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A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy

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Abstract

Clinical provocative tests of the neck, which position the neck and arm inorder to aggravate or relieve arm symptoms, are commonly used in clinical practice in patients with a suspected cervical radiculopathy. Their diagnostic accuracy, however, has never been examined in a systematic review. A comprehensive search was conducted in order to identify all possible studies fulfilling the inclusion criteria. A study was included if: (1) any provocative test of the neck for diagnosing cervical radiculopathy was identified; (2) any reference standard was used; (3) sensitivity and specificity were reported or could be (re-)calculated; and, (4) the publication was a full report. Two reviewers independently selected studies, and assessed methodological quality. Only six studies met the inclusion criteria, which evaluated five provocative tests. In general, Spurling’s test demonstrated low to moderate sensitivity and high specificity, as did traction/neck distraction, and Valsalva’s maneuver. The upper limb tension test (ULTT) demonstrated high sensitivity and low specificity, while the shoulder abduction test demonstrated low to moderate sensitivity and moderate to high specificity. Common methodological flaws included lack of an optimal reference standard, disease progression bias, spectrum bias, and review bias. Limitations include few primary studies, substantial heterogeneity, and numerous methodological flaws among the studies; therefore, a meta-analysis was not conducted. This review suggests that, when consistent with the history and other physical findings, a positive Spurling’s, traction/neck distraction, and Valsalva’s might be indicative of a cervical radiculopathy, while a negative ULTT might be used to rule it out. However, the lack of evidence precludes any firm conclusions regarding their diagnostic value, especially when used in primary care. More high quality studies are necessary in order to resolve this issue.

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Acknowledgments

The principal author Sidney M. Rubinstein would like to thank Dr. Scott Haldeman and Dr. Tammy de Koekkoek for their valuable contributions during the preparation of this manuscript. This study has been funded, in part, by The Netherlands Chiropractic Association and The Netherlands Association for Manual Therapists.

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Correspondence to Sidney M. Rubinstein.

Appendices

Appendix 1

Search strategy used to identify studies on diagnostic accuracy of provocative tests for cervical radiculopathy.

Medion Database

Search conducted on: June 7, 2005

radiculopath* OR radiculit* OR monoradiculopath* OR polyradiculopath* OR cervical OR neck > No reviews were identified.

Dare

Search conducted on: June 7, 2005

  1. 1.

    radiculopath* OR radiculit* OR monoradiculopath* OR polyradiculopath*

  2. 2.

    (cervical OR cervico* OR neck) AND (root* OR radical) AND (nerve* OR spine OR spinal OR vertebr*)

>No reviews were identified.

Ostmed

Search conducted on: June 7, 2005

  1. 1.

    radiculopath* OR radiculit* OR monoradiculopath* OR polyradiculopath*

  2. 2.

    (cervical OR cervico* OR neck) AND (root* OR radical) AND (nerve* OR spine OR spinal OR vertebr*) AND (pain* OR complain* OR compression*) AND (diagnos* OR test* OR screen* OR examinat*)

Five studies were originally identified for possible inclusion, but were found not to meet the inclusion criteria:

  1. 1.

    Gifford L (2001) Acute low cervical nerve root conditions: symptom presentations and pathobiological reasoning. J Osteopath Med 4(2):69

  2. 2.

    Gifford L (2001) Acute low cervical nerve root conditions: symptom presentations and pathobiological reasoning. Man Ther 6(2):106–115

  3. 3.

    Biondi DM Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J Am Osteopath Assoc 100(Suppl 9):S7–S14; quiz S27

  4. 4.

    Stoll ST, Caffrey JL, and Wright TJ (1999) Dermatomal somatosensory evoked potentials: evaluation of manipulative medicine in the treatment of cervical and lumbar radicular symptoms. J Am Osteopath Assoc 99(8):428

  5. 5.

    Gunn CC and Milbrandt WE (1977) Tenderness at motor points: an aid in the diagnosis of pain in the shoulder referred from the cervical spine. J Am Osteopath Assoc 77(3):196–212; quiz 179–180

Cinahl

Search conducted on: June 7, 2005

1982-May, week 4 2005

109 hits > after eliminating duplicates also found in Embase.com, there remained 66 references over.

Embase.com (Medline and Embase combined) search

Search conducted on: April 6, 2005

#1

(Radiculopath* OR Radiculopathy/exp OR radiculit* OR ((spinal-root OR Spinal-root/exp OR nerve-root OR nerve-roots OR radicular OR brachial-plexus) AND (pain* OR complain* OR nerve-root-compression/exp)) OR monoradiculopath* OR polyradiculopath*) AND (cervical OR cervico* OR Cervical-spine/de OR neck OR Neck/exp OR Neck-pain/de OR Neck-injury/exp)

#2

(Tension OR abduction OR reflex OR compression OR traction OR retraction OR depression OR distraction OR elvey* OR spurling* OR orthopedic OR orthopaedic) AND test*

#3

Clinical-examination OR clinical-test OR clinical-tests OR neurologic-examination OR neurologic-examination/de OR Physical-examination/exp OR (physical AND examin*) OR Exercise-test/de

#1 AND (#2 OR #3) > Result 366 hits (311 references were found in Embase only)

PubMed search limited to MEDLINE:

Search conducted on: June 8, 2005

#1

(Radiculopath* OR Polyradiculopathy[mesh] OR radiculit* OR ((spinal root OR Spinal nerve roots[mesh] OR nerve root OR nerve roots OR radicular OR brachial plexus) AND (pain* OR complain* OR nerve compression syndromes[mesh])) OR monoradiculopath* OR polyradiculopath*) AND (cervical OR cervico* OR Cervical vertebrae[mesh] OR neck OR Neck[mesh] OR Neck pain[mesh] OR Neck injuries[mesh] OR Cervical plexus[mesh])

#2

(Tension OR abduction OR reflex OR compression OR traction OR retraction OR depression OR distraction OR elvey* OR spurling* OR orthopedic OR orthopaedic) AND (test OR tests OR tested OR testing)

#3

Clinical examination* OR clinical test OR clinical tests OR neurologic examination* OR Physical examination[mesh] OR (physical AND examin*) OR Diagnostic tests, routine[mesh] OR Exercise-test[mesh]

#1 AND (#2 OR #3) NOT (animals[mesh] NOT humans[mesh]) result 413 hits > after eliminating duplicates from Embase.com en Cinahl: 218 references remaining.

Note: In some cases it would appear that capital and small letters are randomly listed in the search profile, above. Capital letters are official keywords generated in Embase.com; however, this does not have any consequences for the search because the search engines are not sensitive to letter size. In some cases, words are connected to one another by lines (i.e. “-”) in order to indicate that the entire phrase should be located, and not just separate terms. Also it is important to note the difference between “/exp” and “/de”: /exp searches for other terms ‘coupled’ on the given term (i.e. not just the key word listed, but other terms using that key word), while /de searches only the key word used (i.e. the specific keyword). “Exp” is an abbreviation for ‘explode’, while “de” means ‘descriptor’.

Appendix 2

Explanation of items and operationalization of terms used in this review.

General

Diagnostic test or index test = the test under examination.

Reference standard = gold standard (i.e. the test performed for which the diagnostic/index test is to be compared).

Criteria number. Definition of terms

  1. 1.

    Positive if the spectrum of patients included in the study was representative of those for whom the test will be used in primary care/clinical practice. Subjects must have the following characteristics:

    1. a.

      Neck- and radiating pain in an upper extremity.

    2. b.

      Diagnosis was not yet known.

    3. c.

      Possible confounders, such as gender and age were reported. This item was scored negative if subjects were recruited from the neurologist, orthopaedist, or a electrophysiology laboratory.

  2. 2.

    Positive if the selection criteria were clear, including for example, the time period of recruitment, whether subjects were consecutively recruited, and age of the subjects.

  3. 3.

    Positive if both electrodiagnostic testing and advanced imaging (e.g. MRI) were used as the reference standard.

  4. 4.

    Positive if the delay between the application of the index test and reference standard was not more than 7 days.

  5. 5.

    Positive if it was clear that all subjects or a random selection of subjects received verification of their disease status, regardless of the index test results. Also known as “work-up bias”.

  6. 6–7.

    Positive if the study includes sufficient details which permit replication of the index test and reference standard.

  7. 8–9.

    Positive if the results of the index test were interpreted without knowledge of the results of the reference standard, and vice versa. Also known as review bias when clinicians are not “blinded” to the results of either the index test or reference standard.

  8. 10.

    Positive if clinical data (e.g. clinical presentation, symptoms, severity, etc) were also available to the clinician in order to interpret the results of the index test. Since clinical data will also be available to the clinician in the practice, the clinical picture should also be available to clinicians in the study.

  9. 11.

    Positive if all test results, including uninterpretable/intermediate/equivocal test results were included. This item was scored as a “?” in those studies where no equivocal results were reported.

  10. 12.

    Positive if it is clear what happened to all subjects who entered the study. Results are biased if subjects dropped-out systematically. This item was scored negative when some of the subjects did not receive both the index test and reference standard, and these subjects were not described anywhere in the text.

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Rubinstein, S.M., Pool, J.J.M., van Tulder, M.W. et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J 16, 307–319 (2007). https://doi.org/10.1007/s00586-006-0225-6

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