Cervical Spine: 5 Key Special Tests for Diagnosis and Safety

What are the 5 special tests for the cervical system?

Special tests for the cervical system are specific physical examination maneuvers designed to help identify the presence of particular pathologies, such as nerve root compression, vascular insufficiency, or ligamentous instability. The five commonly utilized tests include Spurling's Test, the Cervical Distraction Test, the Vertebral Artery Test, the Upper Limb Tension Test, and the Sharp-Purser Test.

Introduction to Cervical Special Tests

The cervical spine, or neck, is a complex region responsible for supporting the head, facilitating a wide range of motion, and protecting critical neurological and vascular structures. When individuals experience neck pain, stiffness, or radiating symptoms into the arms, a thorough assessment is crucial for accurate diagnosis and effective management. Special tests are a critical component of this assessment, serving as targeted maneuvers that either provoke or relieve symptoms, thereby providing valuable insights into the underlying pathology. While these tests are highly informative, they are always performed as part of a comprehensive clinical examination, which includes a detailed patient history, observation, palpation, range of motion assessment, and neurological screening.

1. Spurling's Test (Cervical Compression Test)

Purpose: To assess for cervical radiculopathy, specifically nerve root compression caused by conditions such as disc herniation or foraminal stenosis.

Procedure: The patient is seated or standing. The examiner passively extends, laterally flexes, and rotates the patient's head towards the symptomatic side. Once in this position, the examiner applies a gentle, sustained axial compression force downwards through the top of the patient's head.

Positive Sign: Reproduction or exacerbation of the patient's radicular symptoms (e.g., pain, numbness, tingling) radiating into the ipsilateral arm or hand. Local neck pain alone is not considered a positive sign for radiculopathy.

Clinical Significance: A positive Spurling's Test strongly suggests irritation or compression of a cervical nerve root, often due to a space-occupying lesion like a herniated disc or osteophyte. It is highly specific, meaning if positive, it's likely radiculopathy, but it's not highly sensitive, so a negative test doesn't rule it out.

Caveats/Considerations:

• Should be performed gently and discontinued immediately if severe symptoms occur.
• Contraindicated in cases of suspected cervical instability or acute trauma.

2. Cervical Distraction Test

Purpose: To assess for cervical radiculopathy, particularly to differentiate nerve root compression from other causes of neck pain. It is often used in conjunction with Spurling's Test.

Procedure: The patient is supine. The examiner places one hand under the patient's chin and the other under the occiput (back of the head). A gentle, sustained upward traction (distraction) force is applied, lifting the head slightly off the examination surface.

Positive Sign: Reduction or alleviation of the patient's radicular symptoms (e.g., pain, numbness, tingling) radiating into the arm or hand. Local neck pain relief may also be noted.

Clinical Significance: Relief of symptoms with distraction suggests that the nerve root compression is being reduced, often due to decreased pressure on the nerve from a disc bulge, stenosis, or muscle spasm. It indicates a favorable response to traction-based interventions.

Caveats/Considerations:

• The amount of force applied should be gentle and comfortable for the patient.
• Lack of symptom relief does not rule out radiculopathy but suggests the source may not be alleviated by distraction.

3. Vertebral Artery Test (Vascular Insufficiency Test)

Purpose: To screen for vertebrobasilar insufficiency (VBI), which is a compromise of blood flow through the vertebral and basilar arteries that supply the brainstem and cerebellum. This test is crucial for patient safety before performing cervical manipulation or certain range of motion exercises.

Procedure: The patient is supine. The examiner passively extends the patient's head and holds it for 10-30 seconds, observing for symptoms. Then, the head is passively rotated to one side and held for 10-30 seconds, followed by rotation to the other side. Some variations also include slight extension with rotation. Throughout the test, the patient's eyes are open, and they may be asked to count or answer questions to assess neurological function.

Positive Sign: Reproduction of symptoms indicative of VBI, such as:

• Dizziness, vertigo, nausea, nystagmus (involuntary eye movements)
• Diplopia (double vision), dysphagia (difficulty swallowing), dysarthria (slurred speech)
• Ataxia (lack of coordination), drop attacks (sudden falls without loss of consciousness)
• Perioral numbness (numbness around the mouth)

Clinical Significance: A positive test indicates a potential compromise of the vertebral artery, suggesting that certain neck movements could restrict blood flow to the brain, posing a significant safety risk. Further medical evaluation is warranted.

Caveats/Considerations:

• This test has variable sensitivity and specificity, and a negative test does not definitively rule out VBI.
• It should be performed cautiously, and immediate cessation is required if any symptoms develop.
• It is vital to screen for risk factors for VBI prior to performing this test (e.g., atherosclerosis, hypertension, diabetes, previous stroke).

4. Upper Limb Tension Test (ULTT) / Brachial Plexus Tension Test

Purpose: To assess for neural tension or irritation of the peripheral nerves of the brachial plexus (median, ulnar, radial nerves) and/or nerve roots, often associated with cervical radiculopathy or peripheral nerve entrapment. There are several variations (ULTT1-4) targeting different nerves. ULTT1 (Median Nerve bias) is the most common.

Procedure (ULTT1 - Median Nerve Bias): The patient is supine. The examiner guides the patient's arm through a sequence of movements:

1. Shoulder depression
2. Shoulder abduction (110 degrees)
3. Elbow extension
4. Forearm supination
5. Wrist and finger extension The patient may also be asked to laterally flex their neck away from the tested arm (sensitizing maneuver).

Positive Sign:

• Reproduction of the patient's neurological symptoms (pain, numbness, tingling) in the distribution of the tested nerve.
• Greater than 10 degrees difference in elbow extension range of motion compared to the unaffected side.
• Symptoms are altered (increased or decreased) with the sensitizing maneuver (neck lateral flexion).

Clinical Significance: A positive ULTT indicates abnormal mechanosensitivity of the neural tissue, suggesting nerve root irritation, peripheral nerve entrapment, or adhesion. It can help identify the specific nerve involved.

Caveats/Considerations:

• Requires careful control of joint angles and sequential movements.
• Symptoms should be distinguished from muscular or joint pain.
• Pain in the cubital fossa (elbow pit) is common and may not be a positive neural sign unless accompanied by other neurological symptoms.

5. Sharp-Purser Test

Purpose: To assess the integrity of the transverse ligament and stability of the atlantoaxial joint (C1-C2). This test is crucial for ruling out atlantoaxial instability, a potentially dangerous condition where the atlas (C1) can sublux anteriorly on the axis (C2), risking spinal cord compression.

Procedure: The patient is seated or supine. The examiner places one hand on the patient's forehead to stabilize the head and the other hand on the spinous process of the axis (C2). The patient is asked to gently flex their head forward (slight cervical flexion). The examiner then applies a posterior translational force through the forehead, attempting to slide the atlas (C1) posteriorly on the axis (C2).

Positive Sign:

• A "clunk" or "clunking" sensation felt by the examiner as the atlas reduces posteriorly.
• A reduction or relief of the patient's neurological symptoms (e.g., paresthesia, dizziness) during the posterior translation, followed by a re-occurrence of symptoms upon releasing the pressure.
• Excessive posterior translation without a clear end-feel.

Clinical Significance: A positive Sharp-Purser Test strongly suggests atlantoaxial instability due to a compromised transverse ligament. This is a medical emergency requiring immediate referral for imaging and neurosurgical consultation, as it indicates a risk of spinal cord injury.

Caveats/Considerations:

• This test should be performed with extreme caution, especially if there is a history of trauma, inflammatory arthritis (e.g., rheumatoid arthritis), or congenital anomalies.
• Any positive finding necessitates immediate medical referral.

Important Considerations for Special Tests

While special tests are invaluable diagnostic tools, it is crucial to understand their limitations:

• Not Definitive: No single special test is 100% accurate in diagnosing a condition. They are indicators that contribute to the overall clinical picture.
• Context is Key: Tests must be interpreted within the context of the patient's history, other physical examination findings, and clinical reasoning.
• Sensitivity and Specificity: Understand that tests have varying levels of sensitivity (ability to correctly identify those with the disease) and specificity (ability to correctly identify those without the disease).
• Clinical Judgment: An experienced clinician uses these tests as part of a comprehensive assessment, not in isolation. When in doubt, further diagnostic imaging or specialist consultation may be warranted.

Conclusion

The five special tests—Spurling's Test, the Cervical Distraction Test, the Vertebral Artery Test, the Upper Limb Tension Test, and the Sharp-Purser Test—provide a foundational toolkit for assessing various pathologies of the cervical spine. From identifying nerve root compression to screening for potentially life-threatening vascular or instability issues, these maneuvers offer critical insights for fitness professionals, personal trainers, and student kinesiologists seeking to understand and address client concerns. Always remember that these tests are components of a holistic assessment, guiding informed decision-making for safe and effective exercise programming and referral when necessary.