Cervical Compression Test: Procedure and Interpretation
Test Procedure
The cervical compression test (Spurling test) should be performed in a staged manner, beginning with extension and lateral bending toward the symptomatic side, followed by axial compression if initial maneuvers are inconclusive. 1
Recommended Technique Sequence
Start with extension and lateral bending: Position the patient's neck in extension and laterally bend toward the side of symptoms without applying axial compression initially 1
Add axial compression if needed: If the initial maneuver is inconclusive, apply downward axial pressure on the top of the patient's head while maintaining extension and lateral bending 1
Alternative high-yield variation: Extension, lateral bending, and axial compression produces the highest pain intensity (mean VAS 7) and most distally radiating pain, making it highly effective when tolerated 1
Rotation variant: Extension, rotation toward the symptomatic side, and axial compression elicits the highest paresthesia levels but may be poorly tolerated, causing test discontinuation in some patients 1
Test Interpretation
Positive Test Criteria
Reproduction of radicular pain: The test is positive when it reproduces the patient's characteristic arm pain radiating in a dermatomal distribution 1, 2
Paresthesia reproduction: Eliciting paresthesias in the affected dermatome supports nerve root compression 1
Distal pain radiation: Pain radiating distal to the elbow is more specific for radiculopathy than neck or proximal arm pain alone 1
Diagnostic Performance
High specificity, low sensitivity: The cervical compression test demonstrates high specificity (meaning few false positives) but sensitivity ranges only 26-50% for individual validity parameters and 40-64% for combined neurologic and radiologic signs 2
Clinical utility despite limitations: Despite low sensitivity, the test remains valuable in clinical examination because a positive result strongly suggests cervical radiculopathy, though a negative test does not rule it out 2
Interobserver reliability: The test shows good reliability with intraclass correlation coefficients of 0.78-0.96 for pain intensity and kappa values of 0.58-1.0 for paresthesia and pain distribution 1
Clinical Context and Red Flags
When Imaging is Indicated
MRI cervical spine without contrast is the preferred imaging modality when radicular symptoms are present, correctly predicting 88% of cervical radiculopathy lesions 3
Immediate imaging required for: Progressive motor weakness, bilateral symptoms affecting upper AND lower extremities, new bladder/bowel dysfunction, loss of perineal sensation, or gait disturbance 3
Atypical Presentations Requiring Broader Evaluation
Unilateral arm and leg symptoms together: This pattern raises concern for cervical myelopathy (spinal cord compression) rather than simple radiculopathy and requires urgent evaluation 4
Consider alternative diagnoses: Plexopathy, multiple levels of compression, or non-spinal causes like multiple sclerosis should be considered with atypical presentations 4
Common Pitfalls
Avoid excessive force: The test can be poorly tolerated, particularly with rotation and compression variants, potentially causing examination discontinuation 1
Don't rely on negative results: Given the low sensitivity (26-50%), a negative compression test does not exclude cervical radiculopathy 2
Correlate with other findings: The compression test should be interpreted alongside dermatomal sensory changes, motor weakness, and reflex abnormalities rather than in isolation 4, 3