What is the significance and management of a positive Spurling sign in a patient?

Spurling Sign: Significance and Management in Cervical Radiculopathy

The Spurling sign is a highly specific physical examination test for cervical radiculopathy that reproduces radicular symptoms by compressing cervical nerve roots through neck extension, rotation, and side-bending, often combined with axial compression.

What is the Spurling Sign?

The Spurling sign (or test) was first described in 1944 by Spurling and Scoville as a diagnostic maneuver for cervical radiculopathy 1. It involves:

• Extension of the neck
• Lateral bending/rotation toward the affected side
• Application of axial compression on the top of the head

A positive test reproduces the patient's radicular symptoms (pain, tingling, or numbness) radiating from the neck into the arm, often beyond the elbow.

Diagnostic Value

The Spurling test has excellent diagnostic properties for cervical radiculopathy:

• Specificity: 94-98.5% (highly specific) 2, 3
• Sensitivity: 55-95% (moderate to high sensitivity) 2, 3
• Accuracy: 77-85.9% 3

Research indicates that the most effective variation of the test includes:

• Extension and lateral bending, followed by axial compression, which produces the highest pain scores (mean VAS 7/10) and most distally elicited pain 4
• Extension, rotation, and axial compression produce the highest paresthesia levels but may be less tolerable for patients 4

Clinical Significance

A positive Spurling sign indicates:

1. Compression of a cervical nerve root, typically due to:

   • Lateral disc herniation
   • Foraminal stenosis from osteophytes
   • Cervical spondylosis with narrowing of the lateral recess 1

2. The need for further diagnostic evaluation:

   • Patients with a positive Spurling test should be referred for imaging studies (MRI or CT) to confirm nerve root compression 2
   • A negative test makes nerve root compression less likely but does not completely rule it out 2

Management Approach for Patients with Positive Spurling Sign

1. Initial Management

• Patient education to avoid positions that exacerbate symptoms:
  • Warn patients specifically about "salon sink radiculopathy" - hyperextension of the neck during hair washing at salons can significantly worsen symptoms 5
  • Teach positions that centralize discomfort 5
• Conservative treatment:
  • NSAIDs for pain and inflammation
  • Physical therapy focusing on cervical spine stabilization
  • Activity modification

2. Diagnostic Workup

• MRI of the cervical spine (preferred) to visualize:
  • Soft tissue structures (discs, nerve roots)
  • Spinal cord compression
  • Foraminal stenosis
• CT may be used if MRI is contraindicated

3. Treatment Escalation

• If symptoms persist despite conservative management:
  • Oral corticosteroids for acute inflammation
  • Epidural steroid injections for persistent radicular pain
  • Cervical traction for appropriate cases

4. Surgical Consideration

• Posterior laminoforaminotomy is recommended as an effective surgical treatment option for symptomatic cervical radiculopathy resulting from:
  • Soft lateral cervical disc displacement
  • Cervical spondylosis with narrowing of the lateral recess 1

Clinical Pearls and Pitfalls

Pearls:

• The Spurling test should be performed carefully and systematically to avoid false negatives
• Consider using a staged approach: first extension and lateral bending, then add axial compression if initial maneuvers are inconclusive 4
• A positive Spurling test combined with other clinical findings (decreased deep tendon reflexes, sensory changes, motor weakness) increases diagnostic certainty

Pitfalls:

• Performing the test too aggressively can cause significant discomfort
• False negatives may occur in acute cases with severe pain where patients cannot tolerate the maneuver
• Relying solely on the Spurling test without comprehensive neurological examination may lead to misdiagnosis
• Failing to warn patients with known or suspected cervical radiculopathy about activities that involve neck hyperextension (like salon hair washing) 5

Alternative Diagnostic Tests

For cases where the Spurling test results are equivocal or the patient cannot tolerate the maneuver:

• The Neck Tornado Test (NTT) has been proposed as an alternative with higher sensitivity (85.07% vs 55.22%) and superior diagnostic accuracy (85.93% vs 77.04%) compared to the Spurling test 3
• Vertical weight-bearing MRI has been suggested as an innovative method for standardizing the Spurling test protocol 6

By understanding the significance of a positive Spurling sign and implementing appropriate management strategies, clinicians can effectively diagnose and treat patients with cervical radiculopathy, potentially avoiding unnecessary imaging in negative cases and expediting appropriate care in positive cases.