Talk:CPR for Cervical Radiculopathy

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The absence of a true gold standard in diagnosing a cervical radiculopathy makes validating test item clusters such as the one proposed by Wainner et al (1) very difficult if not impossible. One has to also take into consideration if the pre-test probability is biased by the target population. Are they patients in a primary care setting? Or have they already been referred on to secondary care facilities and are therefore potentially patients with more aggravated conditions? With regards to the Upper Limb Tension Test proposed in this page: please note that the ULTT is generally considered a screening test due to its relatively high sensitivity (ranging from 0.83-0.97) but very low specificity (ranging from 0.1 -0.2).(1, 2) As a screening test to rule out the possibility of a cervical radiculopathy (CR)(3), the execution should be similar to that of a Straight Leg Raise: a straightforward increasing of tension on the peripheral nerve and thereby the nerve root. A not irritated nerve or nerve root should not produce an adverse response to this, while an adverse response could be due to a number of reasons (e.g. neuromechanosensitivity) and not a CR per se. Also note that differentiating with spinal movements will increase the possibility of a false positive outcome in the diagnosis of a CR, as the diameter of the potentially afflicted foramen will be decreased and thereby produce arm pain.(4) Assessing the presence of less than 60° of cervical rotation of the involved side warrants the use of a reliable and validated measurement, such as an inclinometer or the CROM.(5, 6) Alternatively, it would be useful for the assessor to position himself/ herself more appropriately and have a topside view of the head while perhaps using a goniometer and not mirror the patient’s movements. A more recent systematic review on the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy suggested that, when consistent with the history and other physical findings, a positive Spurling’s, traction/neck distraction and Valsalva’s maneuver might be indicative of a cervical radiculopathy, while a negative ULTT might be used to rule it out. This review also notes that the lack of evidence precludes any firm conclusions regarding their diagnostic value, especially when used in primary care.(3)

References

1. 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 Jan 1;28(1):52-62. PubMed PMID: 12544957.

2. Quintner JL. A study of upper limb pain and paraesthesiae following neck injury in motor vehicle accidents: assessment of the brachial plexus tension test of Elvey. British journal of rheumatology. 1989 Dec;28(6):528-33. PubMed PMID: 2641994.

3. 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. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2007 Mar;16(3):307-19. PubMed PMID: 17013656. Pubmed Central PMCID: 2200707.

4. Coppieters M, Stappaerts K, Janssens K, Jull G. Reliability of detecting 'onset of pain' and 'submaximal pain' during neural provocation testing of the upper quadrant. Physiotherapy research international : the journal for researchers and clinicians in physical therapy. 2002;7(3):146-56. PubMed PMID: 12426912.

5. Youdas JW, Garrett TR, Suman VJ, Bogard CL, Hallman HO, Carey JR. Normal range of motion of the cervical spine: an initial goniometric study. Physical therapy. 1992 Nov;72(11):770-80. PubMed PMID: 1409874.

6. Youdas JW, Carey JR, Garrett TR. Reliability of measurements of cervical spine range of motion--comparison of three methods. Physical therapy. 1991 Feb;71(2):98-104; discussion 5-6. PubMed PMID: 1989013.