Air Neck Traction

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provocative tests for cervical radiculopathy

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Provocative Tests for Cervical Radiculopathy

Cervical radiculopathy is a disorder of the cervical spinal nerve root and most commonly is caused by degenerative changes, cervical disc herniation or other space-occupying lesion, resulting in nerve root inflammation, impingement, or both.

Daffner et al. showed that combined neck and arm pain were much more disabling than either symptom alone. As symptom duration increases, a negative impact on mental health is observed, suggesting that patients with a significant component of axial neck pain in conjunction with cervical radiculopathy should be considered the most affected of all patients with cervical spondylosis or degenerative changes. This study suggests that prompt treatment of these patients may help avoid the harmful effects of chronic symptoms on mental functioning.

Historically, nerve root compression was indicated by abnormal muscle strength, deep tendon reflexes or dermatomal sensation. However, many patients are neurologically intact yet present with cervical radiculopathy symptoms due to inflammatory irritation of the nerve root.

Diagnostic imaging and electrophysiologic studies are most commonly used to establish a diagnosis of cervical radiculopathy. These tests are considered to be the most accurate means of diagnosis available, however, due to the expense and discomfort associated with these studies, it is useful to establish some reliable clinical examination findings for a diagnosis of cervical radiculopathy.

Initially, history should focus on the mechanism of injury (if any) and on symptoms. Any prior neck trauma or symptoms should be noted. There are a number of red flags for potentially serious conditions requiring prompt diagnosis and management. Morning stiffness that improves over the course of the day is sometimes indicative of rheumatic causes. Fever, weight loss, night sweats, and other systemic symptoms are indicative of infection or neoplasm. Unremitting night pain, especially in the context of a prior history of malignancy, may be secondary to a bony tumor. Gait disturbance, balance problems, sphincter dysfunction, or loss of coordination suggests myelopathy. Patients should be carefully questioned about past treatment successes and failures.

Several special maneuvers can be helpful for investigating radiculopathy or pain of radicular origin:

Wainner et al. defined a group of clinical exam tests that could identify with 90% probability the likelihood of the presence of cervical radiculopathy. The tests shown to be most useful for indicating cervical radiculopathy were the upper limb tension test, ipsilateral cervical rotation less than 60 degrees, neck distraction test and Spurling test.

Rubinstein et al. completed a systematic review of the diagnostic accuracy of physical exam tests for cervical radiculopathy. It was concluded that Spurling, neck distraction, Valsalva and upper limb tension tests are most useful in establishing a diagnosis of cervical radiculopathy in patients without neurological deficits.

During provocative testing, it is recommended that the examiner repeatedly question patients regarding the symptoms throughout the test in an open-ended fashion (i.e., “Does that change your symptoms in any way?”).

1) Axial loading

Axial loading of the neck can take different forms. The most well known is Spurling maneuver or test, as originally described by Spurling and Scoville in 1944, where the patient laterally flexes and extends the neck, after which the examiner applies axial pressure on the spine. The results from the Spurling test were scored as positive if it caused pain or tingling that started in the shoulder and radiated distally to the elbow. Specifically, a positive test should reproduce the patient's symptoms; may also indicate facet syndrome.

Spurling and Scoville described “the neck compression test” as follows. “Tilting the head and neck toward the painful side may be sufficient to reproduce the characteristic pain and radicular features of the lesion. Pressure on the top of the head in this position may greatly intensify the symptoms. Tilting the head away from the lesion usually gives relief."

Spurling Test For Cervical RadiculopathySome clinical restraint in applying axial pressure to the cervical spine may be advised because this may exacerbate cervical radiculopathy if it is present. Therefore, the test may be "modified" to be performed without axial pressure. By maximally extending and rotating the neck toward the involved side, the neuroforamen are narrowed and may reproduce the patient’s symptoms. Improvement or relief of symptoms may occur when the patient then flexes and rotates the neck to the opposite side, as this opens up the neuroforamen.

When positive, this test is particularly useful in differentiating cervical radiculopathy from other etiologies of upper extremity pain, such as peripheral nerve entrapment disorders, because the maneuver stresses only the structures within the cervical spine. According to a study by Tong et al. the sensitivity of the Spurling test for cervical radiculopathy is 30%, however, the specificity of the Spurling test for cervical radiculopathy is 93%. It was concluded the Spurling test can be used to help confirm a cervical radiculopathy.

There are different variations of the test including Jackson’s neck compression test in which the neck is flexed laterally then compressed, a neck compression test in which the neck is only rotated then compressed, and a modified version of the Spurling test, as described previous, in which no axial compressive force is applied. Common names for this test are Spurling’s Neck Compression Test, the Foraminal Compression Test, Neck Compression Test, or Quadrant Test.

Takasaki et al noted a reduction in foraminal cross sectional area to approximately 70% of control using the spurling test with 15.4 pounds of axial compressive force as indicated by mri studies.

2) Shoulder Abduction

Shoulder Abduction Relief SignWhile sitting, the patient is instructed to place the hand of the affected extremity on the head in order to support the extremity in the scapular plane. A positive response is alleviation of patient symptoms.

Davidson et al. described the shoulder abduction relief as a sensory sign (or symptom) associated with a high incidence of soft disc protrusion, indicating the sensory root or ganglion is directly lifted cephalad or pulled lateral to the offending extradural compressive lesion by the maneuver. In the study, 68% of patients with radicular signs and symptoms noted relief with shoulder abduction. A positive test was noted with motor weakness, radicular paresthesias, lateral extradural lesions and a good response to surgical treatment.

The shoulder abduction relief sign, or sometimes noted as Bakody's sign, takes stretch off of the affected nerve root and may decrease or relieve radicular symptoms. Significant relief of pressure was noted by Farmer et al. by taking measurements using a pressure transducer and monitor inserted in the neural foramen in cadavers and abducting the shoulder.

A possible mechanism for this finding is a decrease in the tractional forces placed on the brachial plexus by a shortening of the distance between the coracoid and transverse process of C5. Another possible mechanism is lifting of the dorsal root ganglion cephalad from an extradural compression lesion.

Cox relates the shoulder abduction as creating or relieving arm pain depending on whether the nerve is compressed medially or laterally by a cervical disc herniation. He further details how a medial disc will compress the nerve root and is relieved as the nerve is lifted from the disc by arm abduction. Cox further indicates that the pain is made worse when the arm hangs or is tractioned downward. A lateral disc is relieved when the arm hangs and is worse under abduction of the arm. Dr. Cox further explains (personal communication) the illustration shows a medial posture of the disc in relation to the nerve root. Few discussed medial and lateral discs concerning lumbar spine sciatic scoliosis due to medial and lateral contact of the nerve root. We know in lumbar spine that the list is away from the lateral and into in the medial disc protrusion or prolapse. Based on Davidson's Figure, coupled with the lumbar list of medial and lateral, it is my finding that medial discs are the ones relieved with Bakody sign.

Another possible explanation for increased pain on shoulder abduction is thoracic outlet syndrome. The shoulder abduction relief sign is more likely to be present w/ soft disc herniation, whereas, the test is likely to be negative with radiculopathy caused by spondylosis.

According to Fast et al. Relief of pain, induced by arm abduction, may be observed in cervical radiculopathy in which the lower cervical roots are involved. Reduced tension at the nerve root is the probable underlying mechanism that leads to pain relief. Shoulder abduction can be used not only as a diagnostic sign but also may be incorporated in the conservative management of patients suffering from cervical radiculopathy affecting the lower cervical roots. When shoulder abduction significantly diminished upper extremity pain, the patient may be instructed to adopt this position for prolonged periods during rest and at work.

Nordhoff indicates the test position should be held for two to three minutes. He further advocates an Arm Abduction Pull Release Test where the affected arm, once in the abducted position, is pulled upward by the examiner to look for subtle disc lesions not found with abduction only.

3) Neck Distraction

The Neck Distraction Test is also known as the Axial Manual Traction Test. To perform the distraction test, the examiner places one hand under the patient’s chin and the other hand around the occiput, then slowly lifts the patient’s head as axial traction force is gradually applied up to 30 pounds. The test is classified as positive if the pain is relieved or decreased when the head is lifted or distracted, indicating pressure on nerve roots that has been relieved.

Distraction of the neck is commonly performed in the supine position in the presence of radicular symptoms. A positive test is indicated by relief or lessening of the radicular symptoms. Viikari-Juntura concluded that the interexaminer reliability of the Neck Distraction test is “good”. In his prospective study a traction force of up to 33 pounds was applied and the authors conclude that the Axial Manual Traction test is highly specific for radicular pain and for neurologic and radiologic signs of radiculopathy from cervical disc disease.

Takasaki et al noted an increase in foramen cross sectional area to approximately 120% of control using the spurling test with 26.4 pounds of traction force in the supine position as indicated by MRI studies.

Additional information regarding direction of nerve root compromise may be ascertained by applying more distraction force to one side. This is most easily accomplished in the supine position. If more relief or centralization is noted with lateral flexion to one side, the patient may benefit from the Pro Air Neck Traction model which allows separate control of left and right sides.

Sensitivity & Specificity Of Tests According To Viikari-Juntura et al

Test

Position

Sensitivity

Specificity

Spurling Compression

Seated

40-60%

92-100%

Shoulder Abduction

Seated

43-50%

80-100%

Neck Distraction

Supine (10-15kg)

40-43%

100%

4) Valsalva Maneuver

The patient is seated and instructed to take a deep breath and hold it while attempting to exhale for 2-3 seconds. A positive response occurs with reproduction of symptoms.

The pushing increases intrathecal or intraspinal pressure revealing presence of a space occupying mass such as and extruded intervertebral disc, or narrowing due to osteophytes.

5) Upper Limb Tension Test

The patient is supine and the examiner places the patients upper extremity into: 1) scapular depression, 2) shoulder abduction, 3) forearm supination, wrist and finger extension, 4) shoulder external rotation, 5) elbow extension, and 6) contralateral then 7) ipsilateral cervical lateral flexion.

Considered positive if any of the following are recorded: 1) Symptoms are reproduced 2) Side-to-side differences in elbow extension are greater than 10° 3) If contralateral lateral flexion of the cervical spine increases symptoms or ipsilateral lateral flexion decreases symptoms

6) Cervical Range of Motion

The patient is seated and cervical rotation is measured with a standard goniometer. Considered positive if the patients ipsilateral cervical rotation is less than 60°

Wainner et al, in the study measured cervical flexion, extension, bilateral side bending, and bilateral rotation measurements were obtained. Before measurement, the patient was seated in a chair and asked to assume a neutral neck position while the examiner applied a piece of tape to the wall at eye level. The examiner referred to this as the “neutral position.” The patient was then asked to perform warm-up movements consisting of two repetitions in each motion direction. Immediately after the warm-up procedure, the examiner recorded a single range-of motion (ROM) measurement for flexion, extension, and bilateral side bending using an inclinometer. Rotation was measured using a standard long-arm goniometer.

Jellad A, et al. notes that neck traction appears to be a major contribution in the rehabilitation of cervical radiculopathy. This next article relates the benefits of neck traction and some frequently asked questions.

References for Testing Radiculopathy