What is the initial management for a patient with a positive Spurling test?

Initial Management for a Patient with a Positive Spurling Test

The initial management for a patient with a positive Spurling test should focus on conservative treatment with cervical traction, physical therapy, and pain management medications, as these interventions target the cervical nerve root compression that is indicated by the positive test.

Understanding the Significance of a Positive Spurling Test

A positive Spurling test is highly indicative of cervical radiculopathy with excellent diagnostic value:

• Sensitivity of 92-95% and specificity of 94-95% 1, 2
• Positive predictive value of 96.4% for diagnosing soft lateral cervical disc prolapse 1

The test reproduces radicular symptoms (pain radiating from neck to arm) when the head is extended, laterally flexed, and slightly rotated toward the symptomatic side with axial compression applied.

Initial Management Algorithm

Step 1: Pain Management

• Begin with non-steroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation around the compressed nerve root
• Consider muscle relaxants if significant muscle spasm is present
• For moderate to severe pain, short-term use of oral corticosteroids may be considered

Step 2: Physical Interventions

• Cervical traction: Apply intermittent cervical traction to decompress the affected nerve root
• Cervical collar: Short-term use (1-2 weeks maximum) to limit movement and reduce pain in acute cases
• Physical therapy: Initiate gentle manual therapy techniques such as:
  • Sustained natural apophyseal glides (SNAGs) combined with neurodynamic mobilization 3
  • Gentle cervical distraction (which typically reduces symptoms in cervical radiculopathy)
  • Progressive range of motion exercises as tolerated

Step 3: Activity Modification

• Avoid positions that exacerbate symptoms (typically neck extension and lateral flexion toward the affected side)
• Maintain proper ergonomics, especially during work activities
• Implement proper sleep positioning with appropriate pillow support

Step 4: Reassessment

• Evaluate response to conservative treatment within 2 weeks
• If symptoms persist or worsen despite conservative management, proceed to advanced imaging

Imaging Considerations

If symptoms persist after 2-4 weeks of conservative management:

• MRI of the cervical spine is the preferred imaging modality to evaluate for disc herniation, foraminal stenosis, or other causes of nerve root compression
• CT may be considered if MRI is contraindicated or unavailable

Special Considerations

Red Flags Requiring Immediate Advanced Management

• Progressive neurological deficits
• Signs of myelopathy (hyperreflexia, clonus, Babinski sign)
• Severe unremitting pain unresponsive to conservative measures
• Bladder or bowel dysfunction

Clinical Pearls

• The combination of a positive Spurling test with symptom reduction during manual neck distraction strongly supports the diagnosis of cervical radiculopathy
• Patients with a positive Spurling test have a high probability of nerve root compression and should be managed accordingly 2
• Successful conservative management can lead to complete pain resolution in as little as 2 weeks in some cases 3

Conclusion

A positive Spurling test is a reliable indicator of cervical radiculopathy that warrants a structured conservative management approach. While there are variations in how the test is performed 4, its high specificity and positive predictive value make it a valuable clinical tool for guiding initial management decisions.