Spurlings test

Spurling’s Test, also known as the Maximal Cervical Compression Test or Foraminal Compression Test, is commonly used in musculoskeletal assessment of the cervical spine to identify possible compression of cervical nerve roots. This may lead to cervical radiculopathy, characterized by radiating pain, paresthesia, or neurological symptoms in the upper extremity¹.

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Technique

There are several ways to perform Spurling’s Test, with variations described in the literature. The most effective version for provoking arm symptoms involves neck extension, lateral flexion, and axial compression².

• The patient sits upright while the examiner stands behind.

• The patient is instructed to extend, rotate, and laterally flex the neck toward the symptomatic side.

• The examiner applies a gentle axial downward force along the cervical spine.

• A positive test is indicated if the patient experiences radiating pain or paresthesia into the arm in a dermatomal pattern, suggesting cervical nerve root compression¹.

Variants of Spurling’s Test

Two main variants are often described:

• Spurling’s Test A: Lateral flexion toward the symptomatic side followed by light axial compression.

• Spurling’s Test B: Extension combined with lateral flexion before axial compression. This version is considered more sensitive for symptom provocation².

Both variants are used in the evaluation of suspected cervical radiculopathy and should be combined with other clinical tests to improve diagnostic accuracy³.

Clinical Significance

A positive Spurling’s Test indicates possible irritation or compression of a cervical nerve root, often caused by:

• Cervical disc herniation

• Foraminal stenosis

• Degenerative changes in the cervical spine²

The test should always be interpreted in conjunction with other assessments, such as the Cervical Distraction Test, Upper Limb Tension Test, and Bakody’s Sign.

If the maneuver produces bilateral symptoms, dizziness, or increased neurological findings, it may point toward more serious conditions such as cervical myelopathy, warranting further investigation¹.

Diagnostic Accuracy

Understanding diagnostic properties is critical when using clinical tests.

• Sensitivity: Earlier studies reported 0.50⁵; newer research shows 0.59 (95% CI 0.46–0.70)⁶. This means a negative test is not reliable for ruling out radiculopathy.

• Specificity: High, with values of 0.88⁵ and 0.84 (95% CI 0.72–0.91)⁶, meaning a positive test strongly indicates the presence of radiculopathy.

• Negative Likelihood Ratio (–LR): Between 0.47⁶ and 0.58⁵ → insufficient to exclude the condition.

• Positive Likelihood Ratio (+LR): Around 3.5⁵ ⁶ → a positive result moderately increases the likelihood of cervical radiculopathy.

Reliability: A kappa value of 0.60 indicates moderate to good inter-rater reliability, suggesting different clinicians often reach similar results⁵.

Clinical Prediction Rule

In 2003, Dr. Robert Wainner and colleagues developed a clinical prediction rule for cervical radiculopathy. They demonstrated that the combination of four tests greatly improves diagnostic accuracy compared with EMG findings⁸:

• Spurling’s Test

• Upper Limb Tension Test (ULTT)

• Cervical Distraction Test

• Cervical Rotation Test

• All four positive → Post-test probability of cervical radiculopathy = 90%

• Three of four positive → Probability decreases to 65%⁷ ⁸

This highlights the importance of using Spurling’s Test as part of a comprehensive assessment rather than as a standalone diagnostic tool.

References

1. Konin JG, Wiksten DL, Isear JA, Brader H. Special Tests for Orthopedic Examination. Thorofare: SLACK Incorporated; 2006.

2. Anekstein Y, Blecher R, Smorgick Y, Mirovsky Y. What is the best way to apply the Spurling test for cervical radiculopathy? Clin.Orthop.Relat.Res. 2012;470(9):2566-2572.

3. Jmunoz85. Advanced Musculoskeletal Exam (pt. 1 of 7). Available from: http://www.youtube.com/watch?v=YwR9EcKN_Jc [last accessed 10/9/2019]

4. Lalkhen A. McCluskey A. Clinical tests: sensitivity and specificity. Contin Educ Anaesth Crit Care Pain. 2008; 8 (6): 221-223.

5. Flynn TW, Cleland JA, Whitman JM. Users' Guide to the Musculoskeletal Examination. Buckner: Evidence in Motion; 2008.

6. Marije L.S. Sleijser-Koehorst, Michel W. Coppieters, Rob Epping, Servan Rooker, Arianne P. Verhagen, Gwendolyne G.M. Scholten-Peeters, Diagnostic accuracy of patient interview items and clinical tests for cervical radiculopathy, Physiotherapy, Volume 111, 2021, Pages 74-82.

7. 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

8. 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: 307-319.