Cervical Radiculopathy Examination
Commonly Tested
Cervical radiculopathy examination requires precise dermatomal assessment and specific provocative tests. Examiners expect you to perform Spurling's test correctly, know the key differentiating features between cervical nerve root levels, and understand the difference between radiculopathy (root compression) and myelopathy (cord compression).
Quick Reference One-Pager
Exam day cheat sheet
Cervical Radiculopathy Examination Summary
Key Nerve Roots
- C5: Deltoid, biceps (biceps reflex)
- C6: Wrist extensors, brachioradialis (brachioradialis reflex)
- C7: Triceps, wrist flexors, finger extensors (triceps reflex)
- C8: Finger flexors, intrinsics
- T1: Hand intrinsics
Provocative Tests
- Spurling's test (axial compression + rotation)
- Shoulder abduction relief sign
- Neck distraction test
- Upper limb tension test (ULTT)
Dermatomal Pattern
- C5: Lateral arm (deltoid region)
- C6: Lateral forearm, thumb, index finger
- C7: Middle finger
- C8: Medial forearm, ring, little finger
- T1: Medial arm
Red Flags to Exclude
- Cord compression (myelopathy)
- Infection
- Tumor
- Vertebral artery dissection
Pathophysiology
Key Concepts
Cervical Radiculopathy:
- Compression or irritation of cervical nerve root
- Causes unilateral arm pain in dermatomal distribution
- Most common: C6 and C7 roots
Common Causes:
- Disc herniation (younger patients)
- Foraminal stenosis (spondylosis, older patients)
- Cervical disc-osteophyte complex
Root vs Level:
- Cervical nerve roots exit ABOVE their numbered vertebra
- C6 root exits at C5-6 level (C5-6 disc affects C6 root)
- C7 root exits at C6-7 level
- Exception: C8 root exits at C7-T1 (no C8 vertebra)
Clinical Assessment
History Clues
Typical Presentation:
- Neck pain radiating to arm (in dermatomal pattern)
- Pain worse with neck extension and rotation (narrows foramen)
- Better with arm overhead (shoulder abduction relief)
- May have numbness/tingling in specific distribution
- Weakness in myotomal pattern
Aggravating Factors:
- Looking up (extension)
- Rotating head toward affected side
- Sneezing, coughing (Valsalva)
- Reaching overhead (extension)
Relieving Factors:
- Arm overhead (abduction relief sign)
- Neck flexion (opens foramina)
- Neck distraction
Neurological Examination by Root
C5
- motor
- Deltoid, biceps
- sensory
- Lateral arm (badge area)
- reflex
- Biceps
- discLevel
- C4-5
C6
- motor
- Wrist extensors, brachioradialis
- sensory
- Lateral forearm, thumb, index
- reflex
- Brachioradialis
- discLevel
- C5-6
C7
- motor
- Triceps, wrist flexors, finger extensors
- sensory
- Middle finger
- reflex
- Triceps
- discLevel
- C6-7
C8
- motor
- Finger flexors, grip
- sensory
- Medial forearm, ring, little finger
- reflex
- Finger flexor
- discLevel
- C7-T1
T1
- motor
- Hand intrinsics
- sensory
- Medial arm
- reflex
- None reliable
- discLevel
- T1-2
Key Concept
Quick Root Level Identification:
- C5: "Military salute" - deltoid weakness
- C6: Thumb and index "OK sign" + wrist extension
- C7: Middle finger + triceps (most common)
- C8: Grip weakness + medial hand/forearm
- T1: Hand intrinsics (Froment's may be positive)
Provocative Tests
Special test
Spurling's Test
Cervical radiculopathy
Technique
- 1Patient seated
- 2Extend neck (look up)
- 3Laterally flex and rotate toward affected side
- 4Apply axial compression (press down on head)
Positive Sign
Reproduction of radicular arm pain (not just neck pain)
Indicates
Cervical radiculopathy (narrows foramen, compresses root)
Diagnostic Accuracy
Sensitivity50%
Ability to detect true positives
Specificity86%
Ability to exclude false positives
Must Know
Spurling's Test Interpretation:
- Highly SPECIFIC (positive test = likely radiculopathy)
- Low sensitivity (negative test does NOT exclude radiculopathy)
- Must reproduce ARM pain (not just neck pain)
- Contraindicated if myelopathy, instability, or acute trauma suspected
Special test
Shoulder Abduction Relief Sign (Bakody Sign)
Cervical radiculopathy
Technique
- 1Patient with radicular arm pain
- 2Ask patient to place hand on top of head (shoulder abduction, elbow flexion)
- 3Observe for pain relief
Positive Sign
Relief of radicular arm pain with arm overhead
Indicates
Cervical radiculopathy (abduction reduces nerve root tension)
Diagnostic Accuracy
Sensitivity43%
Ability to detect true positives
Specificity80%
Ability to exclude false positives
Special test
Neck Distraction Test
Cervical radiculopathy
Technique
- 1Patient supine or seated
- 2Cradle occiput and chin in hands
- 3Apply gentle axial traction (lift head)
Positive Sign
Relief of radicular arm symptoms
Indicates
Cervical radiculopathy (distraction opens foramina)
Diagnostic Accuracy
Sensitivity44%
Ability to detect true positives
Specificity90%
Ability to exclude false positives
Special test
Upper Limb Tension Test (ULTT / Elvey's Test)
Neural tension (root/plexus/peripheral nerve)
Technique
- 1Patient supine, shoulder at edge of bed
- 2Shoulder abducted to 90°, elbow extended, wrist and fingers extended
- 3Add shoulder external rotation and forearm supination
- 4Final step: lateral neck flexion away (increases neural tension)
Positive Sign
Reproduction of arm symptoms, especially with contralateral neck flexion
Indicates
Neural tension - positive in radiculopathy, brachial plexopathy, peripheral nerve entrapment
Diagnostic Accuracy
Sensitivity72%
Ability to detect true positives
Specificity33%
Ability to exclude false positives
Motor Testing
Key Motor Tests by Root
C5 - Deltoid (shoulder abduction):
- Patient abducts arm against resistance
- "Push up against my hand"
C6 - Wrist Extension:
- Patient extends wrist against resistance
- "Cock your wrist back"
- Also test biceps (elbow flexion)
C7 - Triceps (elbow extension):
- Patient extends elbow against resistance
- "Push me away"
- Also test finger extensors
C8 - Finger Flexion:
- Test grip strength
- Patient makes fist while examiner tries to extend fingers
- Also test FDP: Hold isolated DIP flexion
T1 - Intrinsics:
- Finger abduction (interossei)
- "Spread your fingers"
Reflex Testing
Deep Tendon Reflexes
Technique:
- Patient relaxed, muscle in neutral tension
- Tap tendon briskly with reflex hammer
- Compare both sides
Key Reflexes:
C5/6
- Reflex
- Biceps
- Technique
- Tap biceps tendon in antecubital fossa
C6
- Reflex
- Brachioradialis
- Technique
- Tap radial styloid (supinator reflex)
C7
- Reflex
- Triceps
- Technique
- Tap triceps tendon above olecranon
Grading:
- 0: Absent
- 1+: Diminished
- 2+: Normal
- 3+: Brisk
- 4+: Clonus
Radiculopathy Pattern:
- Hyporeflexia at affected level
- Normal or increased reflexes below suggests myelopathy
Differentiating Radiculopathy from Myelopathy
Pattern
- radiculopathy
- Unilateral, single root
- myelopathy
- Bilateral, below lesion level
Reflexes
- radiculopathy
- Decreased at affected level
- myelopathy
- Increased below lesion
Motor
- radiculopathy
- LMN (weakness, atrophy)
- myelopathy
- UMN (spasticity, weakness)
Sensory
- radiculopathy
- Dermatomal (arm only)
- myelopathy
- May include legs
Pathological Signs
- radiculopathy
- Absent
- myelopathy
- Hoffman's +, Babinski +, clonus
Gait
- radiculopathy
- Normal
- myelopathy
- Spastic, ataxic
Bowel/Bladder
- radiculopathy
- Normal
- myelopathy
- May be affected (late)
Must Know
Myelopathy Signs (Upper Motor Neuron): Always test for these to exclude cord compression:
- Hoffman's sign: Flicking middle finger DIP → thumb/index flexion
- Inverted brachioradialis reflex: Tap brachioradialis → finger flexion
- Hyperreflexia in lower limbs
- Clonus at ankles
- Babinski (extensor plantar response)
- Gait disturbance (spastic, unsteady)
Differential Diagnosis
Cervical Radiculopathy
- distribution
- Dermatomal
- tests
- Spurling's +, motor/sensory deficit
- exam
- LMN signs at level
Cervical Myelopathy
- distribution
- Below lesion level
- tests
- Hoffman's +, hyperreflexia
- exam
- UMN signs
Brachial Plexopathy
- distribution
- Multisegmental (trunk/cord)
- tests
- ULTT +, no neck signs
- exam
- Non-dermatomal
Carpal Tunnel
- distribution
- Median nerve (hand)
- tests
- Phalen's +, Tinel's +
- exam
- Thenar weakness
Cubital Tunnel
- distribution
- Ulnar nerve
- tests
- Elbow flexion test +
- exam
- Intrinsic weakness
Thoracic Outlet
- distribution
- Variable (usually ulnar)
- tests
- Roos test +
- exam
- Vascular/neural
Rotator Cuff
- distribution
- Shoulder/deltoid
- tests
- Impingement tests +
- exam
- Shoulder ROM/strength
Summary Presentation
Viva scenarioStandard
Presenting Your Findings
Clinical prompt
“48-year-old office worker with 4-week history of right neck and arm pain radiating to the thumb and index finger, with numbness in these digits.”
Examination Sequence
Systematic Approach
- Observation: Posture, head position, muscle bulk
- Active ROM: Flexion, extension, rotation, lateral flexion
- Spurling's test: Extension + rotation + compression
- Shoulder abduction relief: Hand on head
- Motor: C5 (deltoid), C6 (wrist extension), C7 (triceps), C8 (grip), T1 (intrinsics)
- Sensory: Dermatomal distribution
- Reflexes: Biceps (C5/6), brachioradialis (C6), triceps (C7)
- Myelopathy screen: Hoffman's, lower limb reflexes, gait
- ULTT: If diagnosis unclear
Examiner Tips
Exam day cheat sheet
Scoring High in Cervical Radiculopathy Examination
Do
- Know the myotomes, dermatomes, and reflexes for each root
- Perform Spurling's test correctly (extension + rotation + compression)
- Always screen for myelopathy (Hoffman's, lower limb reflexes)
- Correlate motor, sensory, and reflex to single root level
- Compare reflexes bilaterally
Don't
- Confuse radiculopathy with myelopathy
- Forget to test for UMN signs
- Accept neck pain alone as positive Spurling's
- Miss carpal tunnel syndrome (C6/7 overlap)
- Forget to specify which root is affected and corresponding disc level