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Research Review By Dr. Jeff Muir©


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Date Posted:

June 2018

Study Title:

Value of physical tests in diagnosing cervical radiculopathy: a systematic review


Thoomes EJ, van Geest S, van der Windt DA et al.

Author's Affiliations:

Fysio-Experts, Hazerswoude, The Netherlands; Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef, Leiden, The Netherlands; Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, Keele, Newcastle, Staffordshire, United Kingdom; Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, United Kingdom; Department of General Practice, Erasmus Medical Centre University, Rotterdam, The Netherlands; Maasstad Hospital, Department of Neurosurgery, Rotterdam, The Netherlands; Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, The Netherlands.

Publication Information:

The Spine Journal 2018; 18: 179-189

Background Information:

Cervical radiculopathy describes radiating pain into the arm corresponding to a dermatomal pattern. Radiculopathy is, by definition, a neurological state characterized by limited or blocked nerve conduction and differentiated from radicular pain, wherein the compression can be caused by the cervical disc, degenerative changes or simple inflammation (1). Diagnosis of radiculopathy is based largely on the history and physical examination, which can then be confirmed through diagnostic imaging or even supported by surgical findings (2). A number of clinical tests, including those for deep tendon reflexes, muscle testing, evaluations for sensory deficits and provocative orthopedic tests are all utilized to confirm the diagnosis suspected following patient history. The specific value and utility of different tests has been evaluated in a number of reviews (3-7); however, these reviews either did not critically appraise study quality (5), were narrative in nature (6, 8) or did not specifically address cervical radiculopathy (7). The North American Spine Society (NASS) has developed clinical guidelines describing commonly used tests (3). The purpose of this review was to update the available evidence on the utility of diagnostic tests for evaluating patients with cervical radiculopathy.

Pertinent Results:

Literature Search Results & Quality:
  • 5 studies were included in the systematic review following full-text review of 87 potential studies
  • All studies had been conducted in a hospital setting
  • The overall methodological quality of studies was poor to moderate, as all studies had either “high” or “unclear” risk of bias in at least one category.
Spurling’s Test:
3 studies (n = 350) evaluated the diagnostic accuracy of Spurling’s Test. Two studies (9, 10) using cervical extension + ipsilateral lateral flexion and ipsilateral lateral flexion + rotation both showed moderate sensitivity (0.65 and 0.38) and high specificity (1.00 and 0.94). A third study (11) combined cervical extension with ipsilateral rotation and demonstrated high sensitivity (0.98) and specificity (0.89).

Upper Limb Neural Tension Test (ULNT):
One study (12) evaluated four separate ULNTs. The combined tests had a sensitivity of 0.97 and a specificity of 0.69. A test focused on the ulnar nerve had the highest overall specificity (0.88) whereas the highest sensitivity (0.83) was observed in the test stressing the median nerve.

Shoulder Abduction (Relief) Test (also called ‘Bakody’s Sign’):
In the only included study (n = 13) (10), the authors defined a positive test as a decrease in radicular symptoms when the patient lifted the affected hand above the head and found a moderate sensitivity (0.47) and high specificity (0.85).

Traction Test:
One study (n = 24) (10) defined a positive test as a decrease or disappearance of radicular symptoms when an axial (traction) force was applied and noted a sensitivity of 0.33 and a specificity of 0.97.

Arm Squeeze Test:
One study (13) evaluated a new test based on the premise that, in the presence of cervical nerve root compression, arm nerves would be painful and a moderate compression of the brachial plexus and triceps would increase arm pain more than in other areas of the arm. This test is performed by squeezing the arm (with one hand or two, depending on your size and the size of your patient) just below the deltoid. A positive test is defined as a 3-point increase in pain on a 0-10 scale and noted high sensitivity (0.97) and specificity (0.97) when using the test to differentiate between those with cervical nerve root compression and shoulder pathology (to clarify, if the patient had a shoulder issue, the Arm Squeeze test would be negative, or not painful). It should be noted that this test was proposed for use primarily in older patients, where differentiation of these two conditions can be challenging.

Clinical Application & Conclusions:

The authors were able to review 5 studies evaluating neurological symptoms as a result of diminished nerve conduction and found that no studies were found that assessed diagnostic accuracy of these broadly used assessment tests. Given the lack of individual tests of proven diagnostic value, the authors recommend a strategy of clustering provocative tests, which has been proposed to increase accuracy (14). They suggest that clustering also better reflects clinical decision making and the reality of clinical practice. When combined with history and physical findings, they suggest positive Spurling’s, axial traction and Arm Squeeze tests will increase the likelihood of cervical radiculopathy, while negative ULNTs and Arm Squeeze tests will decrease the likelihood. More research is needed to further develop the most important and appropriate test item cluster.

Study Methods:

A comprehensive search strategy of the CENTRAL, PubMed, Embase, CINAHL, Web of Science and Google Scholar databases was performed. Methodological quality was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2). Data was extracted from eligible studies and diagnostic two-by-two tables (true positive [TP], false positive [FP], true negative [TN], and false negative [FN] index test results, likelihood ratios, and predictive values) were created for each study. Data was meta-analysed using Review Manager 5.3.

Study Strengths / Weaknesses:

  • Comprehensive search strategy
  • Review quality was improved by assessing methodological quality of eligible studies
  • Eligible studies evaluated clinically relevant tests
  • Tests for heterogeneity were used; appropriate use of mixed and random effects models was also used.
  • Only 5 trials were identified as eligible, only 3 of which were able to be pooled in the meta-analysis.

Additional References:

  1. Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain 2009; 147: 17–19.
  2. Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults—an evidence-based approach—part 3: spinal disorders. J Manipulative Physiol Ther 2008; 31: 33–88.
  3. Bono CM, Ghiselli G, Gilbert TJ, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J 2011; 11: 64–72.
  4. Rubinstein SM, Pool JJ, van Tulder MW, Riphagen II, de Vet HC. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J 2007a; 16: 307–19.
  5. Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther 2000; 30: 728–44.
  6. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil 1994; 75: 342–52. doi:10.1016/0003-9993(94) 90040-x.
  7. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl.): S101–22.
  8. Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc 1997; 29(7 Suppl): S236–45.
  9. Shah KC, Rajshekhar V. Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test. Br J Neurosurg 2004; 18: 480–3. doi:10.1080/02688690400012350.
  10. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine 1989; 14: 253–7.
  11. Shabat S, Leitner Y, David R, Folman Y. The correlation between Spurling test and imaging studies in detecting cervical radiculopathy. J Neuroimaging 2012; 22: 375–8. doi:10.1111/j.1552-6569.2011.00644.x.
  12. Apelby-Albrecht M, Andersson L, Kleiva IW, Kvale K, Skillgate E, Josephson A. Concordance of upper limb neurodynamic tests with medical examination and magnetic resonance imaging in patients with cervical radiculopathy: a diagnostic cohort study. J Manipulative Physiol Ther 2013; 36: 626–32. doi:10.1016/j.jmpt.2013.07.007.
  13. Gumina S, Carbone S, Albino P, Gurzi M, Postacchini F. Arm Squeeze Test: a new clinical test to distinguish neck from shoulder pain. Eur Spine J 2013; 22: 1558–63.
  14. Guttmann A, Li X, Feschet F, Gaudart J, Demongeot J, Boire J-Y, et al. Cluster detection tests in spatial epidemiology: a global indicator for performance assessment. PLoS ONE 2015; 10: doi:10.1371/ journal.pone.0130594. e0130594.

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