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

Abstract

Background: A diagnosis of cervical radiculopathy is based largely on clinical examination, including provocative testing. The most common maneuver was described in 1944 by Spurling and Scoville. Since then, several modifications of the original maneuver have been proposed to improve its value in the diagnosis of cervical radiculopathy.

Questions/purposes: We assessed the ability of six known variations of the Spurling test to reproduce the complaints of patients diagnosed with cervical radiculopathy.

Methods: We prospectively enrolled 67 patients presenting with cervical radicular-like symptoms and concordant radiographic findings. Each patient underwent six distinct provocative cervical spine maneuvers by two examiners, during which three parameters were recorded: (1) pain intensity (VAS score), (2) paresthesia intensity (0 - no paresthesia, 1 - mild to moderate, and 2 - severe), and (3) characteristic pain distribution (0 - no pain, 1 - neck pain only, 2 - arm pain only, 3 - pain elicited distal to the elbow). The interobserver reliability of the reported VAS score (measured by the intraclass coefficient correlation) ranged from 0.78 to 0.96 and the calculated kappa values of the categorical parameters ranged from 0.58 to 1.0 for paresthesia intensity and from 0.63 to 1.0 for pain distribution. Differences in scores elicited between the two examiners for the 67 patients were resolved by consensus.

Results: A maneuver consisting of extension, lateral bending, and axial compression resulted in the highest VAS score (mean, 7) and was associated with the most distally elicited pain on average (mean, 2.5). The highest paresthesia levels were reported after applying extension, rotation, and axial compression (mean, 1). These maneuvers, however, were the least tolerable, causing discontinuation of the examination on three occasions.

Conclusions: Whenever cervical radiculopathy is suspected our observations suggest the staged provocative maneuvers that should be included in the physical evaluation are extension and lateral bending first, followed by the addition of axial compression in cases with an inconclusive effect.

Fig. 1A–F

Six varieties of the Spurling test are shown, including (A) lateral bending and compression; (B) lateral bending, rotation, and compression; (C) extension and compression; (D) extension and lateral bending; (E) extension, lateral bending, and compression; and (F) extension, rotation, and compression.

Fig. 2

The graph shows the mean elicited VAS scores. The highest average VAS score was reported after extension and lateral bending (Maneuver 4).

Fig. 3

The graph shows the mean elicited paresthesia levels. The level increased (p < 0.001) with the addition of extension to the maneuvers, with the highest level evoked after extension, rotation, and axial compression (Maneuver 6).

Fig. 4

The graph shows the mean elicited pain distribution. Maneuvers that included extension were more likely (p = 0.01) to provoke a radicular-type pain (pain provoked distal to the elbow).

Fig. 5

The diagram shows the mean VAS score in the study group compared with both control groups. The study group reported higher VAS scores (p = 0.004) compared with the group with spondylosis (dotted line) and similar VAS scores (p = 0.09) compared with the group with radiculopathy (dashed line).

Fig. 6

The diagram shows the mean paresthesia level in the study group compared with both control groups. No difference was noted between the study group and either the group with spondylosis (p = 0.85) or the group with radiculopathy (p = 0.13).

Fig. 7

The diagram shows the mean pain distribution in the study group compared with both control groups. The group with spondylosis reported pain which was more often (p < 0.001) proximally located in response to the maneuvers compared with the study group. In patients with radiculopathy, performing the maneuvers in the reverse order provoked similar pain distribution in Maneuvers 5 and 6 (p = 0.33 and p = 0.46, respectively), but more often (p < 0.001) elicited proximally located pain thereafter (for Maneuvers 4 through 1).