British Journal of Neurosurgery, October 2004; 18(5): 480 – 483

ORIGINAL ARTICLE

Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test

K. CHHANALAL SHAH & V. RAJSHEKHAR

Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India

Abstract
The purpose of this study was to determine the sensitivity and specificity of the Spurling’s test in predicting the diagnosis of a
soft lateral cervical disc prolapse. A prospective study was performed involving 50 patients with neck and arm pain; of these, 25
patients were managed surgically (Group 1) and the other 25 patients were managed conservatively (Group 2). A Spurling’s
test was performed in all patients and scored as positive or negative. In patients in Group 1, the operative findings were
recorded as a soft or hard disc prolapse (osteophyte). In Group 2 patients, the MR findings were recorded as positive for a soft
disc prolapse or negative (no disc prolapse or osteophyte only). The results of the Spurling’s test were compared with the
surgical or MR findings, which were considered as the gold standard. Spurling’s test had a sensitivity of 92% and specificity of
95% with positive predictive value (PPV) of 96.4% and negative predictive value (NPV) of 90.9% in predicting a diagnosis of a
soft lateral cervical disc prolapse. The high positive predictive value of the test can be utilized to improve the yield of positive
MR examinations in patients with cervical radiculopathy.

Key words: Cervical radiculopathy, Magnetic resonance imaging, Spurling’s test.

Introduction Material and methods

Persistent pain in the neck and upper extremity is
associated in most instances with cervical nerve root
compression at the intervertebral foramen.1 Cervical
disc disease most often involves the C5 – C6, C6 – C7
and C4 – C5 interspaces, singly or in combination.2 – 4
Although cervical radiculopathy remains largely a
clinical diagnosis, the true diagnostic accuracy of the
clinical examination for cervical radiculopathy is
unknown. Imaging (myelogram, CT or MRI) and
electrophysiological tests (electromyography and
nerve conduction studies) are capable of detecting
clinically significant problems in many patients, and
each modality has inherent strength and weaknesses;
technical as well as practical factors affect the choice
of procedure. Such tests often entail lengthy waiting
lists, a degree of discomfort to the patients and extra
resource costs. Thus, a clinical test that could predict
the chance of finding an acute compression of the
root would be an useful addition to the diagnostic
protocol.
Spurling’s test5 is one such clinical test for cervical
radiculopathy. However, there are few available data
on its sensitivity and specificity.
In this prospective study, 50 patients with neck and
arm pain suggestive of radicular pain, presenting to
the neurosurgical units, during the period May 2001
to May 2003, were studied. Patients who had
associated myelopathy, prior surgery on the cervical
spine or history of trauma were excluded from this
study.
There were 37 male and 13 female patients with
age ranging from 22 years to 60 years (mean 42
years). The duration of symptoms ranged from 2
weeks to 36 months (mean 7.2 months). The mean
duration of symptoms in patients with soft disc
prolapse was 6.6 months, while those with hard disc
prolapse it was 8.1 months. Eighteen patients had
radicular pain without any neurological deficits,
while 32 had radicular pain with neurological
deficits. Almost all patients with soft disc prolapse
had associated neurological deficits, while out of 21
patients with hard disc, only five had associated
neurological deficits. Clinically, C5 root was in-
volved in four patients, C6 in 30 patients and C7 in
16 patients.

Correspondence: Dr V. Rajshekhar, Department of Neurological Sciences, Christian Medical College Hospital, Vellore 632004, India. Fax: 091 416 2232103/
2232035. E-mail: rajshekhar@cmcvellore.ac.in

Received for publication 16 March 2004. Accepted 2 September 2004.

ISSN 0268-8697 print/ISSN 1360-046X online # The Neurosurgical Foundation
DOI: 10.1080/02688690400012350

Spurling’s test
A Spurling’s test was performed after history-taking
and examination for every patient, and the result of
the Spurling’s test was scored as either positive or
negative. In performing this test, the patient’s neck
was extended and laterally flexed towards the
involved side, and downward axial pressure was
applied on the head. The result of the Spurling’s test
was scored as positive if radicular pain or tingling in
the upper limb was reproduced or aggravated.
Imaging
All patients had magnetic resonance (MR) imaging
of their cervical spine. The space available for the
root (effective root canal diameter) was measured at
the entry point of root in the canal on T2W axial MR
image at the level of the disc prolapse and compared
with that of the unaffected side. All the MR images
were read by the senior author (VR) who was blinded
to the result of the Spurling’s test.
Patient management
Patients with significant neurological deficits or who
had failed conservative therapy were advised surgery.
All these patients (Group 1, 25 patients) underwent
anterior cervical discoidectomy using the operating
microscope. The operative findings were recorded as
a soft or hard disc prolapse (osteophyte). A soft disc
prolapse was diagnosed when disc fragments were
seen herniated behind or between the layers of the
posterior longitudinal ligament (PLL). When only a
posterior osteophyte was visualized without any
breach in the PLL, a hard disc prolapse was
diagnosed.
Patients with no root compression on MRI, with
minimal or no neurological deficits with the first
episode of radicular pain and those who refused
surgery were managed conservatively (Group 2). In
Group 2 patients, the result of Spurling’s test was
compared with presence or absence of a soft disc
prolapse on MRI. Group 2 patients were included in
the study to obtain a population of true negative
studies.
Statistical analysis
The statistical analysis was performed using chi-
square test. Student’s t-test was used to compare
means. A p value of less than 0.05 was considered
significant.
Results
In Group 1, all the 18 patients in whom the
Spurling’s test was positive had a soft cervical disc
prolapse. Of seven patients with negative Spurling’s
test, two had a soft disc prolapse and five had a hard
Soft cervical disc prolapse 481
disc prolapse. The sensitivity of Spurling’s test for
soft cervical disc prolapse was 90% and specificity
was 100%. The positive predictive value (PPV) was
100% and negative predictive value (NPV) was
71.4%.
In Group 2, in 10 patients in whom the Spurling’s
test was positive, MRI showed soft disc prolapse in
nine and osteophytes in one patient. In 15 patients
with a negative Spurling’s test, MRI showed osteo-
phytes in eight patients and was normal in seven
patients. The sensitivity of Spurling’s test was 90%,
and specificity was 93.3% with PPV of 90% and
NPV of 93.3%.
The results of both groups taken together are
presented in Table I.
The mean diameter of the affected root canal in
patients who had a positive Spurling’s test was
1.35 + 0.20 (range 0.0 – 3.5 mm) compared with
2.46 + 0.25 mm (range 0.0 – 4.1 mm) in patients
with a negative Spurling’s test (p = 0.000). The mean
root canal diameter was, however, significantly
smaller on the affected side in patients with a hard
disc prolapse relative to the normal side (Table II).
Table II summarizes the root canal diameter on
the affected and unaffected sides in patients categor-
ized on the basis of the operative/MRI findings. The
data are represented graphically in Fig. 1.
Discussion
Spurling & Scoville5 had described the ‘neck
compression’ test in 1944, which afterward became
known as the Spurling’s test. Since then the
Spurling’s test has been widely accepted physical
examination test for cervical radiculopathy. There
are, however, very few studies evaluating the
sensitivity and specificity of the Spurling’s test for
cervical radiculopathy using operative findings and
MR imaging findings as the gold standard.6 – 8
Wiikari-Juntura et al.8 evaluated the sensitivity and
specificity of the Spurling’s test for cervical radiculo-
pathy. The most stringent indication of cervical
radiculopathy in this study was the presence of at
least two neurological signs indicating involvement
the C4 – 5 roots and a myelogram study showing a
filling defect of the lateral contrast media at C4 – 5,
or a similar physical examination and radiological
findings at C6 – 8. Thus, a physical examination
abnormality at C6 root and a myelogram filling
defect at the C8 root would be considered as positive
for a disc prolapse. They found the sensitivity of the
Spurling’s test to be 50% and the specificity ranged
from 92 to 100%. Another study by Ton et al.7 had
evaluated the sensitivity and specificity of the
Spurling’s test for cervical radiculopathy verified by
electrodiagnostic testing. They found that the Spur-
ling’s test was very specific (93%), but not a sensitive
(30%) test. However, the sensitivity of the electro-
diagnostic examination for cervical radiculopathy
was found to be only 90% in a study by Marinacci6
482 K. C. Shah & V. Rajshekhar

TABLE I. Spurling’s test results in both groups (n = 50) Spurling’s test. Although, the mean root canal
Positive MR/operative finding*
diameter was smaller in patients with a soft disc
prolapse as compared with that in patients with a
Spurling test yes no hard disc prolapse, this alone may not explain the
difference in the Spurling’s test results in these two
Positive 27 1
Negative 2 20 groups. The mean root canal diameter was, in fact,
significantly smaller on the affected side than the
Sensitivity 93.1%; Spurling’s test specificity 95%; PPV 96.4%; normal side, even in those with a hard disc prolapse.
NPV 90.9%. Therefore, it is likely that factors other than pure
*For soft disc prolapse. Likelihood-ratio (chi-square) = 38.56
(p = 0.000). 95% CI for sensitivity = 83.5 – 100%. 95% CI for
mechanical compression are responsible for the
specificity = 85.7 – 100%. reproduction of radicular pain with the Spurling’s
test. We speculate that in patients with an acute
lateral soft disc prolapse, the root is probably
inflamed and very sensitive to compression induced
TABLE II. Mean root canal diameter by the Spurling’s test. Thus, the test is likely to be
Affected side Normal side
positive in such patients, whereas in patients with an
Disc prolapse (mm) (mm) p value osteophyte, the inflammation might have regressed
to some extent due to the duration that has elapsed
Soft (n = 29) 1.26 + 0.78 3.46 + 0.42 0.000 following the onset of compression and the nerve
Hard (n = 14) 2.65 + 0.81 3.43 + 0.50 0.005
root might not be as sensitive to the induced
None (n = 7) 3.41 + 0.76 3.69 + 0.30 0.37
compression of the Spurling’s test.
Spurling’s test should be included in the clinical
investigations of a patient presenting with neck and
arm pain. A positive test indicates high probability of
finding (on imaging and/or at surgery) a soft lateral
disc prolapse in a patient with neck and arm pain
(PPV 4 96%). Hence, MRI would be strongly
indicated in patients with a positive Spurling’s test.
A negative Spurling’s test, on the other hand, also
predicts that the chance of finding a soft disc
prolapse is low ( 5 10%). In patients with a negative
Spurling’s test the need for imaging should be guided
by other findings (such as neurological deficits) or
symptoms( severe radicular pain). In other words,
Spurling’s test results could be used to rationalize
MR examination in patients with cervical radiculo-
pathy.

FIG. 1. Graph showing the root canal diameter on the
affected (open bars) and normal sides (shaded bars) in
patients with soft and hard disc prolapses, and no disc
prolapse.
using the operative findings of ‘swollen, inflamed or
compressed and hyperirritable’ nerve roots during
cervical spine surgery as the gold standard. Clinical,
radiological or electrophysiologic diagnosis all have
inherent limitations.9 – 12 Asymptomatic radiological
abnormalities are commonly seen in MRI, Myelo-
graphy and computed tomography of the cervical
spine13,14 and, therefore, a combination of clinical
and radiological examinations should form the basis
for the diagnosis of a significant root compression.
Our study showed that the Spurling’s test has a
high positive predictive value for soft cervical disc.
There was significant correlation between root canal
diameter and results of the Spurling’s test. A
narrower root canal is necessary to produce a positive
Conclusions
Spurling’s test is a moderately sensitive and specific
test for soft cervical disc prolapse, and has a high
positive predictive value for soft disc prolapse. It can
be used to confirm a clinical diagnosis of a soft lateral
disc prolapse in patients with cervical radiculopathy.
Its inclusion in the clinical study of such patients can
lead to an increased yield of positive MRI examina-
tion in patients with a suspected soft lateral cervical
disc prolapse. Root canal diameter has significant
correlation with the result of Spurling’s test.
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