THE BACK PAGE RESEARCH REVIEW Diagnosing cervical radiculopathy REVIEWED BY SHAWN THISTLE 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 radi-ating pain into the arm corresponding to a dermatomal pattern. Radiculopa-thy is, by definition, a neurological state characterized by limited or blocked nerve conduction and differ-entiated from radicular pain, wherein the compression can be caused by the cervical disc, degenerative changes or simple inflammation. Diagnosis of ra-diculopathy is based largely on the history and physical examination, which can then be confirmed through diagnostic imaging or even supported by surgical findings. A number of clin-ical tests, including those for deep tendon reflexes, muscle testing, evalu-ations for sensory deficits and provoc-ative orthopedic tests are all utilized to confirm the diagnosis suspected fol-lowing patient history. The specific value and utility of different tests has been evaluated in a number of reviews; however, these reviews either did not critically appraise study quality, were narrative in nature or did not specifi-cally address cervical radiculopathy. The purpose of this review was to up-date the available evidence on the utility of diagnostic tests for evaluating patients with cervical radiculopathy. • 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 Pertinent results of studies was poor to moderate, as all studies had either “high” or “un-clear” 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 using cervical extension + ipsilateral lateral flexion and ipsilateral lateral flexion + rotation both showed moderate sensi-tivity (0.65 and 0.38) and high speci-ficity (1.00 and 0.94). A third study combined cervical extension with ipsi-lateral rotation and demonstrated high sensitivity (0.98) and specificity (0.89). Upper limb neural tension test (ULNT): One study evaluated four separate ULNTs. The combined tests had a sensitivity of 0.97 and a specific-ity 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), the au-thors defined a positive test as a de-crease in radicular symptoms when the patient lifted the affected hand above the head and found a moderate sensi-tivity (0.47) and high specificity (0.85). Traction test: One study (n = 24) defined a positive test as a decrease or disappearance of radicular symptoms when an axial (traction) force was ap-plied and noted a sensitivity of 0.33 and a specificity of 0.97. Arm squeeze test: One study 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 com-pression of the brachial plexus and triceps would increase arm pain more than in other areas of the arm. It’s 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). Applications and conclusions The authors were able to review five studies evaluating neurological symp-toms as a result of diminished nerve conduction and found that no studies were found that assessed diagnostic accuracy of these broadly used assess-ment tests. Given the lack of individual tests of proven diagnostic value, the authors recommend a strategy of clus-tering provocative tests, which has been proposed to increase accuracy. They suggest that clustering also better re-flects clinical decision-making and the reality of clinical practice. When com-bined with history and physical find-ings, 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. For the full research review with references, visit canadianchiropractor.ca/research www.canadianchiropractor.ca SHAWN THISTLE is the CEO of RRS Education, providing weekly research reviews (subscription required), online courses and seminars to help chiropractors integrate current evidence into patient care. For more information, visit rrseducation.com. Shawn can be reached by email at: [email protected]. 30 Canadian Chiropractor September 2018
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