● Upper limb tension test. ● Spurling’s test. ● Distraction test.
plies compression force downward from the top of the head. The purpose of this test is to constrict the patency of the neural fora - men, thus increasing compression on the nerve root. The test is considered positive if the client’s symptoms are reproduced (Flynn et al., 2016). The shoulder abduction test has been shown via electrodiagnos- tic testing to have specificity that is like the Spurling test. For this test, the client could be sitting or lying supine. The assessor puts the palm of the affected arm on top of the patient’s head. If radic- ular symptoms are relieved, this is a positive result. The suggested mechanism for reduction of pain is that this position relieves me - chanical traction to the nerve. The upper limb tension test is the most sensitive for ruling out cervical radiculopathy. For this test, the patient is supine and the examiner performs the following movements with the ipsilateral upper extremity: Begin with scapular depression and then, with the shoulder in 90 degrees abduction and external rotation and with the elbow flexed, put the forearm in supination and the wrist and fingers in extension. Now extend the elbow while side bend- ing the head toward and away from the arm. A positive test oc- curs when one or more of the following occurs: Symptoms are reproduced, there is a side-to-side difference in elbow extension greater than 10 degrees, and/or contralateral side bend of the neck increases symptoms while ipsilateral side bend of the neck decreases them. Flynn et al. (2016) list a cluster of tests that can be used to diagno- sis cervical radiculopathy. When three of these four tests are posi - tive, the likelihood ratio for the presence of cervical radiculopathy is 6.1. When four of them are positive, the likelihood ratio goes up to 30.3. This cluster of test items includes: Cervical myelopathy Cervical myelopathy is a spinal cord dysfunction that occurs when the spinal cord is compressed by narrowing of the spinal canal (McCartney et al., 2018). This condition was referred to as cervi - cal spondylotic myelopathy (CSM) in the past but is now called degenerative cervical myelopathy (DCM). Typically, the cause is a combination of congenital stenosis (narrowing) of the spinal canal, disc herniation, and spondylosis (McCartney et al., 2018). Dynamic factors that influence the onset of myelopathy include repetitive flexion and extension of the cervical spine, which causes spinal cord irritation and compression (Milligan et al., 2019). Flex- ion can cause compression of the spinal cord against anterior os- teophytes and intervertebral discs, while end range extension can lead to spinal cord pinching between the posterior margins of the vertebral body anteriorly and the hypertrophied buckled ligamen- tum flavum posteriorly (Milligan et al., 2019). The most obvious risk factor for degenerative cervical myelopathy is age, given that the development process for this condition is age dependent. Males are more affected than females. A narrow spinal canal has been shown to be a risk factor, as has a history of trauma to the neck. Genetic risk factors also exist (Nouri et al., 2022). Nouri et al. (2020) consider disc changes as the initial step in the onset of cervical myelopathy. With age, the disc becomes less compliant, resulting in increased stresses to the vertebral end- plates. As a result, bone remodeling creates osteophytes and changes in the structure of the vertebrae. These processes lead to a loss of disc and vertebral height, resulting in the infolding of the ligamentum flavum, which may also undergo resultant hyper- trophy and ossification. Ossification and hypertrophy of the pos- terior longitudinal ligament is also common (Gibson et al., 2018). These changes can occur at a single or multiple levels (Nouri et al., 2020). Continuous compression of the spinal cord leads to initiation of an inflammatory reaction and vascular changes, which may result in ischemia and loss of neuronal cells (Manko et al., 2022). Chronic cord compression can lead to neuronal cell loss, degeneration of the posterior columns and anterior horn cells, and endothelial damage that results in a compromised blood–spi- nal cord barrier (Milligan et al., 2019).
● Cervical rotation less than 60 degrees to the ipsilateral side. The distraction test is performed by putting the patient supine with the examiner sitting at their head. While grasping under the chin with one hand and the occiput with the other hand, the pa - tient’s neck is flexed slightly and a distraction force of approxi- mately 14 pounds is applied. This test is positive if it reduces the client’s symptoms. Self-Assessment Quiz Question #38 The levels of the cervical spine most often involved in cervical radiculopathy are:
a. C6 and C7. b. C5 and C6. c. C4 and C5. d. C3 and C4.
Self-Assessment Quiz Question #39 Which special test is highly sensitive and highly specific for di- agnosing cervical radiculopathy as confirmed by magnetic reso- nance imaging and electrodiagnostic findings? a. Cervical side bend less than 30 degrees to the ipsilateral side.
b. Shoulder abduction test. c. Upper limb tension test. d. Spurling test.
Often the onset of this condition is insidious, leading to upper and lower motor and sensory changes of the arms and legs (Mc- Cartney et al., 2018). Cervical myelopathy is progressive and can lead to paralysis (Yanez Touzet et al., 2022). This condition affects up to 2% of adults (Manko et al., 2022). Most patients with cervical myelopathy are diagnosed in their 50s; this condition is consid- ered uncommon before the age of 40 (Davies et al., 2018). Evidence-based practice: Special tests are an impor - tant part of differential diagnosis when the assessing clinician suspects cervical radiculopathy. When testing for weakness that corresponds to myotomes, motor examination may or may not show a grade of muscle weakness that corresponds to the involved nerve. Fur- thermore, no myotomes correspond to the upper cervi - cal nerves (Cervical Radiculopathy, n.d.). When assess- ing dermatomes, the assessing clinician should know that they can vary from individual to individual and that overlap is common (Seladi-Schulman, 2019). Special tests add significant clarity to differential diagnosis for cervical radiculopathy. Flynn describes a cluster of four special tests for determining the presence of cervical radiculopathy. These include the upper limb tension test, Spurling’s test, the distraction test, and cervical ro- tation that is less than 60 degrees on the same side as the neck pain. When three of these four tests are posi- tive, there is a 65% chance that cervical radiculopathy is present. When all four are positive, the chances go up to 90% (Cervical Radiculopathy, n.d.).
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