Should imaging be done before physical therapy in a patient with neck pain and a positive Spurling (Selective Protective Unlocking test)?

Imaging for Neck Pain with Positive Spurling Test

For patients with neck pain and a positive Spurling test, imaging should be performed before physical therapy due to the high likelihood of nerve root compression requiring specific diagnosis and management. 1

Rationale for Imaging First

The positive Spurling test has significant diagnostic implications:

• A positive Spurling test has 95% sensitivity and 94% specificity for nerve root pathology, indicating that patients with this finding likely have nerve root compression and should undergo imaging 2
• The American College of Radiology (ACR) recommends that patients with neck pain be categorized into grades, with Grade III indicating neck pain with neurological signs of nerve compression 1
• A positive Spurling test represents a neurological sign of nerve compression, placing these patients in Grade III, which warrants imaging evaluation before proceeding with treatment 1

Recommended Imaging Approach

1. Initial imaging selection:

   • MRI is the gold standard for evaluating nerve compression in the neck due to superior soft-tissue resolution 1
   • Plain radiographs should be considered as the initial imaging modality if structural abnormalities are suspected 1
   • CT is preferred when evaluating bony detail or fractures, or when MRI is contraindicated 1

2. Clinical context considerations:

   • The presence of "red flags" further strengthens the need for imaging before therapy 1
   • Red flags include: trauma history, progressive neurological deficits, severe unremitting night pain, age >50 with vascular disease risk factors 1

Management Algorithm

1. Positive Spurling test → Imaging (preferably MRI) → Diagnosis → Appropriate treatment

   • This approach ensures proper diagnosis of the underlying pathology before initiating treatment

2. If imaging confirms radiculopathy:

   • Consider targeted physical therapy specific to the diagnosed condition
   • Consider other interventions such as epidural steroid injections for chronic cervical radicular pain 1
   • Surgical consultation for progressive neurological deficits or failure of conservative management after 6-8 weeks 1

3. If imaging is negative or shows minimal pathology:

   • Proceed with conservative management including physical therapy
   • Use NSAIDs at lowest effective dose for shortest duration 1
   • Reassess after 4-6 weeks of conservative management 1

Common Pitfalls to Avoid

• Initiating physical therapy without imaging: This could potentially worsen radicular symptoms if specific exercises are not tailored to the underlying pathology
• Overreliance on the Spurling test alone: While highly sensitive and specific, it should be considered alongside other clinical findings
• Delaying imaging in patients with progressive neurological symptoms: This could lead to missed opportunities for timely intervention

Additional Considerations

• While most cervical radiculopathy cases improve with conservative treatment 3, proper diagnosis through imaging is essential to rule out serious pathology requiring specific management
• The Neck Tornado Test has been reported to have even higher sensitivity (85.07%) than the Spurling test for cervical radiculopathy 4, and could be considered as a complementary examination

By following this approach, clinicians can ensure appropriate diagnosis and targeted treatment for patients with neck pain and positive Spurling test, potentially improving outcomes and avoiding unnecessary or inappropriate interventions.