Letters to the Editor

Low Specificity Limits Use of Test for Spondylolysis in Children and Adolescents


Am Fam Physician. 2021 Jan 15;103(2):68.

Original Article: Back Pain in Children and Adolescents

Issue Date: July 1, 2020

See additional reader comments at: https://www.aafp.org/afp/2020/0701/p19.html

To the Editor: This article discusses the stork test to diagnose spondylolysis. However, this test is useless if not counterproductive because of its low specificity. Given that most children with low back pain do not have spondylolysis, most positive test results are false positives. It would be helpful if the authors provided the sensitivity and specificity for the other diagnostic maneuvers mentioned in the article.

Author disclosure: No relevant financial affiliations.

In Reply: We appreciate the feedback about physical examination maneuvers that are used to diagnose spondylolysis. The use of the stork test is somewhat controversial because of the low specificity (17% to 32%) cited in our article. We are currently working with two groups that are evaluating approaches to better diagnose spondylolysis because radiography is also insensitive. New techniques in magnetic resonance imaging that improve bone visualization can be helpful.1 Although spondylolysis is common, family physicians need an improved understanding of methods to diagnose and treat this condition, which limits the ability of many adolescents to participate in sports.

In response to physical examination testing for specific conditions, other common maneuvers may have limited clinical evidence. For example, absent bowel sounds have classically been associated with small bowel obstruction but have poor sensitivity (32%) and positive predictive value (23%).2,3 We agree that limitations of physical examination testing should be discussed and that these tests should be evaluated through additional research.

Author disclosure: No relevant financial affiliations.


1. Finkenstaedt T, Achar S, Algarni I, et al. From bench to bedside: improved detection of spondylolysis using 3D cones ultrashort time to echo (UTE) MR technique. Joint Annual Meeting ISMRM-ESMRMB. Paris, France. 2018. Accessed September 25, 2020. http://archive.ismrm.org/2018/5173.html

2. Breum BM, Rud B, Kirkegaard T, et al. Accuracy of abdominal auscultation for bowel obstruction. World J Gastroenterol. 2015;21(34):10018–10024.

3. Felder S, Margel D, Murrell Z. Usefulness of bowel sound auscultation: a prospective evaluation. J Surg Educ. 2014;71(5):768–773.

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