7.3 Orthopedic Examination: Cervical Spine

7.3 Orthopedic Examination: Cervical Spine

Quick Answer: Cervical orthopedic testing on NBCE Part II evaluates nerve root compression, cord irritation, thoracic outlet syndrome, and ligamentous or bony pathology through provocative maneuvers. No single test is perfectly sensitive or specific — Part II rewards knowing what tissue each test stresses, the positive finding that matters, and the false-positive mechanism that produces distractor answer choices. Test clusters (Spurling's plus distraction relief plus dermatomal findings) carry far more diagnostic weight than any isolated positive.

General Principles for Cervical Orthopedic Testing

Cervical special tests are provocative or stress maneuvers that reproduce pain or reveal neurological changes by loading, stretching, or compressing specific structures. Before performing any cervical provocative test, complete vertebrobasilar insufficiency screening — if the patient reports dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, or numbness around the mouth, do not perform extension-rotation compression maneuvers.

Most cervical tests have moderate sensitivity and variable specificity. A positive Spurling's test is useful when present but a negative test does not rule out disc herniation. Part II vignettes exploit this by pairing one positive test with contradictory findings and asking which diagnosis best explains the cluster.

Nerve Root Compression Tests

Spurling's Test (Foraminal Compression)

Procedure: Extend the cervical spine, laterally flex and rotate the head toward the symptomatic side, then apply gentle axial compression through the top of the skull.

Positive finding: Reproduction of radicular arm pain in a dermatomal distribution — not merely local neck pain.

Indicates: Cervical nerve root compression from foraminal encroachment (disc herniation, osteophyte, lateral stenosis).

Sensitivity caveat: Spurling's has moderate sensitivity (~30–50%) but higher specificity (~90–95%) for cervical radiculopathy. A negative Spurling's does not exclude root compression; a positive test is more meaningful. False positive: local facet-joint pain without arm radiation — the pain must follow a dermatomal pattern into the arm.

Cervical Distraction Test

Procedure: With the patient supine, the examiner lifts the head axially, unloading the cervical spine and widening the intervertebral foramina.

Positive finding: Relief of radicular arm symptoms during axial distraction.

Indicates: Confirms nerve root compression — the relieving counterpart to Spurling's compression.

Sensitivity caveat: Relief from simple muscle-guarding or general relaxation can mimic a true positive. The relief must specifically target the radicular arm symptoms identified during history and Spurling's testing.

Shoulder Depression Test

Procedure: The head is laterally flexed away from the tested side while the examiner depresses the shoulder on the side being stretched.

Positive finding: Radicular pain on the side being stretched (the side opposite head tilt).

Indicates: Nerve root adhesion, foraminal pathology, or meningeal irritation.

False positive: Upper trapezius muscle strain can mimic radicular pain without a true dermatomal pattern.

Valsalva Maneuver

Procedure: Patient bears down as if straining during a bowel movement.

Positive finding: Reproduction of radicular pain (not just neck ache).

Indicates: Increased intrathecal pressure over a space-occupying lesion (disc herniation, tumor).

False positive: Non-specific pain from increased intra-abdominal pressure unrelated to nerve root compression.

Cord and Meningeal Irritation Tests

Lhermitte's Sign

Procedure: Passive neck flexion with the patient seated or supine.

Positive finding: An electric shock-like sensation shooting down the spine or into the limbs.

Indicates: Cervical cord or dural irritation — cervical myelopathy, multiple sclerosis, disc herniation with cord contact.

Critical distinction: Simple neck stiffness pain is not a true positive. The sensation must have the characteristic electric shock quality. Lhermitte's is highly specific but not sensitive — absence does not rule out cord pathology.

Soto-Hall Test

Procedure: Passive chin-to-chest flexion with a hand placed on the sternum to prevent thoracic flexion.

Positive finding: Localized pain at a specific spinal level during isolated cervical flexion.

Indicates: Ligamentous or vertebral pathology (fracture, disc, bony lesion) at that level.

False positive: Generalized flexion-stretch discomfort without focal localization.

Thoracic Outlet Syndrome (TOS) Provocation Tests

TOS results from compression of the brachial plexus and/or subclavian vessels in the thoracic outlet. Historical clues include arm heaviness with overhead activity, nocturnal ulnar-digit paresthesia, and symptoms worsened by carrying heavy bags.

Adson's Test (Scalene Maneuver)

Procedure: Extend and rotate the head to the tested side; extend, abduct, and externally rotate the arm; patient takes a deep breath and holds it.

Positive finding: Diminution or loss of the radial pulse and/or reproduction of arm paresthesia.

Indicates: TOS compression at the scalene triangle.

Sensitivity caveat: Pulse changes occur in up to 25–30% of asymptomatic individuals. The finding must correlate with symptom reproduction, not pulse change alone. Adson's has low sensitivity and low specificity when used in isolation.

Wright Test (Hyperabduction Test)

Procedure: Passively abduct and externally rotate the arm overhead.

Positive finding: Diminished radial pulse or paresthesia.

Indicates: TOS compression beneath the pectoralis minor or coracoid process.

Same pulse-variability caveat as Adson's.

Roos Test (Elevated Arm Stress Test / EAST)

Procedure: Arms abducted 90 degrees and externally rotated; patient opens and closes the hands repeatedly for up to three minutes.

Positive finding: Reproduction of arm heaviness, paresthesia, or inability to continue.

Indicates: TOS — considered the most clinically reliable of the three TOS provocation tests, though still imperfect.

False positive: Generalized fatigue in deconditioned patients without true neurovascular compression.

Part II Clinical Scenario: Cervical Radiculopathy Cluster

A 48-year-old warehouse worker reports 4 weeks of right neck pain radiating to the thumb and index finger. History notes pain worsened by looking up and coughing. Examination reveals:

• Spurling's test positive on the right (radicular arm pain reproduced)
• Cervical distraction test relieves the arm symptoms
• Diminished brachioradialis reflex on the right
• Decreased sensation over the right thumb

This cluster localizes to C6 radiculopathy (brachioradialis reflex, thumb sensation, Spurling's/distraction concordance). Facet-mediated pain alone would not produce reflex change or dermatomal numbness. TOS would not produce a depressed C6 reflex.

Test Selection Strategy for Part II

When a vignette presents multiple cervical test results, integrate them with history and neurological findings:

Sensitivity and Specificity: What Part II Tests

Part II does not ask you to recite exact percentages, but it expects you to know the direction of test accuracy:

• Spurling's: low-moderate sensitivity, high specificity for radiculopathy
• Distraction: moderate sensitivity as a confirming test when paired with Spurling's
• Lhermitte's: high specificity, low sensitivity for cord involvement
• Adson's/Wright: low sensitivity and specificity; pulse changes alone are unreliable
• Roos: best of the TOS tests but still requires symptom correlation

The recurring exam lesson: never diagnose from a single positive orthopedic test. Always ask whether the historical and neurological findings converge on the same level and mechanism.