Spurling Test Overview

Spurling test is performed if, in the history, the patient has complained of nerve root symptoms, which at the time of examination are diminished or absent. It’s also called Foraminal compression test.

It 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.

Spurling Test was originally named as Spurling’s neck compression test in 1944 by Roy Glenwood Spurling (1894 – 1968) and William Beecher Scoville (1906 – 1984) who were American neurosurgeons. The test has also been referred to as the Foraminal Compression Test, Neck Compression Test, or Quadrant Test.

How do you perform the Spurling’s test?

Spurling’s test is performed in seated position. The patient flexes the head and tilts it laterally, first to the unaffected side and then to the affected side. The examiner stands behind the patient with one hand on the patient’s head. With the other hand, the examiner lightly taps (compresses) the hand resting on the patient’s head applying a downward axial force (classically ~7 kg), thus narrowing the space for cervical nerve roots to exit the spinal cord.

If the patient tolerates this initial step of the test, Spurling Test is then repeated with the cervical spine extended as well.

See Also: Shoulder Abduction Test (Bakody Test)

What is a positive Spurling test?

The Spurling test is considered positive if pain radiates into the limb ipsilateral to the side at which the head is rotated.

• Simultaneous extension of the cervical spine narrows the intervertebral foramina by 20 to 30%.
• In conditions such as cervical stenosis, spondylosis, osteophytes, trophic facet joints, or herniated disks, the foramina may already be smaller than normal.
• The test is not considered to be positive if there is neck pain only, without radiation into the shoulder or arm. Only the pain that is radiating to the arm specific to a certain dermatome suggests nerve root irritation.
• Pain that is already present will be increased by this movement.
• Myalgia and whiplash syndrome can cause pain on the opposite side. This is called a reverse Spurling sign and suggests pain on the side of muscles that have been stretched from muscle strain or functional disturbance with muscle foreshortening.

If the pain is felt in the opposite side to which the head is taken, it is called a reverse Spurling sign and is indicative of muscle spasm in conditions such as tension myalgia and WADs.

Sensitivity & Specificity

The Spurling test sensitivity is low, but it has high specificity ¹ for cervical radiculopathy diagnosed by electromyography:

• Sensitivity: 30 %
• Specificity: 93 %

Because it has low sensitivity, it is not useful as a screening test, but it is clinically useful in helping to confirm a cervical radiculopathy. It is best used combined with other specialized examination tests (some of which are mentioned below) to increase overall screening sensitivity, and should always be accompanied by thorough patient history

Shah and Rajshekhar studied the reliability of Spurling test in the diagnosis of cervical disc disease with the reference standard of magnetic resonance imaging (MRI) in 25 patients who were treated nonoperatively and direct visualization at surgery in 25 patients who were treated operatively. The test was performed by extending and laterally bending the neck and then applying an axial load to the top of the head. The investigators did not rotate the head prior to application of an axial load. The sensitivity and specificity of Spurling’s test was found to range between 0.90 and 1.00, depending on whether MRI or surgery was used as the reference standard.

In contrast, Wainner et al. performed the same test; however, they also rotated the head towards the ipsilateral side before applying an axial load. In that study, they used electromyography (EMG) as the reference standard. The investigators calculated a sensitivity of 0.50 and a specificity of 0.93 for this version of Spurling’s test.

In addition, Tong et al. calculated an even lower sensitivity (0.30) when rotating the neck towards the contralateral shoulder. Combining the results of these three studies, it appears that lateral rotation of the neck decreases the sensitivity of the Spurling test for the detection of cervical radiculopathy. This rationale is supported by Anekstein et al. who found the greatest sensitivity with the combination of lateral bending and extension without rotation. Thus, we prefer to perform the Spurling test in neutral rotation to improve diagnostic efficacy.

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.

Modified Spurling Test stages:

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:

• Nonradicular or pseudoradicular pain includes pain that radiates to the occiput, the scapula, or the shoulders, or occasionally down the arm but not distal to the elbow. Such pseudoradicular pain may be the result of a mechanical or degenerative process in the cervical spine such as spondylolisthesis or degenerative disk disease without nerve root compression.
• Radicular pain radiates into the upper extremity, usually below the elbow, along the distribution of a specific dermatome.

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 be avoided in patients suspected of having cervical instability, such as those with cervical spondylotic myelopathy, infectious process, or malignancy (most commonly metastatic). It should also not be performed in an acute trauma setting.

A very similar test is called the maximum cervical compression test . With this test, the patient side flexes the head and then rotates it to the same side. The test is repeated to the other side. A positive test is indicated if pain radiates into the arm. If the head is taken into extension (as well as side flexion and rotation) and compression is applied, the intervertebral foramina close maximally to the side of movement and symptoms are accentuated.

Pain on the concave side indicates nerve root or facet joint pathology, whereas pain on the convex side indicates muscle strain. This second position may also compress the vertebral artery. If one is testing the vertebral artery, the position should be held for 20 to 30 seconds to elicit symptoms (e.g., dizziness, nystagmus, feeling faint, nausea) that would indicate compression of the vertebral artery.

See Also: Myotomes of the Upper Limb

Reference

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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.
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