_________________________________________________________________________ Neck Pain in Adults
PROVOCATIVE TESTS: DESCRIPTION AND DIAGNOSTIC USE
Test
Description
Cervical radiculopathy Spurling
Radicular pain reproduced by lateral flexion and rotation to affected side with axial compression of the head Ipsilateral cervical radicular symptoms relieved by placing symptomatic arm on head (abduction) Radicular symptom relief when examiner grasps patient’s head under occiput and chin and applies 10–15 kg of axial traction force Radicular pain reproduced by forced expiratory effort with mouth and nose closed
Shoulder abduction Neck distraction test
Valsalva maneuver Jackson compression
Downward pressure on head with lateral flexion
Upper limb tension test 1 (median nerve bias)
Radicular pain reproduced with scapular depression; shoulder abduction; forearm supination, wrist and finger extension; shoulder external rotation; elbow extension; contralateral followed by ipsilateral cervical lateral flexion Radicular pain reproduced with scapular depression; elbow extension; lateral rotation of the whole arm; wrist, finger, and thumb extension Radicular pain reproduced with scapular depression; elbow extension; medial rotation of the whole arm; wrist, finger, and thumb flexion Radicular pain reproduced with scapular depression; shoulder abduction; shoulder external rotation; wrist and finger extension; elbow flexion; shoulder abduction Radicular pain reproduced with scapular depression; elbow extension; shoulder extension; ulnar deviation of the wrist with thumb flexion. Either medial or lateral rotation of the arm could further sensitize this nerve.
Upper limb tension test 2A (median nerve bias) Upper limb tension test 2B (radial nerve bias) Upper limb tension test 3 (ulnar nerve bias) Upper limb tension test (musculocutaneous) Cervical myelopathy Lhermitte sign Hoffmann sign (also for spinal stenosis)
Electrical-like sensations down spine or arms with passive flexion of neck Reflex contraction of thumb and index finger from nipping of the middle finger
Babinski sign
Stimulation of the foot sole elicits dorsiflexion of hallux, or dorsiflexion and abduction of other toes
Hyper-reflexia
Over-reactive deep tendon reflexes
Clonus
More than two repetitive beats during wrist or ankle dorsiflexion movements
Facet joint pain Paraspinal tenderness
Paraspinal > midline pain with palpation. The only test that identifies facet pain, distinguishes from diskogenic pain, and predicts treatment response.
Source: [2; 29; 49; 51; 56]
Table 3
Cervical spine x-ray is indicated for any significant trauma, pain, or cervical spine-related dysfunction; to rule out fracture; or screen for stenosis in symptomatic patients [16; 41; 59]. Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI) is the imaging study of choice for most cervical spinal abnormalities. MRI can add important information about soft tissue injuries related to bony injuries seen on x-ray or computed tomography (CT) or disk or ligamentous injuries suggested by x-ray, CT, or clinical findings [108]. It can also distinguish hematoma from edema. MRI is highly accurate in identifying disk injury and ligament injuries [19; 109]. It is able to detect ligament disruption and subtle vertebral fracture, but is unreliable in depicting sources
of cervical diskogenic pain because significant annular tears can escape MRI detection [16; 41]. Indications for cervical spine MRI at four to six week follow-up include [22; 41; 47]: • Persistent arm pain, neurologic deficits, or clinical signs of nerve root compression • Cervical radiculopathy signs and symptoms • Cervical disk injuries with any neurologic decline • Failure of axial neck pain to resolve as expected Patients with progressive neurologic deficit should receive MRI without delay.
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MDKY1626
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