A physical therapist performs Spurling's test on a patient with right-sided upper extremity neural symptoms. The therapist begins the test by passively placing the patient's neck in right lateral flexion and extension. Before even applying axial compression, the patient reports that their upper extremity symptoms have been reproduced. Which of the following best explains the clinical significance of this test?

Option 1- Increased tension of the brachial plexus as it passes through the thoracic outlet
Option 2- Facet joint irritation from cervical lateral flexion and extension
Option 3- Instability of the upper cervical spine due to ligamentous laxity
Option 4- Compression of a cervical nerve root due to foraminal narrowing 

Transcript

Welcome back to the Scorebuilders' Question and Answer Podcast! This podcast provides members of the Scorebuilders' team with the opportunity to explore challenging multiple-choice examination questions with students actively preparing for the licensing examination.

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Spurling's Test
Spurling's test is a commonly used cervical spine examination technique designed to reproduce or rule out certain causes of upper extremity symptoms. By combining cervical extension, lateral flexion, and axial compression, the test places mechanical stress on several structures in the neck. A positive result helps guide the clinician toward a more specific diagnosis in patients with neck and arm complaints.

Here's what makes this question particularly interesting - the patient's symptoms are reproduced before axial compression is even applied. Just positioning the cervical spine in extension and lateral flexion is enough to bring on the upper extremity symptoms. That's a very telling clinical finding, and it's the key detail that drives us toward the correct answer.

Let's explore each of the options:

Option 1 - Increased tension of the brachial plexus as it passes through the thoracic outlet

Thoracic outlet syndrome is evaluated with other special tests such as Adson's, Wright's, or Roos test. Spurling's test does not significantly tension the brachial plexus and would therefore not reproduce symptoms of thoracic outlet syndrome.

Option 2 - Facet joint irritation from cervical lateral flexion and extension

Cervical extension and lateral flexion can load the facet joints, even prior to the addition of axial compression. However, facet joint irritation would be more likely to reproduce localized cervical pain, not radiating upper extremity symptoms.

This is a reasonable distractor because the facet joints are indeed loaded during Spurling's test positioning. And yes, facet joint irritation can cause pain - but that pain is typically localized to the cervical region, perhaps referring into the shoulder or upper trapezius. It does not produce the kind of radiating upper extremity neural symptoms our patient is experiencing. The radicular pattern of symptoms is the critical differentiator here.

Option 3 - Instability of the upper cervical spine due to ligamentous laxity

Cervical instability is assessed with ligament stress tests such as the alar ligament test or transverse ligament test. Because Spurling's test involves compression, it is typically contraindicated for patients that have suspected ligamentous instability in their cervical spine.

This option actually highlights an important clinical safety consideration. Spurling's test applies compressive forces to the cervical spine, which is precisely why it should not be performed on patients with suspected ligamentous instability. Instability requires a completely different set of assessment tools. This option is not only incorrect - it represents a contraindication to the test itself.

Option 4 - Compression of a cervical nerve root due to foraminal narrowing

Spurling's test primarily narrows the intervertebral foramen, where cervical nerve roots exit. A positive result occurs when the test reproduces radicular symptoms, indicating nerve root involvement such as with cervical radiculopathy. While axial compression is typically applied in the final phase of the test, it is possible that symptoms can be reproduced with only positioning the cervical spine in extension and lateral flexion.

When we consider which structure is being directly stressed by cervical extension and ipsilateral lateral flexion, and which structure would produce radiating upper extremity symptoms when compressed, the cervical nerve root within the intervertebral foramen is the clear and only answer.

The correct answer is Option 4.

Let's explore the all student data:
8% of students selected Option 1 - Increased tension of the brachial plexus as it passes through the thoracic outlet
12% of students selected Option 2 - Facet joint irritation from cervical lateral flexion and extension
2% of students selected Option 3 - Instability of the upper cervical spine due to ligamentous laxity
78% of students selected Option 4 - Compression of a cervical nerve root due to foraminal narrowing - the correct response

System Classification
This question is a Neuromuscular and Nervous Systems question which represents approximately 24% of all exam items.

Content Outline Classification
This question is a Physical Therapy Examination question which represents approximately 24% of all exam items.

Level Classification
This question is a Level 2 question since the question requires students to integrate numerous pieces of information or to apply knowledge in a given clinical scenario. Remediation of Level 2 questions occurs by increasing flexibility with academic content and by carefully analyzing decision making processes when answering applied examination questions.

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