Letters to the Editor

Provocative Diagnostic Testing for Cervical Radiculopathy


Am Fam Physician. 2010 Nov 1;82(9):1051.

Original Article: Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms

Issue Date: January 1, 2010

Available at: https://www.aafp.org/afp/2010/0101/p33.html

to the editor: I read with interest Dr. Eubanks' article on nonoperative management of cervical radiculopathy. Because of the discomfort and expense associated with electrophysiologic and diagnostic imaging studies, it is desirable to have an accurate means to identify patients who need further evaluation.

A systematic review of six studies showed that in patients without neurologic deficits, positive results on the Spurling test, neck distraction test, and Valsalva test (each with low-moderate sensitivity and high specificity) are most useful for ruling in cervical radiculopathy, whereas a negative upper limb tension test result (high sensitivity and low specificity) is most useful for ruling it out.1 In a blinded prospective study, positive results on the Spurling test, neck distraction test, and upper limb tension test coupled with a less than 60 degree cervical rotation toward the symptomatic side was associated with a positive likelihood ratio of 30.3 for detection of cervical radiculopathy compared with the reference standard of electromyography.2

In the classic Spurling test, the neck is passively hyperextended and laterally flexed toward the symptomatic side. The test is positive for cervical radiculopathy if axial loading to the top of the patient's head reproduces the characteristic pain and radicular features. A modification of the Spurling test without head compression has also been used. In the modified test, the neck is maximally extended and rotated to the symptomatic side, thus narrowing the neural foramen and possibly reproducing the patient's symptoms. Flexing and rotating the neck to the contralateral side opens the neural foramen and may improve the patient's symptoms.

One study reported that the classic Spurling test had a sensitivity of 50 percent (95% confidence interval [CI], 0.27 to 0.73) and a specificity of 86 percent (95% CI, 0.77 to −0.94). The modified test had a sensitivity of 50 percent (95% CI, 0.27 to 0.73) and a specificity of 74 percent (95% CI, 0.63 to 0.85).2

The neck distraction test is performed with the patient in a supine position. The examiner places one hand under the patient's chin and the other hand around the occiput, while simultaneously lifting the head and gradually applying an axial traction force of up to 10 to 15 kg. The test is positive for cervical radiculopathy if the pain is relieved with distraction force, indicating that pressure on nerve roots has been relieved. The test has been shown to have a sensitivity of 44 percent (95% CI, 0.21 to 0.67) and a specificity of 90 percent (95% CI, 0.82 to 0.98).3

The upper limb tension test is also performed with the patient in a supine position. The examiner places the patient's upper extremity into: (1) scapular depression; (2) shoulder abduction; (3) forearm supination with wrist and finger extension; (4) shoulder external rotation; (5) elbow extension; and (6) contralateral then ipsilateral cervical lateral flexion. The test is positive for cervical radiculopathy with reproduction or increase of symptoms with contralateral cervical side bending, or with a decrease in symptoms with ipsilateral side bending. This test has been shown to have a sensitivity of 97 percent (95% CI, 0.90 to 1.00) and a specificity of 22 percent (95% CI, 0.12 to 0.33).

Author disclosure: Nothing to disclose.


1. 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. 2007;16(3):307–319.

2. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52–62.

3. Takasaki H, Hall T, Jull G, Kaneko S, Iizawa T, Ikemoto Y. The influence of cervical traction, compression, and Spurling test on cervical intervertebral foramen size. Spine. 2009;34(16):1658–1662.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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