Appropriate Next Step with Positive Spurling Test
Order cervical spine MRI to confirm nerve root compression and guide definitive management. 1
Rationale for Imaging
A positive Spurling test has excellent diagnostic performance for cervical radiculopathy, with 95% sensitivity and 94% specificity for nerve root pathology confirmed on imaging. 1 This high correlation means patients with a positive test have probable nerve root compression and warrant further imaging studies to:
- Confirm the diagnosis of cervical radiculopathy with anatomic localization 1
- Identify the specific level of nerve root compression 2
- Guide treatment decisions between conservative management and surgical intervention 1, 2
Imaging Modality Selection
MRI is the preferred imaging study for evaluating suspected cervical radiculopathy:
- Provides excellent visualization of neural structures, disc herniations, and foraminal stenosis 1, 2
- Does not involve radiation exposure unlike CT scanning 1
- Can identify soft tissue pathology including disc material, ligamentous hypertrophy, and cord signal changes 2
CT myelography may be considered if MRI is contraindicated (pacemaker, severe claustrophobia, metallic implants), though this involves both radiation and invasive contrast administration. 1
Clinical Correlation
The imaging findings must correlate with the clinical presentation:
- Match the dermatomal distribution of symptoms with the imaging-identified level of compression 2
- Assess for myofascial trigger points in neck and upper back muscles (levator scapulae, splenius capitis, rhomboid muscles, upper trapezius), which occur in approximately 51% of cervical radiculopathy patients and may require concurrent treatment 2
- Note that median disc herniations are more frequently associated with active myofascial trigger points than posterolateral herniations 2
Important Caveats
Negative Spurling test does NOT rule out cervical radiculopathy. The test has only 55% sensitivity in some studies, meaning nearly half of patients with confirmed radiculopathy may have a negative test. 3 If clinical suspicion remains high despite a negative Spurling test, imaging should still be pursued based on:
- Persistent radicular symptoms (dermatomal pain, paresthesias extending distal to elbow)
- Neurologic deficits (weakness, reflex changes, sensory loss)
- Failed conservative management
Do not delay imaging for a trial of conservative therapy when the Spurling test is positive, as the high specificity (94-98%) indicates genuine pathology requiring anatomic confirmation. 1, 4
Avoid These Common Pitfalls
- Do not assume all neck pain with positive Spurling test is radiculopathy - imaging may reveal alternative diagnoses such as cervical myelopathy, tumor, or infection 1
- Do not order plain radiographs as the initial imaging study - they have insufficient sensitivity for neural compression and will necessitate subsequent MRI anyway 1
- Do not attribute all symptoms to the imaging findings - asymptomatic cervical disc abnormalities are common in the general population and require clinical correlation 2