|Study title: Value of physical tests in diagnosing cervical radiculopathy: a systematic review
Authors: Thoomes EJ, van Geest S., van der Windt DA et al.
Publication Information:The Spine Journal 2018; 18: 179-189
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.
Literature search results and quality:
• Five 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: Three 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 three-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.
Applications and conclusions
The authors were able to review five 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.
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Dr. Shawn Thistle is a practicing chiropractor, educator, international speaker, knowledge-transfer leader, evidence-based health care advocate, entrepreneur & medicolegal consultant. He founded RRS Education in 2006 and currently acts as the company’s CEO. RRS Education helps chiropractors and other manual medicine clinicians around the world integrate research in to patient care via weekly Research Reviews, Online Courses and Seminars. For more information, visit: www.rrseducation.com.