prolapse.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-02 16:03:20","doi":"10.21203/rs.3.rs-1704214/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26e50815-6769-4112-914a-b93c8eca3958","owner":[],"postedDate":"June 2nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-06-10T18:59:16+00:00","versionOfRecord":[],"versionCreatedAt":"2022-06-02 16:03:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1704214","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1704214","identity":"rs-1704214","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}