Spurling Test | Cervical Radiculopathy

 Spurling Test | Cervical Radiculopathy

What is a Spurling test?

Spurling test (or as it called Spurling compression test) is a provocative test designed to exacerbate encroachment of a cervical nerve root at the neural foramen by extension and rotation of the neck toward the involved side.

It was first described in 1944 by Roy Glenwood Spurling (1894 – 1968) and William Beecher Scoville (1906 – 1984) who were American neurosurgeons.

What is the best way to apply the Spurling test for cervical radiculopathy?

What does a positive Spurling Test mean?

The Spurling test is considered positive when the pain radiates from the cervical spine down the patient’s arm.

Sensitivity & Specificity

The Spurling test sensitivity is low, but it has high specificity 1 for cervical radiculopathy diagnosed by electromyography. Therefore, it is not useful as a screening test, but it is clinically useful in helping to confirm a cervical radiculopathy.

In another study the spurling test has a high Sensitivity (92 – 95 %) and high Specificity (94 – 95 %).

Modified Spurling Test

Modifications to Spurling Test have been advocated, which divide the test into three stages, each of which is more provocative. If symptoms are reproduced, the clinician does not progress to the next stage:

  1. The first stage involves applying compression to the head in neutral.
  2. The second stage involves compression with the head in extension.
  3. The final stage involves compression with the head in extension and rotation to the uninvolved side, and then to the involved side.

No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of these variations.

Notes

Pain on the concave side indicates nerve root irritation or facet joint pathology (Spurling sign), while pain on the convex side indicates muscle strain (reverse Spurling sign).

The patient may feel no discomfort, a sensation of heaviness, nonradicular or pseudoradicular pain, or radicular pain:

Pain related to muscular strains or mild ligamentous sprains is not normally aggravated by these tests.

The test is an aggressive cervical compression test, and the patient should be prepared for each step of the examination.

The Spurling test should not be performed when cervical fracture, dislocation, or instability are suspected.

Anatomically, Cervical nerve roots exit above their corresponding vertebrae (e.g., C5 nerve roots exits at C4-C5 neural foramen). Consequently, disc herniation at C5-C6 involves the C6 nerve root. Recognize that disc herniation at C7-T1 involves the C8 nerve root.

Cervical Radiculopathy

Cervical radiculopathy is a disorder of the cervical nerve root, presenting as pain that radiates from the neck to a dermatomal segment distribution of the affected cervical nerve root. It can be due to a herniated disc, discoosteophytic complex, facet arthropathy, thickened ligamentum flavum, uncovertebral osteophyte, and other conditions.

Numerous clinical examination findings are purported to be diagnostic of cervical radiculopathy including patient history, cervical range of motion limitations, neurologic examination, and specific maneuvers (e.g., Spurling test). Most of these items have demonstrated a fair or better level of reliability.
However, because the clinical presentation of cervical radiculopathy is so variable, it is advisable to use a combination of test results before making a diagnosis.

It is important to obtain a detailed history to establish a diagnosis of a cervical radiculopathy and to rule out other causes. The clinician should first determine the main complaint (i.e., head or neck pain, numbness, weakness, decreased neck function) and location of symptoms. Anatomic pain drawings can be helpful by supplying the clinician with a quick review of the pain pattern.

Magnetic Resonance Imaging (MRI) is the best choice for cervical pathology diagnosis. Computed Tomography (CT) scans can also be used and are less expensive, but should be used with caution as they can expose patients to unnecessary radiation. 

Disk LevelNerve RootMotor DeficitSensory DeficitReflex Compromise
C4-C5C5Deltoid Muscle
Biceps Muscle
Anterolateral shoulder and armBiceps Muscle
C5-C6 C6Wrist extensors
Biceps Muscle
Lateral forearm and hand
Thumb
Brachoradialis Muscle
Pronator teres Muscle
C6-C7C7Wrist flexors Muscle
Triceps Muscle
Finger extensors Muscle
Middle fingerTriceps Muscle
C7-T1C8Finger flexors Muscle
Hand intrinsic Muscles
Medial forearm and hand and ring and little fingersNone
T1-T2T1Hand intrinsic MusclesMedial forearmNone
Common Radicular Syndromes of the Cervical Spine

In middle-aged and older patients, the symptoms are often the result of degenerative changes and compression of the
neural structures by osteophytes rather than disk herniation. Prior episodes of similar symptoms or localized neck pain are important for the diagnosis and ultimate intervention.

The older patient may have had previous episodes of neck pain or give a history of having arthritis of the cervical spine.

Leg symptoms associated with neck dysfunction, especially in the elderly, should arouse the suspicion of cervical spondylotic myelopathy.

Conservative intervention consists of modified rest, a cervical collar, oral corticosteroid, and NSAIDs.

Surgical intervention is reserved for patients with persistent radicular pain who do not respond to conservative measures.

Reference

  1. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine (Phila Pa 1976). 2002 Jan 15;27(2):156-9. doi: 10.1097/00007632-200201150-00007. PMID: 11805661.
  2. Shah KC, Rajshekhar V. Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test. Br J Neurosurg 2004;18(5):480–483.
  3. Shabat, Shay; Leitner, Yossi; David, Rami; Folman, Yoram (September 2011). “The Correlation between Spurling Test and Imaging Studies in Detecting Cervical Radiculopathy”. Journal of Neuroimaging. 22: 375–378. doi:10.1111/j.1552-6569.2011.00644.x. PMID 21883627.
  4. Spurling RG, Scoville WB. Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain. Surg Gynecol Obstet 1944;78:350–358.
  5. Anekstein Y, Blecher R, Smorgick Y, Mirovsky Y. What is the best way to apply the Spurling test for cervical radiculopathy? Clin Orthop Relat Res. 2012 Sep;470(9):2566-72. doi: 10.1007/s11999-012-2492-3. Epub 2012 Jul 18. PMID: 22806265; PMCID: PMC3830095.
  6. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine (Phila Pa 1976). 2002 Jan 15;27(2):156-9. doi: 10.1097/00007632-200201150-00007. PMID: 11805661.
  7. Bradley JP, Tibone JE, Watkins RG: History, physical examination, and diagnostic tests for neck and upper extremity problems. In: Watkins RG, ed. The Spine in Sports. St. Louis, MO: Mosby-YearBook Inc., 1996.
  8. Jones SJ, Miller JMM. Spurling Test. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29630204.
  9. Clinical Tests for the Musculoskeletal System 3rd Edition.
  10. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.

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