CERVICAL and THORACIC SPINE TESTS
Tests for topical diagnosis of the cervical and thoracic spine
Movements testing
The movement tests design to evaluate the involvement in the pathological process particular muscles, nerves and nerve roots. The examiner should not only to conduct the tests but also observe how the patient executes the particular movements. These tests can help localize a lesion to the particular cortical or white matter region, spinal cord level, nerve root, peripheral nerve, or muscle. Movement tests quantify by using muscle strength (MS). All tests and movements testing in particular depend on the patient's cooperation and sufficient efforts. If the patient consciously or unconsciously unable to cooperate, the examiner should document "insufficient efforts" and try to observe and appreciate MS indirectly. For example, observe the patient's ability to put on/ takes off clothes, lace shoes, fasten buttons and zips and write/ type on a computer during fill out the office papers. The examiner may quickly test of the upper extremity movements analyzing muscle strength of the certain muscles. Testing of the strength of each muscle group should be performed in a consistent uniform order. The examiner should test symmetrical muscles started with the dominant extremity. MS is rated on a scale of 0/5 to 5/5:
- 0/5: no contraction.
- 1/5: muscle flicker, but no movements.
- 2/5: movement possible, but not against gravity (test the joint in its horizontal plane).
- 3/5: movement possible against gravity, but not against resistance by the examiner.
- 4/5: movement possible against some resistance by the examiner. This is the most common category. This category is divided into three subcategories: 4-/5, 4/5, and 4+/5. However, this is a very subjective.
- 5/5: normal strength.
Quick topical diagnosis of the cervicothoracic spinal
segments and muscles
Movement tests of upper extremities
*I capitalized first three letters in words Abduction and Adduction to distinguish the opposite movements.
Bakody Sign
Indications: suggestive for the cervical radiculopathy at the levels of C4-C6. Test is indicative for the nerve root irritation due to cervical foraminal compression.
Patient's position: sitting upright.
Technique: Either the patient actively, or the examiner passively, place the patient's hand on top of his/her head.
Interpretation: the test is positive if the patient reports decrease pain.
Clinical Notes: Reverse Bakody Sign can be noted when the patient resists raising the arm and hand toward the head. This finding should be correlated with other orthopedic testing, as it could indicate facet irritation, glenohumeral dysfunction, rotator-cuff trauma or myofascial spasm.
Doorbell Sign (Anterior Cervical Doorbell Push Button Test)
Indications: suggestive for a cervical nerve roots irritation
Patient's position: sitting upright.
Technique: the examiner carefully tractions the sternocleidomastoid muscle laterally out of the way while slowly applying moderate digital pressure in a posterior-medial direction from about the mid-cervical down to the clavicle for up to 2-3 seconds and observes for signs of pain or discomfort.
Interpretation: cervical nerve roots, especially C5 and C6, may be irritated by the test. Compressing these roots may increase the pain propagation along the extremity (a "doorbell" pain radiation).
Test should be performed gently
Muscle atrophy testing- upper limbs
Muscle atrophy is a medical term that is used to describe the loss of muscle size or mass when concerning orthopedic injuries or conditions.
The muscle trophy testing is a compliment of the muscle strength tests, especially in case of the poor patient's cooperation. To test muscle atrophy the extremity circumference should be measure in centimeters at the same level on the affected and non-affected sides. According to the American Medical Association Guidance to the Evaluation of Permanent Impairment - Fifth Edition (AMA-5) the ratable ( significant) atrophy requires at least one centimeter difference or greater in the arm, forearm.
Tests for the cervical radiculopathy and cervical nerve root compression
There are four the most widely used cervical tests: compression tests ( Spurling Test, Jackson Compression Test, and Shoulder Depression Test) and the Cervical Distraction Test. Compression tests are more informative but cause pain and discomfort while the Cervical Distraction Test relieve the pain and discomfort but less informative. I recommend perform initially compression tests and then the distraction test.
Cervical Distraction Test
Indications: suggestive for a cervical radiculopathy. Test is suggestive for a nerve root compression and may be also positive if muscular and/or ligamentous damage is present.
Patient's position: supine or sitting.
Technique: the examiner places one hand under the subject's chin and the other hand around the occiput, slightly flexes the patient's neck and slowly and gently distracts the subject's head from the trunk.
Interpretation: the test is positive if the patient reports decrease pain.
Spurling Test (Maximal Cervical Compression Test,
Foraminal Compression Test)
Indications: suggestive for a cervical radiculopathy. This is the most common diagnostic test for cervical radiculopathy.
Patient's position: sitting.
Technique: there are two variants of the Spurling's test:
Spurling Test A
The examiner bends patient's head toward the symptomatic side and then applies pressure to the top of the patient's head.
Spurling Test B
In addition to bending patient's head toward the symptomatic side, the examiner extends and rotates neck while applying pressure to the top of the head.
Modified Spurling Test B
The examiner rests both hands on the top of the subjects head and applies a downward pressure while the subject laterally flexes the head. When the patient's head is in maximum rotation and flexion, the examiner delivers a vertical blow to the top of the head. The test is repeated with the subject laterally flexing to the opposite side.
Interpretation: the test is positive if the patient reports the pain moves into the upper extremity toward the same side that the head is laterally flexed. The pressure on a nerve root can be correlated by dermatomal distribution of pain.
Clinical Notes: Shabat et al. [1] evaluated 257 patients with clinical cervical radiculopathy and correlated CT scan findings with clinical exam findings using the Spurling test. The Spurling's test was 95% sensitive and 94% specific for diagnosing nerve root pathology. I recommend performing the Cervical Distraction Test after the Spurling's test. It is more comfortable for the patient and adding additional information.
Jackson Compression Test
Indications: suggestive for a cervical nerve root compression.
Patient's position: sitting; the examiner is standing behind.
Technique: the patient is directed to laterally flex the neck and head in an attempt and without undue discomfort to approximate the ear on the effected side to the shoulder. The examiner then clasps his/her hands over the patient's head and exerts downward pressure.
Interpretation: the test is positive if the patient reports exacerbation of cervical and/or radicular pain
Clinical Notes: Jackson Compression test is a little bit more informative than the Spurling but may cause so-called VBI-type symptoms since it also compresses the vertebral artery. VBI-type symptoms include dizziness, vertigo and nystagmus).The test should be performed slowly and steadily to avoid rebound pain....
