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Diagnostic accuracy of the head elevation test: a novel physical examination for vertebral compression fractures in older adults with back pain

Ueda T

Spine (Phila Pa 1976) 2025 Oct 15;epub ahead of print(Check):Check

primary study

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To evaluate the diagnostic accuracy of the head elevation test (HET), a novel bedside physical examination maneuver, for identifying vertebral compression fractures (VCFs) in older adults with acute or subacute back pain. SUMMARY OF BACKGROUND DATA: VCFs are a common cause of acute back pain in older adults but are frequently underdiagnosed, especially in emergency and outpatient settings where MRI is not always immediately available. Existing physical examination signs, such as the closed-fist percussion test (CFPT) and supine sign, have limited validation in prospective studies. METHODS: We prospectively and consecutively enrolled 311 adults presenting with acute or subacute back pain. Two bedside physical examination maneuvers were evaluated: the HET and the CFPT. A positive HET was defined as severe midline spinal pain induced before 60 degrees of head elevation. Imaging-based diagnoses served as the reference standard. Sensitivity, specificity, and likelihood ratios were calculated, including an MRI-confirmed subgroup analysis. RESULTS: The HET demonstrated a sensitivity of 92.2% and specificity of 85.9% for VCFs, outperforming the CFPT (sensitivity 75.6%, specificity 82.4%). Combining both maneuvers yielded a sensitivity of 96.6%. The HET was especially effective for fractures at the thoracolumbar junction. CONCLUSION: The head elevation test demonstrated high diagnostic accuracy for vertebral compression fractures and represents a novel, simple bedside examination to rapidly screen older adults with back pain in both emergency and outpatient settings.
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