History and physical examination is the cornerstone in the appropriate diagnosis and treatment of any patient. A comprehensive physical examination is necessary to aid in determining distributions of symptoms and to lead one to the site of pathology. The aim of this article is to aid the clinician in distinguishing radiculopathy from other causes of neck and low back pain. Physical examination of the patient with suspected radiculopathy needs to be thorough and complete to make the most accurate diagnosis. Thorough knowledge of the evidence-based literature is beneficial in maximizing patient care, particularly in the light of health care reform.
History and physical examination is the cornerstone in any clinician’s foundation of knowledge in the appropriate diagnosis and treatment of any patient. To develop the best differential diagnosis, one must be aware of correlative signs and symptoms. A comprehensive physical examination is necessary to aid in determining distributions of symptoms and to lead one to the site of pathology. The focus of this article is on aiding the clinician in distinguishing radiculopathy from other causes of neck and low back pain.
Dermatomes and myotomes
The term “dermatome” derives from the Greek roots derma , meaning skin, and tome , meaning segment. It is used to define a segment of skin whose sensory innervation is derived from a single spinal segment, spinal nerve, or nerve root. In the diagnosis of a radiculopathy, there is significant clinical utility in understanding the structures in the nervous system responsible for observed sensory deficits over a given area of skin. For example, if a segment of skin with sensory deficits can be reliably mapped to a single spinal nerve, this knowledge can be used to guide targeted therapy to that spinal nerve.
Since the late nineteenth century, efforts have been made to produce dermatomal maps, or visual representations of the various dermatomes. Unfortunately, there has been a lack of consensus with regard to the precise localization of specific dermatomes. There are a variety of reasons why dermatomal mapping is difficult, and these have contributed to variable representations or maps. Four reasons are discussed.
- 1.
Different anatomic structures can be expected to produce different maps. Although a segment of spinal cord is known to contribute many or most of its fibers to a single root and single spinal nerve, connections between roots exist. Therefore, a sensory nerve fiber in the C5 spinal segment may not necessarily contribute to the C5 spinal nerve. As was stated by one author, “to view the spinal cord as composed of a series of independent spinal segments or neuromeres is convenient, but not accurate. ” As a result, differences can be expected to exist in the maps derived from spinal segments as compared with those derived from spinal nerves, which may account for some variability in dermatomal maps derived from various experimental techniques.
- 2.
Multiple sensory modalities contribute to sensation in a particular segment of skin. Sensation to varying modalities is transmitted by varying nerve fibers. As a result, nerve fibers transmitting sensation to different modalities in the same area of skin may derive from different spinal nerves or different spinal segments. For example, a given area of skin may derive pain and temperature sensation from the C6 spinal nerve, but light touch sensation from the C7 spinal nerve; this can lead to confusion and disagreement among different representations of the dermatomal map.
- 3.
Significant overlap exists between dermatomes. A given area of skin may receive sensation from more than one spinal nerve or spinal segment, which can explain the finding that even complete resection of a single spinal nerve may produce no loss of sensibility. Because of the significant overlap between dermatomes, the classic drawing of a human body with distinct areas of skin representing the sensory domain of a particular neural element separated by well-defined lines is likely to be an oversimplification.
- 4.
Significant challenges limit experimental procedures for defining dermatomes. Many techniques have been used to derive dermatomal maps. However, there are limitations to what can be performed experimentally. For example, it would be ethically questionable to experimentally sever human spinal nerves for the purpose of defining the resulting loss of sensation. Several techniques that have been used are described by Greenberg. Among the techniques described are mapping areas of sensory loss in patients with known spinal or peripheral nerve injuries, documenting the locations of rashes in patients with herpes zoster, experimental sectioning of nerve roots in animals, defining areas of sensory loss with surgically confirmed radiculopathy due to disc herniation, and one investigator went so far as to section his own superficial radial nerve to describe the resulting area of sensory loss. None of these experimental techniques is without flaw, and the varying ways in which dermatomal maps have been studied may explain some of their differences.
Similar to a dermatome, the term myotome is used to describe all of the muscles that receive innervation from a single spinal segment or spinal nerve. Significant overlap in myotomes occurs in a similar fashion to dermatomes. Nearly every muscle receives motor nerve fibers from more than one spinal level. Although many muscles have a dominant innervating nerve root, to consider a muscle to be innervated by a single spinal level is not accurate. For many of the same reasons cited above explaining the difficulty in constructing dermatomal maps, there is some disagreement and overlap among varying sources with regard to the spinal levels responsible for the innervation of particular muscles.
With the availability of electrodiagnostic testing, it is possible to study myotomal distributions in human subjects. By performing electrodiagnostic testing on subjects with confirmed single spinal nerve lesions, studies have been designed to determine which muscles receive innervation from a given spinal nerve. Similarly, a single spinal nerve can be electrically stimulated at the time of spinal surgery, and observation of the muscles in which contraction subsequently occurs can be used to define myotomal distributions. Corollaries to mapping dermatomal distributions using similar sensory techniques are not readily available. Several attempts have been made to define myotomal distributions using these techniques.
Despite the seemingly straightforward design of these studies, differences in results can be found. For example, Brendler found that on electrical stimulation of the C6 nerve root, contraction of the flexor carpi radialis occurred in 0 of 3 patients tested. However, Levin and colleagues found that in subjects with surgically confirmed single-level C6 radiculopathies, 4 out of 5 had electrodiagnostic abnormalities in the flexor carpi radialis. This discrepancy, along with others of a similar nature, leaves the reader to wonder about the true contribution of specific nerve roots to the innervation of individual muscles.
Despite these significant challenges, knowledge and understanding of the general concepts of dermatomal and myotomal distributions can be extremely valuable in the clinical evaluation of a suspected radiculopathy. Even if discrepancies exist, there is general agreement on the spinal nerves that provide innervation to most muscles. Similarly, general agreement exists with regard to the approximate sensory distribution of each spinal nerve. When a patient presents with a suspected radiculopathy, a detailed neurologic examination should be performed to include manual muscle testing to determine the distribution of weakness as well as sensory testing to determine the distribution of impaired sensation. If there is correlation in the suspected root levels responsible for sensation in the impaired distribution with those contributing innervation to the muscles found to be weak, this may lead to a diagnosis of involvement of a particular root level based on the physical examination.
Caution must be applied in using physical examination findings to exclude a radiculopathy. Lauder and colleagues showed that in subjects with electrodiagnostic evidence of a radiculopathy, as many as 31% will have no weakness on physical examination and as many as 45% will have no sensory abnormalities detected on physical examination. Based on these results, it is likely that a significant proportion of patients who present with a true radiculopathy may have a normal physical examination.
There are several reasons that a patient with a radiculopathy may have normal physical examination findings. As discussed, the significant overlap between dermatomes results in each segment of skin receiving sensory innervation from more than one spinal nerve. Therefore if a single spinal nerve is injured, the other overlapping spinal nerves will continue to provide at least partial sensation to the area of skin in question. In fact, it would be unusual for a patient with a single-level radiculopathy to have gross loss of sensation.
Furthermore, weakness may not be present even in a severe radiculopathy. There are several reasons for this observation. First, a radiculopathy often involves injury to only a fraction of the fibers contained in the spinal nerve. It would require degeneration or conduction block of a relatively large proportion of axons contributing innervation to a particular muscle before weakness were observed clinically. In addition, as already discussed, nearly all muscles receive innervation from more than one spinal nerve. Therefore, strength can be preserved if axons from other spinal nerves remain intact even in a very severe single-level radiculopathy.
When physical examination findings are present, they can be very helpful in diagnosing a radiculopathy and identifying the involved level. This identification requires an understanding of dermatomal and myotomal distributions. Despite challenges that are present in interpreting dermatomal and myotomal maps, they can be very useful in the evaluation of a radiculopathy ( Table 1 ).
| Muscle | Primary Root(s) from Brendler | Other Root(s) from Brendler | Negative Root(s) from Brendler (Roots not Contributing) | Primary Root(s) from Levin | Other Root(s) from Levin |
|---|---|---|---|---|---|
| Flexor carpi ulnaris | C7, C8 | C6 | |||
| Extensor digitorum communis | C8 | C7 | C7, C8 | C6 | |
| Extensor carpi ulnaris | C8 | C7 | |||
| Abductor pollicis longus | C8 | C7 | |||
| Extensor pollicis longus | C8 | C7 | |||
| Teres minor | C6 | C7, C8 | |||
| Teres major | C6 | C7, C8 | |||
| Latissimus dorsi | C6 | C7, C8 | |||
| Triceps | C7, C8 | C6 | C7 | C6, C8 | |
| Brachioradialis | C5 | C6 | C5,6 | ||
| Flexor carpi radialis | C7 | C6 | C6, C7 | ||
| Abductor pollicis brevis | C8 | C8 | |||
| Extensor carpi radialis | C6 | C5, C7 | C8 | ||
| Pronator teres | C6 | C7 | C6, C7 | ||
| Flexor digitorum Profundus | C8 | C7 | |||
| Pronator quadratus | C6 | C7 | |||
| Flexor pollicis longus | C8 | C7 | C8 | ||
| Deltoid | C5 | C3, C4, C6, C7 | C5 | C6 | |
| Biceps | C5, C6 | C7 | C5,6 | ||
| Pectoralis major | C7, C8 | C6 | C5 | ||
| Levator scapula | C3 | C4 | C5 | ||
| Trapezius | C1, C2, C3, C4 | ||||
| Supraspinatus | C5,6 | ||||
| Infraspinatus | C5 | C6 | |||
| Anconeus | C7, 8 | ||||
| Extensor indicis proprius | C8 | C7 | |||
| First dorsal interosseus | C8 | C7 | |||
| Abductor digiti minimi | C8 |
| Primary Root(s) from Tsao | Other Root(s) from Tsao | Primary Root(s) from Phillips | Other Root(s) from Phillips | ||
|---|---|---|---|---|---|
| Adductor longus | L2, L3, L4 | L3 | L2, L4 | ||
| Iliacus | L2, L3, L4 | L3 | L2, L4 | ||
| Vastus lateralis | L2, L4 | L3 | L2, L4 | ||
| Rectus femoris | L4 | ||||
| Vastus medialis | L3, L4 | ||||
| Posterior tibialis | L5 | S1 | |||
| Tibialis anterior | L5 | L4, L5 | S1 | ||
| Extensor digitorum brevis | L5 | ||||
| Peroneus longus | L5 | L5 | S1, L4 | ||
| Extensor hallucis longus | L5 | S1 | |||
| Gluteus medius | L5 | S1 | |||
| Semitendinosus | L5 | ||||
| Tensor fascia lata | L5 | ||||
| Medial gastrocnemius | S1 | L5 | S1 | L5, S2 | |
| Lateral gastrocnemius | S1 | L5 | S1 | L5, S2 | |
| Abductor digiti quinti pedis | S1 | ||||
| Biceps femoris short head | S1 | ||||
| Biceps femoris long head | S1 | ||||
| Gluteus maximus | S1 | L5 | S1 | L5, S2 | |
| Abductor hallucis | S1 | L5 |
Cervical spine
Provocative Tests
There is a wide variety of provocative tests and signs described in the literature ( Table 2 ) regarding physical examination of the cervical spine to evaluate radiculopathy. In addition to the variance in the nomenclature of these tests, there are multiple descriptions on how these tests should be properly performed. Review of the literature reveals multiple review articles evaluating physical examination for cervical radiculopathy, as well as a volume of evidence-based studies evaluating the validity and reliability of the tests; however, for other tests there is limited or no existing scientific literature.
| Lumbar | ||||||
|---|---|---|---|---|---|---|
| Design | Number | Measures | Control | Results | Conclusion | |
| Ekedahl et al, 2010 | Cross-sectional validity study | 75 | Roland Morris Disability Questionnaire (RMDQ), SLR, Fingertip to floor test, Slump | Slump test | RMDQ/FTF (0.68 men, 0.70 women); RMDQ/SLR (0.60 women, 0.28 men) | Good validity of FTF with both sexes, but SLR has less value especially for men |
| Suri et al, 2010 | Cross-sectional with prospective recruitment | FST, CFST, medial ankle pinprick sensation, sit to stand, patellar reflex, Achilles reflex, anterior thigh sensation, hip abductor strength | None | Midlumbar impingement: FST, CFST, medial ankle pinprick sensation, and patellar reflex testing demonstrated LRs ≥5.0 (LR infinity). LRs ≥5.0 observed with combinations of FST and either patellar reflex testing (LR 7.0; 95% confidence interval [CI] 2.3–21) or the sit-to-stand test (LR infinity). Low lumbar impingement: Achilles reflex test demonstrated an LR ≥5.0 (LR 7.1; 95% CI 0.96–53); test combinations did not increase LRs. Level-specific impingement: LRs ≥5.0 were observed for anterior thigh sensation at L2 (LR 13; 95% CI 1.8–87); FST at L3 (LR 5.7; 95% CI 2.3–4.4); patellar reflex testing (LR 7.7; 95% CI 1.7–35), medial ankle sensation (LR infinity), or CFST (LR 13; 95% CI 1.8–87) at L4; and hip abductor strength at L5 (LR 11; 95% CI 1.3–84). Test combinations increased LRs for level-specific root impingement at the L4 level only | Individual tests alter likelihood of mid, low lumbar, and level-specific impingement; test combinations improve diagnostic accuracy for midlumbar impingement | |
| Barz et al, 2010 | Retrospective case studies | 200 | Nerve root sedimentation sign (radiologic) | Nonspecific LBP (no leg pain, claudication, dural sac CSA >120 mm, walk >1 km) versus symptomatic LSS (+leg pain, claudication, CSA <80 mm, walk <200 m) | Positive sedimentation sign identified in 94 patients in the LSS group (94%; 95% CI, 90%–99%) but none in the LBP group (0%; 95% CI, 0%–4%). Reliability was kappa = 1.0 (intraobserver) and kappa = 0.93 (interobserver), respectively. No difference in the detection between segmental levels L1–L5 in the LSS group | Positive sedimentation exclusive and reliable, suggesting high specificity and sensitivity |
| van der Windt et al, 2010 | Cochrane review | 16 cohort and 3 case-control | Scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits, forward flexion, hyperextension test, slump test, SLR, CSLR | Back pain with diagnostic imaging or findings at surgery | Scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits were poor; forward flexion, hyperextension test, and slump test performed slightly better; SLR (surgical) high prevalence of disc herniation (58%–98%) showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10–1.00, pooled estimate 0.28, 95% CI: 0.18–0.40); CSLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85–0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22–0.35). Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations | Poor diagnostic performance of most physical tests; however, most from surgical populations and may not apply to primary care or nonselected populations. Better performance may be obtained when tests are combined |
| Coster et al, 2010 | Prospective | 202 | SLR, history, EMG | Radiologic nerve root compression (95 patients) | Dermatomal radiation (odds ratio [OR] 2.1), more pain on coughing, sneezing, or straining (OR 2.4), positive straight leg raising (OR 3.0), and ongoing denervation on EMG (OR 4.5) | History and physical helpful in predicting nerve root compression on MRI; EMG may have additional value |
| Summers et al, 2009 | Diagnostic validity | 67 | Flip test, SLR | Supine straight leg raise | 33% no pain, 39% pain on full knee extension, 28% resisted extension due to pain | All patients had +Flip compared with supine SLR below 45° |
| Last and Hulbert, 2009 | Review | Focus on tx, not dx | ||||
| Rubenstein et al, 2008 | Review | SLR | Other neurologic signs and tests | SLR consistently reported sensitive for radicular pain, but limited by low specificity | SLR high sensitivity, low specificity | |
| Majlesi et al, 2008 | Prospective case control | 75 | Slump, SLR, Lasegue | Absence or presence of disc herniation on MRI | Slump test more sensitive (0.84) than the SLR (0.52) with lumbar disc herniations. However, SLR slightly more specific test (0.89) than the slump test (0.83) | Slump test higher sensitivity, SLR more specific |
| Freynhagen et al, 2008 | Prospective | 43 | Sensory testing: vibration, hair contact, cold | Pseudoradicular, healthy normals, radicular pain | Vibration detection was the most sensitive parameter with 73% abnormal values in radicular and 47% in pseudoradicular cases | Vibration testing |
| Chou et al, 2007 | Review | Guide toward imaging and treatment | ||||
| Rabin et al, 2007 | Cohort | 71 | Seated versus Supine SLR | MRI findings | Supine SLR test sensitivity 67% compared with seated SLR sensitivity 41% | Supine SLR higher sensitivity |
| Miller, 2007 | Descriptive | Focus on how to perform, not evidence based | ||||
| van Rijn et al, 2006 | Prospective | 75 | VAS during examination | MRI findings | MRI abnormal 74% symptomatic, 33% asymptomatic | Two-thirds of patients poor predicative value |
| Nadler et al, 2004 | Retrospective | 200 | SLR, strength, sensation, reflexes | Personal injury, workman’s compensation | Positive SLR in women 7.4 more likely in PIP versus WC (95% CI, 11.1–992.6; P <.001). Men, bilateral SLR was 38.9 times more likely PIP (95% CI, 11.3–133.6; P <.001) | Higher rates of positive SLR in PIP versus WC |
| Vroomen et al, 2002 | Prospective | 274 | Paresis, tendon reflexes, +SLR, and finger to floor | MRI findings | SLR not predictive, independent diagnostic value of paresis and finger to floor distance | Tests generally have lower sensitivity and specificity than previously reported |
| Nadler et al, 2001 | Case study | 2 | FNST, crossed FNST | FNST | Upper lumbar radiculopathy confirmed by FNST and crossed FNST | May be a valuable screening tool |
| Patel and Ogle, 2000 | Review | Focus on tx, not dx | ||||
| Deville et al, 2000 | Review | SLR | Overall, pooled data SLR: sensitivity 91%, specificity 26%. CSLR: sensitivity 29%, specificity 88% | SLR: high sensitivity and low specificity; CSLR: high specificity, low sensitivity | ||
| Manifold and McCann, 1999 | Review | H&P can lead to appropriate imaging and EMG | ||||
| Humphreys, 1999 | Review | Focus on tx, not dx | ||||
| Stankovic et al, 1999 | Slump, Braggard | 94% positive slump with frank disc herniation, 78% bulging discs, 75% without disc finding | High prevalence of findings in patients without pathology | |||
| Supik and Broom, 1994 | Bowstring sign | 71 % positive sign in patients with known lumbar disc herniation | ||||
| Alexander et al, 1992 | Retrospective | 154 | Negative extension sign (ability to achieve full extension), SLR, CSLR | EMG, CT, myelography, DTR, sensory and motor deficits | By day 5 94 able to fully extend, 19 of 33 patients with + extension sign on admission became negative within 5 days of admission: 95% satisfaction, 90% without job changes | Extension sign effectively predicts a favorable response to nonoperative therapy of HNP in 91% of cases |
| Kosteljanetz et al, 1988 | Prospective | 100 | SLR (leg pain, leg or back pain) | Leg pain: sensitivity 76%, specificity 45%, prevalence 58%; Leg or back pain: sensitivity 91%, specificity 21%, prevalence 58% | Adding back pain will increase sensitivity but decrease specificity | |
| Hong et al, 1986 | Retrospective | 108 | Clinical findings correlate with EMG findings to greater extent than radiographic findings | EMG beneficial to provide accurate assessment | ||
| Kosteljanetz et al, 1984 | Prospective | 52 | SLR (leg pain, leg or back pain) | SLR: (leg pain) sensitivity 89%, specificity 17%, prevalence 86% (leg or back pain): sensitivity 95%, specificity 14%, prevalence 86%; CSLR: (contralateral leg pain) sensitivity 24%, specificity 96%, prevalence 86% (contralateral leg pain or back pain): sensitivity 42%, specificity 85%, prevalence 86% | Adding back pain will increase sensitivity but decrease specificity | |
| Hudgins, 1979 | Prospective | 274 | CSLR | Sensitivity 24%, specificity 96%, prevalence 83% | ||
| Spangfort, 1972 | Prospective | 2504 | Lasegue (SLR), CSLR | SLR: sensitivity 97% (73% from L1/L2–L3/4), specificity 11%, prevalence 88%; CSLR: sensitivity 23%, specificity 88%, prevalence 86% | SLR: high sensitivity and low specificity, decreased specificity for upper lumbar level; CSLR: high specificity, low sensitivity | |
| Hakelius, 1972 | Prospective | 1986 | SLR, CSLR | Sensitivity 96%, specificity 15%, prevalence 75% | High sensitivity and low specificity | |
| Charnley, 1951 | Prospective | 88 | SLR | Leg or back pain: sensitivity 91%, specificity 21%, prevalence 58% | Moderate sensitivity and specificity | |
| Cervical | ||||||
|---|---|---|---|---|---|---|
| Design | Number | Measures | Control | Results | Conclusion | |
| Eubanks, 2010 | Review | Focus on tx, not dx | ||||
| Kuijper et al, 2009 | Review | Foraminal compression test | MRI, EMG | No well-defined criteria and not properly evaluated | Poor clinical predictive value | |
| Rubenstein et al, 2008 | Review | Spurling, ULTT | Other neurologic signs and tests | Spurling high specificity, ULTT high sensitivity | Value with Spurling and upper limb tension test | |
| Nordin et al, 2008 | Review | 95 articles | Numerous test | Manual provocation test high predictive value | Validity of most tests are lacking | |
| Guzman et al, 2008 | Review | 4 grades | Focus on triage to 4 grades | Focus on guiding treatment | ||
| Rubenstein et al, 2007 | Review | 6 studies | Spurling, upper limb tension test, traction/distraction, Valsalva | Various reference standards | Spurling, traction/distraction, and Valsalva demonstrated low to moderate sensitivity and high specificity, ULTT high sensitivity and low specificity | Spurling, traction/distraction, Valsalva will rule in, and negative ULTT will rule out |
| Rainville et al, 2007 | Case series | 55 | MMT of forearm pronation versus WE, EF, EE | Diagnostic imaging evidence | C6 radiculopathies forearm pronation weakness 72% (twice as common as WE, present in all with EF/WE weakness, and all but 2 with EE weakness); C7 radiculopathies forearm pronation weakness only 10% of subjects | Forearm pronation weakness is the most frequent motor finding in C6 radiculopathies, and may be found in some cases of C7 |
| Shah and Rajshekhar, 2004 | Prospective | 50 | Spurling | Surgical/MRI findings | Spurling 92% sensitive, 95% specific, PPV 96.4%, NPV 90.9% | Spurling is gold standard |
| Douglass and Bope, 2004 | Review | Focus on tx, not dx | ||||
| Malanga et al, 2003 | Review | Spurling, shoulder abduction relief test, neck distraction test, Lhermitte, Hoffman, Adson | High specificity, low sensitivity with good interexaminer reliability: Spurling, neck distraction, and shoulder abduction relief test. Hoffman: no evidence of interexaminer reliability, fair sensitivity, fair to good specificity. Lhermitte/Adson: no existing literature on reliability, sensitivity, or specificity | Spurling, shoulder abduction, and neck distraction highest level of evidence in predicting radiculopathy | ||
| Wainner et al, 2003 | Prospective | 82 | Numerous test | EMG | Combination of tests better than any single test, however ULTT most useful for ruling out | Combination best to rule in, ULTT best to rule out |
| Tong et al, 2002 | Cross-sectional | 255 | Spurling | EMG | Spurling sensitivity of 6/20 (30%), specificity of 160/172 (93%). Positive in 16.6% normal group, 3.4% of group with nerve disorders other than radiculopathy, 25% of the group with abnormality not consistent with any specific diagnosis group, in 37.5% of group with possible radiculopathy, and 40% of the group with certain radiculopathy | Spurling low sensitivity, but is specific for radiculopathy diagnosed by EMG |
| Sung and Wang, 2001 | Prospective | 16 | Hoffman’s reflex + in asymptomatic patients | Asymptomatic patients MRI cervical pathology | 14 spondylosis, 16 had MRI findings, 15 had cervical cord compression with HNP (other had T5–6 disc compression) | Presence of Hoffman in “asymptomatic” patients strongly suggest underlying pathology |
| Haig et al, 1999 | Prospective | 252 | Physical examination | EMG | EMG altered 42% of dx, confirmed 37%, and did not clarify 21% | Necessary to have examination with EMG for accurate diagnosis |
| Dvorak, 1998 | Review | Focus on advanced imaging and EMG | ||||
| Malanga, 1997 | Review | Focus on detailed H&P to guide treatment and return to play | ||||
| Sandmark, 1995 | Prospective, single-blind | 75 | Five manual tests: neck rotation, active flexion/extension, ULTT, palpation, foraminal test | None | Palpation good screening; foraminal and ULTT caused pain in almost all patients, but inconsistent radicular symptoms, neck rotation or flexion/extension insufficient sensitivity | Palpation initial screen, ULTT and foraminal testing may also help |
| Ellenberg et al, 1994 | Review | Examination to guide advanced diagnostics | ||||
| Viikari-Juntura, 1989 | Prospective | 43 | Spurling, shoulder abduction (relief) sign, neck distraction | Spurling: sensitivity 40%–60%, specificity 92%–100%; shoulder abduction relief sign: sensitivity 43%–50%, specificity 80%–100%; neck distraction: sensitivity 40%–43%, specificity 100% | Spurling, shoulder abduction relief, and neck distraction: high specificity, low sensitivity | |
| Viikari-Juntura, 1987 | Prospective | 52 | Spurling, shoulder abduction (relief) sign, neck distraction | Spurling: kappa 0.40–0.77, PSA 0.47–0.80; shoulder abduction relief sign: kappa 0.21–0.40, PSA 0.57–0.67; neck distraction: kappa 0.50, PSA 0.71 | Spurling: fair to excellent; shoulder abduction relief: fair; neck distraction: good reliability | |
Spurling test (foraminal compression test, neck compression test, quadrant test)
During World War II, while working at the Walter Reed General Hospital, Roy Greenwood Spurling, the hospital’s first Chief of Neurosurgery and organizer of neurosurgery for the entire Army, first noted this finding in patients with ruptured cervical discs. During this time, Spurling and Scoville had demonstrated a positive test on 12 patients with presumed ruptured cervical discs who were confirmed surgically in 1943, and reported their findings in 1944. The original description of the test by Spurling and Scoville explained that the head and neck will be tilted toward the painful side to reproduce the patient’s typical radicular symptoms. Pressure will then be placed on the top of the head to further intensify the symptoms, whereas tilting the head away from the painful side will alleviate the symptoms. At present the test, also known as the foraminal compression test, neck compression test, or the quadrant test, is performed by neck extension, rotation, and downward pressure on the head with a positive finding eliciting radicular pain into the ipsilateral arm of head rotation. Overall, the Spurling test has been described as “almost pathognomonic of a cervical intraspinal lesion.”
Recent reviewers in the past several years who completed evaluating the validity of the various cervical provocative maneuvers including the Spurling test concluded that the test demonstrated low to moderate sensitivity and high specificity, and a good interrater reliability. A study by Shah and Rajshekhar in 2004 evaluated the test on 50 surgical patients with findings on magnetic resonance imaging (MRI). The results of the study were that the Spurling test was 92% sensitive and 95% specific, with a positive predictive value of 96.4% and a negative predictive value of 90.9%, concluding that the Spurling test is the gold standard for evaluating cervical radiculopathy. Additional studies on the reliability and validity revealed that interrater reliability for the Spurling test in a seated position had a kappa coefficient of 0.40 to 0.77, and a sensitivity of 40% to 60% and specificity of 92% to 100%. Their conclusions were that the Spurling test had good interrater reliability when testing with the patient in a seated position, and that the test has a high specificity but low sensitivity.
When evaluating the correlation of a positive Spurling test with findings on electrodiagnostics, the Spurling test had a (6/20) sensitivity of 30% and a specificity of (160/172) 93%. There were 2 other studies that did not use the most widely accepted description of a positive Spurling test or used spinal cord deformity as the criterion, and therefore, their contribution to evidence-based evaluation of the Spurling test is limited.
Overall, the recent contributions to the literature have lent significance toward the utility of the Spurling test in the physical examination of patients with suspected cervical radiculopathy.
Lhermitte sign
The Lhermitte sign, also known as the Barber Chair phenomenon, is named after Jacques Jean Lhermitte, who described findings in 1920 when evaluating patients with spinal cord concussion and later in other neurologic diagnoses. However, the sign was previously described by both Marie and Chatelin in 1917 and Babinski and Dubois in 1918. While evaluating patients with head injuries, Marie and Chatelin noted transient pins and needles sensations into the limbs on flexion of the neck. Babinski and Dubois noted electric discharges into the limbs with head flexion, sneezing, or coughing in a patient with Brown-Sequard syndrome.
There are still variations of how the Lhermitte sign is described; however, current description of positive findings is elicited by flexion of the neck producing electric shock-like sensations that extend down the spine and shoot into the limbs. The findings have been described in various pathologic states caused by trauma to the cervical portion of the spinal cord, multiple sclerosis, cervical cord tumor, cervical spondylosis, or even vitamin B12 deficiency.
There is limited literature evaluating the effectiveness of the Lhermitte sign in determining cervical radiculopathy. A review by Malanga and colleagues concluded that there is insufficient evidence of the interrater reliability, sensitivity, and specificity of the Lhermitte sign specifically. However, the active flexion and extension test described by Sandmark and Nissell resembles the Lhermitte sign, and was found to have a high specificity (90%) and low sensitivity (27%) with a negative predictive value of 75% and positive predictive value of 55%. Another study reviewed the Lhermitte test in assessing cervical cord lesions, and reported a high sensitivity and low specificity.
Based on the lack of any recent or previous evidence literature regarding the validity or reliability of the Lhermitte sign, its usefulness in the examination of cervical radiculopathy is limited.
Shoulder abduction test (shoulder abduction relief sign)
In addition to the contribution of the Spurling test, Spurling also was the first to report the shoulder abduction relief sign, more commonly known as the shoulder abduction test, in 1956. The initial description was the relief of radicular symptoms by raising the arm above the head. The shoulder abduction test is now currently described as active or passive abduction of the ipsilateral shoulder. The hand rests on the top of the head, and a positive test is elicited with the relief or reduction of ipsilateral cervical radicular symptoms.
There is limited evidence regarding the validity and reliability of the shoulder abduction test. Both studies in the literature were conducted by Viikari-Juntura and colleagues, and revealed fair interrater reliability (kappa 0.21–0.40), proportion of specific agreement (0.57–0.67), with high specificity (80%–100%) and low sensitivity (43%–50%). However, a review by Malanga and colleagues concluded that the test had good interrater reliability with high specificity and low sensitivity.
There are several studies evaluating the effectiveness in diagnosing radicular pain from shoulder pain as well as disc pathology versus spondylosis ; however, the evidence is limited.
The shoulder abduction test has been claimed to be predictive of excellent response to surgical treatment. The shoulder abduction test had positive relief in 15 of 22 patients who failed conservative management of cervical radicular symptoms, and confirmed disc pathology on myelography ; however, this study had a small sample size and did not provide significant outcome measures. The shoulder abduction relief maneuver has also been reported to benefit patients by incorporating it into a nonsurgical treatment plan.
Overall, the review of the evidence-based literature reveals that currently there is limited research on the validity and reliability for the use of the shoulder adbuction test in the diagnosis of cervical radiculopathy.
Upper limb tension test
The upper limb tension test (ULTT), as described as brachial plexus tension test (BPTT) or test of Elvey, is a lesser known test used in the evaluation of cervical radiculopathy versus brachial plexus. The ULTT appears to offer a means of examining the extensibility and mechanosensitivity of the neural tissues related to an upper limb. It is performed in a sequence of movements with the patient supine. The following sequences of motions are performed: scapular depression, shoulder abduction, forearm supination, wrist and finger extension, shoulder lateral elevation, elbow extension, and contralateral/ipsilateral cervical side bending. The test is positive if one or more of the following occurs: radicular symptoms are reproduced, side-to-side difference in elbow extension is greater than 10°, contralateral cervical side bending increases symptoms, or ipsilateral side bending decreases symptoms.
Wainner and colleagues evaluated several provocative tests for the diagnosis of cervical radiculopathy, and concluded that the ULTT was the most useful test for ruling out cervical radiculopathy, whereas Sandmark and Nisell, in a study of 75 patients, concluded that the ULTT caused pain in almost all patients. The study by Quintner revealed a high sensitivity (83%) and a low specificity (11%). The reviews by Rubenstein and colleagues concluded that the ULTT demonstrated high sensitivity and low specificity.
Overall there is limited evidence regarding the utility of the ULTT in the diagnosis of cervical radiculopathy.
Neck distraction test (manual traction test)
Another infrequently described provocative test is the neck distraction test, also known as the manual traction test. The description on the proper performance of the test is for the examiner to place one hand on the occiput and the other on the chin while slowly lifting the patient. A positive finding is noted when the pain is diminished during the distraction.
Two fairly recent reviews of various provocative tests were conducted that evaluated the current literature supporting the use of the neck distraction test to aid in the diagnosis of cervical radiculopathy. Malanga and colleagues concluded that existing literature appears to indicate high specificity, low sensitivity, and good to fair interexaminer reliability for the neck distraction test, whereas Rubenstein and colleagues felt there was low to moderate sensitivity and high specificity.
In reviewing the literature, the lone studies to evaluate reliability and validity were conducted Viikari-Juntura’s group in 1987 and 1989. The findings in these studies demonstrated good reliability, with kappa values ranging from 0.50 to 0.71, and a high specificity (100%) and low sensitivity (40%–43%).
Overall, there is limited evidence regarding the neck distraction test in the assessment of cervical radicular symptoms.
Hoffmann sign
Historically there have been several variations of the Hoffman sign and controversy regarding its true clinical significance. The Hoffman sign is commonly assessed in the evaluation of the cervical spine. Although it does not indicate cervical radiculopathy, it is useful in the physical examination in determination of the etiology of the symptoms. There are differences in the descriptions of the test and what constitutes a positive finding. The criteria in some studies have been lenient with a positive finding as flexion of the thumb, index finger, or both. On reexamination these positives were later stratified into “true” (flexion of both thumb and index finger) or “incomplete” (with flexion of either).
There has been vast disagreement regarding the clinical significance and whether the phenomenon is pathologic or physiologic. There have been several studies on the incidence of a positive response in normal patients or patients without any clear pathology, with an incidence of 1.63% to 3.4%. However, the prevailing thought is that it is an upper motor neuron (UMN) sign indicating that there is pyramidal tract involvement. If the Hoffman sign truly indicates a UMN disorder such as cervical myelopathy and cord compression, there is enormous value in separating cervical radiculopathy from the differential diagnosis.
There is no current literature evaluating the interrater reliability, and limited literature on the validity of the Hoffman test. The study by Raaf evaluated 124 patients with cervical complaints and advance neuroimaging, and revealed a sensitivity of 58% and specificity of 78%, with a positive predictive value of 62% and negative predictive value of 75%.
Overall, there is no evidence specifically evaluating the Hoffman sign for radiculopathy; however, it may be beneficial in the determination of possible cord versus root injury.
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