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.

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

How do you do 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 does a positive Spurling Test mean?

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.

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.

• Sensitivity: 30 %
• Specificity: 93 %

Shah and Rajshekhar studied the reliability of Spurling’s 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 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’s 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.

Cervical Spine Distraction Test

Cervical Spine Distraction Test is the opposite of spurling test. It helps to determine whether pain in the back of the neck, shoulder, and arm is radicular in origin or is due to ligamentous or muscular causes

While the patient is seated. The examiner grasps the patient’s head about the jaw and the back of the head and applies superior axial traction.

Distraction of the cervical spine reduces the load on the intervertebral disks and exiting nerve roots within the affected levels or segments while producing a gliding motion in the facet joints. Reduction of radicular symptoms, even in passive rotation, when the cervical spine is distracted is a sign of discogenic nerve root irritation. Increased pain during distraction and rotation suggests a functional impairment in the cervical spine due to muscular or ligamentous pathology or articular, possibly degenerative processes.

The Cervical Spine Distraction Test has a Sensitivity of 44 % and a Specificity of 97 %.

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 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 Level	Nerve Root	Motor Deficit	Sensory Deficit	Reflex Compromise
C4-C5	C5	Deltoid Muscle Biceps Muscle	Anterolateral shoulder and arm	Biceps Muscle
C5-C6	C6	Wrist extensors Biceps Muscle	Lateral forearm and hand Thumb	Brachoradialis Muscle Pronator teres Muscle
C6-C7	C7	Wrist flexors Muscle Triceps Muscle Finger extensors Muscle	Middle finger	Triceps Muscle
C7-T1	C8	Finger flexors Muscle Hand intrinsic Muscles	Medial forearm and hand and ring and little fingers	None
T1-T2	T1	Hand intrinsic Muscles	Medial forearm	None

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

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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.
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.
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